Online Book: "Covering Health Issues"

The Alliance for Health Reform makes available online a free 300-page guide to health policy issues, entitled "Covering Health Issues". The guide appears intended for the media, but is a great reference for any teacher, consumer, or professional seeking reliable information about the history of health program reforms, current laws & regulations, various service & funding programs, and other resources on various health care topics. Although not state-specific, it is an up-to-date primer on important health care issues.

It is described by AHR as follows:

This 300-page book contains an overview, expert sources with telephone numbers, story ideas, websites, key facts, and a discussion of current policy proposals for all of the topics below:

• The uninsured
• Private health coverage
• Children’s health coverage
• Medicare
• Medicare prescription drugs
• Medicaid
• Long-term care
• Health care costs
• Quality and health information technology
• Disparities
• Mental health
• Public health

Extras include a step-by-step primer on the congressional budget process, tips on covering health issues for TV and radio, and a list of websites where you can find public opinion polls on health issues. You will also find a glossary of terms related to health coverage.

Found here are the links to the complete book, or to the following individual chapters, for viewing or download:

INTRODUCTION CHAPTER 1 - THE UNINSURED CHAPTER 2 - PRIVATE HEALTH COVERAGE CHAPTER 3 - CHILDREN'S HEALTH COVERAGE CHAPTER 4 - MEDICARE CHAPTER 5 - MEDICARE PRESCRIPTION DRUG PROGRAM CHAPTER 6 - MEDICAID CHAPTER 7 - LONG-TERM CARE CHAPTER 8 - HEALTH CARE COSTS CHAPTER 9 - HEALTH CARE QUALITY CHAPTER 10 - DISPARITIES CHAPTER 11 - MENTAL HEALTH CHAPTER 12 - PUBLIC HEALTH APPENDIX A - THE CONGRESSIONAL BUDGET PROCESS APPENDIX B - POLLS ON HEALTH CARE ISSUES APPENDIX C - COVERING HEALTH ISSUES FOR TV AND RADIO GLOSSARY SOURCES

AHR also offers the book in an HTML version in English or in Spanish.

Physicians on Mortality & Dying: Part II

Another physician who wrote a recently-published book about dying -- and specifically about survival beyond death -- is Deepak Chopra, M.D., in Life After Death: The Burden of Proof (Harmony Books, October 17, 2005).

A press release by Random House summarizes the book's approach:

In this dazzling new book, Dr. Deepak Chopra addresses one of the fundamental questions of existence –- the afterlife.

It is hard to think about death, but in this book, Dr. Chopra explains that death is as much a part of life as birth and it affects every one of us. Drawing upon his personal experiences in India as a child and his understanding of Christianity and particle physics, Chopra helps us to overcome our fears and consider all of the remarkable possibilities that may await us in the afterlife.

Using his own story -- one he has been preparing to tell his entire life and stories from ancient Vedic philosophy -- Chopra addresses the fundamental theories of birth, life and death.

Dr. Deepak Chopra, the son of India's first native cardiac surgeon, trained as a physician in India at two institutions. He emigrated to the United States in 1970. He interned at a New Jersey hospital, and trained for several more years at the Lahey Clinic in Burlington, Massachusetts, and at the University of Virginia Hospital. He became board-certified in internal medicine and endocrinology. He taught at Tufts University and Boston University Schools of Medicine, became the chief of staff at the New England Memorial Hospital, and established a large private practice.

He developed into a leader in the meditation movement, and then in the "mind-body" medical approach to treatment & healing. In 1995, he founded the Chopra Centre for Well-being, located in Carlsbad, California, as an expansion of his healing approach using the integration of the best of western medicine with natural healing traditions of the East. He has written over forty books on various health & spiritual topics.

His most recent book addresses perhaps the most difficult topic of all -- death and the afterlife experience. Dr. Chopra reviews his reasons for writing the book in an interview found here.

I am reading this book now in an "electronic" book format on my Palm organizer. I am entranced by his effective weaving of story-telling, with deep emotions, complex religious concepts, simple common sense, scientific & quantum physics principles, and personally-experienced phenomena -- all directed to answering a compound question, asked universally: What happens when, then after, we die?

The answers ratify what a majority of Americans already believe -- that consciousness and a part of personality survive death. His exploration brings the reader back to living, however, and reinforces the importance of this awareness for daily conduct, including the process of dying.

Others have reviewed the book favorably, as mentioned on Chopra's website here. I agree with one reviewer, Larry Dossey, M.D., who concluded: "This book will help many find certainty and comfort in this possibility by exploring many lines of evidence pointing to the infinite, eternal nature of human consciousness."

At this point in my reading of Chopra's book (supplemented by my peeks ahead towards its conclusion), I also agree with the commentary posted here about his book:

Chopra has waited twenty years to write LIFE AFTER DEATH: The Burden of Proof, the first major book on the afterlife in decades.

Inspiring, brilliant, and ultimately encouraging, his insights will change the minds of countless people who have pondered the mystery that lies on 'the other side.' It also contains a great gift: an antidote to our fears, so we can see clearly the full majesty of the infinite arc of birth, death and the life beyond.

As one might expect from the book's title, Chopra, as a physician-author, assumes a rational, not faith-based, approach to his inquiry. However, his treatment affirms the best in traditions of many faiths. A person of faith, therefore, should not hesitate to read this book.

