Should Not Healthcare Reform Include Costs?

The co-owner of Support For Home In-Home Care submitted this.  I hope it strikes a chord.  Bert

My son, who is still in college, will be turning 24 this year and our family policy was up for renewal in April.  That was before President Obama’s health care reform went through, which now allows family plans to cover their children up to the age of 26.  We went ahead and put him on an individual high deductible plan, as he has been a very healthy person and we wanted to keep the premiums low. 

Unfortunately he had a medical emergency that led us to call the paramedics, and he rode in an ambulance to the hospital.  I haven’t seen the ambulance bill yet, but anyone on a high deductible plan will know that it will not be a small amount.  This is to be followed by a series of tests that are now being conducted on him, including an MRI. 

I was in the radiology department yesterday with him to check in, and we were told it would cost $1,120.  We flinched a little and went ahead and put it on my credit card.  While still in the waiting room, a gentleman in his mid- to late 50s came in to check in and was told "That will be $1,120."  He said "What? I don’t have $1,120 to pay for it. Why is it not only a $30 co-pay?"  The clerk explained to him that he is on a deductible plan and the price will drop after he hits his maximum deductible amount.  He then asked the clerk to cancel the appointment.  The clerk asked him if she could put him in touch with someone to discuss and he said no and left.  What good was talking about $1,120 that he did not have?

This unfortunate gentleman could have a serious medical condition that now may go undiscovered.  An aneurysm or tumor or other potential issue that led his doctor to schedule the MRI in the first place may not be found before something potentially fatal happens.

This immediately triggered my thoughts on the health care reform that was just passed, which does not address the issues around cost that I had just witnessed.  Does this gentleman have health insurance?  Yes, but he does not have the money to cover the out of pocket medical expenses.  Health care reform will help many more people obtain insurance.  But what it does not address is the issue of out of pocket costs, even with an HMO policy. 

There are many, many factors that go into the high cost of healthcare.  But, what happened to the proposal to place a cap on medical malpractice?  A cap on medical malpractice will lower doctors’ liability insurance costs, which in effect will lower the doctors’ or radiologists’ costs and how much the patients will need to pay. 

What happened to allowing Americans buy prescription drugs from Canada and other countries where the prices are much lower?  Americans have been impacted by President Obama's inability to implement his promise that he would reform this during his election campaign. 

Health care reform does not address actual costs of health care for Americans.  Health care reform is just passing around who pays for the costs.  It’s making small businesses, corporations and middle and higher income tax payers pay for them -- but the gentleman who could not afford an MRI still will not be able to pay for it.  Small business and corporations may cut jobs and reduce pay to their workers in order to pay for the health care costs. 

The pharmaceutical companies apparently are going to get richer.  The few who sue at every opportunity may get richer.  Is the rest of the country really going to benefit, if we do not get healthcare costs under control?  What do you think about these issues?

Best wishes, Siew Pheng Tung

More Dangers of "Under the Table" Caregivers

We have talked with so many families and prospective home care clients about the dangers of "independent contractors" who really are not and referral agencies that offer no protection to senior clients and families.

The issues include no liability insurance, dishonesty bonds, background checks, unemployment insurance and on and so forth.  Partially because of the economy the last couple of years, we are now seeing government, both state and federal, get a lot more interested in the issue.

Several months ago, The New York Times published an article, "U.S. Cracks Down on ‘Contractors’ as a Tax Dodge".  It indicates that:

Federal and state officials, many facing record budget deficits, are starting to aggressively pursue companies that try to pass off regular employees as independent contractors.
President Obama’s 2010 budget assumes that the federal crackdown will yield at least $7 billion over 10 years. More than two dozen states also have stepped up enforcement, often by enacting stricter penalties for misclassifying workers.

Interestingly, this emphasis is being supported by organized labor, one of the Obama administration's major supporters.

Another article was published in March by The Wall Street Journal, titled, "Cash & Career: The Perils of 'Off the Book' Jobs". 

The bottom line is that "referral agencies" that do not operate honestly and caregivers who claim to be "independent contractors" but are not doing the right things are increasingly the focus of the IRS and state tax and employment agencies.  it does not stop there, however, because the people who hire -- and that is the right word, because the seniors and their families will be seen as the employers of record in many cases -- are going to be on the hook for Social Security, Workers Comp claims and insurance and a whole lot more.

That is just not right, and we wish all businesses -- and individuals -- would operate ethically and legally.  The home care industry would be so much better.
Your thoughts?  Best wishes, Bert

Say What You Will Do ...

