FLORIDA  EAST  COAST  POST-POLIO  SUPPORT  GROUP   -   Vol. 13   #1

             12 Eclipse Trail  /  Ormond  Beach,  FL  32174  /  386  676-2435

        E-Mail:-  bgold@iag.net   --   Web Site:-  home.iag.net/~bgold/polio.htm

JULY  /  AUGUST   2005

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WISHING   EVERYONE

 

A   SAFE   AND   HAPPY   FOURTH   OF   JULY

-  and  -

A   SUN  FILLED   ENJOYABLE   SUMMER

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MEETING  NOTICE

 

NO MEETINGS IN JULY AND AUGUST

 

September 18th, 2005  --   Dr. David Dysart (Ph.D), “The Polio Legacy: One

Mother and her Child’s Story.”   

November 20th, 2005 --  Speaker from Hill & Ponton, law firm will discuss Social

          Security Disability

January 15th,  2006  --  NEW  YEAR’S  LUNCHEON

 

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CONTENTS

 

My Adventures

Whatever Happened to Polio

Anesthesia Precautions…..

Cashews Deserve Respect

Overview of Medicare Part D

How to Choose an Assisted Living Facility                                             How It Feels to be Old

Your Health

Act Against Incontinence

Stressbusters

Be a Better Caregiver

Upcoming Conferences

Mis-Matched Shoes

 

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MY ADVENTURES

 

          Since our last newsletter, I’ve been doing some traveling.  Thanks to funding by Halifax Medical Center and our Support Group, I was able to attend the 9th International Post-Polio Conference in St. Louis, June 2nd to June 4th.  Then, on June 4th, I left St Louis and went on to Long Island for my 7 year old granddaughter’s dance recital.  In this newsletter and future newsletters, you’ll find articles and features about the conference.  But, now, let me tell you about my “adventures” flying back and forth (or should I say forth and back)….

          When I was up on Long Island earlier this year I brought my older scooter (that I leave by my son) home so that I could take it to the conference.  You see, the company that was renting scooters wanted $200 for the few days and I thought it was just too much of a charge. 

          My flight to St. Louis went without a hitch.  I flew Southwest Airlines and they handled my scooter perfectly.  Going from St Louis to Long Island I had a 3-1/2 hour layover in Chicago – which turned into a 6-1/2 hour layover due to a combination of bad weather and waiting for 8 passengers that were delayed due to the weather.  After waiting for almost 2 hours for them to arrive and their luggage to be placed on-board, we finally taxied out to the runway, only to have the Captain tell us that there was a mechanical problem and we were going back to the gate.  After several maintenance men came on and off the plane, we were told we had to change planes.  As we were “only” going to the adjoining gate, I told the flight attendant not to bother bringing my scooter up, but just to “wheel” me over in one of their manual chairs – which was done.  We finally left Chicago and arrived on Long Island only 3 hours late.  Much to my surprise and pleasure after it’s being moved from plane to plane to plane, my scooter was brought to me in A-1 condition.

          As I left that scooter on Long Island, the flight from Long Island back home (non-stop), went smoothly.

          Now, a little about the conference in St Louis – there were seminars from anesthesia – to PT and OT – to bracing – to emotional eating – to sleep apnea – to updated research…. and many other topics.  In fact, my only real complaint about the conference was that there were times when two of the “talks” I wanted to go to were at the same time and I just couldn’t divide myself in two.   The ones I did attend were most informative. 

          I enjoyed seeing “old” friends that I see only at these conferences and meeting new friends, including some that I have been networking with, via e-mail, for several years – it’s nice being able to put a face to a name/voice.

 

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Whatever Happened

 to Polio

 

     This summer I went to the "Whatever Happened to Polio" exhibit at the Smithsonian Museum.  I learned a lot about polio there.  I wanted to see this exhibit because my grandmother had polio.

      The most interesting display was about the March of Dimes.  What I learned from that display is that if each family gave ten cents to polio research, scientists could have found a cure much earlier.  I really liked the display because it showed dimes dropping into a March of Dimes bucket.

      In another part of the exhibit a lady taught us about polio.  She told us that children who got the polio vaccine got a green ink stamp on their pinky.  The green ink told people who did and didn't get vaccinated.  She also told us about Candyland.  She told us that a little girl with polio made up the game so children with polio would have something to do while they were in the hospital. 

