Medicare Coverage for Detecting Cognitive Impairment

Contributed by: Dennis Fortier, President, Medical Care Corporation
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One of the constant themes of this blog is that Alzheimer's disease is routinely detected too late in today's medical environment. The data show that diagnoses are most common in years 8-10 of a typical disease course that runs 14 years. This means that the opportunity for treatment during years 1 through 7, when the brain is still quite healthy, is lost.

This practice of "late intervention" manifests itself in many of our blog topics. It contributes to the impression that treatment is completely ineffective when, in fact, earlier intervention can lead to meaningful delay of disease progression for some patients. Late intervention not only mitigates treatment effect but drives up health care costs because patients with impaired thinking do not practice effective self care. Also, late intervention has fueled the misdirected belief that Alzheimer's and dementia are one in the same. Sure, a person with Alzheimer's pathology will eventually become demented, but there is a long period of disease progression when the patient has only subtle cognitive difficulties.

As we have written, there are some understandable reasons why we intervene late. However, with the Health Care Reform Act passed in March and clarified last week, this could soon change.

Beginning in January of 2011, Medicare will reimburse primary care physicians to perform a more complete "Welcome to Medicare" visit with newly eligible members. They will also pay physicians to perform a complete "Wellness Visit" on an annual basis. Both the welcome visit and the wellness visit will include "detection of cognitive impairment".

This is a great step in the right direction. It will force a conversation between patients and doctors that has been sorely needed but ignored for some time. I know that not every Medicare recipient will schedule these visits and not every physician will follow all of the guidelines. In fact, I suspect only a small percentage of those on Medicare will actually have their cognition assessed in 2011. But I predict an overwhelmingly clear picture will emerge from this "toe in the door" to better care.

Here is what I envision: Some physicians will take this opportunity seriously and perform careful assessments of their patients. Some of their "seemingly healthy" patients will perform poorly on a simple cognitive test and a diagnostic work-up will ensue. The physician will find and treat a range of memory-impairing medical problems from depression to thyroid disorder to early Alzheimer's disease. Overall, patients will benefit from treatment of these conditions and their cognition will improve. As their minds become sharper than they would have been without treatment, they will do a better job managing their hypertension and their diabetes. They will be less depressed; they will feel better and stay more active. Their overall health will improve and the cost to Medicare for keeping them healthy will plummet.

Such an ideal will never be achieved in an entire population. However, I believe that the impact of such care on even a small scale will be discernible in the data. If so, then each year, more and more physicians and a growing number of patients will embrace the concept of managing their cognitive health. I think we are finally on the right track.