Say What You Will Do, Then Do What You Said

That was the favorite motto of one of my old bosses at Intel.  When you really analyze it, it is a pretty solid axiom by which to live and run a business.  It is absolutely the way we try to run our in-home care company, Support For Home.

It relates to the way we manage our employees and the way we relate to our clients and their families.  One example is that when we started this agency, we encountered what is called Wage Order 15, which governs California employers and employees providing personal attendant care in the home.

The first point to note is that California regulations are stricter than at the Federal level.  The US Department of Labor provides meal time and sleep time exemptions from wage and overtime provisions for 24-hour assignments for personal care attendants.  In California, there are no such exemptions for employers.  They are required, by a literal reading of Wage Order 15, to pay for all 24 hours that the employee is on the assignment.

When we started Support For Home in 2007, we were told no agencies in California were actually complying with Wage Order 15.  CAHSAH (California Association for Health Services at Home) confirmed that the Order required employees to be paid for each hour, but that they did not know of any other agency actually doing so, as they try to rely on the Federal regulations.

So, why is Support For Home following Wage Order 15?  When we started the company, we promised that we would make our employees the heart and soul of the agency.  We told them that and we told them we were going to pay more than any other agency for 24-hour assignments. 

Now, even the labor lawyers are saying the State of California will not prosecute; that agencies can get away with it.  That means we could too.  We could pay what other agencies are paying -- $100-$140 or so.  Not to put too fine a spin on it -- it is not going to happen.

We said we will conform to Wage Order 15, and pay $192 to our 24-hour assignment Home Care Aides.  We are doing what we said.  Do we have to?  Maybe not.  But, it is the right thing to do.  There is that other old saw about "You get what you pay for!"

Mom and Dad, Spend It All!

I came across an interesting blog from Carolyn L. Rosenblatt, Nurse-Attorney, at AgingParents.com.  Carolyn makes some great points, at least from my perspective:

I say let elders stay at home if that’s their choice. Making them poor so Suzy Q can get a chunk of cash when Mom passes seems unfair to me. It’s not Suzy’s money, she’s the child. I hope aging parents will take another look at the future, if they are in declining health.


Make sure your estate plan doesn’t let your kids sell the house, stash the cash legally and put you in a nursing home as long as you are aware of your surroundings. You might not like a nursing home on Medicaid as much as you like your own bed. You’d have at least one roommate, maybe two in a Medicaid nursing home bed.


So, think it over. Kids counting on an inheritance can see their hopes dashed by the need to pay for mom’s care with Mom’s assets. Getting an inheritance is something adult kids are lucky to get, not something to which they are entitled.

The greatest bumper sticker I have seen was on the back of a big motor home: "Spending Our Kids' Inheritance".  That kept me smiling for days, because it said several things to me.

First, it said that this couple were "working" at having a great time in their retirement.  Secondly, it said they had raised kids that were supportive of that goal -- you don't put bumper stickers like that on without laughter from all involved.

A conversation I had with my own father a number of years ago went along similar lines.  Basically, I told him that if he and mom left us kids more than about $.25, I would be disappointed.  Spend it all, I said.  He laughed.  He and mom both passed away this year.  I have no clue what was in their wills.  I'm hoping for $.25.  :-)

Every Day is an Interview

At Support For Home In-Home Care, all of our Home Care Aides are our employees.  We are not a referral agency for some very simple reasons.  As the employer of record, we perform the background checks, determine who is worthy of being a member of our extended family, cover them with liability insurance, our dishonesty bond, workers comp, etc.  That means our home care clients and their families are protected from unemployment claims, injury claims, and so forth.

To be the employer of record, we actually have to assign our Home Care Aides to our clients.  Every once in a while, a client or his / her family will ask to interview the Home Care Aide, first.  When this happens, we explain two things:

• If the client or family "interviews" the potential caregiver, they are indicating to the State that they may be the actual employer, not Support For Home.  That is dangerous for the client or family, because it can result in government burdens and expectations that the client is not prepared for, at all.  We are the employer of record to protect against that.  The client hires and / or fires us, Support For Home, not an individual employee.
• Every day that a Support For Home employee works for a client is an interview, in reality.  We tell our clients several things.  One is that we never want the client to "try to make it work" with a Home Care Aide.  The client and the caregiver are either a good match or they are not.  If they are not, we put a new Home Care Aide in place.  The second message is that things change.  A caregiver who is great for you right now may not be in six months, for whatever reason.  Every day is an interview, at which Support For Home and our employees must excel.

If you or a loved one needs home care, make sure you work with an agency that is the employer or record.  You may pay a bit more per hour, but you avoid a ton of potential liability.