      Another display that we saw demonstrated how an iron lung works.  When you put your arm in the machine, you could feel the pressure like an iron lung.  And we saw a big real iron lung that once helped somebody breathe.

      I wish my grandmother never had polio.  But because she does, we also learned that if you had polio, the effects never go away even after the virus dies.

                                                                                                                     Joseph Buda

 

FECPPSG Editor’s Note:-  The above article was written by my grandson.  The Smithsonian exhibit is teaching the generations that came after the Salk and Sabin vaccines what polio is/was all about.  My only wish is that it would be taken throughout the United States (and, possibly, worldwide) so that many more could see it and learn from it.

 

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The following article is the first of several that is being reprinted from the program guide for the Ninth International Conference on Post-Polio Health and Ventilator-Assisted Living’s Strategies for Living Well, June 2-4, 2005, St. Louis, MO.

 

ANESTHESIA PRECAUTIONS FOR PEOPLE

WITH NEUROLOGIC CONDITIONS

Selma Harrison Calmes, MD

Sylmar, California

 

            The objectives of this session are to briefly review anesthesia care for common operations in polio patients, to review anesthesia safety in general in the United States today, to discuss how to increase the chances of getting the best anesthesia care available in your area and, finally, to answer questions on anesthesia practice and safety from the audience.  The audience should leave the session under-standing what particular issues need to be discussed with an anesthesiologist when surgery is anticipated, how to increase the chance of getting the best anesthesia care available in their geographic area, and how safe anesthesia is today, especially compared to the risk of hospitalization itself.  Handouts of the slide presentation and a single page of recommendations related to anesthesia for post-polio patients will be available at the session.

 

CHOOSING AN ANESTHESIA PLAN:  I’m often asked what anesthetic is best for post-polio patients.  It just depends.  It depends on that patient (with their particular health problems) having that operation (with its own risks and problems) at that point in time and by that particular surgeon (with his/her issues) and that particular anesthesiologist (with their own skills and issues).  And, all these factors interact and interplay with each other.

          Excellent anesthesia depends on understanding a patient’s diseases (this is true for any patient, with any disease, not just post-polio patients) and how the diseases might affect anesthesia management.  Also the planned operation must be considered because different operations have different anesthetic requirements, and not all operations can be done with a particular anesthetic technique.  For example, it is difficult to do a laparoscopic (lap) cholecystectomy (removing the gall bladder through a laparoscope instrument) using regional anesthesia (a spinal or epidural anesthetic).  The operation begins by injecting many liters of CO2 gas into the abdomen, to grossly distend it so the surgeon can reach the needed organs.  The distension is extremely uncomfortable for an awake patient, and also breathing is inadequate if the patient is breathing on their own.  And, the distension can interfere with venous return to the heart, causing low blood pressure.  Low blood pressure can also result from spinal or epidural anesthesia, so using these techniques in this setting is not helpful.  All lap choles need to be done with general anesthesia, with controlled breathing.  Other factors entering into the choice of an anesthesia plan include a surgeon’s ability to operate under regional or local anesthesia and also the anesthesiologists’ particular skills.

 

POLIO CHANGES AND ANESTHESIA: 

What about the disease polio might be important in anesthesia management?  Polio is an inflammatory disease of the nervous system.  We typically think that it involved only the spinal cord, but numerous anatomic research studies document that all parts of the nervous system were affected, not just the spinal cord.  This explains the wide-ranging issues that reveal themselves as post-polio patients age.

          Starting at the brain, central neuronal changes may contribute to the common sensitivity to sedative medications, and can result in a long emergence from anesthesia.  The poliovirus also affected the neuromuscular junctions (the connections between a nerve and its muscles), and this may be one cause of sensitivity to muscle relaxants.  There is also a decrease in total muscle mass, and a standard dose of relaxants may be an overdose for a post-polio patient.  Postop pain may be an issue; this is most likely due to inflammatory changes in the spinal cord, with resultant scarring.  This could affect the transmission of the pain signals through the spinal cord.  The inflammatory process of polio “spills over” to a spinal cord area where autonomic nerve fibers travel.  The autonomic nervous system (the system that keeps your GI tract moving, keeps your heart beating at an appropriate rate and so on) can also be abnormal.  This can cause gastro-esophageal reflux, tachyarrhythmias and sometimes, difficulty maintaining blood pressure under anesthesia.  Because of respiratory muscle weakness, there can be respiratory inadequacy postoperatively.  Laryngeal weakness, including cord paralysis, can also add upper airway obstruction, swallowing problems and aspiration.  Body asymmetry due to muscle mass loss and scoliosis can be an issue.  Osteopenic limbs and exposed peripheral nerves add further positioning problems.

