Beyond Structured Settlements

University of Texas 2016 SNT Conference

Perhaps less well known nationally than the Stetson Law School Special Needs Trust (SNT) Conference, the annual SNT conference presented by the University of Texas (UT) Law School represents a unique and complementary program that more structured settlement and personal injury settlement planning professionals should consider as an educational priority.

Attended by attorneys, financial advisors, trust officers, government agency representatives and care managers, the 12th Annual UT SNT program not only offered an outstanding faculty and comprehensive resource materials, it also integrated federal and Texas state-specific considerations (laws; regulations; current issues and trends; case examples; strategies; best practices) into a detailed learning mosaic that other national (non-state specific) special needs programs are unable to replicate.

Even for attendees venued outside of Texas, however, this integrated federal/state educational perspective provided a valuable analysis of the challenges and alternatives created by the interaction of the multiple sources of ever-changing special needs laws and regulations which sometimes conflict and often are subject to inconsistent administrative rulings.

Kudos to conference co-chairs, Patricia Sitchler and Renee Lovelace, as well as the entire conference faculty. Given the complicated scope and objectives of the UT SNT program, the resulting synthesis could easily have resulted in confusion. Instead, the 12th annual UT SNT conference served both as an excellent updated guidebook for Texas special needs professionals and as a potential model for other state special needs educational institutions and practitioners.

Topics and Speakers

• How to Make a Special Needs Trust - Craig Reaves
• Maximizing Public Benefits - H. Clyde Farrell and Christina Lesher
• Case Law Update - Rebecca Morgan and Elisa Dillard Rainey
• Medicaid Planning for Kids - Christina Lesher
• Texas Health and Human Services Commission Update - Shari Nichols
• Accessible, Available and Affordable Healthcare Resources - Leah Cohen; Anna Marie Mendez; Tresi Moore Weeks
• Working with SSA and the Trust Reviewer Teams - Pi-Yi Mayo (Moderator); Amanda Flood; Dana Marquez
• SNTs and the New SSA Trust Review Procedures - Neal Winston
• The New Texas Supported Decision-Making Agreement Act - Tresi Moore Weeks and Renee Lovelace
• Texas Legislative Update - Craig Hopper
• SNTs and Tax Planning - Bradley Frigon
• IRAs and SNTs - Renee Lovelace
• The Texas ABLE Act - Stephen Dale and Chris Masey
• Veterans Benefits and SNTs - Hon. Robert Davis
• Getting Families to Spend More Time Planning Ahead - Stephen Dale (Moderator); Matthews Badders; H. Clyde Farrell; Nancy Sosa; Scott Stebler
• Paying Caregivers - Katherine Barr; Scott Stebler
• The Role of SNT Attorneys in Personal Injury Settlement Planning - Patricia Flora Sitchler
• Ethical Issues in SNT Planning - Mary Alice Jackson

S2KM Comments About Selected Issues and Presentations

• UT SNT Conference Resources - As stated above, the conference handout materials (1481 pages of conference-specific legal papers and power points, plus sample forms, drafting tips, and other resources) provide valuable and recommended reference and learning resources. These materials are available for purchase in multiple formats on the UT CLE website.
• SNT Professional Education Resources - The number and quality of educational resources available for special needs professionals continues to increase and improve. In addition to the UT SNT conference, S2KM has attended and reviewed the most recent related conferences sponsored by Stetson, the National Academy of Elder Law Attorneys (NAELA ) and the Academy of Special Needs Planners (ASNP ). ASNP has also sponsored a series of special needs planning webinars. Hal Wright's book: "The Complete Guide to Creating a Special Needs Life Care Plan" represents another valuable resource. Wright, a certified financial planner who focused much of his career on special needs clients, recommends and explains "a comprehensive approach integrating life, resource, financial, and legal planning to ensure a brighter future for a person with a disability."
• Personal Injury Settlement Planning - As S2KM has discussed in numerous blog posts (example), personal injury settlement planning represents a strategic, underdeveloped market for both structured settlement and special needs professionals. UT SNT Conference co-Chair Patricia Sitchler's presentation in Austin (see above) highlighted these opportunities for SNT attorneys. Both the National Structured Settlement Trade Association (NSSTA) and the Society of Settlement Planners (SSP) have taken recent steps to expand their collaboration with special needs attorneys. NSSTA has appointed a Special Needs Trust Task Force to develop strategic relationships with special needs attorneys and also featured Sitchler as a speaker at NSSTA's 2015 Fall Conference. SSP's 2016 Annual Conference (March 10-12 in Tucson, Arizona) will include a joint session and social event with ASNP which recently hosted its own settlement planning webinar series.
• Supported Decision-Making - Effective Sept. 1, 2015,Texas became the first state to recognize supported decision-making agreements as a less restrictive alternative to guardianship. As defined under Texas' new law, a supported decision-making agreement is an alternative to guardianship for an adult with a disability who may need assistance with making decisions regarding daily living but is not so incapacitated that he or she needs a guardianship. As explained by Tresi Moore Weeks and Renee Lovelace in their UT conference presentation (see above) and accompanying paper, the supported decision-making process "is an outgrowth of person-centered planning" which in turn "is based on the belief that people with disabilities are people first, with their own gifts and contributions. A person-centered plan develops a life plan for the future by focusing on the individual’s preferences and capacities. It provides supports to the individual while giving the individual as much self determination and independence as he or she wants and is able to take on." Article 12 of the Convention on the Rights of Persons with Disabilities (CRPD), which was adopted by the U.N. in 2006 and signed (but not yet ratified) by the United States and signed or ratified by 159 other countries, requires states to "take appropriate measures to provide access by persons with disabilities to the support they may require in exercising their legal capacity."
• New SSA Trust Review Procedures - As S2KM has previously reported (see: ASNP 2015 Annual Conference and the Stetson 2015 SNT Conference ), the process by which the Social Security Administration (SSA) reviews SNTs has changed dramatically during the past two years as the result of meetings between SSA representatives and advocates who deal with SNT issues. The UT 2016 SNT Conference featured two complementary video presentations explaining the background, processes, status and impact of these changes: 1) Pi-Yi Mayo moderated a discussion with SSA representatives Amanda Flood and Dana Marquez; 2) Neal Winston explained why the problems with inconsistent, erroneous, or vaguely defined SSA SNT decisions occur; reviewed sources of SSA SNT written policy; discussed current SSA SNT policy trends; detailed the new centralized SSA SNT review procedure; and recommended current best practices for communicating with the SSA about SNTs. Both presentations were supported by excellent papers.
• The Texas ABLE Act - Stephen Dale and Chris Masey reported on the Texas ABLE Act under which eligible individuals with disabilities could start an ABLE account, modeled after current Section 529 savings accounts. For additional ABLE Act background, see this S2KM blog post. Their presentations summarized proposed, related IRS regulations as well as new POMS, issued December 21, 2015, in which the SSA explains ABLE accounts and provides instructions for developing and documenting account balances and distributions. In addition, Dale and Masey identified and addressed multiple practical ABLE-related issues to help attendees educate and advise their special needs clients and communities how best and when to utilize this new disability funding option.