We can be grateful to both Dr. Chen (See: Physicians on Mortality & Dying: Part I) and Dr. Chopra for explaining their viewpoints about dying, drawing upon their medical experiences and their soulful reflections.

Update: 03/21/08:

I wrote a posting entitled "Is There An Afterlife?" (03/21/08), which addressed just that question, as considered from a scientific viewpoint.

Physicians on Mortality & Dying: Part I

Physicians -- who daily treat victims of serious accidents or patients with terminal illnesses -- can teach us much about mortality & dying, if they observe & share, and if we listen to them. Two physicians recently wrote their observations -- Pauline W. Chen and Deepak Chopra; and we should listen.

Final Exam: A Surgeon's Reflections on Mortality, published January, 2007, was written by Pauline W. Chen, a transplant surgeon with twenty years' experience. It was recently reviewed nationally with great acclaim for a writer's first book.

Her personal website lists articles that she wrote previously. One listed there is available in full length free: "Dead Enough? The Paradox of Brain Death", published in the Virginia Quarterly Review (Fall, 2005). See also: "The Most-Avoided Conversation in Medicine" (New York Times, December 26, 2006).

Her credentials as a physician -- as noted by the Virginia Quarterly Review in 2005 -- are impressive. Pauline W. Chen was educated at Harvard University and Northwestern University Medical School, and completed her general surgery training at Yale University. Dr. Chen is the recipient of numerous awards, including the UCLA Physician of the Year Award in 1999, and the George Longstreth Humanness Award at Yale for “most exemplifying empathy, kindness, and care in an age of advancing technology.”

Her publisher, Alfred W. Knopf, a division of Random House Books, offers a fifteen-question interview with lengthy answers by the author here at the Borzoi Reader website that reveals her personality & purpose.

The interview concludes with the question: Who does she hope that the book will reach?

I wrote Final Exam with the hope that it would inspire much needed discussions about end-of-life care. People have a hard time talking with one another about dying — we talk around the topic or ignore it all together — and this has been one of the biggest obstacles to all the efforts to improve end-of-life care.

The issue becomes particularly problematic when it occurs between doctors and their patients because any miscommunication means that patient care will in some way suffer. Doctors and non-doctors are often portrayed as standing at odds with one another. But I think that we ultimately share the same difficulties in grappling with death, albeit colored by our personal and professional experiences and by our cultural and ethnic backgrounds.

I hope that Final Exam will bridge the divide between doctors and their patients. I hope that it helps to support the current professional reform efforts in end-of-life care and even helps to accelerate the pace of political change.

But my greatest hope is that Final Exam will create a common ground from which we can all begin to have meaningful discussions: about how we die, how we care for the dying, and ultimately how we live.

Her compassion is evident, as displayed during a different interview, broadcast on Saturday morning, January 27, 2007, by National Public Radio. Scott Simon's interview with Dr. Chen, headlined Surgeon Writes of Death, Dying in 'Final Exam', confirms her genuine intention in writing her book. You can find a link to the interview here for listening through your multimedia computer. It is worth hearing.

Weekend Edition Saturday, January 27, 2007 · When Pauline Chen became a doctor, she was troubled by inconsistencies in the ways that fellow physicians dealt with the emotional aspect of death and dying. Chen tells Scott Simon about her new book: Final Exam: A Surgeon's Reflections on Mortality.

Other literary reviews -- many by physicians -- either compliment or rave about Dr. Chen's new book:

• "Doctor Confronts the Human Drama's Inevitable Finale", by William Grimes, of the New York Times (01/10/2007) -- "When it comes to confronting death, doctors are as much at a loss as the rest of us. They are in the business of saving lives, not ending them. By instinct and by training, they avoid what Pauline W. Chen calls ''the final exam,'' the emotional challenges posed by terminally ill patients. Death represents failure. It asks unanswerable questions. Perhaps most vexingly, it threatens to crack the hard professional shell of detachment that medical training puts in place. In modern American medicine, death is everywhere and nowhere at the same time.

• Review: "Final Exam", in Time Out Chicago (Issue 98, January 17, 2007) -- "If you’ve ever wondered why the doctors on Grey’s Anatomy seem more compassionate than your own M.D., Dr. Chen will tell you why. Chen contends there is a breakdown in the field during real-life medical dramas when it comes to handling end-of-life care — something you don’t see on television. 'Few choose this career to care for the dying; instead they believe they will save others from the inevitability of death.'"

• "Why physicians fight the wisdom of death", by John Vaugh, M.D., of the San Francisco Examiner (01/21/2007) -- "Patients in denial without advance directives, families racked with guilt about losing their loved ones, physicians petrified of being sued for missing something and everyone feeling an overwhelming need to do something during a crisis have made many people's last days a needlessly traumatic, often atrocious experience. Pauline Chen has written Final Exam: A Surgeon's Reflections on Mortality to explore how modern medicine has come to such a state."

• "Final Exam": A surgeon reflects on the nature of mortality and the medical profession's failure to acknowledge it, by Claire Panosian Dunavan, M.D., in the Los Angeles Times (January , 2007) -- "As Chen so eloquently argues, a zeal to cure is no excuse for failing to communicate prognoses honestly or for sidestepping ongoing dialogue with patients and families as medical events deteriorate. Any book that calls a spade a spade on these touchy topics deserves high kudos for candor and compassion. In particular, I commend "Final Exam" to every medical student and young physician. * * * It may seem paradoxical, but as life expectancy increases in privileged societies, a mature awareness and engagement with death is incumbent on us all. The alternate scenario — large-scale warehousing of end-of-life disasters in lieu of wiser societal investments in health — is no longer mere medical sci-fi."

