Going broke during retirement doesn’t scare Americans as much as racking up high medical expenses.

According to a 2015 survey from Bankrate.com, 28% rank high medical expenses as their chief retirement concern, while 23% worry most about running out of savings. One-third of people over age 50 are anxious about expensive illnesses or injuries.

Couples who retired in 2014 at age 65 can expect to incur $220,000 in health-care costs on average during retirement, according to Fidelity Investments. This excludes long-term care, which almost 70% of those who reach age 65 will need for an average of three years, projects the U.S. Department of Health and Human Services.

The good news is more financial advisors, including three-quarters of those responding to a survey conducted last year by FA, say they’re providing health-care advice as part of their retirement planning for clients.

Their efforts run the gamut, such as comparing insurance policies, drafting advance health-care directives, exploring health-compatible housing and accompanying clients to the doctor. How they broach the topic of health with clients also varies.

“They don’t ask us, we ask them,” says Carolyn McClanahan, founder and director of financial planning at Life Planning Partners Inc. in Jacksonville, Fla. The former emergency medicine and family medicine physician, who still volunteers in the medical clinic of a homeless shelter, is comfortable leading these conversations. She also educates other financial planners on how to have these discussions.

A standard question she asks clients to open up conversations is, “What do you do to take care of your health?” She also asks: What is your general health status? Do you have a family history that should worry us? What is your past medical history?

Michelle Rand, founder and president of Cascade Investment Advisors Inc. in Oregon City, Ore., has had health-care discussions with 50% to 60% of her 150 clients. Most have been initiated by clients or are event-driven.

She and her team are asset managers who spend the bulk of their time analyzing investments. “There is no way we can be experts in health care and we don’t even try,” she says. “But we can do math.” So they analyze the costs associated with clients’ likely health-related needs and build them into the financial projections they use to determine what the clients’ asset allocations should be.

Health care is especially high on her radar, she says, because in recent months three clients and a client’s younger brother died. One of the clients had cancer and related health issues for several decades. “He was wildly expensive,” she says, noting that the charges for his last hospital stay were $143,000.

Fortunately, his medical bills were virtually all covered because he had very good health insurance through his job and later through his wife’s job. Rand helps clients with less generous benefits compare supplemental insurance plans.

Another client’s husband had Parkinson’s disease. They maintained separate assets and the wife was using her assets to cover his care. Rand encouraged her to talk to her husband. He started paying for his in-home care and the couple split the cost of renovating their home to accommodate his infirmities.

After an elderly client repeatedly fell at home, skimped on physical therapy and refused to move, her children asked Rand to speak with her. She complained to Rand about what she could no longer do and then agreed to try home health care. When this care proved insufficient, Rand held a family conference and the client conceded she was ready to move to an assisted-living facility.

Rand crunched the numbers to see the type of apartment the client could afford. She also determined the client could keep her house if she rented it out. The client was happy because it gave her a way to think of her move as temporary, even though it didn’t turn out that way. “I think that was the most important part about keeping the house,” says Rand.

Empowering Patients
McClanahan accompanies patients with very serious illnesses—such as cancer, new-onset dementia and ALS—to medical appointments. “They appreciate me being a third ear and brain,” she says. Yet like Rand, she knows that clients must make their own decisions and is careful not to overstep professional boundaries.

McClanahan uses age 100 as a projection when wealth-planning for healthy clients with healthy lifestyles. But if clients have multiple health issues or don’t think they’ll live long, “I don’t want to pick a number out of the air,” she says. Instead, she has them answer in-depth questions on the Living to 100 Life Expectancy Calculator.

To calculate clients’ potential medical expenses, she uses average figures from the Employee Benefit Research Institute that include Medicare premiums (Parts B and D), Medigap premiums and out-of-pocket drug expenses.

McClanahan puts clients in the 10th, 50th or 90th EBRI cost percentile based on whether they are low or high users of health care. An elderly but very healthy client who rarely goes to the doctor may be in the 10th percentile. Clients in the 90th percentile “go to the doctor every time their rear end itches and they have a hangnail,” she says.

Long-term care isn’t included in the EBRI numbers. McClanahan adds in two years for unhealthy clients and five years for healthy clients with healthy lifestyles. The latter are more likely to get dementia before their bodies deteriorate, she says.

