When It Comes to Alzheimer’s, Important Changes Are Coming for MA Beneficiaries

The majority of experts agree that because Alzheimer’s disease is significantly underdiagnosed and underreported, a large number of people may not know they have it. 

We have both spoken at length about the importance of early detection and diagnosis to allow for earlier interventions and care planning along with a broad array of methods and pathways: pharmacological research and development, increased clinical trials, participation in longitudinal studies, proactive brain health programs across the lifespan, and more robust and better-funded clinical care programs.

While the Alzheimer’s community recently experienced a disappointing setback in the area of clinical research with the failure of the drug aducanumab, the need for earlier detection and more accurate diagnoses is all the more urgent.

Ultimately, we need a health care system that is equipped, prepared and — most importantly — incentivized to address what is unquestionably America’s biggest health crisis. Alzheimer’s is the only top-10 disease in the United States without an effective treatment or cure, and, according to the Centers for Disease Control and Prevention, creates an economic burden on our economy equal to that of smoking. At nearly $290 billion annually, with 5.8 million Americans living with the disease, together with 16 million caregivers, it is a leading Medicare and Medicaid cost-driver.

Fortunately, the Centers for Medicare and Medicaid Services has done a great deal for the Alzheimer’s community in recent weeks.

In early April, it was announced that, starting in 2020, CMS will authorize significant payments for Medicare Advantage beneficiaries with a diagnosis of dementia. These payments create unprecedented financial incentives to assess and diagnose patients with dementia and to document all dementia diagnoses in the medical record. Through the addition of two new hierarchical condition category codes, HCC 51 and 52, CMS now recognizes that clinical care needs for patients with dementia are more akin to the needs of patients with other chronic diseases like hypertension and diabetes.

This is good news for 22 million Americans in Medicare Advantage plans but only makes more acute the need to make earlier detection widely available.

The impact of HCC 51 and 52 as new payment mechanisms must also be evaluated to better determine a potentially broader application to all adults who could benefit from a timely and accurate cognitive assessment and diagnosis.

Questions remain around how doctors should be funded and clinically supported given greater reimbursement to Medicare Advantage plans and how Medicare Advantage plans enrich their assessment processes and clinical checkups to meet this challenge.

In addition, directing billions of dollars of funding for detection, assessment, diagnosis and treatment of Alzheimer’s and related dementias does no good if we don’t focus on how to improve and scale our current mechanisms for assessing and diagnosing millions of Americans. What is needed practically is a system of prevention and care in which individuals are educated on asking the right questions and doctors are given the funds and the tools to provide the right answers.

Another welcome development in Washington was the introduction of the bipartisan CHANGE Act in the House and Senate on April 10. The CHANGE Act takes a targeted approach to addressing America’s Alzheimer’s crisis by incentivizing early detection, diagnosis and access to interventions.

Importantly, CHANGE would require CMS to direct the use of National Institutes of Health-identified tools to accurately and expeditiously measure cognitive impairment — though we must continue to push forward to leverage technological innovation for detection and assessment capabilities into the future.

Against this backdrop, the CHANGE Act and increased funding for Medicare Advantage patients with dementia will fundamentally alter the environment moving forward for Alzheimer’s detection, assessment and diagnosis in the United States.

As we continue to explore all clinical and policy avenues, the fundamental system shift that Medicare Advantage and the CHANGE Act represent will help patients, providers, payers and policymakers alike accelerate the discovery of a cure for America’s most devastating health crisis.

George Vradenburg is the co-founder of UsAgainstAlzheimer’s.

John Dwyer is the president of the Global Alzheimer’s Platform Foundation.

Originally posted on Morning Consult on April 19, 2019.

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