++++++January 2nd, 2017:
 
Taxation with Household Employees and Agency aides.

 

When hiring an outside professional to care for an older adult at home, families have two main options: Work with a home care agency, or hire an independent home health aide.

Find a Home Care Provider
Agencies usually handle the employer's side of the tax obligations for their employees, so hiring an aide through an agency typically means that you don't have to concern yourself with additional tax considerations. However, you do need to ask and have confirmation that this is indeed the case.
Hiring a home care aide who is not attached to an agency can have a significant impact on a tax bill. In these situations, the older adult and/or their family is typically regarded, for tax purposes, as the "household employer" of the independent aide. This means that this person is responsible for paying the employer's portion of their new employee's unemployment, Social Security and Medicare taxes.

Are you a "Household Employer?"
For tax purposes, the primary factor that determines whether a home health aide is considered your employee or a self-employed, independent contractor (independent contractors are responsible for their own employment taxes), is whether you dictate how he or she performs their work. You can give a list of things to do and requirements but not manage how they do them. Whereas a household employee will receive their instructions on how to care for the older adult from you or another member of the family.
Home health employees who aren't affiliated with an agency tend to fall into the household employee category. Exceptions are a spouse or child (under 21 years old) who are not considered employees for tax purposes even if they receive compensation for providing care.

Working Legally
Once you've determined that the person is categorized as a household employee, the first thing to do is ensure that he or she can legally work in the United States. Asking to see a prospective employee's Social Security card, or having them tell you their SS# are the simplest ways to determine this status.
Prior to the new employee starting work you need to have a Form I-9 (Employment Eligibility Verification) completed. Thisrequires the aide to produce documentation that proves their eligibility to work in the U.S. The form doesn't have to be formally filed with any government agency, but you, as the employer, need to keep it for your records, since the government can ask you to present the document as proof, at any time.
You'll also need to apply for an Employer Identification Number (EIN) so that you can remit taxes that you retain.

Tax Obligations of a Household Employer
The tax amount that you must contribute for an aide who is a household employee will vary, depending on which state you live in and how much you're paying them for their services.
It's vital that you maintain detailed accounts of all materials related to a home health aide's wages and taxes. You must keep a given year's employment tax records for at least four years after whichever is later: the due date of the return, or the date when the taxes were actually paid.
Each time you pay the aide, be sure to write down the date of the transaction, as well as the following:
Employee's wages, both cash (e.g. cash, check, money order, etc.) and noncash (e.g. food, clothing, lodging, etc.)
Federal income tax withheld
State employment tax withheld
Social security and Medicare tax withheld
Some Useful nformation Employment Taxes

Here are a few key components of the household employment tax process to keep in mind:
Withholding
Household employers are not required to withhold federal income tax for an employee, but they can if the household employee requests it. If an employee wishes you to withhold their income tax amount from their paycheck, simply have them fill out a Form W-4 (Employee's Withholding Allowance Certificate), which you will then file with the IRS on their behalf. The W4 identifies deductions and this helps determine the amount of taxes to be withheld. Just remember, if you withhold their federal income tax, you are responsible for paying the full amount on Tax Day to the taxing authority. Penalties for not doing so can be severe. Additionally, you have to inform the household employee about the Earned Income Tax Credit (EITC), which may reduce the amount that a low-income earner owes in taxes.

Employer/Employee Tax Obligations
If you pay an household employee more than $1,900 in cash wages during the tax year, then the IRS will consider you on the hook for the entire Medicare and Social Security tax amount for their employment, which is 15.3 percent of what you paid them. In a typical employment situation, the two parties split this cost down the middle, with the employer paying 7.65 percent (6.2 percent for Social Security and 1.45 for Medicare) out of their own pocket and withholding the remaining 7.65 percent from their employee's wages.

Calculating Medicare Tax
Once the $1,900 threshold is met, all additional wages are taken into consideration when calculating the dollar amount of an employee's Medicare taxes. The Medicare tax amount will be whatever the aide's total wage amount was for the year, multiplied by .0145.

Calculating Social Security Tax
Social Security taxes for a household employee are only eligible to be taxed up to, and are capped at $118,500. The Social Security tax amount will be all wages up to the capped amount, multiplied by .062.

Calculating Unemployment Tax
If you pay an aide more than $1,000 during any quarter of the tax year, then you also have the obligation to cover the six percent federal unemployment tax amount (FUTA. Once the $1,000 in a single quarter qualification is met, a six percent FUTA tax is applied to wages up to $7,000.

Special Rules for State Taxes
Certain states also require household employers to pay a state unemployment tax as well. Information on state unemployment taxes can be found by contacting your state's unemployment agency, using this contact list for State UI Tax Information and Assistance.

