Snoring Remedy Often a Matter of Trial and Error – NYTimes.com

DR. ELIZABETH WALTON, a 43-year-old internist in Atlanta and the mother of twin 4-year-old boys, has a common, if sometimes embarrassing, health problem. She snores — loudly. And she has tried to fix it with a variety of things, including a machine that blows air down her throat and an oral appliance that looks something like a mouthguard worn by a hockey player.

The appliance works, and Dr. Walton is finally sleeping more easily. (So is her partner.) And because she was told she had obstructive sleep apnea, a more serious disorder than simple snoring, her treatments have been mostly covered by insurance.

Still, she estimates she has spent hundreds of dollars in deductibles, co-payments and fees.

Planning for Home Care After the Hospital Stay – NYTimes.com

Annie Brumbaugh has become a bit of an expert on recuperating at home. Over the last two years, the 65-year-old wardrobe consultant has had two serious operations on her foot, plus a bone graft, each of which left her homebound for weeks at a time. “This is not easy,” said Ms. Brumbaugh, who lives alone in Manhattan. “Most people have no idea what they are in for.”

Even straightforward procedures, like C-sections and hip replacements, can involve longer-than- expected recuperations. Preparing for these requires more than stocking up on novels, DVDs and plenty of frozen entrees (though such supplies certainly are useful). After a hospitalization, you will need help doing things that you’re unable to do for yourself — even with performing basic tasks like cleaning and dressing. You may need a nurse to change the bandage on a wound or to administer intravenous drugs. You may need equipment, too: a walker, a bath seat or a commode to ensure you don’t injure yourself during recovery.

Equipment and support services will help speed up your recovery, but they also can put a dent in your savings. That’s because most insurers pay for home health care by skilled professionals only during the first, acute part of your recovery. Insurers do not pay for care provided by home care aides, often needed for both short and long recuperations.

The gap often comes as a shock to patients and their families. “There’s a big misconception about what home health care is and what services are covered by insurance,” said Heather McKenzie, senior director of clinical education and quality initiatives for the Visiting Nurse Associations of America. “Most people think all home services will be covered on a long-term basis.”

Every recovery is different, of course, but the more you know and the better prepared you are, the easier it will be to make cost-effective decisions. Whether you are entering the hospital for a planned surgery or just want to be better prepared for an emergency, a few strategies can help guide your way.

PLAN AHEAD Many patients wind up in the hospital as a result of an emergency. For them, lining up home care is likely to be a haphazard process. But a surprising number know in advance that they will be convalescing, yet fail to consider the need for help once they return home.

If you plan to go to the hospital for, say, elective surgery, have a frank talk with your doctor about how long your recovery may be and what you will and will not be able to do. Then call your insurer, whether it’s Medicare or a private carrier, and ask about your policy’s home care benefits.

The insurer can give you a general sense of the services you are entitled to. Be sure to check out your long-term care policy, if you have one; it should cover temporary home care. If you’re covered by Medicare, you can find information on covered home health care services on its Web site.

Elderly patients in assisted living may need skilled aides, as well. While the staff can most likely help with showers and dressing, they probably cannot perform medical tasks, like emptying surgical drains. Don’t leave it up to the hospital to figure out what the facility can provide.

“Hospitals often make false assumptions about what assisted living facilities can and cannot do,” said Maribeth Bersani, senior vice president of public policy at the Assisted Living Federation of America. Check with the assisted living facility directly.

APPROACH HOSPITAL STAFF Let’s imagine you land in the hospital as a result of a sudden emergency. The moment you are able, begin talking to the discharge manager or the social worker about what comes after the hospitalization. Better yet, designate a family member to speak on your behalf, someone who can get the ball rolling even if you’re not up to it.

Whoever does the talking should detail the situation at home for the hospital discharge manager or social worker, including who lives with you and how much help can be provided.

“Health professionals frequently assume there is more support at home than there is,” Ms. McKenzie said. It’s important to make clear that there may not be full-time support. The hospital will have to authorize skilled nursing care for your insurer to pay; discharge planners may consider someone living alone to be more qualified for services than someone living with a spouse.

If you feel you are being hustled out the door too quickly, or that more time is needed to make arrangements, say so. If the discharge planner balks, ask to speak to the supervisor or the hospital’s patient advocate.

“Discharge managers are under the gun to get people out when an individual’s insurance company indicates denial of further coverage and may overlook aspects of your case,” said Vanessa R. Bishop, founder of Elder Care Consultants Inc. in Reston, Va.

