History > 2007 > USA > The elderly (I)

In Hospice Care,

Longer Lives Mean Money Lost

November 27, 2007
The New York Times
By KEVIN SACK

CAMDEN, Ala. — Hundreds of hospice providers across the country are facing the catastrophic financial consequence of what would otherwise seem a positive development: their patients are living longer than expected.

Over the last eight years, the refusal of patients to die according to actuarial schedules has led the federal government to demand that hospices exceeding reimbursement limits repay hundreds of millions of dollars to Medicare.

The charges are assessed retrospectively, so in most cases the money has long since been spent on salaries, medicine and supplies. After absorbing huge assessments for several years, often by borrowing at high rates, a number of hospice providers are bracing for a new round that they fear may shut their doors.

One is Hometown Hospice, which has been providing care here since 2003 to some of the most destitute residents of Wilcox County, the poorest place in Alabama.

The locally owned, for-profit agency, which serves about 60 patients, mostly in their homes, had to repay the government $900,000, or 27 percent of its revenues, from its first two years of operation, said Tanya O. Walker-Butts, a co-owner. Its profits were wiped out in the time it took to open the demand letters, Ms. Walker-Butts said.

Hometown paid its first assessment with a bank loan. When the bank declined credit for the second year, the hospice structured a five-year payment plan with the Centers for Medicare and Medicaid Services, the federal agency that administers the program, at 12.5 percent interest.

The next bill is expected any day.

“If they hit us with a number in the several hundred-thousand range, I just don’t see how we can survive,” said Gaines C. McCorquodale, Hometown’s other owner.

In the early days of the Medicare hospice benefit, which was designed for those with less than six months to live, nearly all patients were cancer victims, who tended to die relatively quickly and predictably once curative efforts were abandoned.

But in the last five years, hospice use has skyrocketed among patients with less predictable trajectories, like those with Alzheimer’s disease and dementia. Those patients now form a majority of hospice consumers, and their average stays are far longer — 86 days for Alzheimer’s patients, for instance, compared with 44 for those with lung cancer, according to the Medicare Payment Advisory Commission.

The commission, which analyzes Medicare issues for Congress, recently projected that 220 hospices — about one of every 13 providers — received 2005 repayment demands totaling $166 million. The National Alliance for Hospice Access, a providers’ group that is lobbying for a three-year moratorium on the collections, places the numbers at 250 hospices and $200 million.

Because fewer than a tenth of all hospice providers have faced repayment, Medicare officials suggest that management might have been an issue. But Lois C. Armstrong, president of the hospice access alliance, said that if the cap on Medicare reimbursements was not lifted, the availability of care would tighten at a time when demand for hospice care was exploding and when new research suggests it saves money for the runaway Medicare program.

Many elderly people here in the remotest reaches of the state’s Black Belt would most likely live out their last days alone if not for Hometown Hospice nurses like Meg Appel Youngblood.

One recent autumn morning, Ms. Youngblood forded the Alabama River by ferry and set off on her rounds of the storied quilting enclave of Gees Bend, looking in on old women who had grown too feeble to quilt or to care for themselves.

Inside a clapboard house, she checked the vital signs of Loretta L. Pettway, a former farmhand whose stitchwork has been celebrated in postage stamps and picture books, and found that her blood pressure was a bit high.

“Miss Loretta, have you had your medicine?” she asked, and Ms. Pettway, 65, weary from chronic heart disease, shook her head no. “I didn’t think so,” Ms. Youngblood said, as she started to inventory the 14 pill bottles Ms. Pettway had stowed in a plastic bag.

Medicare’s coverage of hospice, which began in 1983, has become one of the fastest growing components of the government’s fastest growing entitlement. Spending nearly tripled from 2000 to 2005, to $8.2 billion, and nearly 40 percent of Medicare recipients now use the service.

To be eligible, patients must be certified by two doctors as having six months or less to live, assuming their illness runs a normal course. They must agree not to bill Medicare for curative procedures related to their diagnosis.

Medicare, which pays the vast majority of hospice bills, reimburses providers $135 a day for a patient’s routine home care. The hospice is then responsible for providing nurses, social workers, chaplains, doctors, drugs, supplies and equipment, as well as bereavement support to the family.

Studies have reached various conclusions about whether hospice care actually saves money, especially for long-term patients. But a new study by Duke University researchers concluded that it saved Medicare an average of $2,300 per beneficiary, calling hospice “a rare situation whereby something that improves quality of life also appears to reduce costs.”

In 1998, Congress removed limits on the number of days that an individual could receive Medicare hospice coverage, a move that encouraged physicians to refer terminal patients.

But lawmakers did not remove a cap on the aggregate amount that hospice providers could be reimbursed each year, a measure designed to contain the program’s cost. A hospice’s total annual reimbursement cannot exceed the product of the number of patients it serves and a per-patient allowance set by the government each year ($21,410 in 2007).

For reasons that are not fully understood, problems with the cap have been most prevalent at small, for-profit hospices in Southern and Western states like Mississippi, Alabama and Oklahoma.

Those programs typically have had higher proportions of noncancer patients and, thus, longer lengths of stay. But the Medicare advisory commission’s analysis also determined that the average length of stay in the cap-busting programs was significantly higher for all types of patients, including those with cancer.

Herb B. Kuhn, the deputy director of the Center for Medicare and Medicaid Services, said that finding was attracting attention at the center, which is eager to keep the hospice care benefit from morphing into a long-term care entitlement. “Well over nine out of 10 hospices seem to be managing well, including the ones in higher-wage areas, so it does raise an issue of management,” Mr. Kuhn said. Mr. Kuhn said it remained a question whether hospice care saved money, but called it “a wonderful benefit” that “probably needs refinement” after nearly 25 years.

Among the matters meriting review, he said, is whether doctors have been premature in certifying patients as terminal. Medicare has issued disease-specific guidelines for the certifications, which must be made by both a personal physician and the hospice medical director.

The medical director at Hometown Hospice, Dr. Sumpter D. Blackmon, said he relied heavily on the judgment of the hospice’s nurses to determine whether prospective patients were rather likely to live longer than six months. But of the 56 patients on the books on Oct. 31, 17 had been there for at least that period, including two for more than 500 days.

“Doing this for 40-something years,” said Dr. Blackmon, a longtime physician here, “every time I think somebody is going to die tomorrow, damned if they don’t live for a year and a half.”

A number of hospice providers said ethical and legal constraints would prevent them from discharging patients who outlived their profit potential. But some said they sometimes delayed admission for those patients with illnesses that might result in longer stays.

Like other providers, Richard R. Slager, the chairman and chief executive of VistaCare, which is based in Arizona and has programs in 14 states, said his company now aimed its marketing at cancer patients.

“In communities where we have had cap issues, we have to really look hard for shorter-length-of-stay patients to offset it,” Mr. Slager said. “It’s a never-ending nightmare.”

After being hit with $200 million in cap charges over four years — the equivalent of a year’s revenues — Mr. Slager said he chose to close or sell 16 of 58 hospices.

Some providers have survived only by aggressively recruiting new patients, using this year’s Medicare reimbursements to pay off last year’s cap charges, while stalling for Congressional relief. Ms. Youngblood, the Hometown Hospice nurse, said that after she visited her charges — doling out their pills, and turning the sweet potatoes in their ovens — she trolled for new patients at nursing homes and senior centers.

At the small hospital here, she said, the nurses joke about her “marketing” forays: “They’ll say, ‘Here comes Nurse Kevorkian. She has no shame.’ And I’ll say, ‘Look, I have to have a paycheck, too.’”

In Hospice Care, Longer Lives Mean Money Lost, NYT, 28.11.2007, http://www.nytimes.com/2007/11/27/us/27hospice.html

Barely Getting by

and Facing a Cold Maine Winter

November 24, 2007
The New York Times
By ERIK ECKHOLM

MILBRIDGE, Me. — They have worked since their teens in backbreaking seasonal jobs, extracting resources from the sea and the forest. Their yards are filled with peeling boats and broken lobster traps.

In sagging wood homes and aged trailers scattered across Washington County, many of Maine’s poorest and oldest shiver too much in the winter, eat far more biscuits and beans than meat and cannot afford the weekly bingo game at the V.F.W. hall.

In this long-depressed “down east” region, where the wild blueberry patches have turned a brilliant crimson, thousands of elderly residents live on crushingly meager incomes. This winter promises to be especially chilling, with fuel oil prices rising and fuel assistance expected to decline. But many assume that others are worse off than themselves and are too proud to ask for assistance, according to groups that run meal programs and provide aid for heating and weatherizing.

“One of our biggest problems is convincing people to take help,” said Eleanor West, director of services for the Washington Hancock Community Agency, a federally chartered nonprofit group. “I tell them, ‘You worked hard all your life and paid taxes and are getting back a little of what you paid in.’”

Over the last half century, Social Security, Medicare and private pensions have lifted most of the nation’s elderly. In 1960, one in three lived below the poverty line; now fewer than one in 10 do. But in Washington County, the poverty rate among those 65 and older is nearly one in five and many more live only a little above the federal subsistence standard in 2007 of $10,200 for a single person and $13,690 for two.

For thousands on fixed incomes, fuel assistance may decline while Social Security checks are scarcely rising.

Viola Brooks, 81, worked in fish and blueberry factories while her husband worked in textile and logging jobs. Now widowed, she gets $588 a month from Social Security, supplemented by $112 in food stamps and one-time fuel aid of more than $500 for the winter.