For additional S2KM reporting about structured settlements and government benefit issues, see the structured settlement wiki.

SSP 2015 Annual Conference - 2

The Society of Settlement Planners (SSP) hosted its 2015 Annual Conference last week in Las Vegas with an unprecedented number of structured settlement association leaders as speakers and attendees including representatives from the National Structured Settlement Trade Association (NSSTA) and the National Association of Settlement Purchasers (NASP). For a list of SSP speakers and topics, see this prior S2KM blog post.

In his keynote address, SSP President Neil Johnson re-affirmed SSP's traditional commitment to "open dialogue" of industry issues with a mandate for "healthy, respectful discussion of all industry issues, controversial or not - rejecting the the temptation to sweep the uncomfortable under the carpet."

While seeking to engage all perspectives to identify shared permanent interests and discuss industry problems and issues, Johnson acknowledged and accepted that conference attendees would not agree on all issues - and they did not.

Some of the issues discussed:

• The need for structured settlement industry unity - encompassing education and, in some situations, political lobbying.
• How NSSTA and NASP are collaborating to improve state structured settlement protection statutes.
• Improving public relations by first acknowledging and addressing structured settlement primary and secondary market problems.
• The uniqueness of the structured settlement product and the need for better primary market self-regulation.
• The impact of "fiduciary standards" on settlement planning and the future of structured settlements.
• Collaborative primary/secondary market strategies for addressing "the darker side of factoring".
• Settlement planning as an important and distinctive growth strategy for structured settlements.
• Differentiating settlement planners from single-product plaintiff structured settlement brokers.
• Financial planners - a competitive threat or the next generation of structured settlement consultants and settlement planners?
• The inevitability and risks of "off-shore" settlement planning products in a globalized world.
• Lessons learned from the Executive Life debacle for claimants and their attorneys and advisors.
• How settlement planners and structured settlement consultants misuse life care planners and life care plans.
• The Social Security Administration's recent hostility toward special needs trusts (SNTs) and what it means for structured settlements.
• How and why settlement planners must learn to take control of the Medicare set-aside (MSA) process.
• The explosion of multi-claimant QSFs - a missed market for structured settlements?

None of these issues were resolved in Las Vegas. What did occur was a healthy exchange of ideas among leaders of historic structured settlement adversaries (NSSTA, SSP and NASP) with active participation from leaders of other settlement planning associations. The result: a unique industry gathering as much like a diplomatic conference as an educational event.

With NSSTA's President, Executive Director, and several members of its Board of Directors in attendance, whether and how NSSTA (as well as NASP) and its members will respond remains uncertain. NSSTA helped to initiate a more open industry dialogue during its own Fall 2014 Educational Conference by inviting SSP President Johnson and NASP President Patricia LaBorde to appear as featured speakers.

Structured Settlement Industry Unification

During the NSSTA Fall 2014 conference, Johnson outlined a "Blueprint for Industry Unification" which he and NSSTA President Kevin Silo continued to discuss in Las Vegas in a repeat performance of their "Presidents' Panel". Johnson's appeal for unity characterized "industry disarray" as a "threat to our future." Labeling diversity "good" and disparity "bad", he called for a united front before the public.

In Johnson's words: Lack of structured settlement industry unity is "a drain - a drain on financial resources ... a drain on productivity ... a drain on our public image ... a drain on physical and emotional health. Lack of unity diverts attention from productive projects. It always focuses attention on the negative, never on the positive. Lack of industry unity shows no partiality or favoritism for either NSSTA or SSP."

Both Johnson and Silo expressed optimism, however, about the future of structured settlements - especially in the context of generational transition. Johnson, in particular, highlighted potential opportunities amidst his self-described industry disparity, including a strengthened resolve and commitment for improvement and growth. According to Johnson and other settlement planners, the structured settlement industry needs a wakeup call - a fresh look and reevaluation that includes, but extends beyond, NSSTA's "protect and preserve" orientation.

Here are the core components of Johnson's proposed "solution" for structured settlement industry unity:

• Recognizing and accepting product and professional diversity.
• Identifying and pursuing permanent shared interests without necessarily agreeing on all issues.
• Engaging all perspectives to discuss industry problems and issues.
• Promoting and practicing settlement planning with the structured settlement annuity as a core strategic product.

The Future of SSP

Throughout its 15 year history, SSP has punched beyond its weight class. Born out of a troublesome recognition that the structured settlement playing field was seriously tilted to the disadvantage of plaintiffs and their advisors, SSP has helped bring respect and professionalism to the plaintiff side of the table by emphasizing "settlement planning", not "settlement selling".