Ask, too, if the hospital can order equipment, like a walker or commode, so it is there when you arrive home.

DETERMINE YOUR NEEDS There are two basic levels of home care: skilled and unskilled. Most insurers will pay only for skilled care, but even then you must be homebound and require only temporary care. The hospital should have arranged for short-term nursing care, if needed, before you were discharged. But typically a nurse will also come to your home and evaluate your continuing needs.

Private insurers almost never pay for unskilled help, like a home health aide. If you decide you need more help than your insurer will authorize, first consider whether you need a nurse (who may charge $50 or so an hour) or whether a home health aide will suffice (more like $10 to $38, depending on where you live).

If you do want a skilled nurse, you must get a prescription from your doctor ordering the services, even if insurance is paying.

How do you find a home health aide? It’s usually less expensive to find someone on your own than to go through an agency, so start by asking friends and family for referrals. If you do opt to use an agency, call a few and ask for price quotes. Ask, too, whether they do background checks on their workers. (They should, of course.)

A good place to start is the local visiting nurse agency. These agencies are nonprofit and privately operated, so each one offers slightly different services, but some can provide the services of both nurses and home health aides. For tips on selecting health care agencies, go to the V.N.A.A. Web site at vnaa.org.

HIRE A MANAGER If you don’t have the time or stamina to figure out an ideal home health care plan for yourself or a loved one, turn to a health care advocate or, in the case of elderly patients, a geriatric care manager.

These consultants charge an hourly fee of $90 to $160, which is not reimbursed by insurers. But a one-hour consultation could potentially save you hours of precious time.

A nurse advocate or geriatric care manager can explain how insurance and Medicare work and the services you may be entitled to, and they can speak to doctors on your behalf. If you’re interested in hiring a geriatric care manager, contact the National Association of Professional Geriatric Care Managers. If you want to find an advocate, you’ll have to ask around for referrals, as there is no central resource.

Planning for Home Care After the Hospital Stay – NYTimes.com.

Related Articles

• Well: The Cost of Recuperating at Home (well.blogs.nytimes.com)

Long-Term Care Insurance No Longer an Easy Sell – NYTimes.com

Long-term care insurance ought to be an easy sell to families facing the sandwich challenge. Aging parents can buy it for themselves to cover the costs for a lengthy nursing home stay, for assisted living or for a health aide at home a few hours each day.

Or, adult children of parents whose income is limited could buy policies for their parents. That way, the children shield themselves from the cost of their parents’ care later.

But something seems dreadfully wrong in the insurance market for long-term care.

In 2009, there were fewer new individual buyers of the insurance than in any year since Limra, a market research firm, began tracking the data in 1988. It was also the first year that the number of existing policies did not increase.

This year, big players in the industry like John Hancock and MetLife have announced their intent to raise annual premiums by up to a jaw-dropping 40 percent if state regulators let them.

You would think that there would be far more than seven million policyholders, given that costs for long-term care could easily reach seven (yes, seven) figures per individual 20 or 30 years from now.

As you dig deeper, however, you discover at least nine things standing in the way of consumers purchasing coverage, all of which are outlined below. They’re all complicated, with some reflecting outright ignorance and odd rationalizations rooted in emotion. But there is also a great deal of justified skepticism about the long-term care insurance industry.

So consider this a test of whether you’re ultimately delusional about your risks and the cost of being wrong.

MEDICARE COVERAGE According to a 2009 Prudential survey, 37 percent of people think that Medicare will cover their long-term care costs.

But it won’t. Medicare may pay for a nursing home stay under certain circumstances, but it won’t cover long-term care there. The same thing is true with at-home care.

THE ODDS OF NEEDING CARE Why invest in insurance if there’s a chance you’ll never need it? It’s a reasonable question, so consider your odds.

The consulting firm Milliman, which does a lot of work for the long-term care insurance industry, thinks your odds aren’t so great. For people age 65 and older who have long-term care insurance, there is a 45 percent chance of making a claim, though it ranges from 30 to 56 percent depending on gender and marital status.

Using data from long-term care insurance policies that have no spending limits, Milliman also estimates that once you’ve made a claim, the chances that you will continue needing care for more than three years is at least 13.9 percent. There is a 4.3 percent chance of it exceeding five years.

SELF-FUNDING COST How much might it cost to pay for care yourself? Last week, MetLife, a big seller of long-term care insurance, released new survey data suggesting that the average rate for a private room in a nursing home was now $229 a night, or $83,585 a year, on average, though it can range widely by geography. Average costs for home health aides are $21 an hour.