• Must Read: "Final Exam", by Rachel Rosenblit, in ELLE Magazine (January, 2007) -- "In her first book, Final Exam (Knopf), surgeon and writer Pauline W. Chen indicts her profession for too often viewing a patient's imminent death as a procedural failure instead of a final chance at grace. 'The process of dying can be cast as full of potential,' Chen writes. 'There is a chance for real interpersonal reconciliation and emotional expression rather than the hasty symbolic gesture of aggressive treatment.' "

With her book's publication, Dr. Chen began a "blog", found on the Amazon site here (where her book can be purchased), and found also on her personal website here. She writes clearly, openly, & kindly in these entries. I intend to read her book; and I expect the same approach in it, but much greater depth. Her book must have substance & accuracy, given the number of reviewers -- many of them her physician-peers -- who recommend a reading.

Another author-physician attending to the subject of mortality & death is Dr. Deepka Chopra. He approaches the subject from a more universal perspective in a book that he describes as the culmination of a twenty-year writing career. I'll note his contribution tomorrow.

* * *

Update: 02/04/07:

Dr. Chen is mentioned in an interesting article published on February 2, 2007, in the Floridian / St. Petersburg Times:

"A lesson in dying", by John Barry, Deputy Editor (02/04/07) -- Synopsis: While medical students dream of saving lives, the University of South Florida tries to make sure those students are also equipped to deal with death.

Online PA "Elder Law" References

Certain county bar associations in Pennsylvania, through their Elder Law committees or practice sections, make available comprehensive & current elder law references to the public. These references are useful, too, for the professional advisor.

Available for view or download is the 2006 Edition of the Delaware County Elder Law Handbook and Resource Guide. The Guide is published by the Delaware County Services for the Aging (COSA) and the Delaware County (PA) Bar Association, through its "Elder Law Committee for Seniors and Their Families".

Although primarily intended for an audience in Delaware County, Pennsylvania, the Guide remains a useful resource for anyone interested in Pennsylvania "Elder Law" topics, or the Commonwealth's application of federal laws and programs affecting the elderly.

The 2006 Edition of the Delaware County Elder Law Handbook & Resource Guide is available for view or download online in PDF format here (120 pages, 681 KB). A one-page 2007 update, indicating Medicaid changes from the prior online edition, is available here (1 page, 39 KB).

Also, the Montgomery County (PA) Bar Association recently published & posted online its sixth (2005-2006) edition of the Montgomery County Elder Law Handbook, found here (PDF format, 88 pages).

The Handbook is described online here:

The Elder Law Committee of the Montgomery Bar Association accepts responsibility for monitoring issues and changes in law that influence our county's seniors and review and update this publication regularly as part of their ongoing contribution to public outreach. * * *

The Elder Law Handbook is an award winning FREE resource guide for seniors embracing virtually all areas of Elder Law. This perfect bound publication is widely distributed to over 5000 residents throughout Montgomery County via county agencies, libraries, senior centers, and locally based community organizations.

The handbook is also available in disk format directly from the Montgomery County Bar Association at its headquarters, 100 West Airy Street, P.O. Box 268, Norristown, PA 19404-0268 (Ofc: 610-279-9660; Fax 610-279-4321). Contact Patricia Walker at extension 210, or send an email message to: pattie@montgomerybar.org, with your name & mailing address, for a free printed copy.

For those in the northwestern corner of the Commonwealth, the Erie County Bar Association published, in 2002, its Elder Law Handbook, as a comprehensive legal guide to issues of importance to senior citizens. The Handbook, described here, was designed, likewise, to assist groups and organizations that serve senior citizens in Erie, Pennsylvania. It provides information about issues often encountered by the elderly, and incorporates contacts for resources available to seniors in that local community.

The Handbook was produced with financial support from the Erie County Bar Association, the Erie County Bar Foundation and the Erie Community Foundation. It appears not to have been updated since its original publication.

The Table of Contents of this Handbook can be viewed here. The Handbook can be downloaded in PDF format here, or in Word format here.

Finally, the Pennsylvania Bar Association offers a publication entitled "A Guide to Legal Issues for Pennsylvania Senior Citizens" (2005 Revision), available free here in PDF format. That Guide was originally based upon the 2000 edition of the Montgomery County Elder Law Handbook. It is revised annually now by the Senior Lawyers Committee of the PBA.

The Foreword of the PBA's Guide indicates its purpose:

This guide is designed to provide information about legal issues faced by Pennsylvania’s older residents and their caregivers. Its authors and publishers intend to help seniors make appropriate choices so they can maximize personal autonomy, minimize costs, navigate through the maze of government benefits, and protect themselves against predators who want to deceive, exploit or defraud.

Senior citizens within Pennsylvania require timely and reliable access to legal information. The Senior Lawyers Committee of the Pennsylvania Bar Association has determined that it can best serve the needs of the legal community by serving the needs of the citizens of Pennsylvania.

Its concentration on the creation of this statewide Guide for Senior Citizens is complimented by other programs such as a mentoring project, a pro bono project and the sponsorship of continuing legal education (CLE) programs, all designed to aid the legal community by offering the expertise of older, more experienced attorneys to all Pennsylvania practitioners. This in turn helps to bring the best possible representation to the clients of Pennsylvania Lawyers.