Important Dates for Household Employers
Paying taxes as a household employer requires you to fill out and file Schedule H along with your federal income tax return (Form 1040, 1040NR, 1040-SS or 1041), and pay the tax amount due by April 8, 2016.
The following timetable will help you keep track of the important tax dates for submitting forms for the 2015 tax year:
February 1, 2016  --  Submit to your employee Copies B, C and 2 of Form W-2 (Wage and Tax Statement).
February 29, 2016  --  Submit Copy A of Form W-2 with form W-3 to the Social Security Administration (SSA)
April 8, 2016  --  File Schedule H (Form 1040) Household Employment Taxes. And of course, file your own personal income tax return, if necessary Form 1040, 1040NR, 1040-SS or 1041)

IRS Publication 926 (Household Employer's Tax Guide) offers more in-depth information about filing taxes as a household employer, and contains a tax withholding table to help you calculate how much you and your employee will owe in taxes.

 

NOTE: The above is meant only as a guide and because the author is not an accountant (even though he studied accounting). As you will now appreciate, this is complex so you should consult a practicing accountant for advice in setting up to be a Household Employer.

 

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​January 9, 2017
The importance of having an advocate.

As an ombudsman with elder services I am an advocate for the residents. I know an ombudsman is meant to be totally neutral but the reality is that I work for the interests of the residents. Yet, I am fair also with a facility because sometimes they are also in the right, legally, morally and ethically, and its in the interests of all that the ‘right thing’ is done.  Most states have an ombudsman program for nursing homes/skilled nursing facilities/long term care /rest homes. These ombudsmen typically report through their local elder services back to the state.

Assisted Living and Independent living facilities are not, in most cases, participants in the state administered ombudsman program, however, some states do have a nominal service.

Nowadays, when we think of an advocate in the US our thoughts go towards the Affordable Care Act and the advocates who work to ensure people sign on to health insurance programs. But every person, patient in a hospital or resident in a nursing home should have an advocate.

The advocate represents and fights for the patient’s rights and needs regardless of whether a healthcare proxy has been invoked or not. This is the person who communicates these rights and needs to healthcare professionals to ensure the patient gets the care to which they are entitled and deserve. It can be a child, a sibling, a relative or a friend, but this is a role of some responsibility.

The function of an advocate:
The speak for the patient, on their behalf on all issues relating to their care.
To attend ‘family’ meetings and articulate the patient’s position on all matters.
To provide support for the patient as and when needed.
To ensure the patient’s best interests are preserved.
To be there for the patient, whenever needed.

The advocate will engage on all matters with healthcare providers and facilities, so should be a person of trust who is very familiar with the patient. The advocate needs to know what the patient wants for their care. This is not a task for someone who is shy and submissive because it involves being able to take a stand for the patient.
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 January 14, 2017
Some thoughts on reducing fall risk in the home.
 
Falls are the leading cause of death, injury and hospital admissions for the elderly population and comprise a large number of people recovering in nursing homes. In people who are facing a steady decline in health and possibly also cognition at the end of life, falls can be catastrophic leading to an earlier death than would otherwise be the case. As we are looking to be ‘well prepared’, then it makes sense to do what we can to reduce the potential for any unnecessary injury that could complicate or even accelerate any terminal health condition.

Statistically, about 1 in every 3 elders will suffer at least one fall and this metric is directly transferrable to those with terminal health problems. Slips, trips and falls can, to a large part, be avoided if you are aware of their causes. However, as long as people stand upright and move about they are still subject to falling and suffering injury. Causes of falls can include one or more of the following:

Physical strength and balance reduction in the elders. As we age so our physical strength diminishes unless we take steps (exercise) to reduce the effect and our balance can also suffer.
Diminished vision and various eyesight issues (presbyopia, etc.) can impact us as we age. Also either not wearing our glasses, or not having the right prescription in our glasses, can result in a fall.
Medications. Many seniors take multiple medications and any of these may increase the risk of a fall resulting.
Various health problems can increase fall risk by impairing physical mobility or impairing our comprehension of the problems faced with ambulation slip / trip hazards such as throw rugs, clutter, extension cords, etc., may contribute to falls.
Health problems can impact our perceptions and physical capabilities leading to falls.
Impatience in not asking for or waiting for assistance to arise from chair or bed for any reason. Along with this goes a sense that we don’t need help or that we can do it on our own.
Poor lighting in the home so that trip / slip hazards cannot be readily identified.
Lack of fall prevention assistive devices in the home.

