This week, a great team of researchers released a fascinating paper in JAMA Internal Medicine##. They asked a simple question: Do people who are at some point diagnosed with Alzheimer’s disease and related dementias (ADRD) display declining cognition in their financial management before diagnosis.
Results Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture).
Okay, this is just a wicked cool idea and study.
I’ve been spending a lot of my non-COVID related headspace on the challenges of choice in the ACA marketplaces. Choosing insurance under the best of circumstances is tough. There are a lot of things that need to be estimated and assumed and guessed at. There is a lot of language to decipher. There is a lot of edge cases that occur. Insurance choice is, at best, a challenge.
As we were talking about Medicare Open Enrollment yesterday, WVNG made a great comment (my emphasis)
My wife and I are on traditional Medicare, with no D or supplemental. We are betting that our current good health (he says while knocking furiously on wood) will continue, which is an unknown. As others have noted above, it’s a crazy complex system for anyone to navigate, but for a population where many have declining mental resources it is problematic.
Yeah!
The study above is strong evidence of pragmatic consequences of a chronic illness that will present well before diagnosis. It is a disease that makes executive management, and complex cognitive choices either more difficult or impossible as it progresses. Early signs of the disease show that routine choices/daily life management are more difficult for people who will eventually be diagnosed with ADRD. ADRD is not an unusual diagnosis. In this study, about a third of the cohort has at least one ADRD diagnosis on at least one claim. ADRD is tough to diagnose.
Yet we expect a population that has significant decision-making challenges due to their health conditions to sort through a complex decision menus to choose their hopefully optimal, or at least satisficing health finance and financial protection product every year.
OUCH!
##Nicholas LH, Langa KM, Bynum JPW, Hsu JW. Financial Presentation of Alzheimer Disease and Related Dementias. JAMA Intern Med. Published online November 30, 2020. doi:10.1001/jamainternmed.2020.6432
Barry
The most important piece of advice I have for people whose parents are declining is to get an accountant to put their finances in order, get an attorney, and get powers of attorney/medical powers of attorney.
My father was hit up by every frikkin’ right wing set of vultures; I believe that they buy and sell lists of suckers.
Also, you don’t want to find out that they paid into insurance for 30 years, but stopped paying last year, and therefore can’t collect anything.
OzarkHillbilly
We were at our daughter’s for Tday and her in laws were there too. MiL has alzheimers, I would say on a progression scale of 5 she is at 2-3. One thing I noticed with my father and can see in her is that the more choices they have, the more bewildered and confused they get. Looking at all the choices she had to pick from of what to eat, just flat out overwhelmed her.
When it come to my picking out a policy… Fuhgeddaboudit. I’m not even sure what some of the terms they use even mean, and when their descriptions of a policy read just like half the other policies except the prices vary widely. Long story short, last year I pinned the tail on a Humana HMO policy and it worked out pretty well for me thru several medical issues. This year? Screw it, I’m sticking with what I know works.
Lymie
While I absolutely take in and agree with your points, the paper finds statistical significance at a very low level of real difference in the groups, which is what a nice big sample will give you. Like the old Secret deodorant commercial, “because a woman’s pH is different from a man’s”. Well, yes, in the second decimal. Does it matter? In this era of automatic payments, ……?
Perhaps a good measure would be how many duplicate magazine subscriptions a person has….
And why was it only men? Wish I could see the whole text. What was the racial makeup?
P.S. I know Julie Bynum.
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wvng
We actually seemed more protected against ruinous medical costs by our ACA policy, with no caps and maximum annual payouts, than we are now under Medicare, for about the same premium payouts (for B).
gvg
I have thought of this before. I think busy tired people give up and drop out of insurance choices. When I was going through chemo, I knew I was grateful my employer insurance didn’t quibble about any payment, except one that still was paid later. I went to appointments and paid 20 or 40, and everything was fine. I didn’t have enough costs from a major illness to be worth not doing standard deductible, though it was close. It wouldn’t have been if I hadn’t had some major dental before the cancer diagnoses.
Everyone should have that. People who hurt for a long time or who have to take powerful drugs, are not up for wrangling with insurance companies. It has to be easy. The professional language doesn’t even translate and we can’t all be experts in that on top of our other life responsibilities.
Damned_at_Random
@Barry: I had much the same thought when reading this. It confirms what various scammers – including televangelists have known for years.