The closing words of that Foreword can be applied appropriately to each of these fine publications:

Obviously, no publication can cover all the legal issues relating to a group as diverse as this State’s senior citizens. However, this guide offers basic information, points out various services and ways to access them, and outlines areas which may require specific legal advice or expertise, given each individual’s needs.

The emphasis is mine.

* * *

Update: 04/12/07:

I came across a further elder law guide, published by the Chester County (PA) Bar Association five years ago (2002). Although certain laws & regulations have changed since its publication, this Guide still may provide local information for residents of that county. See: The Chester County Guide for Senior Citizens & Their Families (PDF, 82 pages).

The Guide is not posted (according to my site search) on the CCBA website any longer, but remains available through that link (a private law firm).

Two Press Releases on PA Senior Issues

On January 24, 2007, two press releases were issued & posted by the Department of Aging on matters initiated by Governor Edward G. Rendell that will affect seniors in Pennsylvania.

One announced funding for renovations & studies at senior centers, and a second announced the creation of a new position -- the Deputy Secretary for Long Term Living -- to function with the Governor's existing Council on Long-Term Care.

The first press release, entitled Governor Rendell Announces $4 Million in Grants to 153 Senior Centers, announced that 153 senior centers in the Commonwealth would be "revitalized" by improvements funded by grants of varying amounts.

Governor Rendell said the funds will finance necessary repairs, renovations and new equipment at the centers, helping to meet the needs of Pennsylvania’s changing population of older adults.

Department of Aging Secretary Nora Dowd Eisenhower said some centers will receive grants to study how to attract, and better serve, new clients.

"Many forward-thinking senior community centers are working to attract members of the ‘Baby Boomer’ generation, some of whom may mistakenly think senior centers have little to offer them," Eisenhower said. "By investing strategically, and carefully planning ahead, we can ensure that senior centers will continue to be healthy and vibrant contributors to our communities."

Very impressive to me in that Press Release is the listing of the 153 individual senior centers, located (by my count) in 56 counties, that will benefit from the grants. Such senior centers serve many effectively. See my prior postings Ornament (not Organ) Donations Sought and Seniors Salute Soldier.

The second press release, Governor Rendell Names New Deputy to Lead Improvements in Long Term Living Systems and Services, announces the appointment of Mike Hall "to lead the commonwealth’s efforts to expand and strengthen Pennsylvania’s long term living system."

He will serve as Deputy Secretary for Long Term Living, and be responsible for coordinating the extensive network of state-supported long-term living services that are currently funded and administered by the Department of Aging and the Department of Public Welfare.

"As part of my Prescription for Pennsylvania health care reform initiative, I am creating this new position and bringing in a talented and proven leader to boost the quality, cost effectiveness and breadth of options available to Pennsylvanians who need long term living services and supports," Governor Rendell said.

"We want to maximize every dollar we invest in the long term living system to ensure that low- and moderate-income seniors and adults with disabilities can receive the services and supports they need, in the right setting." * * *

At Governor Rendell's direction, the commonwealth has already taken significant steps to improve the long term living system, including dramatically expanding home and community-based options, implementing a successful and innovative nursing home transition program, and creating the inter-agency Long Term Living Council to provide strategic direction to the ongoing reform efforts.

I conclude that, in the year 2007, health care and senior services will continue to be a target of the Rendell administration's thought & energy.

* * *

Post Script: I realized, upon my review of this posting, that I was narrowly adhering to the Julian calendar year in making the last statement about the year 2007.

But, did you know that, according to the Chinese calendar, the year 2006 remains in effect until our Julian date of February 18, 2007?

(year begins on 2/18/2007)
(1/29/2006 - 2/17/2007)

Have I wandered off, or what!?!

Well, as long as I'm here, do you know what is special about 2006 on the Chinese calendar? On that calendar, the year 2006 contained a leap month. Yes, in a Chinese "leap year", instead of adding just one "leap day" in February as we do under the Julian calendar, an entire "leap month" is added. It is very complicated, and the explanation draws upon ancient concepts, as described here.

Aren't you glad you know?

Update: 01/29/07:

In the Daily Item (Lewisburg, PA), on January 27, 2007, columnist John Finnerty notes the various funding grants made by the Pennsylvania Department of Aging, in his article "Why are baby boomers avoiding senior centers? -- Study launched to find answer". Following are the leading paragraphs from his article:

Do you know any baby boomers who hang out at the local senior center? The odds are you don't.

But as people of a certain generation get older, those who provide services to senior citizens are bracing for an increase in business, knowing full well that the existing network of senior centers aren't very inviting to those who came of age in the 1960s and are now in their 60s.

"The median age of people who visit our senior centers is 80," said Farida Zaid, the former director of the Union-Snyder Area Agency on Aging.

For those who are just becoming senior citizens, "even the name — senior centers — has negative connotations," she said.

Down the road, the agency will likely scrap the senior center name for something more palatable to its younger clients, Ms. Zaid said.

She is now working on planning and development for that agency, . . . * * *

It is a good article about a very forward-thinking senior center in Central Pennsylvania imagining itself into its future.

Gerhard's Revised Book on Medicaid in PA

On January 22, 2007, I received from Attorney Robert C. Gerhard, III, of Glenside, PA, a courtesy copy of the 2007 edition of his book "Pennsylvania Medicaid & Long-Term Care", published in December, 2006, by George T. Bisel Co., Inc., of Philadelphia, PA. The book is described online here.