Setting up a home to reduce fall risk:

Some of the things you can do to reduce the potential for fall risk include:
  • Install grab bars or handrails in the shower or bath and install push up handles for the toilet. Note the grab bars should be screwed into a solid part of the wall – suction cups grab bars are not advised as they can release. Grab bars are meant to steady someone, not be a device to haul yourself up on.
  • Get bed rails that can be used as a support when arising from the bed and also reduce the problem of someone rolling out of bed. These should be well fastened, usually going under the mattress as the simple ones that strap on may not be adequate.
  • Apply no-stick tape, or no-slip coatings onto shower recess floor and/or tub. Get rid of the loose bath mat.
  • Install a toilet riser seat onto the toilet. These should be of the type that bolt through under the toilet seat bolts or fasten to the floor. The ones that slip under the seat can be unstable and actually prompt a fall.
  • Install handrails on stairways that go past the end of the steps and onto landings.
  • Ensure lighting is adequate for clear vision of the person concerned. Especially, ensure that the pathway to the toilet is clearly lit.  Suggest that motion sensor lights under the bed to light the bedroom pathway at night, perhaps extending down hallways to the bathroom itself are highly recommended.
  • Ensure all rugs are fastened to the floor and stairs and are not loose or bunched up.  
  • Remove all throw rugs they a re a slip / trip fall hazard.
  • Eliminate clutter by removing things not necessary or needed.
  • Move furniture to make clear walkways, and if possible to provide support to assist in preventing a fall.
  • Remove any electrical cords, especially extension cords that could pose a trip hazard.
  • Reorganize cabinets and closets so that the things that are most often used are easily accessible.
  • Buy several reachers / grabbers to extend reach so that no one has to stand on a chair or ladder to reach anything.
  • Clean up and spills or wet surfaces immediately.
  • Buy Waterhog type mats (they absorb water) for the front and rear entrance doors. Wet floors are conducive to slips and falls.
  • Buy no-slip socks or slippers that have rubber grip pads underneath and make sure they are worn around the home.
  • Finally, take away anything that would prompt a person to move around unnecessarily, and move close to them things that they may need or want. The less the exposure to falls the lower the potential for falling.

Things that can Increase Safety and reduce fall risk

Fall Alarm Monitors and Sensor Pads
Typically pad actuated when the person arises from the bed or chair. These do not prevent a fall but trigger an alarm when the person’s weight is no longer ion the sensor. The alarm comes after the fact and the person may have already fallen so they indicate only that the person is no longer on the pad. They don’t prevent a fall.

There are also passive infrared and optical sensors that trigger when an invisible beam is crossed. Depending on how these are placed they may or may not be effective as a warning.

Fall Mats
Fall mats are a foam cored sensor pad that is typically placed beside a bed and trigger when weight is on them. This may be either when a person puts their feet on them or when they rollout of bed onto them. In the first case they can trigger a warning, but in the second case, as with bed and chair pad sensors, they may be too late. They can also be acquired without the sensor as a straight foam cored pad to place beside the bed

Grab Bars
Grab bars are meant for support and need to be of the type that mechanically screws into the wall (not onto tiles or attaches via suction cups as these can release and trigger a fall because they give a false sense of security).

Shower Chair or Transfer Bench
Useful for getting into and out of the shower and sitting whilst washing under the shower. The transfer bench extends out of the bathtub into the bathroom so you can slide into the shower over the tub easily without having to step up, and then down.

Anti-Slip Mats
These generally work but not on wet surfaces too well. Being rubber (like) when water gets underneath they can slip very easily. Use only on dry surfaces. Surfaces that get wet should be taped with anti-slip tape or treated with an anti-slip compound. Don't put these in the shower.

Canes and Walkers
These are ambulation aids for those who need extra support. They come with a variety of bottom attachments. Walkers can have rubber tips, skis, balls (tennis type) or wheels. Canes can have rubber tips, quad or single tips, or ice grabbers. Make sure that whichever is used it is adjusted o the right height and that it has a non-slip tip on the bottom.  

Clothing
Wearing properly fitted, low-heeled, non-slip footwear is far preferable than either barefoot or standard socks. Flip-flops, slip on shoes or shoes with slippery soles should be avoided. Where the patient has dementia or some other problem that could allow a fall then there are engineered clothing as slacks, under garments and helmets that have been designed to reduce the potential impact and injury in the event of a fall.

Hip protectors are available and they are pads that fit over the hips to afford some protection in the case of a fall.

A useful tip is to protect any sharp edges on furniture that could cause damage to a person if they fell against that furniture. You can but edge protection material which is basically an extruded foam or a simple and inexpensive solution is to buy the foam hot water pipe covers at the local hardward store and cut them to fit and secure with tape.

If your loved one is in a facility, check with the unit manager as to the fall prevention protocols they have instituted. Also, check the call button to ensure it is plugged in and working as often they can become unplugged. And finally, tell the patient that they should call for help using the call button if they need help and then wait till an aide comes. Tell them not to get up unassisted if they are a fall risk.
 