Recognizing the strategic role of structured settlements, settlement planning nonetheless seeks the "best interest" of its injury victim clients and includes multiple products and multiple experts.

Despite these accomplishments, and perhaps because of them, SSP's future as an association is uncertain. NSSTA has more plaintiff structured settlement brokers than SSP and has been more successful in adding a new generation of members.

Other, well-organized, non-structured settlement professionals, such as special needs attorneys and life care planners, increasingly focus their marketing, educational programs and work product on settlement planning using SNTs and MSAs as their gateway.

As was evident in Las Vegas, however, SSP continues to raise the educational bar for an entire industry of settlement professionals. Settlement planning remains an evolving profession - largely unregulated with few industry standards. The ultimate role and growth potential for structured settlements within the settlement planning market have not yet been determined.

SSP's ability to organize an educational conference where an unprecedented cross-section of industry leaders engaged in civil discussions about strategic industry issues suggests SSP has an important continuing role within both the structured settlement and settlement planning markets.

For S2KM reporting about prior structured settlement and settlement planning conferences, see the structured settlement wiki.

Evolve 2014 QSF Symposium

Despite unresolved issues, utilization of IRC 468B Qualified Settlement Funds (QSFs) in "single event" cases, as well as class action and mass tort cases, is expanding, and increasingly represents the preferred method for resolving complex personal injury claims, according to participants at the Third Annual QSF Symposium sponsored by Evolve Bank and Trust on November 14, 2014 in Memphis, Tennessee.

Various speakers estimated the number of QSF cases annually currently exceeds 2500, equally split between single event cases and class action/mass tort cases, increasing by 25% per year. This expansion has occurred as more settlement planning stakeholders learn about the advantages of QSFs - and despite single claimant QSF tax uncertainty.

Although Rev. Proc. 93-34 permits QSFs to make IRC 130 qualified assignments, and no tax authority exists prohibiting single claimant QSFs, structured settlement annuity providers currently refuse to accept single claimant QSFs which they broadly define to encompass claims by family members, plaintiff attorneys, lien holders and creditors.

Organized "to provide a forum for open dialogue that helps shape industry developments", the 2014 QSF Symposium completely avoided the single claimant controversy and focused instead on other important QSF and settlement planning issues.

Topics and Speakers

• Introduction and Welcome - Andrew Cook
• QSF Administrator Control Systems and Fraud Protection - Brian Berning
• QSF State Tax Issues - Mike May
• Tax Issues for Foreign Structured Settlement Assignment Companies - Jeremy Babener
• Calculating Settlement Awards - Chris Lordan
• QSF Settlement Planning Panel - Patrick Hindert (Moderator), Andrew Cook, Wendie Howland, Pi-Yi Mayo, Bryn Poland, Joseph Tombs.
• How New SEC Rules Impact QSF Money Market Fund Investments - John Rush.
• How Plaintiff Attorneys View QSFs - William Burns
• QSF Administrator Compensation Issues - Paige Balnum; Pi-Yi Mayo; Bryn Poland.
• QSF Attorney Fee Programs - Chris Shumate.

QSF Objectives and Benefits

In his legal treatise, "Qualified Settlement Funds and Section 468B", published in 2009, Robert Wood explains QSFs as follows: "Their primary objective is to gather and administer cash or assets and determine the amounts and exact nature of payments that the plaintiffs, attorneys, and other claimants will receive..... QSFs benefit both plaintiffs and defendants alike. They are separate entities for federal income tax purposes and are flexible and easy to establish."

Section 3.08B of "Structured Settlements and Periodic Payment Judgments" (S2P2J) summarizes the benefits of QSFs in more detail: "defendants obtain a binding release from liability by making a currently-deductible payment into a court or government-approved Fund; while claimants, who have no tax consequence as a result of this payment into a Fund, are then afforded as much time as they need to sort out important issues of their own, such as allocating settlement shares, obtaining court approvals for minors or other legally-disabled claimants, resolving liens (which sometimes involve complex pay-back and set-aside issues as to Medicaid and Medicare), and deciding on forms of distribution (whether cash, structured settlements, or special needs trusts that may be used to preserve eligibility for certain government benefits)."

QSFs reconfigure the traditional (ready; shoot; aim) settlement planning process:

1. Needs assessment
2. Design
3. Negotiation
4. Implementation
5. Monitoring

so that needs assessment and settlement design follow the negotiation (and funding) steps rather than precede them.