Previous editions of Bob's book were published in July, 2004, & November, 2005.

This is Bisel's description of the book:

Written by certified elder law specialist Robert C. Gerhard, III Esq. this reference book is a “must have” for anyone advising seniors and their families. This essential guide explains how Medicaid is used to finance long-term care in Pennsylvania. No other text discusses Pennsylvania’s Medicaid rules in such detail. Precise citations are provided to applicable cases, statutes, and regulations.

The [2007] Edition of Pennsylvania Medicaid, Long-Term Care contains significant revisions in light of recently enacted law. Pennsylvania Medicaid law has changed in major ways, thus rendering the First Edition out-of-date and replaced by the new [2007] Edition.

Bob is one of a few highly-qualified attorneys in Pennsylvania who have applied their specialized knowledge to the writing of a legal textbook about a practice area that changes frequently.

His new edition reveals the fast-paced changes in the federal Medicaid program, and in this Commonwealth's administration of it, which affect seniors' long-term care needs. In Pennsylvania, these include Act 42 of 2005, which eliminated the "Hurly appeal" as a way to increase the spousal share, and Department of Public Welfare's Operations Memoranda, which periodically apply legal & policy changes to the program in our state. To track such changes, Rob continues to update his book through Bisel's subscription services.

There are some other dedicated, practicing, Pennsylvania author-attorneys whose publications guide other professionals -- and some sophisticated consumers -- in this Commonwealth on important personal & fiduciary legal matters. I will highlight others periodically. In this posting, I compliment Bob for his scholarship in this important legal area.

AARP Training on Guardianship

The AARP National Legal Training Project (NLTP) is hosting an inter-active web training for legal services and advocacy staff on guardianship. The training will provide a basic overview of guardianship, including how to evaluate capacity, and will emphasize alternatives to guardianship.

NLTP's training programs are described here on its web page:

NLTP trains lawyers and other advocates throughout the country in substantive law and advocacy skills to enhance their free and reduced fee services to older Americans.

NLTP also conducts “Training of Trainers” programs to produce a cadre of elder law trainers who expand the reach of the program. The program’s funding sources include the US Administration on Aging, AARP and private contributions.

The current invitation by NLTP relates to web-training on "Guardianship Issues: What every elder advocate should know". For more information regarding the content, contact Imani Woody, NLTP Training Specialist at: iwoody@aarp.org.

These are the details about the program:

DATE: February 28, 2007
TIME: 2pm-4pm
PLACE: Your Computer
COST: Free of Charge
TRAINER: Carolyn Rodis, Esquire

AARP advises: "SPACE IS LIMITED TO THE FIRST FIFTY PEOPLE WHO REGISTER. E-MAIL SOON TO RESERVE YOUR SPACE."

To register contact the producer, Marie Hubbard (mhubbard@aarp.org). A confirmation e-mail will give directions on how to access the web meeting site and receive training materials.

Thanks to Ana Torres-Davis, Materials Attorney, AARP Foundation, National Legal Training Project (Ofc: 561-242-6012; Fax: 202- 434-2110), for posting this information last Friday on the listserv of the National Center on Elder Abuse.

I suggest that, if you cannot participate, you might still want to access NLTP's website here, to download relevant, related reference materials entitled "Protective Arrangements for Incapacitated Persons" (PDF, 112 pages, 605 KB), updated 08/24/2005.

These materials cover the following topics, according to its Table of Contents:

I. PROTECTIVE ARRANGEMENTS FOR INCAPACITATED PERSONS:
A. Representative Payees
B. State Elder Abuse Laws
C. Guardians and Conservators
D. Involuntary Civil Commitment

II. MODEL PROBLEMS:
A. Problems
B. Answers

III. BIBLIOGRAPHY

IV. APPENDICES
A. Initiation of Guardianship Proceedings
B. Notice in Guardianship Proceedings
C. Representation and Investigation in Guardianship Proceedings
D. Conduct and Findings of Guardianship Proceedings
E. Guardianship Monitoring
F. Transfer of Guardianship/Conservatorship Cases Between States
G. Elder Abuse Hotlines
H. Possible Indicators of Abuse: A Checklist

These materials appear to be a comprehensive, current reference, useful nationally, on the topic of guardianships.

Long-Term Care Study Award in PA

On January 10, 2007, Pennsylvania State University announced that the Pennsylvania Department of Public Welfare commissioned a research study to be conducted by a team located at Penn State Harrisburg on long-term care in the Commonwealth.

It will be funded by a $1.65 Million grant from DPW, "to develop and implement a plan to explore issues related to current and projected participation in long-term care services" in this state. See: Press Release, $1.65 million grant funds long-term care study (01/10/07).

Through a $1.65 million DPW grant, one of the largest ever awarded to Penn State Harrisburg and its Institute of State and Regional Affairs, the team of faculty and staff researchers will assess the current and projected future need for long-term care services in Pennsylvania and the associated cost of service delivery in the coming years.

Cynthia Mara, associate professor of health-care administration and policy, is the principal investigator for the effort, and Michael Behney, director of the Institute of State and Regional Affairs, is serving as project director. Jacob De Rooy, associate professor of managerial economics and statistics, is co-principal investigator with assistance coming from all the applied research centers in the institute.