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Living longer and better at the same time is what my book is about, specifically about the end-of-life when we are aware of the limited time we may have left. However, I am also concerned with an appreciation that if we can live longer and healthier lives through better preventative care then we can move the milestone of the inevitable out further. So the following is about how the ACA is helping do this and the downside of a repeal.
 
Repeal of the Affordable Care Act: The hidden costs

With the Affordable Care Act (ACA) came a number of benefits to the population that are seldom discussed and which, when they are gone will have a direct impact on health care in a significant way. Contrary to what most Americans believe, the US does not have the best healthcare system in the world, but it does have by far the most expensive. Actually more than twice as much as the next most costly healthcare system in any country.

The World Health Organization (WHO) places the USA in the 47th place (2015) in delivering quality health care based on a number of criteria, but focused on quality of care. This position has stabilized and we are seeing an improvement in care quality.

 Maryland hospitals, for example around 2012 adopted a global payment system and consequently they have improved quality care goals. They reduced reduced potentially preventable complications by 48 percent, and have been reducing the Medicare all-cause readmission rate, which was higher than the national norm by 57 percent. This is just in the hospital realm alone.

Inroads have also been made in the global payment model with primary care where incremental care is rendered at a preventative level to reduce the risk of catastrophic illness requiring potentially life threatening and expensive surgical interventions.

The upshot is that the focus has moved from full fee-for-service to a more preventative healthcare delivery model aimed at keeping a population healthy instead of reacting to health problems. It’s a quality model and is becoming increasingly interdisciplinary.

To understand the road healthcare has travelled over the last 70 years up to today, you need to go back to the emergence of the Health Maintenance Organization (HMO) during the second world war. This was a concept formulated by Kaiser to ensure their workers were healthy and able to build the war goods necessary for victory. Kaiser built, amongst other things, liberty ships. The notion behind the HMO was that keeping the population healthy ensured continuity of labor and it was less expensive than letting people become catastrophically ill to the stage where they could no longer work and needed expensive medical interventions. Avoidance of disease is better than cure as any physician will tell you and Kaiser understood this, hence the HMO.

So while this made sense (and still does), post WW2 the population became more mobile, moving from job to job, relocating within the country to work and opportunity locations and this workforce expected benefits, such as health care. The concept of the job-for-life has gradually disappeared from the American dream. This meant the HMO that had kept the population healthy, and this healthy population moved on and was then covered by the insurance carriers who did a fee for service reimbursement. Those insurers gained the benefit of the healthy population and had lower costs. Their overall costs diminished and made them more competitive, not because of what they provided but as a result of what the HMO had done in health maintenance. So having a stable, non-mobile workforce with a health maintenance program became a lesser business model because the HMO was keeping people well to the ultimate benefit of the fee-for-service payers. This led to the eventual demise of the HMO and expansion of fee-for-service.

Fee-for-Service may sound like a good business model but it is not so great for the population. It only fixes problems when there is a problem. You could say its like not having your care serviced with oil changes and only going to the garage when the care breaks down. Healthcare providers post HMO and pre-Affordable Care Act (ACA) had little to no (financial) incentive to keep the population healthy and instead had a very definite incentive to fix major health problems. The reimbursements for a major interventions became – and still are – much more lucrative for the provider than a health maintenance program. Medicine in the US is largely for-profit based and while there are numerous not for profit care organizations most are based on the for-profit model.

Without painting the medical profession as completely mercenary, it is only logical to understand that if you are graduating medical school you see the opportunity more in a sub-specialty (say cardiology, orthopedics, etc) that have higher income potential than one that is paid a lesser amount (say a primary care physician). There is also kudos and status that goes along with a high income generating sub-specialty. This is partly why there seem to be so many cardiologists, for example, and so few primary care physicians, and while this is not the totality of the reasoning, it does go a long way to understanding the reality.

So what we ended up with pre-ACA in the latter part of the 20th century was a fee-for-service health care delivery model, and this explains why America has so many wonderful physicians who are in subspecialties and perform amazing interventions in so many complicated cases.

The revenue differential to the provider between putting a person on a healthy regimen to reduce illness risk is far less profitable than a high tech invasive procedure to remedy the problem if left unchecked. And it goes a long way to explaining why we have so many complicated cases in the US that may have been prevented. In many instances, if the patient’s problem had been checked earlier then the question is whether they would end up in a critical care situation needing expensive and complex intervention. In the US the health system is good at fixing catastrophic health issues but not so good at preventing them in the first place. That is one reason why the US health system ranks at only 47th place on the WHO scale. This is not a cynical view that healthcare providers want people to be sick with complex issues so they can make money, but it is the point at which the for-profit system of healthcare delivery has ended up.