But this year, that fuel aid will not fill a single tank. The average house cost $1,800 to heat last year, and minimal comfort this winter may require closer to $3,000; trailers will require somewhat less. Electricity and rent already take up most of Ms. Brooks’s income.

“I’m broke every month, and the trailer needs storm windows,” she said. “I cook a lot of pea soup and baked beans and buy flour to make biscuits.”

“Some day I’d like to go to a hairdresser,” Ms. Brooks said of a dream deferred. Still she says she enjoys her lovebirds and cats, and points out that “some people have it worse.”

Jobs for the elderly, a growing trend nationwide, are virtually nonexistent in these hamlets. Many people survive with help from a range of programs including food stamps, Medicaid, disability and energy assistance; others suffer silently, long used to hardship and fiercely independent.

In a pattern still common, older people here often held a series of seasonal jobs, usually without benefits. They worked on lobster boats and dug clams or bloodworms (to sell for bait) from spring to fall, raked wild blueberries in August, harvested potatoes and then made Christmas wreaths for mail-order companies to mid-December. Wives often worked in sardine canneries or in blueberry processing.

“By their 50s, their bodies start breaking down,” said Tim King, director of the community agency at its headquarters in Milbridge, adding that high rates of smoking, obesity and diabetes also contributed to early aging. The aid programs define those as 60 and over as elderly.

Because of their irregular careers and payments into the system, many people get Social Security benefits far below the national average of more than $1,000 a month.

Velma L. Harmon, a 79-year-old widow, receives only $220 a month from Social Security and has a grand total of $85 to live on each month after she pays her subsidized rent and utilities at her apartment complex in Machias, one of a growing number of such federally aided facilities for the elderly.

She is grateful for free lunches provided by the Eastern Agency on Aging, another government-financed group, but too proud to apply for food stamps that would give her a bit more spending money. “Trying to buy Christmas presents, that’s the hardest thing,” said Ms. Harmon, who has a mangled finger from her years of snipping sardine heads in a canning factory.

The preoccupation right now is soaring fuel prices: cheaper natural gas is unavailable in this region, and wood heat is often impractical or insufficient. But because of limited federal money, average fuel assistance for the 46,000 low-income Maine families expected to apply will probably decline to $579 this year, from $688 last year, said Jo-Ann Choate of the Maine State Housing Agency.

“Low-income people aren’t even going to be able to fill up a single tank of fuel oil,” Ms. Choate said. “They already wrap themselves up in blankets during the winter. This year they’ll be colder.”

The disabled, and there are many, may have it hardest. Dolly Jordan of Milbridge has a history of two bad marriages, a bone-crushing auto accident and poor health, and looks and feels older than 61. With osteoporosis, arthritis, diabetes and obesity, she spends most of the day in a wheelchair and uses a combination of a gripper, a broom and a cane to make her bed or hang her laundry.

Come winter, she hangs a blanket over the front door of her little red wooden house, where she has lived alone the last 10 years and which sits on concrete blocks with no foundation. She turns the heat off at night to save fuel.

Her disability payment is $623 a month, plus she gets just $10 from the state and $74 in food stamps. After paying the housing tax and her utility bills, she said, she must watch every remaining penny. A daughter drives her to the distant town of Ellsworth for cheaper shopping.

Like many, she keeps a police scanner on as a diversion and, unable to afford cable, she watches the same videos over and over — her favorite is “On Golden Pond.”

“I wish for bedtime to come,” she said. “The days are so long.”

Easing down a ramp to her mailbox is a perilous 15-minute ordeal. Still, she said, “I wait for Fridays.”

“That’s junk-mail day, and I read all the ads. That’s my best day.”

She added, “There’s always older people out there who have it harder.”

Frederick and Kathleen Call, in Harrington, are in their 60s and live in a 1970s trailer with buckling walls. They live on his disability check — he has had six heart attacks — and food stamps and fuel assistance. Like many others in the region, they buy all their clothes at a church-run thrift shop. They spend their days playing board games and rummy and watching squirrels on their porch.

“We used to go to the food pantry for a free box,” Ms. Call said, “but I saw an old woman who looked like she really needed it. She was thin and cold. I gave her a blanket. We haven’t gone for free food for years.”

Some people here seem to have sunny outlooks no matter what. In the fishing village of Jonesport, Elizabeth Emerson, 87, is hard of hearing and has a titanium knee but is spry and irrepressively cheerful.

She lives in the tiny house her husband, a trucker, built in 1949, and has a view of the gravestone where her name is already etched next to his. Having a daughter nearby, and a total of 52 grand-, great-grand and great-great-grandchildren, whose pictures fill the walls and the refrigerator door, helps in ways practical and emotional.

Ms. Emerson said she “thoroughly enjoyed” the 25 years she spent working as an aide in a nursing home, and she demonstrated the yodeling she used to perform on command for one patient.

Each day she walks with her dog, Sabrina, down to the stony beach where her family once swam. “I saw moose tracks the other day,” she exulted. “Here is where I used to pick heather.”

With her Social Security payment of $683 a month, she refuses to feel impoverished.

“I was never a person to be extravagant,” Ms. Emerson said, adding, “I don’t play beano,” using the local term for bingo.

Besides, she said, she can still afford an indulgence here and there. “My greatest vice,” she added, “is Hershey bars.”

    Barely Getting by and Facing a Cold Maine Winter, NYT, 24.11.2007, http://www.nytimes.com/2007/11/24/us/24maine.html

Still Many-Splendored

Love in the Time of Dementia

November 18, 2007
The New York Times
By KATE ZERNIKE

SO this, in the end, is what love is.

Former Justice Sandra Day O’Connor’s husband, suffering from Alzheimer’s disease, has a romance with another woman, and the former justice is thrilled — even visits with the new couple while they hold hands on the porch swing — because it is a relief to see her husband of 55 years so content.

What culture tells us about love is generally young love. Songs and movies and literature show us the rapture and the betrayal, the breathlessness and the tears. The O’Connors’ story, reported by the couple’s son in an interview with a television station in Arizona, where Mr. O’Connor lives in an assisted-living center, opened a window onto what might be called, for comparison’s sake, old love.

Of course, it illuminated the relationships that often develop among Alzheimer’s patients — new attachments, some call them — and how the desire for intimacy persists even when dementia steals so much else. But in the description of Justice O’Connor’s reaction, the story revealed a poignancy and a richness to love in the later years, providing a rare model at a time when people are living longer, and loving longer.

“This is right up there in terms of the cutting-edge ethical and cultural issues of late life love,” said Thomas R. Cole, director of the McGovern Center for Health, Humanities and the Human Spirit at the University of Texas, and author of a cultural history of aging. “We need moral exemplars, not to slavishly imitate, but to help us identify ways of being in love when you’re older.”

Historically, love in older age has not been given much of a place in culture, Dr. Cole said. It once conjured images that were distasteful or even scary: the dirty old man, the erotic old witch.

That is beginning to change, Dr. Cole said, as life expectancy increases, and a generation more sexually liberated begins to age. Nursing homes are being forced to confront an increase in sexual activity.

And despite the stereotypes, researchers who study emotions across the life span say old love is in many ways more satisfying than young love — even as it is also more complex, as the O’Connors’ example shows.

“There’s a difference between love as it is presented in movies and music as this jazzy sexy thing that involves bikini underwear and what love actually turns out to be,” said the psychologist Mary Pipher, whose book “Another Country” looked at the emotional life of the elderly. “The really interesting script isn’t that people like to have sex. The really interesting script is what people are willing to put up with.”

“Young love is about wanting to be happy,” she said. “Old love is about wanting someone else to be happy.”

That’s one way to look at it, at any rate. And it’s not just that relationships are seasoned by time and shared memories — although that’s part of it, as is the inertia the researchers call the familiarity effect, which keeps people from leaving a longtime relationship even though he nags and she won’t ask for directions.

It’s also that brain researchers say older people may simply be better able to deal with the emotional vicissitudes of love. As it ages, the brain becomes more programmed to be happy in relationships.

Researchers trying to understand aging and emotion performed brain scans on people across a range of ages, gauging their reactions to positive and negative scenes. Young people tended to respond to the negative scenes. Those in middle age took in a better balance of the positive. And older people responded only to the positive scenes.

“As people get older, they seem to naturally look at the world through positivity and be willing to accept things that when we’re young we would find disturbing and vexing,” said John Gabrieli, a professor of cognitive neuroscience at the Massachusetts Institute of Technology and one of the researchers.

It is not rationalization: the reaction is instantaneous. “Instead of what would be most disturbing for somebody, feeling betrayed or discomfort, the other thoughts — about how from his perspective it’s not betrayal — can be accommodated much more easily,” Dr. Gabrieli said. “It paves the way for you to be sympathetic to the situation from his perspective, to be less disturbed from her perspective.”

Young brains tend to go to extremes — the swooning or sobbing so characteristic of young love. Old love puts things in soft focus.

“As you get older you begin to recognize that this isn’t going to last forever, for better or for worse,” said Laura L. Carstensen, director of the Stanford Center on Longevity and a research counterpart of Dr. Gabrieli’s in the brain imaging research. “You understand that the bad times pass, and you understand that the good times pass,” Dr. Carstensen said. “As you experience them, they’re more precious, they’re richer.”

Of course, not everyone would show the emotionally generous response that Justice O’Connor did. As Dr. Cole said, “I have many examples in my mind of people who are just as jealous, just as infantile, just as filled with irrationality when they fall in love in their 70s and 80s as she is self-transcendent.”