And what is the true cost of being among the unlucky here if you roll the dice and buy no insurance at all? Ralph Leisle, who runs a software and consulting company focused on long-term care insurance, tried to figure this out in an article in The Journal of Financial Service Professionals in January 2008.

He took a 55-year-old couple and assumed one of them would need four years of care starting at age 75. The current cost of care was $200 a day and would rise by 5 percent annually.

Including the opportunity cost of lost investment gains (6 percent after taxes) from money that ended up being spent on care instead, the total cost without insurance would be about $1.5 million.

Scary, right? Perhaps you could drain your retirement accounts and sell your home or take out a reverse mortgage to pay for the $800,000 in care that was part of this assumption, if it came to that. But then there might be little or nothing left to pay the expenses of the surviving spouse.

COUNTING ON MEDICAID Medicaid will pay for nursing home costs, and depending on your state, some other types of long-term care, too. But first, you have to qualify, and that usually means spending most of the money you have.

Still, plenty of people do qualify because they have very little or no savings. Others count on qualifying someday if they need a lot of long-term care. Amy Finkelstein and Jeffrey R. Brown, two economists who have studied long-term care insurance, call this an “implicit tax” on private long-term care insurance. After all, why buy private insurance when Medicaid would pay for much of what the insurance company is paying for?

While many people probably think this way, Medicaid may not offer the same choices that a long-term care policy will. The best or closest nursing home facility may not take Medicaid patients, for instance, or have room for any when you need it. Program restrictions will only grow over time, given the precarious state of the federal and state budgets that pay for it.

Plus, it is not many people’s idea of a good way to spend your final years. “I don’t think anybody who has worked and saved for a lifetime to accumulate assets now looks and says ‘Great, how do I end my life on welfare?’ ” said Jesse Slome of the American Association for Long Term Care Insurance, a membership organization for people who sell the policies.

THE CHILDREN AS NURSES If you changed your children’s diapers, then they should be prepared to change yours someday too, right?

This is the sort of thing you might say if you’ve never actually had to change an adult relative’s diapers. Or if you’ve never lived through an experience where one nearby relative had to do most of the care, leading to the relative’s physical exhaustion, emotional devastation and extreme financial sacrifice from lost wages.

“The best sales tool we have is their bad experience,” Curt Vahle writes in his book, “How to Sell Long Term Care Insurance to Mr. and Mrs. Jones.”

And while in some cultures or communities, putting a parent in a nursing home is simply not an option, plenty of people planning for their long-term care needs want to shield their children from having to help physically at all. “I don’t want my daughter putting me in the bathtub, especially when I get old and my breasts get bigger than hers,” said Mr. Slome. “There is a sense of personal dignity that you work your whole life for.”

THE CHILDREN AS FINANCIERS Still other parents assume, without really asking, that their children will pay for their care if the parents run out of money. Or one sibling assumes, without ever discussing it with the others, that the children will split any costs for care equally.

Mr. Slome said that it was best not to leave such things unspoken. “Have that conversation and create a written contractual agreement,” he said. “Because what people say and what they do are typically two very different things.”

And consider the fact that your children or other relatives, if any, may not have any spare money when the time comes, even if they agree to help at some later date. Imagine how different these conversations would have sounded in 2006 and in 2009.

THE GOVERNMENT’S PLAN One part of the landmark health care bill earlier this year is something called the Class Act. In effect, it sets the government up in the long-term care insurance business.

No one will be able to enroll until 2012 at the earliest, and the plan may not pay much more than $75 or $100 a day for claims (and only after a five-year period of paying premiums first), though that will be indexed for inflation. Still, since it will be easier to qualify for this coverage than for private insurance, where a medical exam is often necessary, it may be tempting for people to wait and enroll in a couple of years. (Which may turn out fine as long as the program doesn’t get delayed until 2016 and you don’t need care before then.)

The truly cynical may want to max out coverage, assuming that the government will underprice premiums to appease taxpayers and legislators who have pushed for this sort of program for years. And $100 a day will cover four hours a day of care at home, even if it covers only a fraction of nursing home costs.

Just keep your fingers crossed and hope that the federal government doesn’t change the rules or tax the benefit just when you’re getting ready to take it 20 years from now. Not many people expected Social Security benefits to ever be subject to taxes, after all.