Enter the ACA also known as Obamacare. Several innovations came with the ACA in how care could be rendered. Firstly, the ACA invoked and expanded a care model called an Accountable Care Organization (ACO). The ACO looks after a population – sort of like the way an HMO did but updated. The ACO is accountable for the health of that population and are paid based on that population (see Global payment system above). As such have a vested interest in keeping the population healthy and avoiding expensive interventions if they are not necessary. This explains why there is a closer focus by them on disease prevention than previously and in comparison to other types of provider organizations.

Along with the ACA came a focus on quality care that can be measured by outcomes statistics. Keeping the population healthy earned rewards, whereas not doing so earned demerits, so apart from just the cost of delivering care there is an accompanying upside and downside metric.

Part of the outcomes metric is the quality issue surrounding readmissions. Pre-ACA if a person was readmitted because some reason, such as a hospital acquired infection, or because of some quality issue then the hospital would render the necessary remedial care and then bill for it. And they got reimbursed because they got reimbursed for their services. Under the ACA a list of procedures where readmissions occurred within a period of time post discharge would incur a penalty. This penalty started at 2% of the procedure reimbursement and rose to 6% over several years. In addition, under these quality guidelines the hospital was responsible also for the cost – they couldn’t bill to gain revenue from fixing their mistakes anymore. The impact of these quality penalties and the remedy of fixing the problem can be significant to the extent they could even impact the viability of a marginal hospital. The result has been an improvement in the quality of outcomes and a reduction in readmissions. This is another quality measure in the ACA that has worked.

What has resulted under the ACA is a shift in focus to quality care based on evidence, and the management a healthy population rather than a focus on just delivering services. The shift towards incremental preventative and curative care at early stages in a patient rather then reactive care at later stages has begun and is showing the results. As this model of care expands over care networks, augmented by electronic medical records that can be shared by the health care professionals so we can anticipate better quality preventative care. This should lead, and the current indicators show it to be the case, to a healthier population, lower costs and a raising of the US in the WHO listing.

A repeal of the ACA puts this change of core philosophy in rendering quality, preventative healthcare at risk.

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 Reduction in readmissions to hospitals from nursing homes proves ACA quality measures work.

The Affordable Care Act (ACA) has brought with it a raft of value measures based on readmissions to ensure quality healthcare and reward providers for quality rather than quantity (as was the case with fee-for-service).

Repealing the ACA puts this initiative at risk and can reverse the trend toward improved quality in care rendered. Of specific interest is that which concerns seniors and those most vulnerable in our society. Readmissions indicate complications and are linked to increased mortality.

According the the CMS (Center for Medicare and Medicaid) Chief Data Officer Niall Brennan under the Affordable Care Act (Obamacare) there has been a sharp reduction in readmissions of nursing home residents back into hospitals.

This is important because it reflects a fundamental quality of care issue at discharge and reduces unnecessary hospitalizations that complicate life for the elder patients and it also reduces costs. If readmissions can be avoided by ensuring the patient has received full quality care, is stable and can be discharged appropriately then this is an obligation for a hospital. All too often in the past patients have been discharged too soon, triggering a readmission when their health, post-discharge, falters in a short period of time. This is due in part also to many nursing homes opening Transitional Care Units (TCUs) to accept patients with greater complications at discharge and thereby requiring more intensive care.

The CMS office of Enterprise Data and Analytics reported that potentially dangerous readmissions had been very high for the Medicare/Medicaid population. They reported that in 2015, there were some 270,000 instances under Medicare/Medicaid and about 30% of these were because of Pneumonia, UTI, CHF, dehydration, COPD, asthma and skin ulcers. Between 2010 and 2015 the rate of re-hospitalization dropped 31% as a result of quality preventative efforts pre-discharge.

This reduction indicates that some of these issues are really avoidable in many patients and by avoiding them the population at large, especially the elder population, benefits. The focus on quality of care, identified through outcomes, is intrinsic to the essence of the ACA and as such should remain a mainstay in US healthcare.

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February 10, 2017
 
The Falsehood of Death Panels and the Reality of Obamacare

A decade or so ago, Sarah Palin and republicans told people that there was a provision in the Affordable Care Act that would create “death panels”. These panels would selectively kill off elderly and chronically sick people to reduce costs. This of course was a falsehood and has proven to be the case.

So when Rep Gus Bilirakis brought this mistruth up again recently in a forum in New Port Richie, Florida, he was howled down by the audience.

In that time since the Affordable Care Act (ACA or Obamacare) has been law not a single death panel has been invoked, and no one has been killed off.  Instead the reality is that physicians now are able to have longer and more meaningful discussions with their patients, about end-of-life options.  They Zalsohave an incentive to do so - they will get reimbursed for their time (this is really what the ACA does).