          Patients of particular concern are those using ventilators, even part-time, and those who were in iron lungs, even if they don’t use ventilation presently.  Preop pulmonary functions tests are the first step in anesthesia planning for them.  Depending on the results of pulmonary function tests, the surgery and the type of anesthesia needed, it may be possible to continue to use the patient’s ventilator intraoperatively.  If not, the patient’s ventilator can often be initiated after surgery, in recovery room.  Postoperatively, there has to be careful consideration of any respiratory depression from narcotic pain medications and adequacy of the patient’s ventilation.  By careful planning, all polio patients should be able to have surgery without excessive risk.

 

WHAT KINDS OF ANESTHESIA ARE AVAILABLE?  General Anesthesia is not the only way!

 

GENERAL ANESTHESIA:  The patient is completely asleep.  Usually anesthesia begins with an intravenous injection (usually propofol or pentothal).  With the help of a short-acting muscle relaxant, a breathing tube is often (but not always) placed in the trachea (windpipe) to insure that oxygen (O2) can reach the patient’s lungs.  Then anesthesia continues with inhaled gases (often nitrous oxide and a vaporized liquid anesthetic such as sevoflurane) supplemented by injected narcotics, amnesic drugs and muscle relaxants if needed.  At the end of the case, any residual muscle relaxant effect is reversed with drugs, the inhaled gases are stopped and the patient breathe on their own.  In some cases it is left in, to allow assisted ventilation if needed.

 

REGIONAL ANESTHESIA:  This means that only the part of the body being operated on is numb.  The patient can be awake or asleep (using injected drugs) during surgery.  An anesthesia provider should always be present to monitor you, to detect any possible problems early on, and to induce general anesthesia if the block is not satisfactory.  The usual types of regional anesthesia follow:

 

1.  Spinal:  A small amount of local anesthesia is injected into the subarachnoid space, around the spinal cord.  See diagram of spinal cord.)  The procedure is like a lumbar puncture.  The lower half of the body is numb; higher levels can result from higher doses.  Prostate, bladder and rectal surgery are often done with spinal anesthesia.  It usually gives good solid pain relief unless the abdomen is open and the surgeon pulls on the bowel.

 

2.  Epidural:  Instead of putting local anesthesia in the fluid-filled space around the spinal cord, a larger amount (and perhaps some narcotics) is placed in a potential space, the epidural space.  In the lower back (occasionally higher).  (See diagram of spinal cord.)  The anesthestic drug migrates across several levels of tissue to reach the spinal cord itself.  The advantage to this is that a small plastic catheter can be placed in the epidural space and used for additional anesthesia and additional pain-relieving drugs in the postop period.  Physiologically, this is safer than spinal, the block is of slow onset, it is a little less predicable than a spinal.  It is used for the same operations as spinal and also for vascular operations on the legs.

 

3.  BLOCKS OF THE ARM:  The nerves to the arm can be approached from above (supraclavicular block) or below (infraclavicular) the clavicle and through the axilla (axillary block), usually giving good relief for most arm and shoulder surgery.  An IV block of the arm (also called a Bier block after the German surgeon who first did it’ occasionally used for the leg in unusual situations) is an easy block in which the venous structure of the arm are emptied and then filled with a dilute local anesthesia solution.  Although seemingly easy and safe, there have been deaths when this is done in emergency rooms or plastic surgeons’ offices.  Because these blocks require a larger volume of local anesthetic, there is a risk of local anesthetic toxicity.  This can be prevented by careful placement and calculation of the maximum dose for that patient.

          Nerves to the hand and lower forearm can be easily blocked at the elbow and wrist.