The research, which will cover 18 months through June 2008, includes six objectives:

• Production of detailed state population projections by age, sex and race;
• Documentation of social, cultural and other factors in the long-term care environment that affect demand;
• Gauging of consumer choice factors relating to long-term care services;
• Identification of demand for and supply of long-term care services in Pennsylvania;
• Documentation of current and projected costs of long-term care services in Pennsylvania; and
• Development of a predictive model of consumer demand and cost of long-term care services in Pennsylvania.

The grant & study were the subject of a report, Aging population drives new study of long-term care, broadcast on WITF-FM (Harrisburg, PA) on January 19, 2007, for public radio affiliates in Pennsylvania:

* * *Cynthia Mara, an associate professor of health care administration and policy, says the issue is an important one in Pennsylvania, where the 85-plus population is rapidly growing. However, she notes age isn't the only factor to consider. The researchers will examine what types of care exists, as well as what areas are underserved. Mara says she expects the team's work to play a key role in decision making at the state level.

There is much attention lately to the growing need nationally for long-term personal care, seeking innovative solutions to meet such needs.

The current health care system favors institutional caretaking, according to a study recently referenced in an online article Bias in Long-Term Care Favors Nursing Homes, Government.

The National Bureau of Economic Research performed that study & also issued a report in 2006 entitled "Medicaid Crowd-Out of Private Long-Term Care Insurance Demand: Evidence from the Health and Retirement Survey" (NBER Working Paper No. 12526).

The report begins with a summary of its key findings:

This paper provides empirical evidence of Medicaid crowd out of demand for private long-term care insurance.

Using data on the near- and young-elderly in the Health and Retirement Survey, our central estimate suggests that a $10,000 decrease in the level of assets an individual can keep while qualifying for Medicaid would increase private long-term care insurance coverage by 1.1 percentage points.

These estimates imply that if every state in the country moved from their current Medicaid asset eligibility requirements to the most stringent Medicaid eligibility requirements allowed by federal law -- a change that would decrease average household assets protected by Medicaid by about $25,000 -- demand for private long-term care insurance would rise by 2.7 percentage points.

While this represents a 30 percent increase in insurance coverage relative to the baseline ownership rate of 9.1 percent, it also indicates that the vast majority of households would still find it unattractive to purchase private insurance.

We discuss reasons why, even with extremely stringent eligibility requirements, Medicaid may still exert a large crowd-out effect on demand for private insurance.

The long-term health care system forces the elderly into nursing homes -- the only long-term care option covered by Medicaid -- opines Dr. Ira Rosofsky, a psychologist who practices in nursing homes and who is working on a book about caring for the elderly.

In his opinion/editorial "Escape from the Nursing Home", published in the New York Times on January 17, 2007, he urges innovative thinking:

Seventy-five thousand dollars is the average yearly cost of living in a nursing home, whether you pay out of pocket, whether you have long-term-care insurance, or whether you’re on welfare and your stay is paid for by Medicaid. (In 2005, Medicaid paid an estimated $54 billion of the $122 billion national expenditure on nursing homes.) * * * But for long-term care, couldn’t we imagine a better way to spend that $75,000? * * *

[T]hree frail elderly people could share an apartment and a 24-hour aide and, by pooling the cost, have more than $58,000 left over among them for food, clothing, shelter, physical therapy and even fun and frolic.

Crisis entry of an elderly person into a nursing home that becomes residence long-term "grossly violates" the "accepted gold standard" that health care should provide services in the least restrictive manner, he says. "We are faced with a public health system that resists innovation, but the sheer size" of the baby-boom generation "may force the issue."

Such are the long-term care issues that the Penn State Harrisburg Study Team will be challenged to assess and explore.

PA Governor Unveils New Health Care Proposals

On January 17, 2007 -- one day after his re-inauguration for a second term as Governor of Pennsylvania -- Edward G. Rendell announced his administration's new program that would address the quality & cost of health care services in Pennsylvania, and would increase health care coverage to all its residents.

A Press Release (PDF, 4 pages), dated January 17, 2007, entitled Governor Rendell Unveils Historic “Prescription for Pennsylvania” to Provide Access to Affordable, Quality Health Care for All Pennsylvanians, announced the state government's initiative regarding health care coverage in the Commonwealth. It was posted on the site of the Governor's Office of Health Care Reform:

Building on his successful initiatives to expand access to health care including Cover All Kids and PACE/PACENET, Governor Edward G. Rendell today offered a sweeping and bold “Prescription for Pennsylvania” to increase access to affordable health care coverage for all Pennsylvanians by lowering costs, improve the quality of care available in the state and bring health care costs under control for employers and employees.

“We can no longer stand by while health care costs spiral out of control, leaving some 767,000 adult Pennsylvanians without the basic health care they need and creating a drag on our economy,” Governor Rendell said. “It is no longer a question of whether we can afford to act – the cost of inaction is far greater; both in terms of individual health consequences and from the increasing burden on taxpayers.

“Every year, Pennsylvania businesses, consumers and taxpayers pay at least $7.6 billion for unnecessary and avoidable health care costs. That is money that isn’t improving the quality of care we receive, nor making Pennsylvanians healthier. It doesn’t make sense. We should be redirecting that money to fix our broken health care system.”