This has coincided with a rise in utilization of both palliative care and hospice.  These care options, in turn, have both been linked to better outcomes. Palliative care and hospice are life related. Palliative care to managing pain and symptoms regardless of age and care plan. Hospice to those whose primary diagnoses, if left without intervention would result in 6 months or less of life expectancy. The reality is that hospice patients choose quality of life over quantity of life. They choose to live without heroic interventions, unnecessary medication and invasive treatment and they do this so they can enjoy as much as they can. In reality, nearly 10% of hospice patients defy and outlive their prognosis by more than the 6 months. Hospice has been shown to extend life, not limit it.

Palliative care is available to all, regardless of age,  and reimbursed under health plans and Medicare B. Hospice is Medicare A and therefore fits the population over 65, veterans and some others who qualify under Medicare, so it is more aimed at the elder population.

Under the Affordable Care Act (ACA or Obamacare) physicians can now discuss end-of-life options with their patients, and be reimbursed. This is something that was well overdue and any repeal of the ACA could put this danger. Palliative care and hospice are just two options available to people. They are not mandatory, totally optional for the patient and the patient can always opt out if they so desire.  

Repeal of the Affordable Care Act may put this provision at risk. Having the options, and having the benefit of having them explained by your trusted physician makes so much sense because this is a subject of such great importance. Reimbursing physicians for their time in explaining options (including hospice and palliative care) is something very reasonable. Death Panels are a nonsense contrived by ill informed people with the intent to put fear into the population for political ends.  They are a falsehood and do not exist, and never have under Obamacare.

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On March 1st I shall be hosted a discussion at the Somerville Central Library, 79 Highland Ave in Somerville on my book - Dying Well Prepared. The discussion was in the auditorium and was co-hosted by Somerville Council on Aging (SCOA) and the Somerville Public Library (SPL). 

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 Review by Amazon customer – January 15, 2017.  You can see this online at amazon.com. Thank you to the person who lodged this review

“Thank you for this easy to read, not too big guide for those of us who are surprised to discover that we are aging! Life can change in a moment: stroke, heart attack, broken bones, much less a terminal diagnosis and suddenly you feel unprepared; grown children are asking questions - do we have the answers? Do we even know where to begin? - And then in walks this wonderful guide covering everything imaginable and lots we've never thought of! Perhaps you have not received the "bad news" and don't need to tie up all the bits and pieces right away. Nevertheless questions are popping up. This book has also served as a great comfort in that regard. It is wonderful food for thought and allows for intelligent conversation. I have found it so useful and calming when feeling overwhelmed. Even recommended it to my daughter who is facing medical challenges from other people in her life. Our lives and this world are so complicated; it is a relief to have such an all-encompassing guide. I highly recommend this book.”

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On caregivers - some issues when there is reluctance and how to introduce them into their function successfully. Overcoming fears and apprehension for a successful caregiving experience.This is in addition to what is in the book.


After the decision has been made to hire a third party caregiver, the integration into the daily life of the patient becomes a paramount issue. Bringing a ‘stranger’ into the family home introduces a level of apprehension, and often a resistance on the part of the patient if this initiative is at the behest of relatives.

Different fears may prevail with the patient. These can include:

Fear that the family does not care enough to provide the care and that they want to ‘farm it out’ so as to avoid the unpleasant task. Some patients feel they have done everything to look after their relatives for years and now its someone’s turn to look after them. This can become a resentment if not resolved.

There is a fear of strangers which causes a level of anxiety because the patient is put into a position of dependence and can feel a need to supervise / watch the caregiver to ensure they do nothing wrong. How to resolve this trust feeling is very important if the the caregiver is to be able to render the care and the patient to accept it willingly.

There is the fear also of a loss of independence, which, if a person elects to stay in their home is significant. The loss of independence is emotionally threatening and with it comes the realization that we are aging and approaching end of life. We have been independent all our lives and now we are faced with losing this independence and with it self esteem.

Resolving these issues for an effective caregiving experience before they are an issue can be facilitated with a multi-step process.

Firstly, everyone concerned should engage in a discussion about the need for a third party caregiver, and what they should be doing. Deciding on the expectations of the person (s) filling that role as a group sets the stage. The discussion is important. Its important to share with the patient, especially if they show reluctance, that you need help to render the best care because you want them to have more than you feel you can provide. You need build the case for a caregiver first, and you need to get buy in from the patient. 

If they are reluctant or have any fears at all suggest a trial period during which there will be some reviews and a decision to either continue of not.

Starting the process with a third party caregiver.

After checking out the caregiver, and their organization, to ensure you are getting a trustworthy, bonded and insured third party you need to start the process of integrating the caregiver into the daily life. Think of this as a number of steps to take.

