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Practice Management

From planning for future healthcare costs to helping a client move elderly parents, advisors are bracing for a "tsunami" of demand. The needs of an aging client base will require planners to master a new set of complex financial solutions.

This Practice Management article is intended for financial advisors only (registered representatives of broker dealers or associated persons of Registered Investment Advisors).
 

Fifty may be the new 30, but James Bashaw is feeling old. The founder of a namesake private wealth management firm in Houston is reasonably healthy, but his wife Kim, who is just three years older than he, was diagnosed three years ago with Huntington's disease, a genetic illness that causes progressive degeneration of nerve cells in the brain, resulting in physical and cognitive disorders and eventually dementia. Lately, Bashaw has spent hours filling out forms to move Kim into an assisted-living facility. The questions are "overwhelming," he says. "It's not that you don't know the answer, it's that you don't want to think about it." Fortunately for the couple, the cost of Kim's care is covered by the long-term care insurance he bought many years ago, when Kim's father was diagnosed with the disease.

Yet Bashaw also believes that, although he and his wife are younger than many who face similar health concerns, the experience gives him a window into the challenging issues that advisors and their clients are likely to encounter with increasing frequency.

Perils of Longevity
Whether it's planning for future healthcare costs, helping a client move elderly parents into assisted living, or recognizing the early signs of cognitive impairment, advisors are bracing for what one calls an impending "tsunami" of demand. The needs of an aging client base, planners say, will require them to master a new set of complex financial solutions.

Americans are living longer on average than ever before. A 65-year-old can now expect to live an additional 19.2 years—five more years than in 1960. By 2050, the number of Americans age 85 and older is forecast to reach 19 million, up from 5.5 million in 2010.

With advanced age often comes illness. Three out of four Americans older than 65 suffer from health issues like cardiovascular disease, diabetes, cancer, or chronic respiratory illnesses. Of those who are 71 or older, 15% (3.8 million people) have dementia. By 2040, that number will swell to 9.1 million, according to new research from the RAND Corp. that was financed by the federal government.

The emotional and financial toll of dementia on family members and caregivers is immense. Each year, dementia care costs between $41,689 and $56,290, depending on how informal care is valued. In total, the cost of dementia care in 2010 was estimated to be between $157 billion and $215 billion.

Planning for these outcomes often involves uncomfortable conversations, planners say. Asking clients to envision future health problems, and determine what they want to happen if they become incapacitated, forces them to face their own mortality.

Cliff Ryan, founder of Elder Planning Advisors of Maine in south Portland, who has since 1989 focused his holistic planning practice on working with pre-retirees and retirees, says these topics get easier as clients age. "The older someone is, the more easily they will talk about their own potential demise," he says. "When they're getting a bit older, they've seen their friends, relatives, or parents go through it—and they realize it's a reality."

Sourcing Care
Earlier this year, Dennis Stearns, president of Stearns Financial Services Group in Greensboro, North Carolina, hired client specialist Libby Stafford to help the firm prepare for the wave of older baby boomers. Though Stafford helps with more than just aging issues, projects so far have included researching, vetting and pricing assisted-living facilities for one client's mother, and finding geriatric care managers for another client's sister.

"It's such a great service to offer our clients," Stafford says. "Even if some are not in that aging bracket yet, they do know that we provide this service and that it will be there for them when they get there."

Stafford is trying to establish an "updated and ongoing preferred provider list" so the advisors in Stearns' practice have vetted go-to resources for the medical and legal dilemmas their clients are sure to face. As these aging issues come up more frequently, this preapproved list will save precious time for the advisors, who provide this help to clients for free as part of the firm's broader wealth management services.

"We can foresee a time when we are going to see tons of these issues. We wanted to get ahead and be prepared," Stearns says. "Each aging situation has its messy parts and unique attributes, so I'm not sure we'll ever be fully prepared for every situation we'll encounter, but we can certainly be better prepared."

