Planning For Long-Term Care In Your Older Age

This post isn’t about caring for your elderly parents, it’s about the care you might need when you reach that time in your life. I realize this is a bold viewpoint but every physician should be planning for their death, disability, and old age. Even if you are 30 years old, fresh out of residency, you should have the means to decide upon your funeral arrangements and set aside the funds necessary to get it done. Otherwise, you might put undue tension on loved ones around you.

With those lovely, warm thoughts, let’s get right into wet diapers, drooling and making sure we don’t have to deal with mud-butt at an old age.

Elder Care – Defined

It’s possible that any of us at any age would need major assistance with daily living, should we become disabled at a young age. Though most disabilities are short-term in nature, this post won’t be addressing disability.

Some individuals who take very good care of themselves in their youth tend to have a very healthy and functional geriatric life. However, it’s more common in the US to suffer from lifestyle diseases, most of which have their onset around the time of traditional retirement.

Thanks (?) to modern medicine, we can extend the life of anyone for decades, even a person on a ventilator. Very little discussion is openly had on the real quality of life and the meaning of life itself in our Western cultures – so it’s the norm to suddenly find ourselves not being able to take care of ourselves at an older age.

I see 3 likely scenarios, having taken care of my share of geriatric patients:

1. You’ll be healthy and strong up until you take your last nap.
2. You will decline over a 5-8 year period and need more and more assistance over the years.
3. You have a sudden decline due to an unforeseen health event.

In the last 2 situations you will need assistance, but what kind and to what extent? Here we go again:

1. Minimal assistance, someone checking in on you a few times a week.
2. Moderate, daily assistance with bills/shopping/chores but you can manage feeding yourself, going to bed, and sleeping.
3. Full-time, you need supervision and around the hour care.

Single person facing old age

I’m often told that my life is simple and easy because I’m single and that I can do xyz because I’m single. But don’t be fooled, you have one income to depend on, you have only one person responsible for your future and well-being. You can’t depend on your children to take care of you. You can’t rely on your significant other to provide you with daily assistance.

As a single person you can either do everything possible to stay as healthy as possible or you have to buy into long-term care insurance (LTC). This could cost somewhere in the $2,000-$3,000 range per year or ~$200/month. There are various factors to consider so shop around if you want exact numbers.

Alternatively, if you plan your retirement well, you can take long-term care into consideration with your own budget. This is where it gets tricky because it’s quite dependent on your personal preferences.

Some people want to be kept alive as long as possible even if it means living in a nursing home, having to have their toileting managed by a caregiver and having to take their medication and food through tubing.

Some of my specialist colleagues have never set foot in a nursing home and others have rarely interacted with fragile geriatric patients. Working with nursing home patients was the most eye-opening experience of my medical education. I learned that longevity of life far superseded quality of life for the majority of Americans – that includes many physicians.

A Family Facing Old Age

If you are in a relationship with a partner and have offspring then you have a few extra options available to you. Depending on the social structure you have within your household, it might be expected for the kids or grandkids to take care of their elderly parents – I still see this to be quite the norm despite what I hear in popular media.

Being in a relationship has the added advantage of having one partner who is more capable until later in life while the other may lose their independent living sooner.

I keep trying to think of a couple who lives in a cooperative relationship, enjoying a high income in their younger years and having 2 sets of eyes and 2 brains planning out their retirement and care needs at an older age – I can’t see why they would need to purchase LTC. I am not saying they shouldn’t – that’s for the couple to decide with their financial adviser.

A Blurb For Women

A man-woman relationship often ends in the woman outliving the man which often comes with the responsibility of the woman taking care of the man. Though in our society women have taken on the caretaker responsibility from a very young age, it may be something to consider/anticipate if you are the woman in the man-woman relationship.

I suppose it wouldn’t be a gender-statistic issue if you are in a same-sex relationship. Though, if one partner has the better gene or takes better care of themselves, they may end up being the main caregiver to their significant other.

