Brief and Accurate Cognitive Assessment:
The Key to Delivering Accountable Care for an Aging Population
Under the Affordable Care Act of 2010 (ACA), Medicare has embraced a new economic
model for delivering higher quality health care at lower costs. This legislation establishes
the groundwork for new entities known as “Accountable Care Organizations” or ACO’s,
with specific operating guidelines and a new reimbursement model. The model is
outlined in the Medicare Shared Savings program, and has been put forth as the solution
to sustainable viability for the Medicare program.
The concept of accountable care shifts the focus of the medical
disease at all costs” to “maintaining wellness at justified costs”.
reward ACO’s for investing in wellness, and for reducing the
medical interventions and expensive emergency care. The twin
care are “quality outcomes” and “reduced costs”.
system from “treating
The philosophy is to
burden of redundant
pillars of accountable
Cognition: A Key Lever in Delivering Accountable Care
In considering the factors that affect accountable care, it is clear that cognition is a key
lever affecting both the quality and the cost of care.
A patient with a memory deficit or poor judgment is less likely to stay compliant with
prescribed therapy for chronic conditions such as diabetes and hypertension. It follows
that poor compliance, and a general inability to perform effective self-care, can translate
into a cascade of declining health and worsening outcomes across a host of medical
problems. This in turn drives worsening health, increased medical attention, and
expensive emergency care, all of which exact a financial toll and work against the
accountable care principle of cost control. In this regard, cognition plays a key role in the
quality of care and the ensuing costs of delivering high quality care.
The magnitude of this financial toll has
been calculated using recent Medicare
data. Cost analyses compiled by the
National Alzheimer’s Association in
partnership
with
Johns
Hopkins
University, has clearly delineated the
striking
cost
differential
between
demented patients and non-demented
patients.1
Cost of Care
For a Medicare recipient aged 65+, the
average annual cost for physician visits,
hospital
stays,
procedures,
and
medications, is $3,851 if the patient is
not demented. However, if the patient is
demented due to Alzheimer’s disease,
the most common cause of dementia,
the annual cost to Medicare is $15,998.1
This demonstrates a massive economic
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opportunity to constrain the rising costs associated with caring for an aging population,
by delaying the current rate of progression from Alzheimer’s related cognitive impairment
to dementia.
Alzheimer’s Disease: Early Detection is Critical
The most immediate opportunity to improve care in the field of Alzheimer’s disease is in
earlier detection and intervention. For many patients, doing so will facilitate a delay of
cognitive decline and postpone the high costs of dementia by up to several years in
some cases.
It is well understood that Alzheimer’s disease has a long period of pathological
progression, beginning many years prior to clinical symptoms, and we typically do not
intervene until the final stages of the disease. In fact, Alzheimer’s is typically diagnosed
only after the patient becomes demented, in years 8 through 10 of a typical 14-year
clinical disease course.2 At that stage, massive irreversible brain damage has occurred
and the opportunity to forestall progression has been largely missed.
The importance of earlier detection and intervention was highlighted in April of 2011,
when the National Institute of Aging announced new diagnostic guidelines for
Alzheimer’s disease.3 The new guidelines reflect the knowledge that the disease is
present, is progressing, and is treatable, long before patients reach the expensive
stages of dementia.
Why is Alzheimer’s detected so late?
The current practice of late intervention is primarily due to the difficulty in distinguishing
Alzheimer’s earliest signs from the outwardly similar signs of normal aging. Since
working memory and cognitive processing speed decline linearly through mid-life and
later adulthood,4 many people over the age of 50 have a subjective sense that their
cognition is declining. Given that such mild memory disturbances are also the most
common early signs of Alzheimer’s disease, it is difficult for a busy primary care
physician to distinguish, in an economical manner, those patients who are aging
normally from those patients who need a more thorough evaluation.
Detection of Alzheimer’s Disease and Normal Aging
Some physicians are making an effort to evaluate subtle memory concerns and identify
progressive cognitive decline early on. Unfortunately, the vast majority of MRI scans
ordered as part of a work-up for memory loss, are negative. This belies an underlying
trend of increasing patient concerns about memory, even among the normally aging
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population, and is a major driver of unnecessary cost increases. As bio-markers for
Alzheimer’s disease are commercialized in the coming years, awareness of such
diagnostic approaches is expected to drive increasing demand from an aging and
anxious patient population. This will put additional pressure on the cost structure of
delivering accountable care.
Despite a somewhat more proactive physician population, studies have shown that 75%
to 90% of patients with mild cognitive impairment are not diagnosed in primary care.2
Rather, patients with impaired cognition are allowed to progress until more severe
symptoms warrant a specialist referral. The implications of this approach are “lower
quality care” and “increased costs,” a stark rebuttal to the principles of accountable care.