Medicaid Planning
Financing continuing care is another key issue for advisors. In determining whether clients should purchase long-term care insurance or self-insure, the question is whether the client can easily handle the incremental cost of one or both spouses entering a continuing care community, compared with current living expenses that might be saved.

Though every situation is different, Stearns says, "Our basic rule of thumb has been that clients with more than $2.5 million in investable assets, including the value of a downsized home, may want to self-insure rather than buy long-term care insurance."

This rule of thumb works in areas with lower long-term care costs, but not in more expensive cities like New York or Los Angeles, he says. Stearns has one client with $5 million in investable assets who is now considering a New York facility that will cost $125,000 a year (compared with the $75,000 that might be more common in North Carolina, he says). In this case, because the client also wants to leave some assets to heirs, Stearns' team recommended purchasing long-term care insurance.

Advisor P. Alan Loss, of Personal Wealth Advisory in Lancaster, Pennsylvania, consults estate planning and elder law attorneys to get his older clients' legal affairs in order and acts as a resource for Medicaid planning. Attorneys review the clients' investments and important estate planning documents—such as a will, durable power of attorney, and a health care directive—to see how assets are owned and to make sure they are protected. Then they develop strategies to preserve assets in the event that one spouse needs continuing care.

One way to do this, Loss says, is through a Medicaid-approved immediate annuity—a strategy that aims to protect the healthy spouse's assets while reducing the assets of the spouse entering the facility, in order to make that person eligible for Medicaid. For this to work, assets must be owned individually and must not exceed certain limitations, which vary by state; there's a significantly lower limit for the spouse entering the Medicaid facility.

In order to pay for the Medicaid-approved annuity, it may make sense (as it did recently with one of Loss's clients) for the spouse entering the facility to cash out an IRA or a nonqualified annuity, pay the tax on it, and use the sum to purchase the Medicaid-approved annuity. (Be advised that state laws can differ.) In this case, the annuity's premium was determined by the elder law attorney Loss works with and took into account the health and life expectancy of the spouse entering the facility.

In the case of Loss's clients, the healthy spouse was allowed to have the "maximum community reserve" for 2013 of $115,920 in her name, in addition to her retirement accounts, a car and the couple's primary residence, Loss says. Her husband could only have $2,400 in his name.

"This is totally different from what we're used to doing, because of how specific the rules are," Loss says. "The annuity may come from the same companies we use, but it has to be Medicaid approved." That means the annuity must:

  • Be immediate, irrevocable, and non-assignable.
  • Be actuarially sound based on the clients' health and life expectancy.
  • Have payments made monthly in equal amounts with no deferral and no balloon payments.
  • Irrevocably name the appropriate state entity as a primary beneficiary, up to the amount of Medicaid paid on the Medicaid patient's behalf.

If the patient dies before the term of the annuity is up, the surviving spouse can keep the difference between the value of the annuity and what must be paid out to the state.

This type of planning is not something Loss expected to do for his wealthy clients—but ballooning care costs and the potential savings have made it more attractive. "My eyes have been opened," he says. "You can preserve a lot more with proper planning and documentation."

Defining an Approach
While many advisors have already begun to alter their practices and processes to serve an aging client base, approaches vary. Some advisors choose to hire additional staff or build out their practices to meet these clients' needs. Others select external partners.

In 2008, Lauren Locker, outgoing NAPFA chairwoman and founder of Locker Financial Services, created ElderLife (a division devoted to the needs of older clients) and hired para-planner Holly Deni to run it. Deni works with older clients on Social Security benefit strategies and Medicare issues; depending on the client's needs, she also helps research in-home and institutional care options. Much like a professional geriatric care manager, Deni helps clients understand the differences in costs, services, and contractual agreements; she also covers evaluation tools, questions to ask at facilities, considerations for hiring in-home aides, and even home modifications and safety issues.