And it still is possible to have a broken heart in old age. But in general, Dr. Carstensen said: “A broken heart looks different in somebody old. You don’t yell and scream and cry all day long like you might if you were 20.”

In one of the few cultural examples exploring old love — the film “Away From Her,” based on an Alice Munro short story and released in the spring — the starting point is similar to the O’Connors’ story. A man who cannot imagine life without his sparkling wife of some decades watches her slip into Alzheimer’s and then a romance with another patient in a nursing home. In the fictional example, the spousal devotion is such that he arranges for her new boyfriend to return to the nursing home after seeing how crushed she is when the man moves away.

But the story is more complex. The husband had a series of affairs years earlier, so what seems like devotion is also a desire to pay her back and to ease his own remorse.

For Olympia Dukakis, whose mother had Alzheimer’s and who played the wife of the other man in the film, that wrinkle explains the resonance of Ms. Munro’s story.

“She was very aware that contradictory things live together,” Ms. Dukakis said. “You can’t look at it and say he did it purely for love. It’s a complicated issue, because there’s a lot of life that has been lived. It’s not going to be simple.”

Still, for all those kinds of complications, those who study aging can only smile at young lovers who say they never want to become like an old married couple. Despite the popular preference for young love, the O’Connors’ example suggests that we should all aspire to old love, for better and for worse.

“Young love is very privileged, and as a culture that may be a mistake,” Dr. Pipher said. “If you want a communal culture where people make sacrifices for each other and work for the common good, you would have a culture that privileges the stories of older people.”

Those stories would not be without their troubles. But nor would they be without rewards. “If you stay married,” Dr. Pipher said, “there’s riches in store that nobody 25 years old can imagine.”

    Love in the Time of Dementia, NYT, 18.11.2007, http://www.nytimes.com/2007/11/18/weekinreview/18zernike.html

Aging and Gay, and Facing Prejudice in Twilight

October 9, 2007
The New York Times
By JANE GROSS

Even now, at 81 and with her memory beginning to fade, Gloria Donadello recalls her painful brush with bigotry at an assisted-living center in Santa Fe, N.M. Sitting with those she considered friends, “people were laughing and making certain kinds of comments, and I told them, ‘Please don’t do that, because I’m gay.’”

The result of her outspokenness, Ms. Donadello said, was swift and merciless. “Everyone looked horrified,” she said. No longer included in conversation or welcome at meals, she plunged into depression. Medication did not help. With her emotional health deteriorating, Ms. Donadello moved into an adult community nearby that caters to gay men and lesbians.

“I felt like I was a pariah,” she said, settled in her new home. “For me, it was a choice between life and death.”

Elderly gay people like Ms. Donadello, living in nursing homes or assisted-living centers or receiving home care, increasingly report that they have been disrespected, shunned or mistreated in ways that range from hurtful to deadly, even leading some to commit suicide.

Some have seen their partners and friends insulted or isolated. Others live in fear of the day when they are dependent on strangers for the most personal care. That dread alone can be damaging, physically and emotionally, say geriatric doctors, psychiatrists and social workers.

The plight of the gay elderly has been taken up by a generation of gay men and lesbians, concerned about their own futures, who have begun a national drive to educate care providers about the social isolation, even outright discrimination, that lesbian, gay, bisexual and transgender clients face.

Several solutions are emerging. In Boston, New York, Chicago, Atlanta and other urban centers, so-called L.G.B.T. Aging Projects are springing up, to train long-term care providers. At the same time, there is a move to separate care, with the comfort of the familiar.

In the Boston suburbs, the Chelsea Jewish Nursing Home will break ground in December for a complex that includes a unit for the gay and lesbian elderly. And Stonewall Communities in Boston has begun selling homes designed for older gay people with support services similar to assisted-living centers. There are also openly gay geriatric case managers who can guide clients to compassionate services.

“Many times gay people avoid seeking help at all because of their fears about how they’ll be treated,” said David Aronstein, president of Stonewall Communities. “Unless they see affirming actions, they’ll assume the worst.”

Homophobia directed at the elderly has many faces.

Home health aides must be reminded not to wear gloves at inappropriate times, for example while opening the front door or making the bed, when there is no evidence of H.I.V. infection, said Joe Collura, a nurse at the largest home care agency in Greenwich Village.

A lesbian checking into a double room at a Chicago rehabilitation center was greeted by a roommate yelling, “Get the man out of here!” The lesbian patient, Renae Ogletree, summoned a friend to take her elsewhere.

Sometimes tragedy results. In one nursing home, an openly gay man, without family or friends, was recently moved off his floor to quiet the protests of other residents and their families. He was given a room among patients with severe disabilities or dementia. The home called upon Amber Hollibaugh, now a senior strategist at the National Gay and Lesbian Task Force and the author of the first training curriculum for nursing homes. Ms. Hollibaugh assured the 79-year-old man that a more humane solution would be found, but he hanged himself, Ms. Hollibaugh said. She was unwilling to identify the nursing home or even its East Coast city, because she still consults there, among other places.

While this outcome is exceedingly rare, moving gay residents to placate others is common, said Dr. Melinda Lantz, chief of geriatric psychiatry at Beth Israel Medical Center in New York, who spent 13 years in a similar post at the Jewish Home and Hospital Lifecare System. “When you’re stuck and have to move someone because they’re being ganged up on, you put them with people who are very confused,” Dr. Lantz said. “That’s a terrible nuts-and-bolts reality.”

The most common reaction, in a generation accustomed to being in the closet, is a retreat back to the invisibility that was necessary for most of their lives, when homosexuality was considered both a crime and a mental illness. A partner is identified as a brother. No pictures or gay-themed books are left around.

Elderly heterosexuals also suffer the indignities of old age, but not to the same extent, Dr. Lantz said. “There is something special about having to hide this part of your identity at a time when your entire identity is threatened,” she said. “That’s a faster pathway to depression, failure to thrive and even premature death.”

The movement to improve conditions for the gay elderly is driven by demographics. There are an estimated 2.4 million gay, lesbian or bisexual Americans over the age of 55, said Gary Gates, a senior research fellow at the Williams Institute at the University of California, Los Angeles. That estimate was extrapolated by Dr. Gates using census data that counts only same-sex couples along with other government data that counts both single and coupled gay people. Among those in same-sex couples, the number of gay men and women over 55 has almost doubled from 2000 to 2006, Dr. Gates said, to 416,000, from 222,000.

California is the only state with a law saying the gay elderly have special needs, like other members of minority groups. A new law encourages training for employees and contractors who work with the elderly and permits state financing of projects like gay senior centers.

Federal law provides no antidiscrimination protections to gay people. Twenty states explicitly outlaw such discrimination in housing and public accommodations. But no civil rights claims have been made by gay residents of nursing homes, according to the Lambda Legal Defense Fund, which litigates and monitors such cases. Potential plaintiffs, the organization says, are too frail or frightened to bring action.

The problem is compounded, experts say, because most of the gay elderly do not declare their identity, and institutions rarely make an effort to find out who they are to prepare staff members and residents for what may be an unfamiliar situation.

So that is where Lisa Krinsky, the director of the L.G.B.T. Aging Project in Massachusetts, begins her “cultural competency” training sessions, including one last month at North Shore Elder Services in Danvers.

Admissions forms for long-term care have boxes to check for marital status and next of kin. But none of the boxes match the circumstances of gay men or lesbians. Ms. Krinsky suggested follow-up questions like “Who is important in your life?”

In the last two years, Ms. Krinsky has trained more than 2,000 employees of agencies serving the elderly across Massachusetts. She presents them with common problems and nudges them toward solutions.

A gay man fired his home health aide. Did the case manager ask why? The patient might be receiving unwanted Bible readings from someone who thinks homosexuality is a sin. What about a lesbian at an assisted-living center refusing visitors? Maybe she is afraid that her friends’ appearance will give her away to fellow residents.

“We need to be open and sensitive,” Ms. Krinsky said, “but not wrap them in a rainbow flag and make them march in a parade.”

Some of the gay elderly chose openness as the quickest and most painless way of finding compassionate care. That is the case for Bruce Steiner, 76, of Sudbury, Mass., whose 71-year-old partner, Jim Anthony, has had Alzheimer’s disease for more than a decade and can no longer feed himself or speak.

Mr. Steiner is resisting a nursing home for Mr. Anthony, even after several hospitalizations last year. The care had been uneven, Mr. Steiner said, and it was unclear whether homosexuality was a factor. But Mr. Steiner decided to take no chances and hired a gay case manager who helped him “do some filtering.”

They selected a home care agency with a reputation for treating gay clients well. Preparing for an unknown future, Mr. Steiner also visited several nursing homes, “giving them the opportunity to encourage or discourage me.” His favorite “is one run by the Carmelite sisters, of all things, because they had a sense of humor.”

They are the exception, not the rule.

Jalna Perry, a 77-year-old lesbian and psychiatrist in Boston, is out, she said, but does not broadcast the fact, which would feel unnatural to someone of her generation. Dr. Perry, who uses a wheelchair, has spent time in assisted-living centers and nursing homes. There, she said, her guard was up all the time.

Dr. Perry came out to a few other residents in the assisted-living center — artsy, professional women who she figured would accept her. But even with them, she said, “You don’t talk about gay things.” Mostly, she kept to herself. “You size people up,” Dr. Perry said. “You know the activities person is a lesbian; that’s a quick read.”

Trickier was an aide who was gentle with others but surly and heavy-handed when helping Dr. Perry with personal tasks. Did the aide suspect and disapprove? With a male nurse who was gay, Dr. Perry said she felt “extremely comfortable.”

