By John Mach, MD.

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Dementia affects approximately 10% of Medicare beneficiaries aged 65 and over with about 24 million family caregivers supporting them. Individuals with dementia incur nearly three times the Medicare expenses of those without dementia and dementia is a significant multiplier of costs for people with other chronic diseases, largely from avoidable hospitalizations. Caregivers provide on average 20-25 hours of typically unpaid care per week with an average duration of four years and lasting up to ten years. Thirty-five to sixty percent of caregivers experience significant depression or anxiety and have a higher rate of chronic illness. Few conditions have such a dramatic impact on patients and families as dementia.

Alarmingly, nearly half of Medicare beneficiaries with dementia are undiagnosed leaving many patients and families without proper medical management or support. Several factors have been attributed to this underdiagnosis rate including physician time constraints, atypical and subtle clinical presentations, limited primary care training and patient and/or family reluctance. All these factors likely contribute given that most physicians practice within a time-based rather than an outcome-based payment paradigm, the inherent challenges of recognizing and diagnosing dementia, the paucity of dementia-related curricula in medical training programs and the stigma and functional dependence associated with having the disease. Access to neurologists and geriatric psychiatrists is often limited in many settings and likely creates additional barriers to improving the diagnosis rate.  Rates of undiagnosed dementia are even higher in traditionally underserved populations.  Whereas interest in making a dementia diagnosis may have previously been inhibited by the lack of effective treatments, that is now changing.

Diagnosis is Critical to Care

Considering the high cost and high burden of dementia and with the emergence of several evidence-based clinical support models showing improved care and lower cost, CMS launched an eight-year, national commitment called the Guiding an Improved Dementia Experience (GUIDE) model in 2024 to support Medicare beneficiaries with dementia and their caregivers.  Provider interest in the program is high, with 390 organizations selected to participate. This program seeks to scale supportive care for people with dementia and their families that has shown promising results in several studies – but the diagnosis must be well-documented to be eligible for GUIDE. Thus, underdiagnosis of dementia may significantly limit the potential impact of GUIDE. And though GUIDE specifically excludes Medicare beneficiaries enrolled in Medicare Advantage, the same dementia clinical models that serve as the basis for GUIDE can be deployed within these health plans, making diagnosis important in those populations as well.  Furthermore, though the practical utility of newly developed medication therapies for dementia remains controversial, they are mainly indicated for earlier stages. Failure to diagnose dementia early enough to reap any potential benefit from these therapies is also a cause for concern.

Practical Solutions for Dementia Diagnosis

Given the challenges in improving the diagnosis rate for dementia, the question of population screening arises.  To date, the U.S. Preventative Services Task Force (USPSTF) has not pushed for wide screening of “asymptomatic” Medicare beneficiaries. But given the addition of dementia into the CMS HCC category risk-adjustment model in 2020 and the emergence of clinical programs to improve care and lower cost, a strong case can be made for practice entities in Medicare value-based arrangements (Medicare Advantage and Medicare ACOs) to screen their Medicare populations for dementia.

Many value-based practices emphasize the Medicare Annual Wellness Visit (AWV) to their patients. Established in 2011, the AWV requires “detection of any cognitive impairment…” but a study suggests less than a third of beneficiaries report having received a structured cognitive assessment. Despite this low rate of screening, studies show AWV improves overall dementia diagnosis rates. The AWV is a great opportunity to improve screening for dementia but it needs to include a specific, standardized screen.

Whereas physician time constraints are important, having a standardized, computer-based cognitive impairment screening tool that the patient can self-administer or be guided by non-physician staff is a practical yet effective way to include cognitive screening into the AWV.  If the screening is positive, then a separate visit for Cognitive Assessment and Care Plan Services can be scheduled for the physician or a referral made to a specialist. Though more work needs to be conducted to understand the best screening tools, whether to only screen a high-risk subset of patients and to determine the most effective and efficient manner to approach patient screening, the current tools are widely deployed in clinical use. Though some tools may have a lower sensitivity for detecting Mild Cognitive Impairment or early-stage dementias, the screening tool can be repeated at future visits.

Conclusion

Taken together, the high prevalence of undiagnosed dementia, the very high cost of care, the importance of accurately capturing and documenting dementia diagnoses in value-based settings, and the emergence of cost-effective care models for patients and caregivers as modeled in GUIDE create an imperative whereby practices should more actively screen for cognitive impairment in their Medicare populations. The AWV is an ideal time to conduct such screening.  The availability of standardized, easy to use screening tools and the development of computer-based screening tools can enhance the diagnosis rate without undue burden to the practice. Most importantly, with better screening and diagnosis, more Medicare beneficiaries with dementia and their caregivers will benefit from cost-effective programs such as GUIDE.

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John Mach, M.D., is a geriatrician and Chief Medical Officer of Ceresti Health.

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