Highlighted Issues

• QSF Administrator - The QSF Symposium emphasized the important role of the QSF administrator as well as the services he or she may provide and/or require including: investment, expense and distribution management; tax reporting and filing; legal and regulatory compliance; and fraud control. The QSF administer appears best positioned to quarterback the QSF settlement planning team. An apparent need exists for more (and better qualified) QSF administrators.
• Life Care Planners and Case Managers - Life care planners and case managers are frequently overlooked in traditional settlement planning. Life care planners are rarely asked to revise their pre-trial and trial-focused life care plans to account for collateral sources or the actual amount of settlement funding. Case managers (who are separately certified) increasingly are retained to "monitor" settlement plans by providing post-settlement medical advice and services for serious personal injury victims.
• Compensation Issues - For QSFs to achieve their potential improvements for single event settlement planning, multiple compensation issues must still be addressed and resolved:
  • Administrators - The QSF Symposium devoted one of its panels to administrator compensation issues, including: who pays their fee? what fee is appropriate for what services? and how should the fee be calculated (flat fee; per claimant fee; or fee based on QSF earnings)? Complicating these issues, many attorney QSF administrators play multiple roles (trustee; administrator) in addition to drafting QSF documents and making court appearances.
  • Structured settlement brokers - In many single event QSFs, the plaintiff structured settlement broker plays key roles: 1) selecting and paying the QSF administrator; 2) performing "value added" settlement planning services as part of his/her contingent commission compensation. Not only do these arrangements create potential conflicts of interest ("needs based" selling determined by the needs of the broker and administrator), they also increase a broker's risk of loss in the the event of an unsuccessful structured settlement sale.
  • Additional compensation issues arise when: 1) a case settles with no allowance for QSF expenses; 2) a case involves minors or incompetents requiring a guardian and court to approve QSF expenses; and also because 3) in the current low interest rate environment, QSF fees often exceed investment yields. Although not discussed during the Symposium, defense structured settlement brokers have opposed QSFs fearing a reduction or the elimination of their contingent commission compensation.
• Tax topics - The QSF Symposium featured three tax topics:
  • State taxation - State taxation of QSFs is inconsistent with little guidance. Many states have not yet addressed QSF taxation. Potential penalties exist for failure to file including interest on any unpaid liability without any statute of limitations. QSF administrators are advised to follow a two step analysis: 1) can a specific state tax a QSF based upon the situs of the court or the administrator or the bank where funds are deposited? 2) assuming a filing obligation exists, how will a state tax a QSF - as a corporation or a trust?
  • Foreign structured settlement assignment companies - Potential tax issues exist for defendants, plaintiffs and the foreign assignment company. Can a defendant deduct its payment to a foreign assignment company? When does a plaintiff receive payments for tax purposes and what is the character of those payments? Does the foreign assignment company recognize income when it receives an assignment payment? If yes, will it be considered active or passive income or does a treaty override exist?
  • Structured attorney fees - When properly arranged, structured attorney fees allow a contingently-compensated attorney to defer portions of his or her compensation and pay tax upon receipt regardless of the type of case or whether the client receives a lump sum or periodic payments.
• Education issues - Single event QSF education is needed for plaintiff attorneys and judges who are still unfamiliar with the QSF concept. Among the most likely education providers are special needs attorneys who serve as QSF administrators or trustees and structured settlement brokers. In addition to litigating attorneys and judges, QSF educational targets should include other settlement planning stakeholders such as: liability insurers; settlement trustees, guardians; mediators; and life care planners.

Conclusion - Evolve's QSF Symposium offers a valuable and unique addition to the growing number of personal injury settlement planning conferences and educational resources. When Robert Wood's QSF legal treatise was published in 2009, he acknowledged his analysis "clearly enters unchartered ground". Congratulations to Chairman Andy Cook and Evolve Bank and Trust for helping to survey this unchartered QSF terrain by sponsoring an educational event specifically designed to promote discussion and exchange of ideas about QSF issues, standards and best practices.

For S2KM's complete coverage of 2014 structured settlement and settlement planning conferences, see the structured settlement wiki.

ASNP Settlement Planning Webinar Series - 1

The Academy of Special Needs Planners' (ASNP) 12-part "Settlement Planning" webinar series , which begins today, offers an important educational opportunity to learn more about this evolving profession. Evaluated in advance, based upon its online descriptive materials:

• The strengths of this webinar series appear to be the quality of the presenters and the broad scope of topics to be addressed.
• The primary omission and challenges appear to be:
  • Not including a life care planner presenter to explain the critical role life care plans play in settlement planning "needs analysis".
  • Addressing and defining: 1) settlement planning market metrics; and 2) how various settlement planning professionals integrate their work product - and at what individual and overall cost.

Despite multiple professional associations, participants and conferences, as well as legislative and regulatory developments, personal injury settlement planning (settlement planning) remains an evolving concept and market with competing definitions, standards and business models and many unanswered questions.

Settlement planning has been defined as both a process and a profession - and also represents a largely undefined market.

Kevin Urbatsch, ASNP's National Director and introductory webinar presenter, defines settlement planning as "the process of ensuring that a plaintiff who has a significant disability, lacks capacity, or has a complex financial situation will receive his or her litigation proceeds in such a way that it fully enhances his or her quality of life."

Joseph Tombs, Director of the Society of Settlement Planners (SSP) Registered Settlement Planner (RSP) certification program, has defined settlement planning as "a profession helping recipients of settlement proceeds use those proceeds to achieve post-loss goals and transition successfully to post-settlement financial life."

With the exception of the structured settlement market (which generated an estimated annuity premium of $5.1 billion in 2013 and $139 billion from 1975-2013), the size of the United States settlement planning market and its various component markets has not yet been defined. Based upon industry sources, S2KM estimates the 2013 structured settlement secondary market resulted in 12,800 transfers (factoring transactions) and generated $385 million PV of secondary market purchases.

S2KM estimates more than $170 billion of annual United States tort costs represents payments to personal injury victims and their attorneys based upon Towers Watson's most recently published "Annual Studies of United States Tort Costs", and utilizing Towers Watson's 2002 "best estimate" formula for calculating payout percentages. Towers Watson's tort cost studies historically exclude property losses, workers' compensation payouts and no-fault claims.

Founded in 2000, SSP has published "Standards of Professional Conduct for Settlement Planners" and sponsors an annual educational conference as well as a settlement planning certification program. To S2KM's knowledge, however, neither SSP nor any other professional association has addressed, in a comprehensive manner, basic questions about "settlement plans" (see below) - presumably the most fundamental and important settlement planning work product.

Especially because of inadequate information about the settlement planning market and collaborative work product, ASNP's webinar represents a valuable opportunity to advance industry knowledge and better define settlement planning as a strategic and evolving process, profession and market.

