Author Archives: Dianne Savastano

Recommended Reading: Thank someone special

I mentioned earlier that for me, this year is about reconnection. Well, last week I visited a high school teacher that I had not seen since graduation! She had tremendous influence over who I became as a person, and I think of her often. So, I finally followed through on something I’d been thinking about doing for years. She had no idea of my admiration and all that she had taught me.

Soon after, I read an article titled, “The 7-Day Happiness Challenge.” I was so pleased to learn that I had inadvertently met the Day 4 challenge: “Thank someone special.”

Over the course of my career, I have had many jobs. I am fortunate to have made wonderful friends along the way and remain close to many of them. On the one hand, I loved reading in this article that scientific studies affirm my belief in the value of friendships. On the other hand, I wonder if those friendships would have “clicked” if we had been working virtually.

Recommended Reading: A moving article

Our work with clients often revolves around assisting them with dying without suffering. 

We were moved by this article — A Son’s Decision to Help His Father Die — in which Ben Griffith’s dad chose a method to end his life that was controversial — but protected by a Supreme Court ruling.

Our relationships with our pets can be lovely and we found two segments from 60 Minutes fascinating on so many levels. One was about the importance to humans of research with dogs. The other was about the importance of connection.

Clarifying Common Medicare Misconceptions

Medicare began in 1965. Since then, it has continued to evolve. 

Significant changes were made in 2010 with the passage of the Affordable Care Act. Additional changes occurred more recently with the passage of the Inflation Reduction Act. And so I am not surprised that many people are unaware of all the nuances. However, there are fundamental aspects of the program that continue to be misunderstood.With that in mind, let’s review some of the most common misconceptions…

“Medicare is free.”

Medicare Part A (inpatient care)

Part A is, in fact, free for most people, provided they have worked the requisite 40 quarters (10 years) in the US during their lifetime. If they have not, they can still enroll, but there is a cost. Individuals will pay $278/month if they’ve worked between 30 and 39 quarters (7.5–10 years) and $506/month if they’ve worked fewer than 30 quarters. 

Note that based on the work history of a spouse, an individual may still be eligible for Part A at no cost.

Medicare Part B (outpatient care)

This component always has a cost associated with it.In 2023, the base premium decreased to $164.50 from $170.10/month.

Individuals who fall into higher income categories must pay more — IRMAA (Income Related Monthly Adjustment Amounts) — in addition to the standard Part B premium and Part D premium. Both the ranges of income and the amounts required to pay changed in 2023.

“Medicare covers everything.”

On average, Medicare covers approximately 80% of healthcare costs. The remaining 20% is the responsibility of the individual and the amount is not capped. 

In order to mitigate the risk of this uncapped 20%, one may purchase a Medigap / Medicare Supplement Plan that will cover some or all of the balance. Another option is to enroll in a Medicare Advantage Plan that has an out-of-pocket maximum, in lieu of traditional Medicare. If you meet this maximum, the plan pays all balances at 100% for the rest of the year.

“COBRA is a good option if I am over 65 and retiring.”

COBRA allows the continuation of employer-sponsored health insurance. However, the full cost of the plan, along with an administrative fee, now becomes the responsibility of the insured. For those who did not realize how much their insurance had been subsidized by their employer, this can come as a surprise!

Although you may be eligible for COBRA, when you are over 65, it is not a good option and could leave you underinsured. This is because once you reach 65, Medicare is considered your primary coverage — whether you’ve enrolled in it or not. Your COBRA coverage will cover health insurance claims only after what Medicare paid or should have paid, so you may be held responsible for covering the first 80% of health insurance costs.

We frequently see misunderstandings about this topic when an employee negotiates a Separation Agreementwith an employer that includes the employer paying for some or all of the cost of COBRA for a period. Because the individual assumes they have adequate health insurance coverage, they don’t enroll in Medicare when they are supposed to.

In our experience, and although companies are trying to do a good thing for their exiting employee, we find the human resource professionals executing the arrangements are not always fully aware of how the rules surrounding Medicare work. Despite their positive efforts, they provide inaccurate advice that can lead to significant issues related to coverage and enrollment down the line.