“Except for that nurse, I was very lonely,” she said. “It would have been nice if someone else was out among the residents.”

Such loneliness is a source of dread to the members of the Prime Timers, a Boston social group for older gay men. Among the regulars, who meet for lunch once a week, are Emile Dufour, 70, a former priest, and Fred Riley, 75, who has a 30-year heterosexual marriage behind him. The pair have been together for two decades and married in 2004. But their default position, should they need nursing care, will be to hide their gayness, as they did for half a lifetime, rather than face slurs and whispers.

“As strong as I am today,” Mr. Riley said, “when I’m at the gate of the nursing home, the closet door is going to slam shut behind me.”

Dan Frosch contributed reporting.

    Aging and Gay, and Facing Prejudice in Twilight, NYT, 9.10.2007, http://www.nytimes.com/2007/10/09/us/09aged.html?hp

Bilking the Elderly,

With a Corporate Assist

May 20, 2007
The New York Times
By CHARLES DUHIGG

The thieves operated from small offices in Toronto and hangar-size rooms in India. Every night, working from lists of names and phone numbers, they called World War II veterans, retired schoolteachers and thousands of other elderly Americans and posed as government and insurance workers updating their files.

Then, the criminals emptied their victims’ bank accounts.

Richard Guthrie, a 92-year-old Army veteran, was one of those victims. He ended up on scam artists’ lists because his name, like millions of others, was sold by large companies to telemarketing criminals, who then turned to major banks to steal his life’s savings.

Mr. Guthrie, who lives in Iowa, had entered a few sweepstakes that caused his name to appear in a database advertised by infoUSA, one of the largest compilers of consumer information. InfoUSA sold his name, and data on scores of other elderly Americans, to known lawbreakers, regulators say.

InfoUSA advertised lists of “Elderly Opportunity Seekers,” 3.3 million older people “looking for ways to make money,” and “Suffering Seniors,” 4.7 million people with cancer or Alzheimer’s disease. “Oldies but Goodies” contained 500,000 gamblers over 55 years old, for 8.5 cents apiece. One list said: “These people are gullible. They want to believe that their luck can change.”

As Mr. Guthrie sat home alone — surrounded by his Purple Heart medal, photos of eight children and mementos of a wife who was buried nine years earlier — the telephone rang day and night. After criminals tricked him into revealing his banking information, they went to Wachovia, the nation’s fourth-largest bank, and raided his account, according to banking records.

“I loved getting those calls,” Mr. Guthrie said in an interview. “Since my wife passed away, I don’t have many people to talk with. I didn’t even know they were stealing from me until everything was gone.”

Telemarketing fraud, once limited to small-time thieves, has become a global criminal enterprise preying upon millions of elderly and other Americans every year, authorities say. Vast databases of names and personal information, sold to thieves by large publicly traded companies, have put almost anyone within reach of fraudulent telemarketers. And major banks have made it possible for criminals to dip into victims’ accounts without their authorization, according to court records.

The banks and companies that sell such services often confront evidence that they are used for fraud, according to thousands of banking documents, court filings and e-mail messages reviewed by The New York Times.

Although some companies, including Wachovia, have made refunds to victims who have complained, neither that bank nor infoUSA stopped working with criminals even after executives were warned that they were aiding continuing crimes, according to government investigators. Instead, those companies collected millions of dollars in fees from scam artists. (Neither company has been formally accused of wrongdoing by the authorities.)

“Only one kind of customer wants to buy lists of seniors interested in lotteries and sweepstakes: criminals,” said Sgt. Yves Leblanc of the Royal Canadian Mounted Police. “If someone advertises a list by saying it contains gullible or elderly people, it’s like putting out a sign saying ‘Thieves welcome here.’ ”

In recent years, despite the creation of a national “do not call” registry, the legitimate telemarketing industry has grown, according to the Direct Marketing Association. Callers pitching insurance plans, subscriptions and precooked meals collected more than $177 billion in 2006, an increase of $4.5 billion since the federal do-not-call restrictions were put in place three years ago.

That growth can be partly attributed to the industry’s renewed focus on the elderly. Older Americans are perfect telemarketing customers, analysts say, because they are often at home, rely on delivery services, and are lonely for the companionship that telephone callers provide. Some researchers estimate that the elderly account for 30 percent of telemarketing sales — another example of how companies and investors are profiting from the growing numbers of Americans in their final years.

While many telemarketing pitches are for legitimate products, the number of scams aimed at older Americans is on the rise, the authorities say. In 2003, the Federal Trade Commission estimated that 11 percent of Americans over age 55 had been victims of consumer fraud. The following year, the Federal Bureau of Investigation shut down one telemarketing ring that stole more than $1 billion, spanned seven countries and resulted in 565 arrests. Since the start of last year, federal agencies have filed lawsuits or injunctions against at least 68 telemarketing companies and individuals accused of stealing more than $622 million.

“Most people have no idea how widespread and sophisticated telemarketing fraud has become,” said James Davis, a Federal Trade Commission lawyer. “It shocks even us.”

Many of the victims are people like Mr. Guthrie, whose name was among the millions that infoUSA sold to companies under investigation for fraud, according to regulators. Scam artists stole more than $100,000 from Mr. Guthrie, his family says. How they took much of it is unclear, because Mr. Guthrie’s memory is faulty and many financial records are incomplete.

What is certain is that a large sum was withdrawn from his account by thieves relying on Wachovia and other banks, according to banking and court records. Though 20 percent of the total amount stolen was recovered, investigators say the rest has gone to schemes too complicated to untangle.

Senior executives at infoUSA were contacted by telephone and e-mail messages at least 30 times. They did not respond.

Wachovia, in a statement, said that it had honored all requests for refunds and that it was cooperating with authorities.

Mr. Guthrie, however, says that thieves should have been prevented from getting access to his funds in the first place.

“I can’t understand why they were allowed inside my account,” said Mr. Guthrie, who lives near Des Moines. “I just chatted with this woman for a few minutes, and the next thing I knew, they took everything I had.”

Sweepstakes a Common Tactic

Investigators suspect that Mr. Guthrie’s name first appeared on a list used by scam artists around 2002, after he filled out a few contest entries that asked about his buying habits and other personal information.

He had lived alone since his wife died. Five of his eight children had moved away from the farm. Mr. Guthrie survived on roughly $800 that he received from Social Security each month. Because painful arthritis kept him home, he spent many mornings organizing the mail, filling out sweepstakes entries and listening to big-band albums as he chatted with telemarketers.

“I really enjoyed those calls,” Mr. Guthrie said. “One gal in particular loved to hear stories about when I was younger.”

Some of those entries and calls, however, were intended solely to create databases of information on millions of elderly Americans. Many sweepstakes were fakes, investigators say, and existed only to ask entrants about shopping habits, religion or other personal details. Databases of such responses can be profitably sold, often via electronic download, through list brokers like Walter Karl Inc., a division of infoUSA.

The list brokering industry has existed for decades, primarily serving legitimate customers like magazine and catalog companies. InfoUSA, one of the nation’s largest list brokers and a publicly held company, matches buyers and sellers of data. The company maintains records on 210 million Americans, according to its Web site. In 2006, it collected more than $430 million from clients like Reader’s Digest, Publishers Clearinghouse and Condé Nast.

But infoUSA has also helped sell lists to companies that were under investigation or had been prosecuted for fraud, according to records collected by the Iowa attorney general. Those records stemmed from a now completed investigation of a suspected telemarketing criminal.

By 2004, Mr. Guthrie’s name was part of a list titled “Astroluck,” which included 19,000 other sweepstakes players, Iowa’s records show. InfoUSA sold the Astroluck list dozens of times, to companies including HMS Direct, which Canadian authorities had sued the previous year for deceptive mailings; Westport Enterprises, the subject of consumer complaints in Kansas, Connecticut and Missouri; and Arlimbow, a European company that Swiss authorities were prosecuting at the time for a lottery scam.

(In 2005, HMS’s director was found not guilty on a technicality. Arlimbow was shut down in 2004. Those companies did not return phone calls. Westport Enterprises said it has resolved all complaints, complies with all laws and engages only in direct-mail solicitations.)

Records also indicate that infoUSA sold thousands of other elderly Americans’ names to Windfall Investments after the F.B.I. had accused the company in 2002 of stealing $600,000 from a California woman.

Between 2001 and 2004, infoUSA also sold lists to World Marketing Service, a company that a judge shut down in 2003 for running a lottery scam; to Atlas Marketing, which a court closed in 2006 for selling $86 million of bogus business opportunities; and to Emerald Marketing Enterprises, a Canadian firm that was investigated multiple times but never charged with wrongdoing.

The investigation of Windfall Investments was closed after its owners could not be located. Representatives of Windfall Investments, World Marketing Services, Atlas Marketing and Emerald Marketing Enterprises could not be located or did not return calls.

The Federal Trade Commission’s rules prohibit list brokers from selling to companies engaged in obvious frauds. In 2004, the agency fined three brokers accused of knowingly, or purposely ignoring, that clients were breaking the law. The Direct Marketing Association, which infoUSA belongs to, requires brokers to screen buyers for suspicious activity.

But internal infoUSA e-mail messages indicate that employees did not abide by those standards. In 2003, two infoUSA employees traded e-mail messages discussing the fact that Nevada authorities were seeking Richard Panas, a frequent infoUSA client, in connection with a lottery scam.