She also encourages clients to take care of their health, retain copies of medical records and communicate with doctors. Writing down questions and the history of a medical problem to bring to appointments, especially with new doctors, is more likely to result in satisfactory patient-doctor interactions, she says.

Although Life Planning Partners doesn’t generally deal with clients’ medical bills, “if there is a serious illness we kind of go into triage mode,” says McClanahan. She encourages all clients to track expenses using her firm’s eMoney portal. Organizing health-related expenses can save much time and money down the road, she says.

People are often unaware that home health care, trips to receive medical care and the retrofitting of homes to make them friendly to those with medical problems (by widening doors and installing ramps and grab bars) are deductible expenses, she says.

Last year, Life Planning Partners made every client fill out a quality-of-life directive. This year, it is creating documents that let clients spell out their preferred long-term care scenarios. It is also creating agreements aimed at preventing squabbles within families and protecting family members who quit work to be caregivers.

Be Prepared
Gary Shor, a financial planner with Warren, N.J.-based AEPG Wealth Strategies, is especially concerned about the impact of health-care expenses on clients with $1 million to $2 million in assets. With taxes, “It’s a double hit if they have to take $300,000 out of a qualified account,” he says.

AEPG brings up the topic of health care with every client. “I don’t know how you can do a plan without this being a big part of it—it touches everything,” he says. “A health-care event is one thing that can devastate a family pretty quickly.”

New clients are asked if their parents and siblings are alive or what happened to them. At review meetings, AEPG asks clients if there is anything new health-wise with them, their parents or children. “We want to prepare, not repair,” says Shor.

AEPG discusses disability insurance with all its clients. Younger people are often in denial about the need for this coverage or too busy to consider it, but Shor stresses it’s essential for them to protect their working capital. Some plans include income replacement and retirement funding replacement, he notes.

Shor says the sweet spot for pricing of long-term-care insurance is generally between ages 57 and 63. He generally recommends minimum coverage of three years and likes to see an inflation rider included. When clients reach their mid-60s, AEPG begins stress-testing their portfolios for a possible long-term-care event.

AEPG is continuously building its life-planning manual to provide its advisors with guidance, says Shor. The firm works with outside experts, including eldercare attorneys and geriatric case managers. Caregiver.org is a good place for clients to start gathering information when care is needed anywhere across the U.S., he says.

AEPG works with many small business owners who sponsor health-care plans. They are worried about rising costs. And although 90% of proposed legislation doesn’t pass, says Shor, “the changing regulatory landscape is their biggest headache.” Debora Ristau, AEPG’s vice president of group benefits, keeps these clients up to date on changes in regulations and recently sent them a compliance checklist.

Mark Baniewicz, president and CEO of Socius Family Office, headquartered in Boca Raton, Fla., makes sure clients have advance medical directives including health-care proxies and living wills. “It doesn’t matter if you have no wealth or a lot of wealth,” he says. Clients often need coaxing to consider these issues. “It’s a reminder we all have an expiration date,” he says.

Socius discusses long-term care with clients. Baniewicz is aware of its importance because three of his four grandparents required it. An average stay of two to three years runs $100,000 to $200,000, he says. Most families Socius works with prefer to self-insure this coverage. If so, he says it’s important to set aside a portion of a portfolio with immediate liquidity in case there is a health event.

The firm also brings up disability insurance with its clients, about half of whom are professional athletes. A key question it asks is, “What would happen to your human capital if you were to get hurt?” says Baniewicz, a former NFL football player.

He tries to meet in person with clients at least once a year and converse with them quarterly. During meetings, he can often tell if a client is deteriorating. When working with family members, it’s helpful to observe how relatives may react to an older client’s comments, he says. This could include a nod, a head shake or shrug.

McClanahan expects the medical system to change dramatically over the next few decades. While the legislative picture is a big unknown, she anticipates more patient-centered care, stepped-up use of technology in medicine and more patients using “Dr. Google,” she says.

Her prescription for better health outcomes—physically and financially—is to enjoy life, save for the future and do the work you love for as long as you can. She has even sent patients who are unhappy in their jobs to career therapists. “We weren’t made to live 30 years in retirement,” she says.