The Press Release provided an outline of the proposal, but noted that its implementation would require state & federal action:

Specific components of Governor Rendell’s initiative will require legislative and federal approvals. If the necessary approvals are timely, the CAP program is expected to begin operating in January 2008. The financial aspects of the plan will be further detailed when Governor Rendell announces his budget plan for the 2007-08 state fiscal year in early February.

The Governor's Office followed the initial Press Release with another, dated January 18, 2007, entitled Governor Rendell's "Prescription for Pennsylvania" Will Enhance Access to Quality Health Care in a Variety of Settings. These are the advocated advantages of the proposed program, which the second Press Release addressed in more detail:

• Enable nurses, advanced nurse practitioners, midwives, physician assistants, pharmacists, dental hygienists and other licensed health care providers to practice to the fullest extent of their training and skills.
• Promote incentives for health care providers who offer services in the evenings and on weekends, which will help to discourage consumers from seeking emergency room treatment for routine medical concerns.
• Expand access to care by addressing urgent workforce needs in rural regions.
• Increase the diversity of the health care labor force in an effort to improve the provision of care to historically underserved communities.
• Expand access to care by creation of "Cover All Pennsylvanians" (CAP), a program offering affordable basic health coverage to small businesses and the uninsured through the private insurance market.
• Increase accountability of everyone in the health care system -- consumers, hospitals and other care providers.
• Improve patient safety by eliminating hospital-acquired infections and targeting avoidable medical errors.

Reactions were immediately posted online by various key "stakeholder" organizations involved in Pennsylvania health care, including:

• Pennsylvania Medical Society:
• Pennsylvania Medical Society Comments on Governor Rendell’s ‘Prescription for Pennsylvania’ Announcement -- A statement from Mark A. Piasio, MD, MBA, president of the Pennsylvania Medical Society, in response to Governor Rendell’s ‘Prescription for Pennsylvania’ announcement on January 17, 2007. Dr. Piasio is a practicing orthopedic surgeon from Dubois, Pa. (01/17/07).
  
• Governor Announces Health System Reform Plan -- Governor Rendell's “Prescription for Pennsylvania” looks to reduce health care costs and expand access to care to almost 1 million uninsured Pennsylvanians. (01/18/07).
  
• Hospital & Health Systems Association of Pennsylvania -- Rendell Health Plan Has Major Impact On Hospitals (01/17/07).
• SMC Business Councils --Statement of SMC Business Councils Regarding Governor Rendell's Prescription for Pennsylvania (01/17/07).
  

News reports about the announcement provided background, some public reactions, and questions:

• Rendell wants to put the care into Pennsylvanians' health -- Morning Call (Allentown, PA, 01/17/07) -- He says all businesses should offer insurance to workers, and he has a plan to make that happen.
• Rendell unveils sweeping health care plan -- Pittsburgh Post-Gazette (01/17/07).
• Rendell unveils sweeping health plan -- Philadelphia Inquirer (01/17/07).
• Rendell Unveils Prescription for Pennsylvania -- WNEP-TV (Ch. 16, Northeastern PA, 01/17/07).

Rendell's plan follows prior initiatives in the states of Massachusetts, California, Maine and Vermont, but it would go beyond universal insurance coverage, he says:

"I believe ours is the most comprehensive of any of the five states that have announced plans," Rendell said.

"It's a health plan that will benefit all Pennsylvanians, all Pennsylvania businesses, and all people who provide health care services."

On the same day as the Governor's announcement, January 17, 2007, an article was posted on Pennsylvania State University's website that highlights the national problems in healthcare. See: The Medical Minute: Medical care costs -- Are Americans getting their money's worth?, by John Messmer, of the Penn State Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine. Following are some excerpts:

Health care costs a lot in the United States -- somewhere around $6,000 for every person annually. That’s what Americans as a nation paid in 2004 for everyone’s medical care when it’s all added together -- a total of just under $2 trillion in government and non-government spending. * * *

What does all that money buy? About a third is for hospital-based services, and a fifth is for services provided by physicians and related health-care providers. Approximately one-tenth is for dental care, and another tenth buys pharmaceuticals. The remainder is divided among administration, home health, public health, investment and other costs. It’s about 16 percent of the gross national product.

Approximately 42 million Americans have no health insurance. The $2 trillion we spend includes the cost of care for these uninsured who enter the health-care system with advanced medical problems. About a third of the $2 trillion is paid by the federal government (Americans' tax money); a third by private insurance companies (premiums paid by employers or by employees); and of the remainder, state and local government and out-of-pocket payments comprise the largest shares.

Are Americans getting their money's worth? * * *

Pundits and politicians point to various "causes" of the problem. But the nation's health-care delivery is a complex system with so many things out of balance, just about every part must be addressed in order to fix it, and everyone involved will be required to sacrifice something.

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“Government alone cannot –- and should not –- attempt to solve every problem facing our state’s health care system.” -- Governor Edward G. Rendell

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Update: 01/24/07:

See Governor Rendell's two Press Releases, both issued January 24, 2007, regarding the Rx for Pa initiative:

• GOVERNOR RENDELL’S PRESCRIPTION FOR PENNSYLVANIA WILL TARGET HOSPITAL-ACQUIRED INFECTIONS, BOOST PATIENT SAFETY & REDUCE COSTS
• GOVERNOR RENDELL’S PRESCRIPTION FOR PENNSYLVANIA WILL IMPROVE ACCESS TO HEALTH CARE, ENHANCE QUALITY, CONTROL COSTS

2007 Heckerling Institute Summaries Available

The 41st Annual Heckerling Institute on Estate Planning, offered by the University of Miami School of Law, was held January 8-12, 2007, in Orlando, Florida.