“This kind of behavior does not surprise me, but it adds to my concerns about doing business with these people,” an infoUSA executive wrote to colleagues. Yet, over the next 10 months, infoUSA sold Mr. Panas an additional 155,000 names, even after he pleaded guilty to criminal charges in Nevada and was barred from operating in Iowa.

Mr. Panas did not return calls.

“Red flags should have been waving,” said Steve St. Clair, an Iowa assistant attorney general who oversaw the infoUSA investigation. “But the attitude of these list brokers is that it’s not their responsibility if someone else breaks the law.”

Millions of Americans Are Called

Within months of the sale of the Astroluck list, groups of scam artists in Canada, the Caribbean and elsewhere had the names of Mr. Guthrie and millions of other Americans, authorities say. Such countries are popular among con artists because they are outside the jurisdiction of the United States.

The thieves would call and pose as government workers or pharmacy employees. They would contend that the Social Security Administration’s computers had crashed, or prescription records were incomplete. Payments and pills would be delayed, they warned, unless the older Americans provided their banking information.

Many people hung up. But Mr. Guthrie and hundreds of others gave the callers whatever they asked.

“I was afraid if I didn’t give her my bank information, I wouldn’t have money for my heart medicine,” Mr. Guthrie said.

Criminals can use such banking data to create unsigned checks that withdraw funds from victims’ accounts. Such checks, once widely used by gyms and other businesses that collect monthly fees, are allowed under a provision of the banking code. The difficult part is finding a bank willing to accept them.

In the case of Mr. Guthrie, criminals turned to Wachovia.

Between 2003 and 2005, scam artists submitted at least seven unsigned checks to Wachovia that withdrew funds from Mr. Guthrie’s account, according to banking records. Wachovia accepted those checks and forwarded them to Mr. Guthrie’s bank in Iowa, which in turn sent back $1,603 for distribution to the checks’ creators that submitted them.

Within days, however, Mr. Guthrie’s bank, a branch of Wells Fargo, became concerned and told Wachovia that the checks had not been authorized. At Wells Fargo’s request, Wachovia returned the funds. But it failed to investigate whether Wachovia’s accounts were being used by criminals, according to prosecutors who studied the transactions.

In all, Wachovia accepted $142 million of unsigned checks from companies that made unauthorized withdrawals from thousands of accounts, federal prosecutors say. Wachovia collected millions of dollars in fees from those companies, even as it failed to act on warnings, according to records.

In 2006, after account holders at Citizens Bank were victimized by the same thieves that singled out Mr. Guthrie, an executive wrote to Wachovia that “the purpose of this message is to put your bank on notice of this situation and to ask for your assistance in trying to shut down this scam.”

But Wachovia, which declined to comment on that communication, did not shut down the accounts.

Banking rules required Wachovia to periodically screen companies submitting unsigned checks. Yet there is little evidence Wachovia screened most of the firms that profited from the withdrawals.

In a lawsuit filed last year, the United States attorney in Philadelphia said Wachovia received thousands of warnings that it was processing fraudulent checks, but ignored them. That suit, against the company that printed those unsigned checks, Payment Processing Center, or P.P.C., did not name Wachovia as a defendant, though at least one victim has filed a pending lawsuit against the bank.

During 2005, according to the United States attorney’s lawsuit, 59 percent of the unsigned checks that Wachovia accepted from P.P.C. and forwarded to other banks were ultimately refused by other financial institutions. Wachovia was informed each time a check was returned.

“When between 50 and 60 percent of transactions are returned, that tells you at gut level that something’s not right,” said the United States attorney in Philadelphia, Patrick L. Meehan.

Other banks, when confronted with similar evidence, have closed questionable accounts. But Wachovia continued accepting unsigned checks printed by P.P.C. until the government filed suit in 2006.

Wachovia declined to respond to the accusations in the lawsuit, citing the continuing civil litigation.

Although Wachovia is the largest bank that processed transactions that stole from Mr. Guthrie, at least five other banks accepted 31 unsigned checks that withdrew $9,228 from his account. Nearly every time, Mr. Guthrie’s bank told those financial institutions the checks were fraudulent, and his money was refunded. But few investigated further.

The suit against P.P.C. ended in February. A court-appointed receiver will liquidate the firm and make refunds to consumers. P.P.C.’s owners admitted no wrongdoing.

Wachovia was asked in detail about its relationship with P.P.C., the withdrawals from Mr. Guthrie’s account and the accusations in the United States attorney’s lawsuit. The company declined to comment, except to say: “Wachovia works diligently to detect and end fraudulent use of its accounts. During the time P.P.C. was a customer, Wachovia honored all requests for returns related to the P.P.C. accounts, which in turn protected consumers from loss.”

Prosecutors argue that many elderly accountholders never realized Wachovia had processed checks that withdrew from their accounts, and so never requested refunds. Wachovia declined to respond.

The bank’s statement continued: “Wachovia is cooperating fully with authorities on this matter.”

Some Afraid to Seek Help

By 2005, Mr. Guthrie was in dire straits. When tellers at his bank noticed suspicious transactions, they helped him request refunds. But dozens of unauthorized withdrawals slipped through. Sometimes, he went to the grocery store and discovered that he could not buy food because his account was empty. He didn’t know why. And he was afraid to seek help.

“I didn’t want to say anything that would cause my kids to take over my accounts,” he said. Such concerns play into thieves’ plans, investigators say.

“Criminals focus on the elderly because they know authorities will blame the victims or seniors will worry about their kids throwing them into nursing homes,” said C. Steven Baker, a lawyer with the Federal Trade Commission. “Frequently, the victims are too distracted from dementia or Alzheimer’s to figure out something’s wrong.”

Within a few months, Mr. Guthrie’s children noticed that he was skipping meals and was behind on bills. By then, all of his savings — including the proceeds of selling his farm and money set aside to send great-grandchildren to college — was gone.

State regulators have tried to protect victims like Mr. Guthrie. In 2005, attorneys general of 35 states urged the Federal Reserve to end the unsigned check system.

“Such drafts should be eliminated in favor of electronic funds transfers that can serve the same payment function” but are less susceptible to manipulation, they wrote.

But the Federal Reserve disagreed. It changed its rules to place greater responsibility on banks that first accept unsigned checks, but has permitted their continued use.

Today, just as he feared, Mr. Guthrie’s financial freedom is gone. He gets a weekly $50 allowance to buy food and gasoline. His children now own his home, and his grandson controls his bank account. He must ask permission for large or unusual purchases.

And because he can’t buy anything, many telemarketers have stopped calling.

“It’s lonelier now,” he said at his kitchen table, which is crowded with mail. “I really enjoy when those salespeople call. But when I tell them I can’t buy anything now, they hang up. I miss the good chats we used to have.”

    Bilking the Elderly, With a Corporate Assist, NYT, 20.5.2007, http://www.nytimes.com/2007/05/20/business/20tele.html?hp

Cool Reception for Plan

to Let Elderly Ride Free

May 13, 2007
The New York Times
By ALISON LEIGH COWAN

STAMFORD, Conn, May 11 — To many commuters in Connecticut, the state’s overworked mass transit system would be vastly improved by an infusion of new rail cars providing more seats and new bus routes to cover more ground.

But to Senator Donald E. Williams Jr., the system would also benefit from the infusion of something old, namely more residents 65 and older. Lots of them.

Mr. Williams, the president pro tem of the State Senate, introduced a measure now before the General Assembly that would let elderly residents ride free on trains and buses during off-peak hours.

Yet the Connecticut chapter of AARP is not lobbying for the free ride — “It wasn’t our proposal,” said John Erlingheuser, the group’s advocacy director — preferring that the money to go toward shoring up a different program already in place.

That, and the opposition of a statewide commuter organization, has not stopped Mr. Williams, a Democrat from the rural town of Brooklyn on the eastern fringe of the state, from pressing ahead.

Mass transit agencies around the country are offering discounted fares to elderly residents, from Charlotte, N. C., to Portland, Ore., which diplomatically calls its program an “honored citizens” fare.

Yet few, if any, places have gone as far as Pennsylvania did in 1973, when it introduced free rides for elderly residents at off-peak times, subsidizing the program with funds from the state-run lottery.

“My understanding is that it’s the only state that does that,” said Virginia Miller, a spokeswoman for the American Passenger Transport Association in Washington, which represents transit agencies.

In Connecticut , the measure introduced by Senator Williams, which would cost the state an estimated $9.7 million a year, is being debated as part of the budget-wrangling in Hartford.

Because his party holds a veto-proof majority in both houses, bills that carry Senator’s Williams’s imprimatur have a good chance of becoming law, whether or not Gov. M. Jodi Rell or her fellow Republicans agree with them. In this case, the governor’s spokesman, Chris Cooper, said that Governor Rell was interested in seeing the final language but had qualms about the cost of the program and the risk that it could cause overcrowding on buses and trains.

For now, Senator Williams shows little sign of retreating. In his view, offering the state’s 480,000 elderly residents a powerful incentive to board buses and trains is “a natural idea” that helps maintain the independence of people who have given up driving and eases traffic congestion.

In addition, he said that by having more elderly residents using the trains and buses, “We build a stronger and more powerful constituency for improvement and expansion of public transportation.”

Mr. Erlingheuser said his group would rather see the proposed subsidies go toward dial-a-ride services currently used in 136 Connecticut towns and cities, which typically pick up and discharge elderly and disabled passengers at their door and are credited with keeping many people from becoming housebound.