 

4.  BLOCKS OF THE EYE:  A retro-bulbar (behind the eye) block is the standard regional anesthetic for eye surgery.  In most parts of the country, the surgeon places this rather than an anesthesiologist.  An anesthesia provider is still present, to detect any complications of the block, to give any needed sedation and to induce general anesthesia if needed.

 

5.  BLOCKS OF LOWER EXTREMITY:  The nerves to the leg can be relatively easily blocked in the inguinal area.

 

MONITORED ANESTHESIA CARE (MAC):  The surgeon injects local anesthesia at the site of surgery; anesthesia staff is present to sedate and monitor the patient and to induce general anesthesia, if needed.  Not all operations can be done with MAC; it is best with superficial, simple surgeries such as carpal tunnel release.  The surgeon’s skills contribute greatly to the success of MAC.

 

ANESTHESIA SAFETY:  There has historically been a great fear of anesthesia in the polio community because of patient reports of problems allegedly due to anesthesia management, especially related to muscle relaxants.  Although there are issues for post-polio patients having anesthesia, the general level of fear of anesthesia in the polio community is probably excessive, and there are many other, much higher incidence problems that can harm polio patients when hospitalized.

          Anesthesia today is safe!  Over the last three decades, the number of deaths attributed to anesthesia dropped from 1 in 10,000 cases to 1 in 250,000 cases.  This is a remarkable achievement, especially considering that 40 million anesthetics are now administered each year in the U.S.  Our professional organization, the American Society of Anesthesiologists (ASA, 100 years old this year), led the way to greatly improved patient safety, and our organization serves as the national and international example for other specialties wanting to improve patient safety.  We’re proud of that!  The ASA’s safety achievements have been recognized by the prestigious Institute of Medicine’s 1999 report, To Err is Human, the only specialty to be mentioned as improving patient safety.  This report documented that an estimated 44,000 to 98,000 patients die each year from hospital safety issues.

          Also at the national level, the American Medical Association (AMA) recognized our specialty’s leadership when they patterned their patient safety institute, the National Patient Safety Foundation (established in 1996), after our Anesthesia Patient Safety Foundation (APSF).  The APSF was created in 1985, to raise awareness of patient safety issues.  The APSF publishes a quarterly newsletter, funds research on safety issues, presents educational sessions and exhibits at the annual ASA meeting and maintains a web site.  In 1986, the ASA adopted monitoring standards for the first time.  These list monitors, such as EKG, temperature and so on, that must be in use for each anesthetized patient.  This was the first expected standard of care for our specialty.

          In the mid-1970’s, anesthesiologists began to analyze malpractice cases that had “closed,” (settled) to try to identify what clinical practices might be associated with malpractice claims, so these could be improved.  This became an official ASA project, the “Closed Claims Study” in 1985.  Volunteer reviewers do a standard analysis of settled claims at 35 malpractice insurance companies.  Currently, 6,448 claims are in the data base.  Trends are analyzed, results summarized, and then these analyses are published in the anesthesia literature.

          Some extremely important results have come out of these analyses.  Two of these papers are among the 50 most cited scientific papers in the anesthesia literature.  The first report, published in 1990 (Caplan RA, Posner KL, Ward RJ, Cheney FW.  Adverse respiratory events in anesthesia:  A closed claims analysis.  Anesthesiology 1990: 72;828-833),showed that airway (breathing) problems were the most common cause of a closed claim.  As a result, major efforts to anticipate airway problems and to devise alternate approaches to usual airway management began, have been very successful and continue to this day.  Each annual meeting has many sessions on the latest in airway management.  This is just one example of how our specialty works to improve patient safety.

          Finally, advances in technology such as in monitoring, anesthesia machines and airway devices made critically important contributions to improved patient safety.  To illustrate this, we will see a video of a monitor of neuromuscular transmission.  This monitors the effect of muscle relaxants, one of the areas of fear for polio patients.  This standard monitor allows muscle relaxants to be used safely in all patients.

          Hopefully, this section makes it clear how committed the specialty of anesthesiology is to improving patient safety and what significant progress has been made in decreasing harmful anesthesia incidents.  Post-polio patients who will be hospitalized for surgery have a much greater chance of dying or being harmed during hospitalization from other medical errors, such as getting an incorrect drug, rather than their anesthesia.  At the current rate, 160 would be predicted to die from an anesthesia accident each year, compared to 44,000 to 98,000 from other hospital errors.  Clearly hospitalization itself should become the worry, and there could be a decrease in concern about anesthesia.