“I must do something about Medicare as soon as I turn 65.”

We often receive anxious calls from clients who have heard something to this effect from a family member, neighbor, employer, etc. Let me assure you, it is not always true. Everyone’s situation is different and decisions about when to enroll in all components of Medicare must be made in the context of your life situation. Considerations include:

  • Whether you are continuing to work beyond the age of 65 and work for an employer with greater than 20 employees
  • Whether you have health insurance through a spouse
  • Whether you are participating in a Health Savings Account (HSA) with a high deductible health insurance plan
  • Whether you are eligible to participate in some form of retiree medical plan through your own employment or through that of a spouse

You can enroll in Medicare at different times, such as during an Initial Enrollment Period (IEP) or a Special Enrollment Period (SEP). Provided you follow the rules, you can remain continuously insured and can enroll for an effective date you desire without suffering any penalties. If you don’t enroll then, you will still have an opportunity at the beginning of every year during a General Enrollment Period (GEP). (Note that if you wait to enroll then, you may have an interruption in coverage and be required to pay a penalty.)

Steps to Take

  • One year before your 65th birthday, begin to research the topic of Medicare. This will allow you to develop a timeline for when you need to act in the context of your individual circumstances.
  • Enroll in a My Social Security account. This will help you identify if you are eligible for premium-free Part A. If you are not, and you think you may be eligible under a spouse’s work history, call Social Security to verify your understanding and ask about the process for enrollment. This may require a phone appointment with Social Security, rather than enrolling online. 
  • Consider any dependents on your current health insurance plan and develop a strategy for each of them, whether you plan to work beyond the age of 65 or if you plan to retire and transition to Medicare. You may have different solutions for each member of the family, such as COBRA coverage for one, an individual open market plan for another, or a university-sponsored health insurance plan for a college student.
  • Conduct a thorough analysis of the Medicare options you have and the cost of each so that you can make an informed decision and budget accordingly. Be sure to consider both the cost of the premium and the out-of-pocket costs you will incur.

Final Thoughts

Medicare is a comprehensive program that covers our healthcare costs when we are over the age of 65. However, as you can see, there are a lot of nuances regarding when to enroll, the enrollment process, and the available choices and products. 

Do your homework well in advance of when you should enroll! This will allow you to take actions that provide the best, most appropriate coverage for you and your family.

Recommended Reading: Family members

Many members of “The Sandwich Generation” are surprised by what it takes to simultaneously care for both children and aging parents. As a recent article points out, “The average caregiver is a 49-year-old woman who works outside the home and provides 20 hours per week of unpaid care to her mother.” Read more here.

Another family situation that requires careful planning is thinking ahead regarding those with intellectual and/or developmental disabilities. Many do not have long-term plans for when family members lose the ability to help them access government services or care for them directly. Read more here.

Preparing for Upcoming Outpatient Surgery

Years ago, when I worked as a surgical nurse, things were different. Patients came into the hospital the night before surgery and a major component of their pre-operative care was the education we provided to both the patient and their family (Care Partner). 

The content included what to expect and, more importantly, what they would be asked to do to prevent complications and enhance recovery. Although they were often anxious, having a discussion before an individual experienced physical pain made it more likely they would remember our recommendations and do what was required to help themselves afterward. 

Post-op was different as well. Patients stayed in the hospital much longer. For example, a gallbladder removal, an outpatient procedure today, involved a five-day stay. This additional time allowed us to provide physical care, adjusting our interventions as necessary, based on progress or complications.

As you can see, there have been a lot of changes over the past few decades! And yet, a trusting relationship with your surgeon and their associates, together with patient education before and after surgery, remains a key component of successful treatment. That’s why I am always looking to engage with surgeons that work with a team to provide a comprehensive approach. Today’s newsletter takes a closer look at what matters.

What You Should Know

Our healthcare system includes very high expectations of what consumers and their care partners can handle at home, without the privilege of onsite clinical guidance.