Best Laid Plans -- Oh, Well

At Support For Home, we urge families -- whether they will be working with us or some other agency -- to plan ahead, in terms of homecare for loved ones.  That planning involves a number of factors, including:

1. What is the budget? 
• What will homecare cost, at several levels of care, from perhaps 4 hours a few days per week to 24 hours, 7 days per week?  That is a wide range of care, and it corresponds to very different costs.
• How will homecare costs be paid?  Is there Long-Term Care Insurance?  Is the loved one eligible for Veteran's Aid & Attendance benefits to subsidize homecare costs?
2. What is the "tolerance" for homecare?
• While it may be clear that assistance with ADLs (Activities of Daily Living) and Instrumental ADLs is critical to success in aging in place, we all have different levels of tolerance for that assistance.  We have each been independent for a long time.  There are issues of pride and privacy that need long and sensitive discussions.  Often it is better to start with a smaller schedule, to allow adjustments, if #3 allows it.
3. What is the goal of implementing homecare?
• This is actually a big deal.  In our view, homecare support should be started before there is a major crisis, such as a fall and a broken hip or a stroke.  Our goal is to begin supporting our clients early enough that we are able to help maintain a safe environment and high quality of life for them, avoiding crises to the extent possible.  If we are already in a crisis, the immediate well-being of the senior is the key, always.

One of the reasons it is so important to have these discussions and make plans early enough is that we do not know when the crisis will arise.  A family called us in last Tuesday, to begin a schedule of 4.5 hours per day, Monday through Friday.  By Thursday, when we met with the senior and her family, the need had changed to seven days per week, starting the following Monday.  By Sunday morning, the need had changed to 24-hour shifts, seven days per week, starting that day.  The crisis was here.

Neither the family nor the client have had time to adjust to homecare or the costs of it.  That means more stress than they need, but ...

So, plan ahead, but be ready to move quickly, as the situation changes.  Need for homecare goes up, down and sideways.  We can help you deal with it.

Best wishes, Bert

Stair Lifts and Homecare

I saw a tweet this morning about how stairlifts reduce the need for homecare.  At Support For Home, we think stairlifts can be extremely helpful, but, frankly, I think that is the wrong point, entirely. 

If seniors need to utilize a stairlift to stay in their multi-story home, they almost certainly need other help, as well.  Stairlifts can absolutely make it possible for seniors to stay in the home they love, providing they have support for ADLs (Activities of Daily Living) and Instrumental ADLs.

When we bought our current two-story home, we knew that visits from my mother were going to be very difficult for her, without a stairlift, because her mobility would not be sufficient to climb the stairs.  So, we had one installed.  It made it possible for her to enjoy our home any time she wished.  It did not remove the need for support with other ADLs / IADLs.

Stairlifts are not cheap, but they can still be less expensive -- and traumatic -- than disrupting our clients' lives and homes and forcing a move.  It is something we always look at as we do homecare client assessments, putting together a comprehensive plan of care.  We do not sell or install stairlifts, or make a penny from them, but we make sure we know great resources for our clients, to help them stay at home.

Maximizing Long-Term Care Insurance Benefits

We have talked about long-term care insurance (LTCI) before.  It is a very good thing, in our view.  We strongly recommend everyone take a serious look at purchasing it, before something happens that would keep them from qualifying.  And, no, we do not sell insurance or get commissions!

Below are some questions that we think folks who are making a choice of which LTCI provider to buy from.  The questions are equally important for people who have already purchased long-term care insurance, as the answers will help them manage their use of the benefits, to maximize them.

The first question is -- Is there a waiting period before benefits can be used?

• This question has some definite twists and turns, depending on the insurance company involved.  Waiting periods can range from zero days (very rare) to 100 days, in our experience.  You want to find out from the insurance company what event starts the clock running.  Is it a doctor's order?  Is it such an order plus the actual start of privately paid care?  Within the waiting period is any agency-provided care required?  If so, is there a minimum number of days?  For example, if the waiting period is 30 days, does the insurance company mean 30 calendar days or does it mean 30 days of actual care?  Obviously, that makes a very big difference.

The second question is -- Does payment of the premium end when benefits begin?

• This sounds elementary, but you really need to confirm it with the company.  Premiums may end when the claim is made or when payment of benefits begin.  Continuing to collect premiums after benefits begin is non-standard.  If you are looking to buy, make sure your company does not do that.

Third question -- Is the benefit a purely daily amount, or is there really a monthly budget that you have the ability to manage?

• Most policies will state that there is a daily benefit.  For illustration, we will use $150 per day.  For some companies, they will pay up to $150 per day, maximum.  If you are authorized for care every day, you will receive up to that amount on any day you have care.  However, some of the better companies actually consider the benefit as a monthly budget.  In other words, if the daily benefit is $150 per day, that would create a pool of $4500 for use in a 30-day month.  In these cases, some days might use less than $150 and some days might cost more, but be managed on a monthly, rather than a daily basis.