Related questions S2KM hopes one or more of the ASNP webinar presenters (or subsequent settlement planning conferences) will address:

• Who comprises (and selects) the settlement planning team?
• What criteria and process (e.g. request for proposal) are appropriate for selecting members of the settlement planning team?
• What professional licenses and certifications are applicable?
• What work product does each settlement planning team member provide?
• Who integrates their individual work product into a settlement plan - and how?
• When is a settlement plan appropriate?
• What are the standard components of a settlement plan?
• What does a settlement plan cost?
• What settlement planning licensing and e&o coverage are necessary and applicable to protect customers?
• What does a settlement planning " fiduciary standard " mean in terms of: " best interest ", " full disclosure " and " informed consent "?
• What other metrics (besides cost) are appropriate for evaluating the success of a settlement plan?
• How are settlement planning team members compensated?
• What alternative compensation methods and/or business models would allow settlement planning to become more efficient and/or reduce costs?
• Once implemented, who has responsibility to monitor and/or amend the settlement plan?
• Which professional associations include " settlement planners " and what relevant certification programs do they offer?
• How does settlement planning differ from special needs planning? ASNP's earlier 12-part "Special Needs Planning" webinar series provides a framework for analyzing this issue.

S2KM summaries of past ASNP educational conferences:

• 2007 ASNP Annual Meeting
• 2008 ASNP Annual Meeting
• 2009 ASNP Annual Meeting
• 2010 ASNP Annual Meeting
• 2011 ASNP Annual Meeting
• 2012 ASNP Annual Meeting
• 2013 ASNP Annual Meeting
• 2014 ASNP Annual Meeting

For additional S2KM reporting about settlement planning, see the structured settlement wiki.

Wendie Howland Interview - 3

In two prior S2KM blog posts (Part 1 and Part 2), Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC, a nationally recognized life care planning expert, has helped to explain why life care planners increasingly impact multiple overlapping markets including structured settlements, personal injury settlement planning, special needs planning, and Medicare set-asides (MSAs).

In this blog post, which concludes the interview series, Wendie responds to criticism of life care planners promulgated by some attorneys.

The following criticisms appear in this online copy (beginning page 32) of a July 10, 2014 presentation titled "The Affordable Care Act: Taking a New Approach to Damages" by attorneys Caryn L. Lilling and Thomas R. Shimmel at the American Conference Institute's 13th Annual "Advanced Forum on Obstetric Malpractice Claims."

Ms. HOWLAND: Before I respond to specific criticism, let me say that some of the criticism below may result from lack of understanding or familiarity with nurse life care planning as opposed to life care planners whose underlying credential is vocational rehabilitation or related fields, and who may use proprietary software to produce canned life care plans. My responses apply to certified nurse life care planners and, more specifically, to me.

CRITICISM: Life care planning is a profession sponsored by the plaintiff's bar.

Ms. HOWLAND: I do approximately half of my expert work as a life care planner on the defense side. If a defense attorney made this criticism, you can send him or her my contact information and I would be happy to help them also.

CRITICISM: There is no government licensure or government endorsed certification for life care planners in most states.

Ms. HOWLAND: This criticism indicates unfamiliarity with life care planning, professional licensure, and certification in general. It is true that there are no states that license any form of life care planners or that endorse any certification program for life care planning. However, all states do license, regulate, and endorse registered nurse practice, the basis for certification and practice in nurse life care planning and which mandates RNs’ nursing assessment, planning, and treatment of human response to illness or injury. Non-RN life care planners who do personal assessments and form opinions that exceed the scope of practice of their basic licensure often rely on other professionals’ imprimatur for their plans, and attorneys often take such endorsement as a guarantee of comprehensiveness and accuracy. This practice does not represent a wise or informed decision. By comparison, RN legal scope of practice fully encompasses what we do as evidenced by the Certified Nurse Life Care Planning Certification Board requirements for the CNLCP examination.

CRITICISM: Life care planners' "expert testimony" is raw hearsay and largely fictions.

Ms. HOWLAND: The rules of evidence are clear that we and other experts are entitled to rely upon documents, such as medical records and opinions from other disciplines, about the status and care of individuals when forming our opinions. This is not hearsay. As to any implication that I would lie under oath at deposition or trial, I have no wish to dignify it with further comment.

CRITICISM: Life care plans are not based on real economic or medical data.

Ms. HOWLAND: A good and proper life care plan is based on research about items and services that will be reasonably necessary. This includes using medical records. It also includes literature searches for the most current applicable research-based guidelines, with appropriate citations, and current pricing in today’s dollars obtained from named sources, e.g., vendors or suppliers.

CRITICISM: Life care planners purposely ignore past actual medical expenses and costs.

Ms. HOWLAND: It is not that we ignore past costs. A life care plan is, by definition, for the future. I cannot predict - for example, that any past agreement on discounts or write-offs will continue. My role is to look at future needs and give today’s costs and let a qualified medical economist calculate future costs. Further, when medical bills are on a self-pay basis, as they will be post settlement, negotiations with providers are usually not possible. Self-pay rates are substantially higher than plan reimbursement rates.

CRITICISM: Life care planners do not know the average life time costs for normal individuals.

Ms. HOWLAND: Many good sources exist for current costs of everything under the sun. Examples: you can look up the costs of raising a child from birth through college, home ownership vs. rentals, home maintenance, transportation, clothing, food, utilities, preventative medical and dental care, long-term care, and just about anything else you can think of. This criticism could imply that there should be offsets for these items against any increased costs related to an injury. Some life care planners, for example, will subtract the average cost of an unmodified van from the cost of a van modified. The litigating attorneys should sort out these types of issues. The injury victim might have been a Zipcar user or a bicycling commuter who now needs a modified van is because he is a quadriplegic.