The MCI Screen: A Primary Care Traffic Cop
To improve detection of emerging cognitive problems in a primary care setting,
physicians need a brief but accurate tool for cognitive assessment. The tool must
effectively distinguish between patients whose perceived memory decline is likely to be
caused by a medical condition, and those whose perceived decline is likely due to
normal aging. This will facilitate a justified investment in working up those who need
further evaluation and treatment.
It will also constrain unnecessary diagnostic
investments in the increasing number of healthy people who are concerned about
Alzheimer’s disease.
The MCI Screen Accurately Classifies Cognitive Status
The MCI Screen is a tool that fills this need. It is a ten-minute test that requires no
specialized training or knowledge to administer, is appropriately reimbursed by
Medicare, and differentiates disease-related declines from those due to normal aging
with 96-97% accuracy.5-7 This enables early intervention against medical problems that,
left untreated, would drive poor self-care, declining health, and increased costs.
Importantly, the MCI Screen also accurately detects normal aging, which effectively
discourages unwarranted diagnostic investment in those who are aging normally.
Economic Impact of Managing Cognitive Health in Primary Care
The model below is useful in understanding the potential savings associated with better
management of cognitive health in a primary care population. The model is based on
the following assumptions, which denote a typical small group practice of 2-3 physicians,
with a primary care population of 6500 patients, and published prevalence of cognitive
impairment, progression rates, and costs of care.
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Assumption
Patient population
% of patient population Aged 65+
Prevalence of cognitive impairment in 65+ population
Impaired Patient Population
Annual progression rate from MCI to dementia
Achievable delay of AD-Dementia with timely intervention
Annual cost to CMS for non-demented patient aged 65+
Annual cost to CMS for demented patient aged 65+
8
6500
9
20%
6,10
25%
1300
11
15%
12,13
1-5 Years
1
$3,851
1
$15,998
This analysis distills the incremental costs of care, in an aged 65+ patient population,
attributable to the incidence of dementia within that population, over a ten-year
timeframe. It demonstrates the potential cost savings that accrue from vigilantly
monitoring cognitive health, intervening as appropriate, and delaying the onset of
dementia to the extent achievable.
These conservative projections, based on a typical primary care practice, show that
about 413 out of 1300 patients 65 years and older will become demented over a 10-year
period. This is based on data showing that, for patients 65 years and older in a primary
care practice, the prevalence of cognitive impairment is 25%6,10,14 and about 15% of the
impaired progress to dementia each year. Approximately half of these demented
patients will have Alzheimer’s disease, with the next most common cause being
cerebrovascular disease, the progression of which can be arrested with proper
intervention. Given the significantly higher costs associated with care for demented
patients, any delay in the rate of progression to dementia will significantly constrain the
economic impact of managing an aging population.
Based on these assumptions, 20.6% of the primary care patient population will become
demented over a ten-year horizon and they will generate 48% of healthcare costs across
the entire practice. In fact, dementia-related care will increase costs for this cohort of
patients by $29M, from $50M (if no patients were demented) to $79M (based on the
expected prevalence of dementia).
Over a 10-Year Course of Progression
Population Age 65+
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Cost of Care Age 65+
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Below are the calculated costs of implementing a rigorous cognitive assessment
program, including follow-up evaluations, and added to the known costs of providing
general care for a primary care population aged 65+ years. The table also includes the
calculated savings associated with incremental delays in the rate of progression to
dementia, and the expected savings for an organization delivering such accountable
care to its patient population.
Cohort of 1300 Patients Aged 65+
With No Dementia
With Expected Dementia
Incremental Cost of Expected Dementia
With 1-Yr Delay
With 2-Yr Delay
With 3-Yr Delay
With 4-Yr Delay
With 5-Yr Delay
in Expected Dementia
in Expected Dementia
in Expected Dementia
in Expected Dementia
in Expected Dementia
10-Year Costs
$50.0 M
$79.2 M
$29.2 M
$74.8
$70.8
$67.2
$64.1
$61.5
M
M
M
M
M
$ Savings
% Savings
$4.4 M
$8.4 M
$12.0 M
$15.1 M
$17.7 M
5.6%
10.6%
15.1%
19.1%
22.4%
An effective program detecting a high percentage of cognitive problems and delaying
progression to dementia by 2-3 years would unlock double-digit savings on a percentage
basis, across a typical primary care practice. It should be clear that proactive
management of cognitive health is a key strategy for optimizing patient health, while
effectively constraining dementia-related cost increases. The MCI Screen is a proven
and effective tool for enabling such accountable care in a clinical environment.
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