Next question -- Whether it is a daily or monthly benefit budget, are unspent benefit dollars available for the future, or do they "disappear?"

• If the daily benefit is $150 and I only use $100, does the extra $50 go into the "bank" to be used in a future period?  Same question applies for a monthly pool -- if I only use $3000 of the $4500 available for the month, does the extra $1500 go back in my "bank" of benefits?

The inflation factor -- Does the benefit keep pace with inflation?

• Is there a guaranteed increase in benefits (either a specified percentage, say 5%, or tied to the Consumer Price Index) over time, or is the benefit fixed forever?  This is definitely something you want to consider.  $100 per day now, while you are healthy and 45, may not be nearly enough after 35 years of inflation.

Keeping the benefit coming -- Is there a recurring validation process required by the insurance company?

• Some companies will send out an RN periodically (every 6-12 months) to do an assessment of on-going need for care.  Others may want an updated doctor's order.  Find out how intrusive this process is going to be.  We have sat through some nasty ones with our clients.

If you have other questions, comments or suggestions about LTCI, we would love to hear from you.  Drop me a line at bertcave@supportforhome.com.

I Hope Congress Actually Read It!

On September 14, 2009, a concurrent resolution was passed by Congress, on the topic of homecare.  We have posted the text and document on our Web site.  There are a number of excellent data points in the resolution, as well as a very positive recognition of "caregiving as a profession."

I don't usually care much for quoting dictionary definitions, but this one calls for it, in my view.  Dictionary.com says that a profession is "a vocation requiring knowledge of some department of learning or science". 

At Support For Home, we believe that our Home Care Aides are, indeed professionals.  Over 75% of our employees are certified -- Certified Nurse Assistants, Certified Home Health Aides or Licensed Vocational Nurses.  Others are certified as Direct Support Professionals.  These are not agency designations -- although some agencies will try to fake it, with similar titles.  These are actual State of California certifications.  Even our folks who have nto yet achieved certification are truly professional, in terms of knowledge and attitude, or we would not hire them.

The bottom line is that a professional caregiver is a person with character, dignity, passion and knowledge, all of which are applied within a structured, disciplined plan of care, to ensure the highest possible quality of life for the clients they serve.  These caregivers deserve respect and support, from us and from our clients.  They are the heart and soul of Support For Home.  Any homecare agency that does not feel that way and treat their Home Care Aides that way needs to find another business to pursue.

Bert and Siew Pheng, Support For Home

A Focus on IADLs

For most of us, if there is an issue with Activities of Daily Living (ADLs), such as bathing or dressing or eating, the need for support is very obvious.  We will return to this topic (ADLs) in a future blog, but today we want to talk about Instrumental ADLs (IADLs) as a basis for determining need for homecare support.  We have adapted an IADL discussion from an early gerontology article, because we think it is still one of the most useful.  We have provided just three examples, below, of the seven IADLs included in an Excel spreadsheet we have created that is posted on our Web site.

IADL Status

Ability to Use Telephone (4 points - highest - to 1 point)
Operates telephone on own initiative; looks up and dials numbers, etc.
Dials a few well-known numbers
Answers telephone but does not dial
Does not use telephone at all.


Shopping (4 points to 1 point)
Takes care of all shopping needs independently
Shops independently for small purchases
Needs to be accompanied on any shopping trip
Completely unable to shop.


Food Preparation (4 points to 1 point)
Plans, prepares and serves adequate meals independently
Prepares adequate meals if supplied with ingredients
Heats, serves and prepares meals or prepares meals but does not maintain adequate diet
Needs to have meals prepared and served

The idea, for each IADL, is that the more functionality I have, the higher my score will be.  In this particular scale, as we have implemented it, there is a maximum of 31 points, total, for all seven IADLs.  However, each IADL needs to be looked at by itself, as well as being part of an overall pattern.

In my current baseline (as discussed in a prior blog), I'm doing okay and do not need home care.  However, for each IADL, I have set a lowest acceptable status before taking a very serious look at getting home care for myself.

We would be delighted to have your feedback and suggestions.  Thanks for listening.

Long-Term Care Insurance - Don't Stay Home Without It!

Obviously, that title is an overstatement, as some families have the resources to self-fund home care - and the willingness to spend money to get the care they need to be able to safely live at home, when the time comes.