CRITICISM: Life care planning testimony (LCPT) is unfairly prejudicial and likely to mislead the jury because:

• CRITICISM: LCPT has no basis in fact.
• Ms. HOWLAND: Again, as to any implication that I would purposely attempt to mislead or lie under oath at deposition or trial, I have no wish to dignify it with further comment.
• CRITICISM: LCPT is not substantiated by national statistics.
• Ms. HOWLAND: National statistics related to what? As Tip O’Neil famously said, all politics is local. When I estimate future costs, I look at local suppliers and facilities when at all possible. If I need to rely on a national database for particular information, e.g., the U.S. Renal Data Systems for information on renal failure, dialysis, and transplantation, or the National Vital Statistics Report for life expectancy (required, by the way for MSAs), or the National Spinal Cord Injury Statistical Center for outcomes on different levels of spinal cord injury, I will.
• CRITICISM: LCPT is not supported by past costs.
• Ms. HOWLAND: Past costs are no guarantee of future costs, or even today’s costs. “Today’s dollars” represent the best and most appropriate benchmark. Let the economists do the prognostications.
• CRITICISM: LCPT is designed to create the largest possible award rather than actual recognized cost.
• Ms. HOWLAND: A responsible life care planner should provide the sources of every cost for every item in the plan, in today’s dollars. Using an old canned database without personal assessment and current cost sourcing is not standard of practice. Many persons holding themselves out as life care planners, including physicians, do their clients a disservice because they do not know enough about assessing future needs. I routinely critique plaintiff plans and sometimes tell my defense clients, “If this is all they’re asking for, write the check with a smile, because it’s very inadequate for this person.”

S2KM: Wendie, thank you for participating in this three part interview which is also featured on the structured settlement wiki.

Wendie Howland Interview - 2

The increasing number, importance and roles of life care planners represents a significant development impacting several overlapping markets including structured settlements, personal injury settlement planning, special needs planning, and Medicare set-asides (MSAs).

This S2KM blog post continues a three part interview with Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC, a nationally recognized life care planning expert, in which Wendie addresses life care planning qualifications, case management, industry standards, and criticism of life care planners among other issues. Link for Part 1.

S2KM: The two most important U.S. based life care planning professional associations appear to be the International Association of Life Care Planners (IALCP) and the American Association of Nurse Life Care Planners (AANLCP). You belong to the AANLCP.

• How many nurses belong to AANLCP?
• Who are/were the pioneers responsible for developing nurse life care planning?

Ms. HOWLAND: Currently, there are roughly 350 AANLCP members. Not all have earned CNLCP certification. Some are LNCP-Cs and CLCPs, and/or nurses without formal life care planning credentials. All full AANLCP members are registered nurses bound by the ANA Scope and Standards of Nursing Practice and the nurse practice acts of our respective states. Some CNLCPs and RN CLCPs are not AANLCP members. There are also some associate AANLCP members who are not RNs. AANLCP has some Canadian members who are bound by their own nurse practice act.

These excerpts from the AANLCP Core Curriculum for Nurse Life Care Planning (2013) highlight some of our profession's pioneers:

• Lillian Wald - "In the early 1900s, Lillian Wald promoted the term 'public health nurse,' expanding nursing practice to encompass employment, recreation, health education, and sanitation....By the 1940s, the insurance industry was using case management as a method of cost containment"
• Paul Deutsch - "In the mid-1970s, Paul Deutsch first identified the term 'Life Care Planning,' referring to future needs, to describe a tool to project the costs of medical care in the litigation environment." In "Damages in Tort Actions" (1981), a multi-volume text, Deutsch and co-author Fred Raffa "referenced case management, catastrophic disability case management, and catastrophic disability research as means to project future medical care."
• Kelly Lance - "In 1997, the discipline of nurse life care planning (NLCP) began" when Kelly Lance founded AANLCP. "She developed a NLCP curriculum with the nursing process methodology at its core, including concepts and skills pertaining to LCP application in the medical-legal arena."

S2KM: What advantages and disadvantages do nurse life care planners offer compared with life care planners with alternative professional backgrounds and certifications?

Ms. HOWLAND: Our advantage is our licensure as registered nurses. We explicitly use nursing diagnosis, a recognized scientifically validated taxonomy to justify the items in our plan that are based on our nursing assessments. This means that we do not practice medicine, we stay within our scope of practice, and our recommendations stand independent of approval from any other discipline.

S2KM: As editor of the AANCPL Journal, how do you stay "ahead of the knowledge curve" on life care planning issues and developments?

Ms. HOWLAND: Serving as editor of professional journals and the AANLCP Core Curriculum helps inform my practice of life care planning. Reading submissions and working with peer reviewers and authors are excellent ways to learn and help guide my professional practice. Of course, I also attend national educational forums, speak at some, and write articles.

S2KM: What are the most important current issues and developments facing life care planning?

Ms. HOWLAND: Whether and how the Patient Protection and Affordable Care Act (ACA) affects life care planning is probably our most important current issue. For example, two recent California cases appear to require cost offsets based on past or existing insurance benefits. Historically, only Federal vaccine injury fund cases have required such offsets in life care plans. An upcoming issue of the Journal of Legal Nursing will focus on ACA-related issues.

S2KM: Some commentators have suggested the ACA will eliminate the need for life care plans in personal injury cases. Do you agree or disagree?

Ms. HOWLAND: I disagree. The vast majority of life care plan items and their associated costs are not covered by health insurance, including Medicare or Medicaid. Persons who seriously suggest that the ACA will render the need for life care plans moot are poorly-informed on health insurance, life care planning, or both. They should pull out the big booklet that describes their own health insurance and read it. They will be shocked.

S2KM: How important is the Medicare set-aside (MSA) market for life care planners? How does a life care planner's work product for MSAs differ, if at all, compared to work product for non-MSA applications?

Ms. HOWLAND: MSAs take Medicare’s interest into account in funding settlements. Currently, they are only required for worker’s compensation cases. Most life care plan costs are for items that Medicare does not cover. Therefore, it is comparatively simple for whoever prepares the MSA to abstract the applicable information from the much more comprehensive life care plan. Your readers should also know that although MSA certifications exist, Medicare has no requirement whatsoever for persons preparing MSAs to hold any type of certification.