 

GETTING THE BEST ANESTHESIA:  This is a difficult issue.  The first step is an adequate evaluation by your usual polio physician, the surgeon and a pulmonologist.  After group evaluation of your situation and a decision about exactly what surgery will be done, the hospital to be used can be chosen.  In most areas of the country, you can have several choices of hospitals.  An academic hospital with an affiliated rehab hospital would be ideal.  In general, academic centers tend to have the best anesthesia departments.  If your hospital is not an academic center, you might ask how many of the anesthesiologists are Board-certified and also is the hospital JCAHO accredited (you can check this yourself on the JCAHO web site).  The surgeon may know of a particular anesthesiologist who might have experience in this area or at least listen to patients’ concerns.  A preop evaluation would be done and an anesthesia plan, with a backup plan in place, made.  You are welcome to use my handout when you visit the anesthesiologist.  And, don’t forget the operation!  It’s best to go to an institution that specializes in whatever surgery you are to have.

          There is a significant shortage of anesthesiologists today, and many are seriously over-worked.  That might result in another anesthesiologist replacing one that you’ve talked with, at the last minute.  (Usually this would be because the first anesthesiologist has been up all night, on call.)  That may not be preventable and, hopefully, communication between the two will take place.  Through the entire operative process, I urge polio patients to make clear what their expectations for care are and to not be satisfied until you get what you need.  This can be wearing, and hopefully a companion can carry out some of this for you.  Today, all American health care organizations are under enormous stress, and this tends to show in the patient care area; it helps to be a “squeaky wheel.”

         

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SUMMARY OF ANESTHESIA ISSUES

FOR POST-POLIO PATIENTS

 

          Polio results in wide-spread neural changes, not just destruction of the spinal cord anterior horn (motor nerve) cells, and these changes can get worse as patients age.  These anatomic changes affect many aspects of anesthesia care.  No study of polio patients having anesthesia has been done.  These recommendations are based on extensive review of the current literature and clinical experience with these patients.  They may need to be adjusted for a particular patient.

 

1.  Post-polio patients are nearly always very sensitive to sedative meds, and emergence can be prolonged.  This is probably due to central neuronal changes, especially in the Reticular Activating System, from the original disease.

 

2.  Non-depolarizing muscle relaxants cause a greater degree of block for a longer period of time in post-polio patients.  The current recommendation is to start with half the usual dose of whatever you’re using, adding more as needed.  This is because the poliovirus actually lived at the neuromuscular junctions during the original disease, and there are extensive anatomic changes there, even in seemingly normal muscles, which make for greater sensitivity to relaxants.  Also, many patients have a significant decrease in total muscle mass.  Neuromuscular monitoring intraop helps prevent overdose of muscle relaxants.  Overdose has been a frequent problem.

 

3.  Succinylcholine often causes severe, generalized muscle pain postop.  It’s useful if this can be avoided, if possible.

 

4.  Postop pain is often a significant issue.  The anatomic changes from the original disease can affect pain pathways due to “spill-over” of the inflammatory response.  Spinal cord “wind-up” of pain signals seems to occur.  Proactive multimodal postop pain control (local anesthesia at the incision plus PCA, etc.) helps.

 

5.  The autonomic nervous system is often dysfunctional, again due to anatomic changes from the original disease (the inflammation and scarring in the anterior horn “spills over” to the intermediolateral column, where sympathetic nerves travel).  This can cause gastro-esophageal reflux, tachyarrhythmias and, sometimes, difficulty maintaining BP when anesthetics are given.

 

6.  Patients who use ventilators often have worsening of ventilatory function postop, and some patients who did not need assisted ventilation have had to go onto a ventilator (including long-term use) postop.  It’s useful to get at least a VC preop, and full pulmonary function studies may be helpful.  One group that should all have preop PFT’s is those who were in iron lungs.  The marker for real difficulty is thought to be a VC<1.0 liter.  Such a patient needs good pulmonary preparation preop and a plan for postop ventilatory support.  Another ventilation risk is obstructive sleep apnea in the postop period.  Many post-polios are turning out to have significant sleep apnea due to new weakness in their upper airway muscles as they age.