For the rest of us, building Long-Term Care Insurance (LTCI) premiums into our budgets -- and getting qualified while we're still healthy enough -- is something to very seriously consider.  That last point is an important one.  Siew Pheng and I recently applied for LTCI.  She got it.  I did not, because of my Diabetes.  Even though it is well controlled, the insurance company said, "No thanks," when it came to covering me.  I should have bought it five or six years ago.

Even for clients who can afford to self-fund home care, we at Support For Home have seen many instances where they are reluctant to do so.  They know they need care, but the idea of spending money on themselves (or having their families do so) just goes against the grain of a life time of independence and self-reliance.  If they have already paid for LTCI, the clients are much more likely to get the care they need, as they feel they have already paid for it, through premiums -- and they are right.

So, the bottom line is, if you can self-fund your future long-term care needs, great, but create a special account that you build up over time to provide that funding.  Set the money aside, invest it and let it grow.  If you cannot reasonably expect to self-fund, explore Long-Term Care Insurance, early, and do some research as to what real costs are going to be, when you will need home care.  Get enough coverage.  Get peace of mind for the future.  I wish I had!

Homecare Employers - Who's on First?

Who is the employer of the caregiver supporting your mother's, father's or your activities of daily living (ADLs)?

This is a subject that just keeps coming up, because it continues to cause so many issues for families.  In the State of California, the law is actually quite simple about who is the employer of a caregiver or other household employee, but unscrupulous referral agencies try to avoid providing clients with information about the issue.  Some even intentionally -- well, I cannot find a polite word, but ...

First, let's make our position clear.  The employer of Home Care Aides / caregivers should be the agency that is sending them to the home.  For us, at Support For Home, that is the case.  We are the employer.  We provide liability insurance and bonding, pay payroll taxes, Workers Comp insurance, background screening, and so forth.  There are a number of other reputable agencies who are doing the same (we talk about certification by the California Association for Health Services at Home on our Web site).  Unfortunately, many referral agencies (sometimes called DRAs) operate very, very differently.

These folks simply will not raise the issue of who is the employer -- too often, it is going to be the client and / or the client's family or trustee.  Then, if something happens (the caregiver trips over an ottoman or is let go or commits a dishonest act, ...) the client is left holding the bag -- with the State of California wanting the bag to be filled up with taxes and fines and handed over.

One very good document on this subject from the Employment Development Department (EDD) is called "Household Employment."  This talks about the client's / family's responsibilities when hiring an "independent contractor" from a DRA.  Basically, the referral agency is off the hook, if they follow a simple set of rules, and the client is on that same hook.

The discussion starts with some definitions:


So, becoming the employer of your -- or your family member's -- caregiver is pretty easy.  Operating in that role, following all the rules of an employer, understanding the financial implications ...  That's not nearly as easy.  That does not mean that being the employer is always the wrong answer.  It just means when you are making that hardest decision -- about who is going to provide home care -- it needs to be an important factor.

If you have any questions, please feel free to contact us, by email at info@supportforhome.com or by phone at 916 482-8484 or 530 792-8484.
Good luck, Bert and Siew Pheng

Who is a Household Employer?

A household employer is someone who has paid $750 in cash wages to one or more individuals in a calendar quarter to household workers. You must register with EDD within 15 days after you pay $750 in total cash wages.

What Are Wages?

Wages are all payments made to employees for personal services, whether paid by check, cash, or the reasonable cash value of noncash payments, such as meals and lodging.

Help With Homecare Costs

Paying for homecare for our family members is not always an easy task. Since medical insurance and Medicare do not pay for non-medical in-home care, recipients of care are in a "private pay" situation. Our family is doing this, right now, in fact.

When the economy dips and people's income is impacted, it gets harder. We even had a client or two have to stop receiving professional care when a family member is laid off and returns home. They know, and we do, that the level of care -- not love, but care -- is going to be reduced, but reality is reality.

To try to help with this issue of affordability of homecare, we've posted some information and documents on our Web site, concerning two major sources of financial support -- Long-Term Care Insurance (LTCI) and Veteran's Aid and Attendance benefits.

If either the client or the spouse is a veteran, it is important to check out Aid and Attendance, from the VA. There are income and asset criteria, but there are good sources of help to determine eligibility (again, you can check our Web site).

Long-Term Care Insurance is something that most people are just learning about. We think it is a critical piece of planning for the future. We purchased LTCI for ourselves -- and no, we don't sell it :-). There are good sources of information (there is an AARP link in the page on our site) and a number of good companies. Like all insurance, you have to buy it before you need it.

The bottom line, whether a family turns to VA Aid and Attendance or LTCI or other forms of budgeting for future care needs, making a plan is critical -- as earlier as families can do so. Good luck from Support For Home. Bert and Siew Pheng