S2KM: How can structured settlement professionals, settlement planners and special needs attorneys learn more about life care planning?

Ms. HOWLAND: I recommend that they ask us directly. Most life care planners welcome opportunities to visit an office or to attend a conference. Understanding the differences between certified nurse life care planners (CNLCP, LNCP-C) and non-nurse CLCPs is also important. Interested professionals should review the IARP and AANCLP websites for information, attend our conferences, and/or invite us to speak at their conferences.

In Part 3 of S2KM's interview with Wendie Howland, Wendie will respond to criticism some attorneys have directed at life care planners.

Wendie Howland Interview - 1

The most recent S2KM blog post highlights the growing strategic importance of life care planners for structured settlement and personal injury settlement planning professionals.

To gain additional knowledge about life care planners, S2KM interviewed Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC, owner of Howland Health Consulting, Inc., which S2KM will publish in three blog posts addressing life care planning qualifications, case management, industry standards, and criticism of life care planners.

In addition to her education and certifications, Wendie's professional background includes work as a critical care nurse; catastrophically-injured workers case manager for multiple insurance carriers; and complex medical records review and analysis for catastrophic workers' compensation and liability cases at the reinsurance level.

Recognized as a national expert for nurse standards of practice and care issues, Wendie's current practice includes life care planning and complex medical records review and analysis for liability, workers compensation, elder/trustee, SSDI and Medicare set-aside (MSA) cases. Among her many professional affiliations, Wendie also serves as Editor for both the Journal of Nurse Life Care Planning and the Journal of Legal Nurse Consulting.

S2KM: Wendie, thank you for participating in this interview. What is your best estimate of the number of life care planners in the United States? How many (or what percentage) of the total have:

• A life care planning certification credential?
• A nursing background?

Ms. HOWLAND: I am not sure it is possible to know exactly how many people hold current life care planning credentials of any kind, but the last numbers I have heard are roughly 800 for Certified Nurse Life Care Planner (CNLCP), 2000 for Certified Life Care Planner (CLCP) (approximately 80% of which are not nurses), and 100 for Lifetime Nurse Care Planners (LNCP-C).

S2KM: One of the impressive characteristics about life care planners appears to be their commitment to certification and continuing education. What is your educational background and what certification credentials have your earned?

Ms. HOWLAND: My primary credential in nursing was a B.S. degree from Boston University (nursing major). I earned my master’s degree from the University of Washington in Seattle, in the thesis program for physiological nursing (cardiovascular/critical care). Since my first clinical work was in critical care as a staff nurse and then as a critical care clinical specialist, I earned certifications in critical care nursing and nursing education.

My second career in nursing was in case management, primarily in worker’s compensation and liability for which I earned certifications in case management (CCM, RN-BC) and rehabilitation nursing (CRRN). Many of us in legal nursing consider life care planning “case management on steroids,” so life care planning was a logical next step as I gained expertise.

Now, as a certified nurse life care planner I hold the CNLCP and LNCP-C credentials, and the LNCC for legal nurse consulting. These credentials require both education and experience, what the military would call “time in grade,” as well as sitting for psychometrically-validated exams. To renew them, I take many hours of continuing education and perform other qualifying activities (such as editing professional journals, teaching, and publishing) and submit proof for approval to the respective certifying bodies every five years.

S2KM: What criteria are most important in selecting a life care planner?

Ms. HOWLAND: There are several, in my opinion. First, of course, is looking at the life care planner’s clinical experience. Does the planner have expertise, experience, and connections in the injury or condition involved in the case? Second, certifications are important as they demonstrate experience, competence, and commitment to continued learning in the field. Certification in life care planning should be a given, but judging by some of the plans I have been asked to review, apparently it is not. Third, looking at the credentials and licensure that underlie the planner’s practice is critical. Do they grant the ability to assess, opine, and prescribe for the injury or conditions involved?

Many people think that only physicians are licensed to assess and prescribe for ill or injured people, but that’s not true. It’s important to know the difference between the legal requirement for physicians to prescribe medications or perform surgery, for example, and an insurance company’s requirement to have a physician’s name on a request for goods and services (such as equipment, physical therapy, visiting nursing, assisted living, and others) solely as a means of financial control. I always collaborate with treating physicians and therapists if possible when I’m formulating a life care plan and include their recommendations.

Registered nurses are required to implement some (not all) parts of a medical plan of care. RNs are also licensed to assess function and response to illness or injury and to develop an independent nursing plan of care. We can and do recommend further assessments by other disciplines, adaptive equipment, hours and kinds of nursing care in any setting, and many other needs found in a good life care plan.

In addition, good research and writing skills are important. Life care plans should never be “canned,” i.e., the same for every case, with no evidence of individualization or current research. Every item should have reference to a current assessment need, availability, replacement/maintenance, and source for cost.

Lastly, since much life care planning work involves litigation and may call for deposition or trial testimony, it is generally a good idea to look for someone with public speaking experience and confidence under questioning.

S2KM: How important is the personal injury market for life care planners? How much of your own work involves personal injury cases?

Ms. HOWLAND: Most (but not all) life care planning practices do work that involves litigation, and that usually involves some kind of injury. Examples include workers' compensation, medical malpractice, and personal liability. MSAs represent a growing field of practice. Almost all of my work involves personal injury cases.

S2KM: When you work on personal injury cases, in what percentage of your cases:

• Are your clients plaintiffs vs. defendants?
• Are you retained as a potential expert witness?
• Are you directly involved in settlement negotiations?

Ms. HOWLAND: My cases are about half plaintiff and half defense. Plaintiff clients are interested in knowing about needs and related costs over life expectancy for a person with an injury or other condition. Defense clients are interested in knowing what potential costs could be and why, so they can set reserves and prepare for negotiations. They also want to know if a plaintiff life care plan is reasonable and fair.