Alex
@Barry: It’s so true– my grandparents both have dementia, and the power of attorney and healthcare agent forms they did beforehand are the only reason I was able to get them care and prevent them from becoming homeless. By the time they have bad dementia, they aren’t competent to do those forms.
But power of attorney won’t let you do things that the person objects to, and this can be a problem. My grandfather was so resistant to allowing me to help that I couldn’t step in until he was essentially no longer able to stop me. In those few years, he lost about half a million dollars of their life savings to fraud and bad investments, defaulted on the life insurance, tanked their credit ratings with late bills, missed checkups and medicines resulting in him going blind, refused to get in-home care resulting in my grandmother falling, and missed the opportunity for them to go into their preferred senior housing option. Guardianship is not easy to get, and in their state if you try and fail you can’t try again for 2 years.
karensky
Just another reminder that our health care “system” is a piece of crap. It certainly improved with the ACA. I was lucky enough to keep my Federal BCBS plan that works well with Medicare Part B at Temple Health but I struggled during the Great Recession to keep it paid.
Ruckus
I get my healthcare in a federally supplied program that gives you much less choice than public medicine. You still have choice, you still can decline their advice, the docs are still licensed docs in the state you live in and regulated as such. It’s the VA. It has co-pays, depending on you, are you a combat vet, how much do you earn per year. The docs vary from insanely good to just above insane, like anywhere else. The bad ones don’t seem to last a long time. But the constancy of process seems to lead to good medicine on the whole. It’s a frustrating system if you want it to be, but not if you actually look at the entire system. IOW I’ve never had such good medical care and a lot of that is that it is an entire system, not a system of somewhat interconnected, somewhat related specialties that work on their timeline and total care is an afterthought.
Now on to the post at hand. I’ve known a couple of relatives with dementia/alzheimers and a few outside my family. Basic humanity does not go out the window but civilization’s version of humanity does. Responsibility takes understanding and application, neither of which a dementia patient is capable of after a certain point in the progression, which is not all that far along. Aging without dementia has a touch of that for almost everyone. The world around you changes as you age up. You change as you age up. Things that worked last week may not work as well or at all. Your ability to adjust to them will likely lessen. You will most likely need more medical care, irrespective of the level you had at a younger age.
Obvious Russian Troll
@Barry: We were lucky with my mother-in-law. While she did send checks to a few too many organizations that called (like the damn Fraternal Order of Police), she was still too skeptical to fall for any of the costlier scams.
I will add that even when we had to move her into the memory care unit she still couldn’t stand Trump.
When we were going through her papers before we moved her into the nursing home, I discovered we could track her decline by how she organized her papers. Files from before about 2000 were meticulously organized. Files after 2000 started to get a little sloppy, and after about 2010 she was just paper clipping random things together and throwing them into a file folder.
dnfree
If WVNG is around, I’d like to make a comment on not taking Part D because of being in good health and not currently needing medications. This can backfire on you, as I’ve heard from others. If your health changes five years down the road and you need an expensive medication, your premium for Part D will be increased every year to make up for the years you didn’t sign up for it. (The idea is like the individual mandate—keep the plans cheaper because even the healthy have them. Otherwise it’s like not buying homeowners insurance until the house is on fire.)
Generally there are plans that have a negligible premium and a deductible for people in this situation. I’d suggest checking with an insurance broker.
dnfree
@Obvious Russian Troll: we had a friend who stopped by his dad’s house every morning for coffee. On the way in the house, he would pick up the envelopes with checks for various scams that his dad had left for the mail carrier to pick up.
I spent years after my dad’s death removing him from right-wing mailing lists. The solicitations they sent alarmed him and he wanted to help save the country. We were just fortunate that he generally sent relatively small donations.
Lobo
Re: Choice Complexity
The usual market solution is to offer a range of choices. Past a certain point, the choices become overwhelming. Good policy is to often provide a set of three – five choices with a matrix showing differences. While the usual thinking is to get to the optimum plan, actually the less cognitive intensive method is to choose something that satisfies 80% of the most important areas. Optimizing the other 20% is usually not worth the cost. I have seen 401k’s start to move in this direction. Empowering people past a certain point becomes debilitating.