THE COST TODAY In the first half of 2010, individuals buying through an insurance agent or financial adviser paid a $2,180 annual premium for common plans that pay claims that are not taxable for the policy holder. Given the price tag, it’s easy to see why shoppers might have demurred as the economy swooned over the last two years.

And for people who are struggling, paying for health insurance in the here and now is probably a higher priority.

FUTURE COSTS Long-term care insurance premiums aren’t like those for, say, term life insurance. They can go up. The fact that they didn’t rise very often until recently led many agents to lead customers to believe (or buyers to fool themselves into believing) that they would never go up.

But now, stalwarts like John Hancock and MetLife are trying to raise rates by large amounts, even as others like New York Life have never had a premium increase.

Rochelle Fulleton, a 73-year-old who lives in Camarillo, Calif., and bought long-term care insurance when she was in her 50s, recently received a letter from MetLife letting her know that it intended to raise her $2,968 annual premium by 39 percent.

“This is an assault on the most vulnerable part of the population,” she said. “I understand that they don’t want to pay the bill, but they are the ones who wrote the policies and they have actuarial tables and they knew about inflation costs in medical care even back then.”

A MetLife spokeswoman said that the company actually had not anticipated the costs. “While we are sensitive to any rate increase that impacts our policyholders, assumptions used to initially price many long-term care insurance products have changed,” Karen Eldred said in a statement. She added that the company misjudged interest rates, life expectancy and the number of people who would drop their policies.

The good news here is that the increase seems to be necessary in part because long-term care itself is so good. People are staying alive longer than companies predicted, and they’re continuing to pay their premiums for longer periods of time, too, in order to remain eligible for that care.

But the bad news is that a price increase of this magnitude suggests that some companies had no idea how to set prices on many of their policies. If they have it wrong today too, you could sign up for a $2,500 premium at age 60 and end up paying two or three times as much for it when you’re 85 and on a fixed income.

If you have no interest in turning your money over to companies who have gotten it so wrong, I salute you. But if the insurance company professionals can blow the projections, you certainly can too. So you had better have a plan, and a backup plan, too, for when your forecasts inevitably go awry.

Long-Term Care Insurance No Longer an Easy Sell – NYTimes.com.

Related Articles

• ZocDoc Insurance 101 – Long-Term Care Insurance (zocdoc.com)
• Long Term Care Insurance: How do LTC Policies Work? (retirementplanning.suite101.com)

More Americans opt for high-deductible health insurance plans – latimes.com

Looking to save money in a weak economy, Americans increasingly are turning to health insurance plans with low premiums and high deductibles — prompting doctors and health experts to worry that consumers may be skipping routine care that could head off serious ailments.

Nationally, the number of workers with individual deductibles of at least $1,000 has nearly tripled over the last four years, reaching about 20 million, according to a recent survey of employers.

Some have pushed their deductibles as high as $10,000, and, to keep medical bills low, are forgoing colonoscopies, blood tests and other preventive procedures.

This month, when most workers enroll for another year of health benefits, the number of people who opt for high-deductible plans — or are forced into them by their employers — is expected to rise yet again.

The potential consequences are serious, experts warn. A new study by UCLA‘s Center for Health Policy Research found that 504,000 of 3 million Californians with high deductibles held off seeing doctors and specialists, and that half cited cost as the primary reason.

“They are more likely to end up in emergency rooms or hospitals because they are delaying more appropriate preventive care,” said Dylan Roby, a researcher with the UCLA center, which based its findings on 2007 data, the most recent available.

Nancy Hendrickson of San Diego knows the dilemma firsthand. She doubled the deductible on her policy to $5,000 when she turned 60 to help bring down her premium every two months to $530 from more than $800.

That helped Hendrickson cut her expenses, but it also led her to stop going to the doctor for routine checkups and other care for fear of running up big medical bills.

Now 63, the Internet consultant is paying the price for that decision: A blocked artery landed her in the hospital this year. She had to take a personal loan to cover the deductible and pay about $7,000 more in medical costs.

“What is the better choice: Paying the rent or paying the higher deductible?” Hendrickson asked. “I’m sure there are lots of people just like me.”

Health experts say preventive care is key to reducing the cost of medical care, and the nation’s new healthcare reform law provides an incentive for people to get regular checkups.

Under measures that started to take effect in September, insurers will be required to pay for several costly procedures such as colonoscopies and mammograms that people with high deductibles might now seek to avoid. And starting in 2014, deductibles for workers in small firms will be limited to $2,000 for individuals and $4,000 for families.