Life care planners who are not employees of a defense or plaintiff entity expect to have their work product introduced as part of litigation. I have never been directly involved in settlement negotiations, nor have most life care planners in my experience. I work with my client to make my work comprehensive enough that it can stand on its own as counsel’s tool for negotiations. Some life care planners also work with trust officers after litigation is settled, to help them understand how the money can be spent most appropriately and identify case managers to implement the plan.

S2KM: How much time does it take to develop a personal injury life care plan and how are you compensated?

Ms. HOWLAND: My life care plans for catastrophic injury cases generally take between forty to sixty hours of work, not including travel and testimony time. Like most of my colleagues, I take a retainer and work against it, having it replenished as needed, and provide a detailed invoice monthly or more often if the client requests it.

S2KM: What is the difference between a life care plan and a medical cost projection?

Ms. HOWLAND: A medical cost projection is generalized for a medical diagnosis, as opposed to a comprehensive nursing assessment. It does not include a personal patient assessment. A medical cost projection may be important early post-injury, for example, to help a client set preliminary reserves. I am usually asked to provide medical cost projections soon after injury or as a preoperative estimate when precision isn’t necessarily critical. Since every case progresses differently, it is not possible to know what complications or special circumstances will arise. So the disclaimer says that further information will be helpful to make a more meaningful estimate.

S2KM: Assuming your work product (life care plan) is utilized to develop a personal injury settlement plan, how frequently are you asked to review the settlement plan: 1) prior to its implementation and 2) subsequent to implementation to adjust for new developments or changed circumstances?

Ms. HOWLAND: I have never been asked to review a settlement plan to see how well it matches my recommendations. It is almost impossible for life care planners to obtain information about outcomes or to discover how much, if any, of their life care plan recommendations were actually implemented, or how effectively. That is one of the major barriers to better research in life care planning. Most responsible life care planners inform their clients that a life care plan should be updated at intervals to account for changes in the individual’s condition and also include provisions for a case manager to implement their plan.

S2KM: How can other settlement planning professionals (including plaintiff attorneys, special needs attorneys, settlement trustees and structured settlement brokers) improve their working relationship with life care planners?

Ms. HOWLAND: They should know what they want, know what they can get from us, and know how to use us to their best advantage. They should communicate clearly, with adequate advance notice, what their expectations are, how much they expect and are willing to pay, and how they will use our work products. Nobody wants surprises.

In Parts 2 and 3 of S2KM's interview with Wendie Howland, Wendie will discuss life care planning associations, industry standards and issues as well as criticism of life care planners.

ACA and Future Medical Expenses – 1

What impact will the Patient Protection and Affordable Care Act (ACA) have on future medical expenses in personal injury cases?

This question, perhaps the most important ACA-related issue for personal injury stakeholders, including settlement planners and structured settlement professionals, is addressed by plaintiff attorney Seth Cardeli in an article featured in the May 2014 issue of the AAJ's Trial Magazine titled "Thwart the Assault on Future Medical Expenses".

S2KM summarizes Cardeli's article in this blog post - the first of a series about how the ACA impacts future medical expenses in personal injury cases.

Defense Argument

Cardeli labels as "speculative and misleading" current defense efforts to convince courts the ACA changed how courts should calculate future medical expenses thereby transforming the ACA into "the latest tort 'reform' vehicle." Their efforts should fail, Cardeli maintains, because they wrongly attempt to circumvent states' collateral source and subrogation rules.

Because of the ACA's individual mandate, some defendants argue, incorrectly according to Cardeli, that plaintiffs' recoveries for future medical expenses should now be restricted to the ACA’s annual maximum out-of-pocket limit plus the current cost of purchasing medical insurance.

Cardeli highlights attempts by defendants to effectuate their strategy by filing motions in limine which, Cardeli maintains, apply a lower judicial standard than post verdict motions.

Instead of defendants having to prove future medical benefits are reasonably certain to by paid by ACA insurance policies, Cardeli characterizes motions in limine as merely requiring a judge to decide whether the probative value of such evidence is outweighed by the unfair prejudice such evidence will cause defendants.

The result: in some cases, according to Cardeli, juries may reduce the amount of recoverable future damages while still permitting the collateral source provider to seek reimbursement from the plaintiff.

Plaintiff Counter Argument

Cardeli's article cites cases from several state venues where courts have rejected defendants' attempts to limit plaintiff evidence of future medical expenses or to present their own evidence of ACA-related health care coverage. He urges plaintiff attorneys to aggressively oppose all related motions in limine by arguing:

• The effect of the ACA on a plaintiff's recoverable future medical expenses is speculative.
• Evidence of collateral sources is prejudicial to personal injury plaintiffs.
• Tortfeasors should bear the risk that any future medical expenses will not be covered by medical insurance.

Of these three proposed counter arguments, the first (speculative) appears the strongest and most widely applicable among various state venues. Cardeli supports his first proposed counter argument as follows:

• The ACA does not assure that all components of a plaintiff's life care plan will be covered by future health insurance.
• In fact, ACA health insurance is not required to cover many such life care plan costs which are not subject to the maximum ACA out-of-pocket limit.
• ACA insurance plans are not required to count co-payments, deductibles, coinsurance payments and/or out-of-network payments toward the maximum out-of-pocket limit.
• The ACA does not require health insurers to cover long-term facility care or in-home skilled nursing care.
• U.S. courts historically have refused a collateral source reduction when future benefits depend on government action or inaction.

Cardeli's second (prejudice) and third (risk) counter arguments, however, are not as convincing - or at least not as complete. They depend not only on the provisions of the ACA, but also on how the ACA, tort reform, and subrogation impact state-specific collateral source rules.

Fortunately and helpfully, Cardeli's Trial Magazine article footnotes valuable law review articles relevant to these issues which S2KM will summarize in subsequent blog posts.

For S2KM's complete reporting about the ACA, see the structured settlement wiki.