There’s a reason for insurance brokers, finance experts, etc. Maybe this is a place for AI. Plug in your situation and have the algorithm spit out the 3-5 best fits.
Your thoughts?
David Anderson
@Lobo: FUCK; are you scooping the perspective piece I submitted yesterday?
Yeah, getting a choice menu where the worst is not that bad OR it is pretty easy to make a pretty good even if not perfect choice, is what I want to see.
laura
@Obvious Russian Troll: All my life, my mom made sure that I knew where all the important papers were – in the alligator portfolio. Insurance policies, bank accounts, etc.,. When her dementia unravelled my parent’s well tended lives and I began the conservatorship process, I found the alligator portfolio. It was empty. I am sure that there are benefits they never received for lack of a record.
Alex
@Obvious Russian Troll: The organizational decline was a huge indicator. My grandfather still had every bit of correspondence regarding his WWII military service and VA from 70 years ago, meticulously filed. But by the time I had to move them to a nursing home, the living room was knee-deep in magazines and unopened mail.
I did get a kick out of listening to my grandmother talk to a collections agency on the phone about a medical bill they’d forgotten to pay. “Oh, that doesn’t sound right, I don’t think we owe anybody money. What did you say your name was? All right, and what were you calling about? Oh, dear, I don’t think we owe Dr. SoandSo money…”
Kelly
Same. I’ll age into Medicare in June so I’m shopping Obamacare and Medicare. I’d rather stay with Obamacare.
J R in WV
My dad never quite got to dementia, but he had leukemia, chemo, followed later on by COPD from chemo damage to his lungs. Long story short, he forgot to pay his Supplemental insurance for 2 or 3 months.
Sister-in-law (CPA accountant) spent a ton of time on the phone to the insurance company convincing them to accept payment of back due bills to reinstate his policy. Which was a great benefit to my dad. She is a RWNJ, as is my brother, but I will always be grateful for the help they gave my dad in his declining years.
I spent a lot of time in TX back then, don’t much care to go back. Hard memories.
ETA: Our insurance is Medicare, my supplemental is through my former employer, wife’s through her former employer; all paid automatically out of pension deduction. Hope that never changes!!!
wvng
@dnfree: Thanks.
J R in WV
@Kelly:
The difference is Medicare isn’t a for-profit corporation seeking ways to deny claims.
Wife spent 2 months in hospital starting at the ER with septic shock caused by necrotic pneumonia, a month in ICU on a vent, a couple surgeries, heart cath diagnostic, after Medicare payments our out-of-pocket was low 4 figures.
dnfree
@J R in WV: We have a supplement plan for Medicare, and I’ve had very expensive situations arise without a cent out of pocket. When I had my cataract surgeries, there was a charge of about $24 for each one because of some test Medicare doesn’t cover. And of course with a supplement we have to pay our own dental and vision (but an annual vision checkup is covered for me because of the aforementioned situations).
I always remember the Advantage salesman replying, in answer to someone else’s question in a group sales situation, “IF you have known medical conditions, and IF you can afford it, you’ll be better off with a supplement than an Advantage plan.”
WeimarGerman
Just wondering about the study design. 1999-2018 seems like a huge epoch to analyze with many technological changes (Internet, AutoPay, …) that could bias the study results if not handled very carefully.
So without AutoPay (say pre-2005) the cohort would have defaulted more often in those years while in later years some of the people with compromised cognition may have avoided the outcome.
Lobo
@David Anderson @Lobo: FUCK; are you scooping the perspective piece I submitted yesterday?
Yeah, getting a choice menu where the worst is not that bad OR it is pretty easy to make a pretty good even if not perfect choice, is what I want to see.:
I have a background in decision analysis. One part of the field that has always fascinated me has been choice “exhaustion”. Also, going with imperfect choices but ones that will work. Could you share that perspective with us all that you submitted? I enjoy what you post here.
wvng
@Kelly: So, My mind is officially blown. My wife signed up for a zero premium add on to Medicare and I couldn’t find what she was talking about at Medicare. No such thing as Medicare supplemental plans. She found a link and I started to think she had made a terrible mistake, but it turns out that a fair number of Medicare Advantage plans are zero premium for a LOT better coverage, including Part D. But you have to somehow know this. Which goes to David’s “complexity” issue. I had simply assumed that Medicare Advantage was more than I needed at greater cost.