We expect individuals to follow detailed instructions about what to do the night before and on the morning of surgery. Those instructions might include the following:

  • How to prepare your skin
  • What medication regimen to follow, possibly including medications to prevent infection, to manage pain, and to prevent constipation
  • What to eat and drink and when
  • When to arrive at the facility and what to bring or not bring with you

Then, when the surgery is over and the person has recovered enough to be placed in a car for the ride home, the care partner is expected to take over and assimilate all the post-operative instructions. Often, these include:

  • How to care for the operative site, including observing for any signs of bleeding or infection
  • How to manage swelling with the use of ice and careful positioning
  • How to manage pain with a combination of medications, including making judgements as to the need and the effectiveness
  • How to manage the risk of infection with the use of antibiotics and/or wound care
  • How to accomplish personal care in the face of severe limitations in mobility
  • When and how to implement recommended exercise
  • How to prevent constipation
  • How to recognize if things are not going as expected and when to reach out for assistance

In my experience, when the post-operative care is performed well, individuals experience minimal suffering and recover expeditiously. When that does not occur, it is often the result of:

  • Not keeping limbs elevated and icing areas effectively enough to prevent swelling and pain
  • Not drinking enough fluids to stay hydrated
  • Not preventing the constipation that can result from a combination of anesthesia, insufficient fluid intake, minimized mobility, and pain medications. (For some, this issue can be more problematic than the pain from surgery.)
  • Decision making regarding the appropriate use of pain medications

Overall, although post-operative instructions may appear to be simple and easily achievable by an individual and a care-partner, what is missing is clinical judgement and effective problem-solving.

What to Look for From Your Surgeon and Team

When attending physician visits with clients, here is what I look for in a surgeon’s practice:

  • A comprehensive explanation of the surgical procedure and what the expected outcome should be on the day of surgery, the first week after, in 6 weeks, in 6 months
  • How they provide the education that includes a discussion of the following:
    • How to prepare for the event in the days preceding it and what to expect afterward
    • A description of anesthesia options, what to expect from the experience of having anesthesia, and how to prevent complications while recovering
    • Instructions about post-operative equipment that may be used, including ice packs/machines, splints, slings, etc.
    • Creative ways to achieve good positioning to achieve elevation of limbs
    • A discussion about pain and effective techniques to manage it, including options in addition to, or in replacement of, prescribed pain medication
    • A robust discussion about the appropriate and creative use of prescribed pain medications in combination with over-the-counter options such as Tylenol and anti-inflammatory medications
    • An outline of how to resume physical activity, what exercises should be implemented independently, and when to start formal physical therapy
    • Established written protocols with clear parameters that take the guesswork out of decision making
    • A clear way to be in quick touch with a member of the team if questions or concerns arise

There’s a Lot to Keep Track Of

A client of mine, Julie, recently had rotator cuff surgery and recovered beautifully. I was so impressed as I accompanied her and her husband/care partner, Jim, through it all. But even with all the preparation, and Jim’s obvious motivation to assist, he still required frequent advice. So we communicated regularly through the first post-op week. 

When I read the post-op instructions and saw that the protocols outlined to manage swelling, pain, and bowel function required interventions every two hours, I developed a spreadsheet to help Jim track what he was doing and included a space to make notes as to how the interventions were helping or not. 

After a few days, as he and Julie were making more mutual decisions, they were able to use the data and discuss what they felt was most helpful at achieving improvement. When Julie returned to see her surgeon, she and Jim brought the spreadsheet to refer to as they shared their experience and articulated their questions. The Physician’s Assistant (PA)was so impressed with their awareness and knowledge, that she asked for an electronic copy of the spreadsheet so that she could offer it to other patients. We were happy to share!

Final Thoughts

I have spent many years assisting both family and clients with the management of outpatient surgery (the principles are the same for non-orthopedic procedures). Preparation and education are key. 

Our system has high expectations of what you and your care partner can manage. It is all achievable. However, having a surgical team that provides comprehensive education and easily accessible support is needed, along with your motivation to strictly follow protocols, document outcomes, relay information, and do what it takes to help yourself. 

If surgery is on the horizon for you, I wish you all the best.