 

7.  Laryngeal and swallowing problems due to muscle weakness are being recognized more often.  Many patients have at least one paralyzed cord, and several cases of bilateral cord paralysis have occurred postop, after intubation or upper extremity blocks.  ENT evaluation of the upper airway in suspicious patients would be useful.

 

8.  Positioning can be difficult due to body asymmetry.  Affected limbs are osteopenic and can be easily fractured during positioning for surgery.  There seems to be greater risk for peripheral nerve damage (includes brachial plexus) during long cases, probably because nerves are not normal and also because peripheral nerves may be unprotected by the usual muscle mass or tendons.

Please feel free to call me (pager 818-529-0325, office 818-364-3019), email scalmes@ladhs.org) if you have any questions.  This brief summary may not cover everything you want to know.

Selma Harrison Calmes, MD

Clinical Professor of Anesthesiology, UCLA

 

FECPPSG Editor’s Note:-  As you know our newsletter does not do graphics.  If you want a copy of the “slide” presentation of Dr. Calmes’ presentation, just let us know and we’ll mail you a copy.

 

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Reprinted from USA Weekend, Dec 10-12, 2004

 

EatSmart by Jean Caspar

 

Cashews deserve respect

 

Q:  I eat a lot of cashews.  How do they rate as a healthful nut?

Very high, although they rarely make health headlines.  Cashews have almost as much magnesium as almonds, and more zinc and selenium than most nuts.  Like almonds, cashews are rich in monounsaturated fat ad are apt to improve cholesterol and cut heart disease risk, says Gene Spiller, a leading researcher on nuts and director of the Health Research and Studies Center.  But cashews rank far below pecans, hazelnuts, walnuts, pistachios and almonds in antioxidants, finds recent USDA research.

 

FECPPSG Editor’s Note:-  I was thrilled to read this as cashews are my favorite nut.  However, let’s not overdo the cashews and forget about the rest.  An equal serving of all nuts is really best for us.

 

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The following article was distributed at a meeting of the Volusia/Flagler Senior Association Coalition on April 5, 2005.  After reading it I called Donna Maitland, the Assistant District manager of our local Social Security office and asked her to be the speaker at our May 15th, meeting, to which Ms. Maitland agreed.  Those of us who were at that meeting learned an awful lot about the new Medicare Part D Program.

 

OVERVIEW OF

MEDICARE PART D

 

Eligibility and Enrollment

          The new Medicare Part D prescription drug coverage begins on January 1, 2006.  Initial open enrollment will begin November 15, 2005 and will run for six months to May 15, 2006.  In later years, open enrollment will run from November 15 to December 31 for the next benefit year.  The enrollment periods for Prescription Drug Plans (PDP) and Medicare Advantage (MA) plans will run concurrently.

          Anyone entitled to Medicare Part A or enrolled in Part B is eligible to join the new Medicare drug benefit plan.  Joining will involve selecting an approved PDP or MA plan offering drug coverage, and enrolling in that plan for the year.  While full dual eligible beneficiaries and other individuals who are eligible for the low income subsidy will be auto-enrolled after having the opportunity to select a plan themselves, enrollment for all other beneficiaries is entirely voluntary.  However, beneficiaries who choose not to join at the first opportunity may face a late enrollment penalty if they later choose to enter the program.  This penalty is similar to a penalty currently in place for late enrollment in Medicare Part B and is meant to make sure that people don’t wait until they are sick to sign up, thus skewing the risk pool.

          Beneficiaries who have other sources of drug coverage – through a former employer, for example – may stay in that plan and not enroll in one of the new drug plans under Medicare.  If their other coverage is at least as good as that offered under Medicare (*and therefore considered “creditable coverage”), the beneficiary can avoid any late enrollment penalties when or if they lose that coverage and choose to enroll in a Medicare plan at some later date.

          The new drug benefit has an “opt-in” rule.  That means that, with limited exceptions, beneficiaries will need to make an affirmative statement to enroll in a prescription drug plan by filling out an enrollment form and joining an approved plan.  This will be different from the “opt-out” rule that exists in Part B, where people are deemed to have enrolled in the program when they turn 65 unless they notify Medicare otherwise.