The Heckerling Institute on Estate Planning is the nation’s leading conference for estate planning professionals. The program is designed for sophisticated attorneys, trust officers, accountants, insurance advisors, and wealth management professionals who are familiar with the principles of estate planning. The Institute offers something of interest to every member of the estate planning team.

Summaries of presentations made during past Institutes traditionally were posted online by the Real Property, Probate & Trust Law Section, of the American Bar Association. For past years, see these links:

• 2006
  
• 2005
  
• 2004
  
• 2003
  
• 2002
  
• 2001
  
• 2000

The summaries for the 2007 Institute are available. See: New Reports from the 2007 Heckerling Institute. The index for the various reports is found here.

These "reports from the event" were already provided contemporaneously to ABA-RPPT Section members on its Probate-Trust Listserv (ABA-PTL List), and also to ACTEC members on its listserv. Each report can also be accessed at any time from the ABA-PTL Discussion List's Web-based Archive.

These summaries are not the same as the detailed materials distributed to registered participants; but all the concepts discussed during the sessions are mentioned.

So, if you seek general acquaintance with recent developments or overall trends in estate planning, these summaries deliver both. And you could always obtain specific detailed materials from the Institute as you might need.

Spotting Financial Elder Abuse

I received an email message on January 16, 2007, from Dr. Bennett Blum about his offer for a free online resource regarding an "assessment tool" for spotting "undue influence" in relationships involving elderly persons.

What is "undue influence"? Wikipedia (a general reference, to be sure) introduces the concept here as follows:

In probate law, it is generally defined as a testator's loss of free agency regarding property disposition through contemporaneous psychological domination by an advisor which results in an excessive benefit to the advisor.

Dr. Blum, on his website, indicates the importance of this concept in situations of potential elder abuse:

Common concerns arising in elder financial abuse involve issues regarding: 1) the relationship between the elder and supposed perpetrator; and 2) biological factors that may impair the victim’s ability to know and understand what was happening.

If a relationship was manipulated in order to defraud or financially exploit the victim, it is important to determine whether the psychological and social elements of undue influence were present.

If there was no misuse of a relationship, then the financial abuse is usually considered to be a form of theft or consumer fraud – ex. identity theft, Internet scams, embezzlement, etc.

The goal of Dr. Blum, through his assessment tool, is "to provide practical, yet sophisticated, information that may be used immediately" to identify such "undue influence". He then described the free resource, offered on the website of CaseSoft, a producer of litigation software, as follows:

CaseSoft® - a division of LexisNexis® - is sponsoring a series of web-based seminars based upon my work. The series is entitled "Undue Influence & Elder Financial Abuse." These "webinars" are free and available to the public.

Chapter 1 of the series is an overview of the concept of undue influence, including some of the major subdivisions and associated behavioral models. References are given for those interested in more detailed study. (Available now).

Chapter 2 of the series contains an in-depth introduction to IDEAL - a behavior-based method of analyzing claims of undue influence. Sample cases and assessments are included. (Available February, 2007).

Chapter 3 will cover advanced issues in undue influence and IDEAL. Tips for investigation, case presentation, and cross-examination will also be included. (Release date to be announced).

To view the webinars, click here. You can view his website here.

There are many organizations that offer information online to educate citizens & professionals about "elder abuse" in general. Among the many resource sites available, these are excellent websites or web portals:

• American Psychological Association -- Elder Abuse & Neglect: In Search of Solutions
• Clearinghouse on Abuse and Neglect of the Elderly (CANE)
  
• Office for Victims of Crime (a component of the Office of Justice Programs, U.S. Department of Justice) -- Elder Abuse.
• Medline Plus -- A service of the U.S. National Library of Medicine and the National Institutes of Health -- Elder Abuse Resources.
  
• National Center on Elder Abuse (NCEA) -- Training Library for APS and Elder Abuse
• U.S. Administration on Aging -- Elder Rights & Resources
• National Committee for the Prevention of Elder Abuse -- Mental Capacity, Consent & Undue Influence

Pennsylvania does not have a statute mandating the reporting of suspected financial abuse of the elderly. California has much stricter laws. See: "When the Elderly Become Financial Targets", broadcast by National Public Radio, by Judy Campbell (May 31, 2005).

A 2005 enactment in California made those laws even stronger. See: California Welfare & Institutions Code ,Elder Abuse and Dependent Adult Civil Protection Act. The California Bankers Association now trains bank employees to spot elder abuse occurring with customers.

Is it time for stricter, confidential reporting in Pennsylvania by banks or other institutions to the Pennsylvania Department of Aging as to suspected financial elder abuse? I think so.

Update: 07/17/07:

AARP has compiled & posted in its online AARP Bulletin, a state-by-state listing of resources that address "elder abuse" situations. See: "State-by-State Elder Abuse Resource List", compiled by Christopher J. Gearon (July-August 2007).

These are the resources listed for Pennsylvania:

• Adult Protective Services: call the statewide elder abuse hotline toll-free at (800) 490-8505 or contact your Area Agency on Aging
• Long-Term Care Ombudsman: call (717) 783-8975; or contact your local ombudsman
• Attorney General: call the Attorney General's Elder Abuse Hotline toll-free at (866) 623-2137 (in state only)