The introduction of the person(s) who will be the actual caregivers. This person(s) may be different for the person you had interviewed and if there are to be more than one who will alternate, all should come for a sit down introduction and discussion. This introduction where the caregivers, family and recipient of the care are all present in a discussion build confidence because what is discussed is shared and open. Contact information should also be shared at this time and the contact information listed onto paper and posted near the phone and the contacts entered into mobile (cell) phone contact lists.
Following the introduction, the next item to be discussed is the plan of care. What is the third party caregiver going to do, when and how. This sets the expectation level by which the caregiver will be assessed and from this a schedule of activity linked to dates and times can be documented. This could be in the form of a checklist by day that will enable all parties to review the activity and be confident that all has been done. The plan of care is essential so that the caregiver can attend to everything expected and the patient can feel confident that all the needs are accommodated.

Also, any likes / dislikes, hobbies, crafts, special events or activities or anything at all unique for the patient and / or family need be discussed and documented.

A tour of the home should be provided as a group so that the caregiver(s) know where everything is and all the aspects of care that are dependent on the layout of the home. Any areas that are private, off-limits or personal should be pointed out so that everyone knows where they can and cannot go and what rules apply.
Set up a follow up appointment between the caregiver(s), family and patient to review at the end of the first period – say week or month depending on your choice of tine frame. This is a meeting to review and discuss how the care is going and air any issues and make any changes to the plan of care. Sometimes a patient will not want to air issues because they don’t want to compromise the caregiver with their employer. IN a case like this the family should speak directly with the caregiver organization and discuss the issues, taking it away from the concern of the patient.

Caregiving is a process over a period of time and during this period it is usual for the health and mobility of the patient, as well as their ability to accommodate the activities of daily living (ADLs) to diminish. This leads to a higher intensity of care required so constant monitoring of the process is required. As the patient’s condition lessens then an update to the plan of care may need to be made. Where this is the case then a new family conference is required and a discussion on the changes to be made to the plan of care. In some instances this can trigger a new caregiver(s) who have different skills / qualifications and if this is the case then the introduction process with the tour should be repeated and coupled to a regular review.

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On Advance Directives and ICDs.
When framing advance directives, if you have an Implanted cardioverter defibrillator (ICD), and have a DNR (Do not resuscitate) then you may want to think about disabling the ICD as part of your advance directives. Do you want to have the ICD maintain your heart at end of life or not? You may want to have it disabled when facing limited life expectancy in the immediate time frame because the ICD will attempt to restart the heart if your heart slows too much and/or stops. The ICD stimulates the heart to keep it beating at a ‘normal’ rhythm. Leaving it activated, when you have a DNR, could result in an unwanted revival or keeping of your heart pumping when other organs are failing and this may be something you don’t want. You should discuss this with your physician, act upon your wishes and also document you decision.

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 Medicaid and the attempts by the GOP to withdraw healthcare access.
Thankfully, all the GOP efforts to extinguish access to affordable healthcare and Medicaid have been averted, thanks to 3 GOP senators who listened to their constituents and voted sensibly. 


As I visit residents in long term care, I note how many are dependent upon Medicaid for their care. With the aging population, we need more help for seniors, the disabled and the disadvantaged than ever before, not less. Considering that a Medicaid recipient can have no more than $2000 in liquid assets, earn less than $1000 a month and be essentially impoverished. The recipient is checked for assets over all 50 states and needs reapply annually. Though how states implement this differs slightly, the essence is that it is for those who have little to nothing. Long term care in a nursing home costs around $350 a week and a recipients Social Security goes to the base part of this with the balance paid by Medicaid. 
The most vulnerable of our society have been spared, hopefully for good but at least for the time being from selfish measures.
Now there are rumors of Medicare being changed to a voucher system. This would also be a disaster as it would limit care to those in high need.  Having worked in hospice, I know that while some have brief hospice stays, some have extended and complex diseases that require a lot of care, and vouchers may run out before care has been fully rendered. One size does not fit all.
And to those who are young and healthy who don't feel a need for health cover insurance just imagine if you were totally and permanently disabled after an accident. Its not just disease, its accidents too. Health care access is essential and for those who can't afford it it may well be a death sentence.
In my book I address many of these issues because they are so very important and so seldom discussed, and that is why I wrote the book.

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Question on whether switching off an ICD (Implanted Cardioverter defibrillator) is the same as a Pacer (Pacemaker implanted) when you have a DNR. These devices manage the rhythm of the heart and provide stimulus to ensure that the rhythm is maintained. So the answer is that if you want to have a DNR and don't switch off (or have removed) any device that would keep resuscitating you when you don't want it. This prevents these devices from stimulating the heart and may lead to resuscitation in circumstances where the person would otherwise pass away naturally. If it is a natural death that is preferred then disabling them would be an appropriate measure to consider. 

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Medicaid - GOP - and the states.

Medicai is administered by the states and even though the senate did not approve McConnell's bill on 'healthcare reform' the states as well as President Trump may make Medicaid impossible for some. Work requirements, drug testing and time limits are being considered by some states. How a disabled person on Medicaid will work and what they could do, as well as the time limit concept are amazing to me and beyond belief. But they are in the works.  Read more on this on http://khn.org/news/even-without-congress-trump-can-still-cut-medicaid-enrollment/.