LTC Insurance versus Self-Insuring

We are bombarded with insurance products to solve damn near any problem which we come across in our society. The “better safe than sorry” mindset is perhaps one of the most lucrative catch phrases for insurance groups.

LTC insurance isn’t all that expensive when considering the physician household income. However, before making that decision, it’s important to weigh all the options and consider all the costs involved.

Self-Insuring

I am a fan of self-insuring, when possible. I certainly understand the need to insure against all sorts of random shit when you are a high-net-worth individual. But most of us aren’t, and until we become that, it’s important to learn to protect our assets.

I won’t spend too much time on around-the-clock high acuity nursing care. I don’t think it’s impossible to insource that into your own home but due to your likely mental incapacity, it’s impossible to self-manage.

Thinking back to family members, patients and stories which friends have told me when an elderly person gets to the point of not being able to manage some of the more consuming tasks, a set of helping hands is often all that is needed.

There are great resources such as Eldercare Locator to find out about traditional resources available.

The option that I see the most cost-effective is hiring your own help for your needs. It might be good to have a friend or a family member assist you with this but it’s as simple as doing an interview.

Where to find your aid? In another country. Our western culture looks down on certain jobs such as being a caretaker or demands such high wages that it’s not sustainable. Saving all your life to spend most of your money on aid seems backwards to me.

I’m usually not sensitive about such topics but I know my audience could be so I’ll leave out specific countries but will give you a very useful case example. One of our doctors who was elderly recently became the caregiver to his wife who suffered a debilitating stroke to the point of needing assistance with most of her daily activities.

One of the nurses at our workplace who wasn’t born in the US suggested that he hire a nurse from overseas who is looking to settle down in the US but would otherwise have no easy access to a visa. So, after putting him in touch with some friends/relatives, he hired a foreign-trained RN who he hired and sponsored for a visa. The last I heard he was happy with his decisions and was paying a lot less than what he would for Home Health Care or an Assisted Living Facility. 

The above screenshot is from this website where you can estimate the cost of care for a person with disabilities or an elderly person.

In order to be able to afford care in your old age you need money, of course. Sure, you can pay it bit by bit over many years to an insurance company or you can self-insure by building the kind of portfolio that will have some residual value for this purpose.

LTC Insurance

I won’t spend much time on this because there are too many factors to consider when purchasing insurance. LTC insurance won’t just pay an infinite amount towards the care of the elderly individual – there is a cap.

The amount paid out per day and the length of time that the policy will cover you for, are all factors which affect the price. If you are older the cost will be appropriately higher when you purchase the plan. And since you need medical underwriting for most LTC plans, you may not even qualify or, like most insurances, you might have to haggle on various things that will/won’t get covered.

Another useful resource is LongTermCare.Gov.

The Actual cost of long-term care

Genworth, one of many insurance companies on the scene, has some interesting facts to review on their website.

If you are 65 years old and live in Cali, and should you need care starting at around age 79, then the above is what you would need to save for each scenario. The options are Home Care, Assisted Living Facility, or Nursing Home. The above infographic also has the approximate length of stay – presumably until your death.

However, if you are 39 years old (like myself), then you need to save quite a bit more, factoring for inflation and rise of cost of care. Below are the numbers for such a scenario.

Action Steps For The Physician

Financial advisers should be very proficient at recognizing gaps in your risk or coverage in any aspect of your financial life. They are often a great resource to discuss your options.

Thinking outside the box is such a useful skill to have. It’s how one person can achieve the same or a better result with half the resources. The main factor is that you must be willing to put in the research or hire the right people to discuss your options.

After you get all the facts, decide how you want to live the last few years of your life. Some will want everything done possible to extend their life, others will want minimal intervention in order to die peacefully at home, and others may not be comfortable discussing/thinking about this topic, leaving it up to chance when the time comes.

Finally, if you want to hire a company/group to manage your eldercare needs then identify them and their resources while you are still young/healthy. If you want to hire your own care, make sure you have the right connections in place in order to hire the help you need from overseas or wherever else you prefer.