Sponsors of these programs were promised they could share up to $5 million a year in matching state grants when the law was approved eight years ago, but for six years legislators did not subsidize the program. They then appropriated only $6.1 million for fiscal 2006 and 2007, leaving an anticipated $3.9 million shortfall.

Without state funds, Mr. Erlingheuser said, operators of existing programs are skittish about continuing, and the few dozen municipalities without programs are sitting on the fence.

“At the end of the day, does anyone who is of a certain age need a free bus or train ride?” Mr. Erlingheuser asked. “No. Are there people who have no access to any transportation who face insurmountable obstacles? Yes.”

For its part, he said his group preferred “fully funding what we do know seniors need and rely on before we start talking about other transportation proposals.”

Nor is that group the only one that is not sold on the free rides. At a public hearing, Jim Cameron, a Darien resident who is chairman of the Connecticut Rail Commuter Council, called the proposal a “feel-good bill based on a false premise” that the rail system has any capacity to give away.

“In Hartford, on the bus, maybe there are empty seats,” Mr. Cameron said. “I can tell you on Metro-North, whether it’s peak or off-peak, there are not empty seats.”

He predicted ugly clashes between commuters paying hundreds of dollars for their monthly tickets and affluent retirees from Greenwich or Darien riding the train to New York free to see a Broadway show.

“I’m not insensitive to the seniors if they want to take the train,” Mr. Cameron said, “but they’re not taking it every day, and they already get a 50 percent fare cut.”

Another concern that has been raised is that the cost to taxpayers could balloon if the giveaway proves too popular. The estimate prepared by the nonpartisan Office of Fiscal Analysis in January that put the cost of the program at $9.7 million a year was made on the assumption that there would be “no significant increase in overall ridership.”

The analysts factored in 1 million free rides on off-peak trains and 2 million on buses, but they warned that “the estimate could significantly escalate” if the program proved too popular.

Dan Brucker, a spokesman for the Metro-North Railroad in New York, which operates the New Haven line for New York and Connecticut, said any decision to allow the state’s elderly residents to ride free was strictly “a State of Connecticut issue.”

“The cost of that missing revenue would have to be borne by the state of Connecticut,” said Mr. Brucker, noting that Connecticut already shoulders 65 percent of the losses incurred by its interstate trains, and paid $52 million to Metro-North last year as its share.

Senior citizens who had gathered at Stamford’s government center on Tuesday, some to play bridge, others to have their blood pressure checked, practice their tai chi and enjoy a subsidized lunch with friends, were divided on the wisdom of the proposed legislation.

“Even if I don’t use it, I think it’s a valuable service,” said Rea Greenman, 87, a former customer service specialist.

But told that the association for retired persons preferred to finance the dial-a-ride programs, Ms. Greenman cooled quickly on the notion of a free train ride. “I really think the dial-a-ride is more important than the train,” she said. “How often do senior citizens go out of town?”

Jim Goodridge, 95, was even more opposed to the proposal.

“What are the train people going to say if the trains are full of people and no money?” Mr. Goodridge asked.

“Well, if it’s off-peak, no one should care,” countered Lois PontBriant, a fellow bridge player.

“The trains are crowded now,” Mr. Goodridge said.

Many younger commuters approached at the Stamford train station were more cavalier about the proposal.

“I don’t think it will appreciably add to the numbers riding the trains,” said Richard Noyes, an executive with Cisco Systems. “It’s such a small issue — the money — when we spend $10 million on pork projects.”

And boarding a New York-bound train, Steve Striffler said that even if he had to stand once in a while, “I don’t oppose the elderly riding for free.” After all, he said, “They’ve earned it.”

Ernie Matarasso, who described himself as an occasional rider, urged another approach altogether.

“Do what they do with the museums,” Mr. Matarasso recommended. “Make it voluntary. If a couple of wealthy people get on without paying, so be it. It’s the advantage of being old.”

    Cool Reception for Plan to Let Elderly Ride Free, NYT, 13.5.2007, http://www.nytimes.com/2007/05/13/nyregion/13seniors.html

Aged, Frail and Denied Care

by Their Insurers

March 26, 2007
The New York Times
By CHARLES DUHIGG

CONRAD, Mont. — Mary Rose Derks was a 65-year-old widow in 1990, when she began preparing for the day she could no longer care for herself. Every month, out of her grocery fund, she scrimped together about $100 for an insurance policy that promised to pay eventually for a room in an assisted living home.

On a May afternoon in 2002, after bouts of diabetes had hospitalized her dozens of times, Mrs. Derks reluctantly agreed that it was time. She shed a few tears, watched her family pack her favorite blankets and rode to Beehive Homes, five blocks from her daughter’s farm equipment dealership, content that she would not be a financial burden on her family.

But when she filed a claim with her insurer, Conseco, it said she had waited too long. Then it said Beehive Homes was not an approved facility, despite its state license. Eventually, Conseco argued that Mrs. Derks was not sufficiently infirm, despite her early-stage dementia and the 37 pills she takes each day.

After more than four years, Mrs. Derks, now 81, has yet to receive a penny from Conseco, while her family has paid about $70,000. Her daughter has sent Conseco dozens of bulky envelopes and spent hours on the phone. Each time the answer is the same: Denied.

Tens of thousands of elderly Americans have received life-prolonging care as a result of their long-term-care policies. With more than eight million customers, such insurance is one of the many products that companies are pitching to older Americans reaching retirement.

Yet thousands of policyholders say they have received only excuses about why insurers will not pay. Interviews by The New York Times and confidential depositions indicate that some long-term-care insurers have developed procedures that make it difficult — if not impossible — for policyholders to get paid. A review of more than 400 of the thousands of grievances and lawsuits filed in recent years shows elderly policyholders confronting unnecessary delays and overwhelming bureaucracies. In California alone, nearly one in every four long-term-care claims was denied in 2005, according to the state.

“The bottom line is that insurance companies make money when they don’t pay claims,” said Mary Beth Senkewicz, who resigned last year as a senior executive at the National Association of Insurance Commissioners. “They’ll do anything to avoid paying, because if they wait long enough, they know the policyholders will die.”

In 2003, a subsidiary of Conseco, Bankers Life and Casualty, sent an 85-year-old woman suffering from dementia the wrong form to fill out, according to a lawsuit, then denied her claim because of improper paperwork. Last year, according to another pending suit, the insurer Penn Treaty American decided that a 92-year-old man had so improved that he should leave his nursing home despite his forgetfulness, anxiety and doctor’s orders to seek continued care. Another suit contended that a company owned by the John Hancock Insurance Company had tried to rescind the coverage of a 72-year-old man when he was diagnosed with Alzheimer’s disease four years after buying the policy.

In court filings, all three companies said the denials had been proper. They declined further comment on the cases, though Bankers Life and John Hancock eventually settled for unspecified amounts.

In general, insurers say criticisms of claims-handling are unfair because most policyholders are paid promptly and some denials are necessary to root out fraud.

In a statement, Conseco said the company “is committed to the highest standards for ethics, fairness and accountability, and strives to pay all claims in accordance with policy contracts.” Penn Treaty said in a statement, “We strive to treat all policyholders fairly, and to deliver the best, most efficient evaluation of their claim as possible.”

But policyholders have lodged thousands of complaints against the major long-term-care insurers. A disproportionate number have focused on Conseco, its affiliate, Bankers Life, and Penn Treaty. In 2005, Conseco received more than one complaint regarding long-term-care insurance for every 383 such policyholders, according to data from the insurance commissioners’ association. Penn Treaty received one complaint for every 1,207 long-term-care policyholders. (The complaints touch on a variety of topics, including claims handling, price increases and advertising methods.)

By comparison, Genworth Financial, the largest long-term-care insurer, received only one complaint for every 12,434 policies.

Conseco is among the nation’s largest insurers, collecting premiums worth more than $4.2 billion in 2006, of which long-term-care policies contributed 21 percent. Penn Treaty focuses primarily on long-term-care products and collected premiums of about $320 million in 2004, the last year the company filed an audited annual report.

In depositions and interviews, current and former employees at Conseco, Bankers Life and Penn Treaty described business practices that denied or delayed policyholders’ claims for seemingly trivial reasons. Employees said they had been prohibited from making phone calls to policyholders and that claims had been abandoned without informing policyholders. Such tactics, advocates for the elderly say, are becoming common throughout the industry.

“These companies have essentially turned their bureaucracies into profit centers,” said Glenn R. Kantor, a California lawyer who has represented policyholders.

Yet these concerns have been ignored by state regulators, advocates say, and have gone unnoticed by federal lawmakers who recently passed incentives intended to promote purchases of long-term-care policies, in the hopes of forestalling a Medicare funding crisis.

Conseco and Bankers Life “made it so hard to make a claim that people either died or gave up,” said Betty J. Hobel, a former Bankers Life agent in Cedar Rapids, Iowa.

“When someone is 70 or 80 years old,” she said, “how many times are they going to try before they just give up?”

A Race to Sell Policies

When Mrs. Derks bought her long-term-care policy from a door-to-door salesman in 1990, she was unaware that she represented the insurance industry’s newest gold mine.

Her husband had died eight years earlier of a stroke, leaving her to run a barley farm in northern Montana, where she lived with her three children and her aging mother. As she watched her own parent decline, Mrs. Derks became preoccupied with sparing her children the expense of her final years.

“She was terrified that she would bankrupt us or get sent to a public nursing home,” said Ken E. Wheeler, her son-in-law.