High-deductible plans have become a growing necessity in recent years not only for individual consumers looking to cut corners but also for financially strapped businesses.

Small companies, in particular, that pay all or part of their workers’ insurance have seized on the strategy. Raising deductibles lowers premiums, cutting their costs.

The number of workers nationally with high-deductible plans has nearly tripled in firms with fewer than 200 employees since 2006 — reaching 11.7 million this year, according to a survey of employer health benefits by the Kaiser Family Foundation and the Health Research & Educational Trust.

In California, the number of workers in this category more than tripled from 2006 to 2009, rising to 674,000 employees.

“The way employers have been dealing with cost is by moving to less comprehensive, flimsier coverage with higher deductibles because it costs them less,” Kaiser foundation President Drew Altman said. “That’s why workers have never been more upset about their own healthcare costs. The share they pay out of their pockets has been going up mostly because more people are in high-deductible plans.”

Businesses say they have little choice as soaring costs for insurance, materials and labor bring unwelcome decisions about how much they can afford for health insurance, if they can offer it at all.

“It all comes down to dollars and cents,” said Michael Shaw, the California legislative director for the National Federation of Independent Business. “For small businesses, being able to provide any benefit is a struggle, especially given the economy we’ve had over the last few years.”

The highest deductibles are often found in the individual market, where consumers buy insurance on their own and lack the leverage enjoyed by businesses to negotiate rates and benefits.

The average deductible for an individual policy in this market — which provides coverage for about 14 million people — is nearly $2,500, according to a June survey by the Kaiser foundation. It’s more than $5,100 for families.

Doctors and hospitals say the high costs can be devastating for people who become sick.

Riverside internist Richard Frankenstein said that high-deductible patients served by his group practice have put off colonoscopies because of the cost.

“Statistically, some of them will have a disease that will be fatal that could have been prevented,” said Frankenstein, a past president of the California Medical Assn. “That is a tragedy. I’ve spent my whole life trying to prevent that.”

Healthcare advocates say that high-deductible plans can be useful, if tied to so-called health savings accounts that allow policyholders to set aside tax-deductible money for medical expenses.

More than 10 million people are now covered by such arrangements that were introduced in 2004, according to America’s Health Insurance Plans, an insurance industry trade group in Washington. That’s up from just 438,000 six years ago.

“You see a tremendous amount of growth … as families and employers have looked for affordable coverage options,” said Robert Zirkelbach, a spokesman for the trade group.

Los Angeles architect Ron Frink, for one, has been putting money into a health savings account for about three years. He has amassed $10,000, more than enough to cover his $3,500 deductible and other out-of-pocket expenses.

“It gives me a great deal of security to know that, should something happen, I have money to cover the deductible and I won’t be stressing about where the money is going to come from,” Frink said.

But he also said the plan has worked because he has remained healthy. That has enabled him to save without having to dip into his wallet to pay doctors.

“It’s a great program if you are willing to be responsible about saving some or all of your deductible in a given year,” he said. “If you don’t, it’s not a wise choice at all.”

For Hendrickson, the San Diego Internet consultant, the idea of putting money into a health savings account is a nonstarter.

Hendrickson is bracing for her $5,000 deductible to reset Jan. 1, worried about the potential costs of treating the early-stage diabetes doctors discovered when she was in the hospital this year.

“I sure hope nothing else happens until I hit Medicare,” said Hendrickson, who will be eligible in two years for the government-run insurance program for seniors. “You don’t want to go in to see the doctor when you know you’re going to pay the whole thing out of your pocket.”

More Americans opt for high-deductible health insurance plans – latimes.com.

Some Companies Shift Health Costs to Better-Paid – NYTimes.com

This is just re-arranging the deck chairs on a sinking boat. And big business spent millions to defeat democrats who supported health care reform!

 

With health care costs climbing even higher during this enrollment season, more employers are adopting a tiered system to pass on the bulk of those costs to their employees by assigning bigger contributions to workers in top salary brackets and offering some relief to workers who make less money.

More…

via Some Companies Shift Health Costs to Better-Paid – NYTimes.com.

People with Disabilities: The Affordable Care Act creates options and affordability

Related Articles

• Understanding The New Health Care Bill: Persons With Disabilities (zocdoc.com)
• Steve Joyce: Affordable Care Act Grants to Help Seniors, Caregivers Meet Health, Long-Term Care Needs (seniorjournal.com)