Like Stearns, Locker offers the in-house help with geriatric-planning issues to existing clients, covered by their financial planning or asset management fees. And the new unit seems to have struck a chord with Locker's clients. "Clients come in for financial planning, but they are attracted to ElderLife," she says. "I have to say it has been very successful."

That doesn't mean it's rolled out exactly as the two women had planned. "We originally envisioned working primarily with baby boomers who wanted to be proactive about planning for their own elder-care needs," Deni says. "What has evolved, however, is a more integrated value-add for our current asset management clients, many of whom are in the 60- to 80-year-old range."

Deni also sees some ElderLife clients who are not current Locker Financial clients, she says. For them, she charges an hourly fee that's about half the cost of Locker's time.

Other firms develop relationships with outside experts to help clients navigate some of the complexities of aging. Glenn Frank, a partner with Lexington Wealth Management in Lexington, Massachusetts, refers clients to geriatric care manager Suzanne Modigliani in nearby Brookline. Geriatric care managers can help advisors understand the costs that will come up for clients who need care, as well as the nuances in care options that advisors might not be familiar with, Modigliani says. For example, assisted-living facilities and continuing-care communities have very different fee structures—and those differences can, in turn, have a significant impact on a client's financial picture.

Financial planners "are trusted advisors [to their clients], but they are not experts on this," Modigliani says. Frank agrees that engaging a geriatric care manager has been crucial for clients. "It's priceless in many cases," he says. "In addition to getting the best care for the older person, it can be invaluable for the rest of the family to have an independent resource."

Educate Clients
Whatever their staffing strategy, advisors say an educational approach can help kick-start a dialogue with clients. In addition to partnering with specialists on individual cases, Loss has also held "Long-Term Living" seminars, bringing in a local expert to discuss types of care and facilities. Now his firm is taking on end-of-life planning with a seminar called "Preparing for Family Transitions." A local attorney will cover what family members need to know to take over for an older person in case of illness or death; the session will also cover how to select an executor.

These may be uncomfortable topics, Loss says, but the need is inevitable; he encourages clients to not only come but to bring their children. "We're trying to facilitate the process so that the clients' wishes are followed."

Similarly, Bashaw is bringing in Alzheimer's advocate Jack Broyles, chairman emeritus of the board of the Dallas chapter of the Alzheimer's Association, to talk to advisors, and now some clients, about the financial and emotional toll of Alzheimer's care. Bashaw found Broyles through the firm's relationship with investment manager American Beacon, which has sponsored the speaking engagements.

Bashaw, too, says he wants clients to start thinking and talking about how to plan for an uncertain future. "It's about changing the conversation with clients," he says. "We are a part of the fabric of our clients' lives. How can you [help] if you're not asking these really important questions?"

Cognitive Watch
One key issue for advisors working with older clients is cognitive impairment. Brian Parker, who works with retirees and elderly clients as managing director and co-founder of EP Wealth Advisors in Los Angeles, suggests that advisors document the planning process carefully, especially with regard to who will make financial decisions on the elder person's behalf.

"We don't have a form or a 'to-do' checklist, but I could see us having something like that soon," he says.

Parker and other advisors suggest a systematic approach that will both help clients and avoid potential legal trouble for the firm.

  • Review—Check the planning done to date, including wills, trusts, and durable powers of attorney. Get outside legal help if any changes need to be made.
  • Big questions—Address a few of the most crucial issues: Will a client stay in the home or go to a facility? If clients leave, will they sell their home? Do they want to involve their children in the planning or decision-making? How do they plan to handle everyday tasks such as paying bills?
  • Document—Keep notes on all client conversations and the resulting decisions. Record the names of people and contact info, as well as the names of organizations that can be called upon for help.
  • Meet with a trusted circle—Be proactive about connecting with any children, other family members, or trusted advisors whom the client wants to involve. Parker also emphasizes the value of getting outside help when necessary. "We have to remember that we're not doctors," he says. "You always want to get outside counsel."

Samantha Allen is a senior digital editor of Financial Planning.

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