At the time, long-term-care policies, which can cover the costs of assisted-living facilities, nursing homes and at-home care, were becoming one of the insurance industry’s fastest-growing products. Companies like Conseco, Bankers Life and Penn Treaty were aggressively signing up clients who were not in the best health at rates far below their competitors’ in order to win more business, former agents said. From 1991 to 1999, long-term-care sales helped drive total revenue gains of roughly 500 percent each at Penn Treaty and Conseco, including its affiliate Bankers Life.

Cracks in the business, however, soon started to appear. Insurance executives began warning they had underestimated how long policyholders would live after entering nursing homes. The costs of treating Alzheimer’s, Parkinson’s and diabetes ballooned.

As insurers began realizing their miscalculations, they persuaded insurance commissioners in California, Pennsylvania, Florida and other states to approve price increases of as much as 40 percent a year.

By 2002, Conseco’s long-term-care payouts exceeded revenue. Those and other disappointing results prompted the company to file for bankruptcy, from which it emerged 10 months later.

That same year, Mrs. Derks entered Beehive Homes, a cheery, 12-bed center one block from the Prairie View elementary school. In the previous four years, she had been hospitalized more than two dozen times. She had once lain unconscious in her living room for a day and a half. Her physician ordered her into an assisted-living center.

Initially, Conseco told Mrs. Derks’s daughter, Jackie Wheeler, that her claim would go through smoothly, Mrs. Wheeler said. The family began paying Beehive Homes’s $1,900 monthly fee.

But three months after submitting her claim, Mrs. Derks received a letter from Conseco saying she had waited too long, and her earliest costs would not be reimbursed. Two months later, she received another letter denying her entire claim because she had not submitted proof of illness.

Yet a copy of Mrs. Derks’s policy, sent to the Wheelers by Conseco in 2004 and reviewed by The Times, mentions no requirement for proof of illness. The policy requires only that the confinement be ordered by a physician, and it allows for a notice of claim to be sent “as soon as reasonably possible.”

Mrs. Derks’s daughter called Conseco and explained that her mother could not recall the date or people’s names and had started multiple fires by forgetting to turn off the stove. She sent letters stating that her mother needed assistance to dress, eat, go to the bathroom and inject insulin.

“This is medically necessary!!!” reads a form signed by Mrs. Derks’s physician in 2004. “This has been filled out three times! This person needs assistance!”

Seven months later, Conseco sent another letter, this time denying Mrs. Derks’s claim because her policy “requires a staffed registered nurse 24 hours per day.” Her policy does not mention such a requirement.

Conseco also sent letters denying Mrs. Derks’s claim because her policy had an “assisted living facility rider,” and because Mrs. Derks “does not have an assisted living facility rider.” In all, the family received more than a dozen letters from the company. Many contradict one another, and frequently cite requirements that are nowhere mentioned in Mrs. Derks’s policy.

“There was always a new step in the runaround,” Mrs. Wheeler said. “It felt like everything was designed to make me just go away.”

Over two years, Mrs. Wheeler estimated, she called the company about 100 times. Twice a month, she sent envelopes stuffed with medical records. Some afternoons, she spent hours making calls. After one conversation, Mrs. Wheeler slammed down the phone and started to cry. Then she drove to Beehive Homes, where her mother was surrounded by faded photos of her childhood and boxes of adult diapers.

“I wouldn’t tell her about the problems we were having with Conseco, because I knew it would cause her so much worry,” Mrs. Wheeler said.

Eventually, the Wheelers sold part of their John Deere dealership to raise money to pay for her mother’s care. In October 2006, they sued.

Conseco, asked by a reporter about the company’s handling of the Derks claim, declined to answer, citing the pending litigation. In court documents, the company denied Mrs. Derks’s allegations without specifying why her claim was denied.

“We did everything they asked,” Mrs. Wheeler said. “And this company just treats us like dirt.”

Tales of Bureaucracy

Inside the large Conseco headquarters in Carmel, Ind., scores of employees receive the flood of documents and calls that arrive each day. At times, according to depositions and interviews, that deluge became so overwhelming that documents were lost, calls went unreturned and mistakes occurred.

Some employees describe vast mailrooms where documents appear and disappear. One call-center representative said he was afforded an average of only four minutes to handle each policyholder’s call, no matter how complicated the questions. Employees said they were instructed not to say when the company was behind in processing paperwork, even when the backlog extended to 45 days. Workers were prohibited from contacting each other by phone, although such calls might have quickly resolved obstacles, according to depositions.

Conseco, asked in detail about the company’s policies, declined to respond.

Bureaucratic obstacles were pervasive, according to interviews with 10 former Conseco employees and depositions of more than a dozen others. Robert W. Ragle, a former Bankers Life branch manager, once contacted the claims department on behalf of a client, and “they just laughed us off the phone,” he said. “Their mentality is to keep every dollar they can.” Mr. Ragle was dismissed by Bankers Life in 2002. He sued for wrongful termination and settled out of court.

In lawsuits, complaints and interviews, policyholders contend that Conseco, Bankers Life or Penn Treaty denied claims because policyholders failed to submit unimportant paperwork; because daily nursing notes did not detail minute procedures; because policyholders filled out the wrong forms after receiving them from the insurance companies; and because facilities were deemed inappropriate even though they were licensed by state regulators.

In depositions conducted on behalf of angry policyholders, Conseco employees described bureaucratic obstacles that prevented payment of claims. Those depositions were sealed in settlement agreements but were obtained by The Times.

In a 2006 deposition, a Bankers Life and Conseco claims adjuster, Teresa Carbonel, testified that she denied claims because of missing records but was prohibited from calling nursing homes or physicians to request the documents. She also testified that when a claim was denied, she was forbidden to phone a policyholder, but instead used a time-consuming mailing system.

Ms. Carbonel’s testimony, recorded during lawsuit on behalf of a 94-year-old policyholder, Rhodes K. Scherer, also disclosed that if policyholders did not mail requested documents within 21 days, Conseco might abandon their claim, sometimes without informing them.

In the case of Mr. Scherer, who was institutionalized after a bathroom fall, it was difficult to obtain a response, Ms. Carbonel said, because the company’s requests were mailed to his home address, rather than the nursing center where the company had been notified that he had moved. Ms. Carbonel, who is no longer with the company, did not return calls. Conseco declined to comment on her testimony.

In another deposition, Conseco’s then-senior manager for long-term- care claims, Jose S. Torres, testified that Conseco would sometimes withhold payments until it received documents not required by customers’ policies. In Mr. Scherer’s case, Mr. Torres said, the company refused to pay his nursing home costs unless he sent copies of the home’s license, payment invoices and medical records, even though those documents had no bearing on approving his claim.

Mr. Scherer’s claim “was handled not in the best way, but it was handled according to the processes and procedures placed at the time,” Mr. Torres testified. “Mistakes are going to be made, you know.”

Other executives testified that when Conseco appeared to have lost important documents in Mr. Scherer’s claim, no investigation was initiated. Shawn Michael Schechter, a Conseco claims supervisor who left the company in 2005 on positive terms, according to the deposition, testified that the handling of Mr. Scherer’s claim violated the principle of good faith, which requires insurance companies to treat customers fairly.

“The claim adjuster could have made that very easy and not have put the burden back onto the policyholder,” he testified.

Mr. Torres did not return calls. Mr. Schechter declined to answer questions.

Mr. Scherer died in 2004 without receiving benefits from Conseco. His estate settled with the company in February for an undisclosed amount, according to a lawyer representing the estate.

Conseco declined to discuss its complaint history or individual cases, citing confidentiality agreements. In its statement, the company said that in 2006, Conseco paid nearly $2.3 billion on 9.8 million claims in all types of insurance sold by the company.

The company added: “Conseco, through training, education and process improvements in all of its insurance companies, is continuously focused on enhancing service and resolving any problems expeditiously. The Conseco Insurance Group’s overall insurance department complaints decreased 20 percent from 2005 to 2006.”

Depositions of executives at Penn Treaty also point to questionable practices. In a 2005 lawsuit, a Penn Treaty senior vice president, Stephen Robert LaPierre, testified that the company rejected one claim without informing the policyholder why, asked for information that was not required to process a claim, gave incomplete information about a claim’s status and said the company was delaying payment because of an investigation while failing to take steps that might have resolved the inquiry.

Mr. LaPierre declined to discuss his testimony. Penn Treaty settled the lawsuit by paying the policyholder an unspecified amount, the policyholder’s lawyer said.

Penn Treaty said in a statement that evaluating a company by measuring its complaints was flawed, and that since 2003, the company has denied an average of less than 1.7 percent of the up to 8,000 claims it received every year because of reasons related to policyholder eligibility. “From time to time, Penn Treaty is compelled to investigate fraud or questionable billing activities,” the company added.

Few Regulatory Inquiries

Few of the cases or complaints filed against Conseco, Bankers Life, Penn Treaty or other insurers have received much attention, in part because many lawsuits filed against long-term-care insurers have been settled with the requirement that depositions, documents and settlement terms be kept confidential. Frequently, say policyholders’ lawyers, the companies have been willing to pay millions of dollars in exchange for confidentiality.

Furthermore, despite the complaints against long-term-care insurers, few states have conducted meaningful investigations.

Ron Gallagher, a deputy commissioner with the Pennsylvania Insurance Department, said, “I don’t know that we have a real problem with improper claim denials.”

Yet data from the National Association of Insurance Commissioners show that from 2003 to 2005, Pennsylvania received more complaints regarding Conseco, Bankers Life and Penn Treaty than any other state. Mr. Gallagher said he might begin a new review of those companies.