          Low-income beneficiaries who need help with Medicare drug costs can file for subsidy eligibility determinations with the Social Security Administration (SSA) or with the States.  SSA has developed a simplified application that is scannable and an application to be used via the Internet.  Beneficiaries will be able to complete the application themselves or with the help of State or other community based support organizations.  State personnel and other partners assisting beneficiaries will use the SSA application and eligibility determination process.

          Keep in mind that beneficiaries who are dually eligible for Medicare and Medicaid, about 6.4 million, as well as those eligible for SSI or in a Medicare Savings Program (QMB, SLMB, and QI beneficiaries – about one million individuals) will not have to complete an eligibility application.  These beneficiaries are deemed eligible and will automatically qualify for the subsidy.  Non-full benefit dual eligible individuals will still need to enroll in a plan offering prescription drug benefits.  If they do not do so before the end of their enrollment period, CMS will enroll them in a plan; they will have the option of disenrolling.

 

Premium, Deductible and Cost Sharing

          Beneficiaries who do not fall into one of the several low-income categories, and therefore do not qualify for additional assistance available to these individuals, will be responsible for monthly premiums, annual deductibles and cost sharing, up to a certain point.

          The standard benefit features a $4250 annual deductible and 25 percent beneficiary cost sharing, up to an initial coverage limit of $2,250.  After that, catastrophic coverage begins once a beneficiary reaches $3,600 in out-of-pocket expenses ($5,200 in total drug spending).  To be counted as out-of-pocket expenses, the beneficiary (or another individual, such as a family member) must actually be paying the costs.  In general, the costs cannot be paid by another insurer and count toward the $3,600 limit, though contributions by state pharmacy assistance programs do count.  In the catastrophic coverage range, the beneficiary pays the greater of 5 percent cost sharing or $2 and $5 co-pays.  This catastrophic coverage is something that has not been available to most Medicare beneficiaries, even those with supplemental coverage, since the Medicare-approved Medigap plans did not allow such coverage.

          Currently, Medicare beneficiaries without coverage pay full retail prices.  With coverage under one of the Medicare prescription drug plans, beneficiaries will save in two ways – first through the direct coverage, and second when they pay for drugs out of their own pockets, they will be making purchases based on prices that are substantially reduced from what they otherwise would pay as a result of their plan’s negotiated discounts with manufacturers.

 

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Reprinted from Daytona Beach News-Journal, Health Section, June 12, 2005

 

HOW  TO….

Choose an Assisted Living Facility

Services ease transition from living on your own.

 

          If you or a loved one suddenly has a need for an assisted living facility there are a lot of options to consider before making a selection.

          First, it is important to understand that assisted living is not a nursing home, but a bridge to that step from living on your own.  Assisted-living residences are designed to meet special personal services and housing needs, and sometimes healthcare needs as well.

          When selecting a facility, choices can include single or double rooms and sometimes even suites and apartments.

          Typical services that may be provided include meals, assistance with daily living activities such as bathing and dressing, help with medications, housekeeping, laundry, transportation and shopping.

          When the time comes to make that transition, research is the best way to ensure that you make the right selection for your loved one.

          It is a good idea to visit several assisted-living residences before making a choice.  Ask those who live in the community to be sure the facility and the owner or sponsor have a good reputation.  Talk with residents about life in the facility.  Be sure the staff is respectful and friendly.  Also, make sure the activities are appropriate for your individual needs.  Find out how much input you will have in your daily life and care, and how much flexibility there is in the schedule.  For example, if you need assistance with bathing, will you be able to choose when and how often?

          Requirements for staff and administrators for assisted-living facilities vary from state to state.  Many assisted-living facilities have very minimal hiring standards.  Some of these may include:

·        Administrator must be at least 18 years of age.

·        Workers may have a high school diploma or GED.

·        Some previous experience working with the aged.

 

When you begin your search, consider the following questions as a starting point::

·        What kinds of services are available and are services provided by the facility’s employees, or are arrangements made with other agencies?

·        What types of accommodations are there?

·        Do family and friends have unlimited and/or convenient visitation?

·        What is included in the daily or monthly rate?  What services are available for extra charges?

·        Can furniture and other personal items be brought from home?

·        What kinds of activities and recreation are available and how often?

·