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A primer on the stupidity of medical billing and what should be done to make it sensible (if we don't have a single payer system). I wrote this short article for a medical journal.

The elephant in the surgery

The US healthcare system has a unique problem – the Chargemaster. This is the basis of the confusing billing and the absurd amount of administrative overhead. It could have had a remedy under the Affordable Care Act (ACA) but alas it remains in situ.

To understand the Chargemaster imagine a large grid or matrix of rows and columns. Each medical procedure has a code (HCPCS, ICD, DRG, etc.) The DRG is like a bill of materials containing all the things needed and performed under a ‘standardized’ medical procedure and so is a combination of different codes. And codes can be tiered in (billing) importance depending on primary and subsequent diagnoses, so that the one with the greatest reimbursement can be organized to be the primary diagnoses. Obviously, this is a simplification but the Chargemaster can be, and usually is, very complex. This is especially so in large hospital groups.

Here’s the issue. Every procedure and/or billable item can have multiple reimbursements. Every PPO, ACO, hospital group, and provider, including Medicare, Medicaid, VA, etc., will have negotiated a different dollar reimbursement amount. Complicating this are the accident and rehabilitation codes that can also vary in reimbursement of the patient is billed under property & casualty insurance (think motor vehicle accidents, workers’ compensation, public liability) as opposed to general group health. And of course you have ‘private pay’. Private pay usually has its own fee based on what it called the ‘Usual & Customary’ fee. This is a moving averaged amount calculated on the broad basis of bills/claims received and is not at all cost related. It’s a made up number.

So the Chargemaster is a matrix, as it were, of rows of item numbers and numerous columns of fees for the same procedure depending on who is being paid according to the negotiated contracts between providers and insurers. 

Those who are uninsured pay the highest fee – Usual & Customary. Those who have insurance usually get sent what is called an ‘Explanation of Benefits’ (EoB) that shows how much was actually paid by the insurer. You get to actually see the amount billed and the amount reimbursed. That this varies from provider-to-provider, from insurer-to-insurer, and differs in the case of the same HCPCS (procedure) or service/product if group health/motor vehicle accident/workers’ compensation is a form of madness. The only fees that are consistent are the Medicare fees because they are federally mandated. 

The insurance companies use what they call a ‘repricing engine’ which is a software program that holds the contract conditions for discounts on claims / bills. Some do it in-house and others use outside services that specialize in ‘repricing’. A claim/bill submitted is parsed through the repricing engine to determine if it is valid, and that services billed make sense (some services are gender of age specific and can be filtered out for denial). The claim/bill is then repriced according to the contract discount or fee from the fee billed. The ‘Explanation of Benefits’ for repriced valid claims/bills then is produced and the insurer pays the provider that amount. 
Anyone who can’t afford insurance and is not covered under a governmental umbrella pays full amount. Yet the large insurance carrier pays far less because they have negotiated a contract price with different providers for a specific fee or discount. 

The stupidity of the Chargemaster has a number of issues. 
• Firstly, those who cannot afford to have health of liability insurance pay the full amount, usually the highest fee. In reality, those who can least afford it are penalized the most. 
• Secondly, the Usual & Customary fee is a made up amount that keeps moving upward. Because it is based on gross billing per billable item, the larger the fee charged the move the formula moves the fee upwards. 
• Thirdly, it makes no sense for the same procedure performed by the same provider to have different fees reimbursed. If the provider is rendering care then it would seem to make sense that it takes what it takes and the fee should be standardize. Appreciating of course that severity and complications can be accommodated appropriately. 
• Fourthly, the savings represented to the insurance payer are bogus because they represent the delta between what was billed by a provider and what was reimbursed according to the contract between the two parties. 

If the ACA had decreed that the standard Medicare fee would apply to all services provided, it would be fair and make sense. Significant overhead reductions would result for both providers and payers and financial management for providers would become more predictable. Uninsured people would be billed at the fair rate and not at the inflated (Usual & Customary) rate.

As an additional part of the insanity of the billing chargemaster, insurance payers have aligned with Pharmacy Benefit Managers (PBMs). These are companies that buy medications, usually the generic, in bulk at the lowest cost. Thy call this their ‘formulary’. The insurance companies steer their patients who need medications to these PBMs for their meds. So those who are uninsured pay full retail price whereas those who have health cover get meds at a lower rate – as does their insurance payer. 

The uninsured get slugged by the provider - and on their meds. 

The Chargemaster is the elephant in the surgery and it has been continually ignored by our legislators but it is the root cause of much inequity in medical billing. No fee should be greater than the Medicare fee and that is the fee on which services should be standardized.