Other states with large numbers of long-term-care complaints, including California, Missouri, Maryland, Indiana and Washington have not begun investigations, or have reviewed only small numbers of policies.

As a result, other seniors may end up like Mrs. Derks.

While she was waiting for her lawsuit to proceed, Medicaid began contributing to Ms. Derks’s care. Taxpayers now pay Beehive Homes about $32 daily for her care.

“Long-term-care insurance is supposed to result in less pressure on Medicaid, not more,” said Ms. Senkewicz, the former executive at the insurance commissioners’ association.

For Mrs. Derks’s family, things have already broken down.

“How many other people are out there who don’t have a family to fight for them and have just given up?” asked Jackie Wheeler. “This company should be ashamed.”

    Aged, Frail and Denied Care by Their Insurers, NYT, 26.3.2007, http://www.nytimes.com/2007/03/26/business/26care.html?hp

New Options (and Risks)

in Home Care for Elderly

March 1, 2007
The New York Times
By JANE GROSS

Dr. Diane E. Meier, a geriatrician at Mount Sinai Medical Center in New York, is an expert on end-of-life care. So when her elderly parents needed long-term help at home with bathing, dressing and cooking after her father’s stroke, she knew where to find assistance.

It was not through agencies in Manhattan that provide home health aides who are bonded, insured and certified. A year of custodial care from such an agency would cost her family $150,000, and in short order exhaust its savings because aides are not covered by government assistance unless patients are poor or fresh from a hospital stay.

Instead Dr. Meier turned to “a little list” of aides from the so-called gray market, an over-the-back-fence network of women. They are usually untrained, unscreened and unsupervised, but more affordable without an agency’s fee, less constrained by regulations and hired through personal recommendation.

With 4.2 million Americans currently over 85 — a number expected to grow to 5.9 million by 2014 and then accelerate with the baby boom generation — the exploding need for long-term care is remaking the home-care industry, driving more of it underground. Gray-market hiring, fraught with risks, is a solution that middle-class families are turning to as they face the crushing burden of indefinite home-care expenses. But it is hardly the only one, as businesses rush to meet the needs of these families, the fastest-growing segment of the marketplace, who are intent on keeping their loved ones out of nursing homes.

Traditional agencies like the Visiting Nurse Service, founded to serve the poor with all manner of home health care, are opening divisions geared toward clients who must pay their own way. At VNS, 15 percent of clients now pay out of pocket, an 11 percent increase over last year, and aides trained in wound care and vital signs are also learning to interact with doormen, use espresso machines or escort a client to the opera.

At the same time, upscale agencies providing trained aides are proliferating solely for the private-pay market, as are national chains with more modest services — and more reasonable prices. These franchises are intended for today’s consumer of home health care who need simple companionship, reminders to take medication, an escort to doctors’ appointments and help preparing meals.

The largest of these chains, Home Instead, opened in 1994 with six franchises and now has 722. Their 37,000 part-time workers tend to the needs of 43,000 elderly clients. The advantage is a lower hourly fee — say, $15 an hour for nonmedical needs vs. $20 an hour for a trained agency aide — and the disadvantage a scramble to find more skilled help as a patient’s health declines.

Policy experts worry that the new home health care businesses could put profit above quality.

“Consumers are always in jeopardy when there’s an opportunity to make a lot of money,” said Val J. Halamandaris, president of the National Association of Home Care, who 40 years ago was chief counsel to the Senate Committee on Aging. “Sometimes it works out beautifully, and sometimes it doesn’t. But nobody’s policing it; that’s for sure.”

Gray-market hiring, which Dr. Meier says most of her patients choose, is largely a financial decision to avoid the fees of home-care agencies, where perhaps $9 of the $20 hourly fee goes to the aide. In a gray-market arrangement, the aide might get $12, a 33 percent increase — although sometimes without benefits, worker’s compensation or Social Security — leaving a family able to afford additional hours.

Many who have hired by word-of-mouth, without criminal background checks, and paid directly cite the loyalty of employees and their ability to work unfettered by regulations. Some agencies, for example, prohibit their aides from lifting a patient who has fallen without calling 911 or getting approval from a supervisor. That rule protects a client from being moved improperly, the aide from injury and an agency from liability. But some families shudder at the prospect of a loved one lying on the floor.

Many families worry more about temperament than tasks. Dr. Meier, and most of her patients say that entrusting someone with intimate care is less a reasoned decision than an intuition about character.

“You can teach someone how to turn a bed-bound person,” Dr. Meier said, “but you can’t teach the milk of human kindness.”

Others say they chose gray-market employees if family members insisted upon someone of the same race. That is why Michael Elsas, president of Cooperative Home Care Associates in the Bronx, a worker-owned agency, turned to what he called “the German au pair network,” rather than his own better-trained aides, for his mother. But as her Parkinson’s disease progressed, Mr. Elsas said, the au pairs were not up to the task. He hired two aides from his agency, keeping one of the German women to placate his mother.

“The cost quadrupled,” Mr. Elsas said, to $1,400 a week, from $350.

Referrals from corporate employee-assistance plans and also coverage under long-term care insurance are fueling the growth of the full-service agencies. Senior Bridge, for example, has expanded from New York City to 18 suburban and Sun Belt locations. And House Works in Boston, a boutique agency with fewer than 700 clients, has seen its gross revenue grow in six years to $9 million, from $590,000.

According to the American Association of Long-Term Care Insurance, a trade group for agents, more than one-third of the $63.3 billion in benefits paid in 2006 went toward home care. But policies differ in whether they cover only certified aides or a broader menu including gray-market employees or companions. And state insurance officials worry about the pressure to deny benefits as more policyholders, now in their 50s and 60s, begin to make claims.

The demand for home care aides throughout the industry is expected to outstrip supply. The Bureau of Labor Statistics counted 663,280 such aides in 2005, up from 577,530 in 1999, a tally that does not include gray-market workers. But the Census Bureau reports a stagnant number of women with little education, ages 25 to 54, the traditional labor pool for this occupation, just as the 85-and-over population is soaring.

Innovators in the field are looking for ways to reduce turnover, estimated at 40 percent to 100 percent a year by various agencies. This so-called churn results in an inexperienced and uncommitted work force.

The Service Employees International Union has been at the cutting edge of creating a more stable pool of workers. In New York, Local 1199 unionized 60,000 home-care employees. Unionized aides, many of them former welfare recipients, get a full array of benefits, rare in this industry, and opportunities to master English, study nursing or learn computer skills.

One of the union’s newest offerings is a sort of consciousness-raising group, focusing on self-esteem and a sense of community among otherwise isolated workers. Last month, 13 aides from an agency in Queens shared their gripes with a facilitator. Many had been summoned from clients’ homes just moments before the workshop. This sort of administrative confusion was typical, they said, and along with wages, which average $9.34 an hour nationwide, is their main complaint. But aides also said clients criticized their broken English, refused to eat their ethnic food, touched them inappropriately or assumed they would steal.

The Visiting Nurse Service is raising its pay scale to $10 an hour by 2008. Compensation will be tied to seniority, which VNS hopes will reduce turnover, and to the completion of specialty training in areas like Alzheimer’s disease, which will provide career ladders for aides.

By all accounts, there is only one training program in the country for gray-market aides, at the Schmieding Center for Senior Health and Education at the University of Arkansas. There, Dr. Larry Wright, a geriatrician, designed a 119-hour curriculum for independent contractors, most enrolled by private employers. The course costs only $275, thanks to the subsidy of a benefactor.

Dr. Wright makes a case for buttressing the independent work force.

“If I saw agencies doing fantastic work, it would be one thing,” said Dr. Wright, who says most agencies do little more than criminal background checks. “But there’s not much value added and significant cost.”

Even the best-trained agency aides wind up improvising in the privacy of a client’s home. It may be against the rules to escort patients in a private vehicle or use their credit cards when shopping. But Mr. Elsas, of Cooperative Home Care Associates, has no doubt it happens.

“The system depends on the good judgment and integrity of workers who may be making $7 an hour,” he said. “What’s wrong with that picture?”

One effort to instill good judgment is a peer-mentoring program at Mr. Elsas’s agency where senior aides make in-home visits to newcomers. But a home setting precludes the oversight found in nursing homes, tightened after the scandals of the 1970s. Setting national standards for agency employees, independent contractors and even family caretakers is one goal of a conference in March at the International Longevity Center in New York.

Sheila Baker, a geriatric social worker who has hired gray-market help for her mother, prefers informal oversight. At Mount Sinai’s geriatric clinic, for example, aides escorting patients to medical appointments are always asked to leave the room long enough for the elderly person to speak freely about the arrangement. And at Ms. Baker’s mother’s apartment, even with a gray-market aide who was once a physician in the Philippines, Ms. Baker and her sister, a nurse, make unannounced visits.

Larry Minnix, head of the American Association of Homes and Services for the Aging, advocates national standards to prevent a repeat of the nursing home scandals in the home-care arena. And he speaks from personal experience.

Before they died, Mr. Minnix’s in-laws were cared for at home by one beloved aide hired from the gray market. That aide, in turn, hired friends for additional help. One, who did yard work, had a criminal record. Another, with a family of nine, ran up exorbitant grocery bills because she was taking most of the food home. But his in-laws, Mr. Minnix said, were dependent on the original aide and fearful of changing the arrangement.

“This could happen to anyone,” he said. “And it’s something the country doesn’t know what to do about yet.”

New Options (and Risks) in Home Care for Elderly, NYT, 1.3.2007, http://www.nytimes.com/2007/03/01/us/01aides.html