Health Law Requires Medicare To Cover Dementia Evaluation

By Michelle Andrews

MAY 06, 2014

For the millions of seniors who worry that losing their keys may mean they’re losing their minds, the health law now requires Medicare to cover a screening for cognitive impairment during an annual wellness visit.

But in a recent review of the scientific research, an influential group said there wasn’t enough evidence to recommend dementia screening for asymptomatic people over age 65.

What’s a worried senior to think?

Dementia screening tests are typically short questionnaires that assess such things as memory, attention and language and/or visuospatial skills. One of the most common, the mini-mental state examination, consists of 30 questions (such as “What month is this?” and “What country are we in?”) and may be completed in about 10 minutes.

In its review, the U.S. Preventive Services Task Force, an independent panel of medical experts, evaluated the evidence of the benefits, harms and clinical utility of various screening instruments for cognitive impairment. It concluded that the evidence for routine population-based screening was insufficient. While declining to recommend the practice for everyone older than 65, the reviewers noted that some screening tools can be useful in identifying dementia.

“Clinicians need to use their judgment,” says Albert Siu, professor and chair of geriatrics and palliative care at Mount Sinai School of Medicine in New York who was co-vice chair of the task force on dementia screening. “The evidence isn’t clear that there is a net benefit to screening for individuals that are asymptomatic.”

The risk of dementia increases with age: its prevalence is 5 percent in people aged 71 to 79, rising to 37 percent of those older than 90. Mild cognitive impairment has many definitions, but the term generally refers to people whose impairment isn’t severe enough to hamper their ability to manage their daily lives. By some estimates up to 42 percent of people older than 65 have it. Mild cognitive impairment is a warning sign, but it may not progress to Alzheimer’s disease, says Dean Hartley, director of science initiatives at the Alzheimer’s Association.  

Alzheimer’s is the most common form of dementia, accounting for up to 80 percent of cases. Other types include vascular dementia, many cases of Parkinson’s disease and Huntington’s disease.

Someone without symptoms who does poorly on a screening test may have other medical conditions, such as depression or sleep apnea, that can cause memory or other problems, says Hartley. That’s why it’s important that people take the tests in a medical setting with a trained professional who can evaluate them and take a good medical history from patients and their family members, he says.

One-time screenings at shopping malls or health fairs should be avoided, experts agree. Taking a quick test without any accompanying medical evaluation may raise more questions than it answers.

But seniors may want to consider having an evaluation for cognitive impairment as part of their annual wellness visit with their health provider. It is covered with no out-of-pocket charge.

The Alzheimer’s Association recommends seniors undergo cognitive impairment screening and evaluation to establish a baseline for comparison, and then have regular follow-up assessments in subsequent years.

There is no cure for Alzheimer’s disease. Some drugs, such as Aricept, may improve memory or other symptoms temporarily, but no medical treatment halts or reverses the disease.

That is a key argument against large-scale routine screening of people older than 65, says Ariel Green, a geriatrician at Johns Hopkins Bayview Medical Center. “We don’t have studies that show that such a screening program improves the care of people with dementia,” she says.

Still, if an individual has concerns about dementia because of a family history of Alzheimer’s or memory lapses, for example, a medical professional should evaluate the person and a screening test may be appropriate.

And although research hasn’t yet shown that large-scale screening is effective at improving dementia care overall, screening may help individuals and their families identify a cognitive impairment or dementia early on. The drugs that are available are most effective in the early stages of the disease. In addition, Green says, “it’s helpful for people to hear a diagnosis of dementia, if it’s an accurate diagnosis, because it can help people anticipate their future needs and plan for that.”

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

http://www.kaiserhealthnews.org/Stories/2014/May/06/health-law-requires-medicare-to-cover-dementia-evaluation.aspx

Panel Tells Congress Medicare Is Unfairly Penalizing Hospitals Serving The Poor - Kaiser Health News

Panel Tells Congress Medicare Is Unfairly Penalizing Hospitals Serving The Poor - Kaiser Health News

Panel Tells Congress Medicare Is Unfairly Penalizing Hospitals Serving The Poor

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TOPICS: MEDICARE, AGING, HOSPITALS, HEALTH REFORM, HEALTH DISPARITIES

By Jordan Rau

KHN Staff Writer

JUN 14, 2013

This KHN story was produced in collaboration with 

The financial penalties that Medicare imposes on hospitals with high rates of patient readmissions are too harsh for hospitals serving the poor and should be changed, according to a congressional advisory agency.

Since last fall, Medicare has been reducing its payments to 2,213 hospitals under a provision in the health care law that aims to improve quality at the nation's hospitals. The penalties kick in when patients with heart failure, heart attack or pneumonia are readmitted at higher than expected rates within 30 days.

While the Medicare policy seems to be having an effect - facilities are scurrying to keep better tabs on their high-risk patients after discharge - some hospital officials and other experts say the penalties are unfair because hospitals that treat the poorest patients are getting hit harder than others.

"The idea is right, but the implementation has been greatly flawed by penalizing hospitals that take care of the most vulnerable patients," said Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges.

Low-income patients, doctors and researchers say, are more likely to have trouble following hospital instructions for taking care of themselves after discharge. They don't always have easy access to doctors to monitor their recuperations and sometimes can't afford needed medications.

The maximum penalties, now set at 1 percent of Medicare payments, are scheduled to double to 2 percent starting in October and 3 percent in the fall of 2014.

In the District of Columbia, Howard University Hospital, which treats the largest share of low-income patients, is being penalized the most of any area hospital; since last October, its Medicare payments have been reduced by 0.95 percent. Sibley Memorial Hospital, which treats the smallest share of poor patients, was the only District hospital to avoid a penalty, data show.

In Virginia, Mary Washington Hospital in Fredericksburg and Culpeper Regional Hospital were penalized 1 percent. Maryland hospitals are exempted from the federal program because the state has a unique reimbursement system.

Medicare has disagreed that the readmissions penalty program needs revisions. But thereport to Congress from the Medicare Payment Advisory Commission, or MedPAC, agreed with critics that there are "shortcomings" that "can work at cross purposes to the policy's intent." The criticisms carry extra weight because MedPAC helped devise the readmission penalties, calling for them back in 2008.

MedPAC found that hospitals where fewer than 3 percent of Medicare patients were low income received an average penalty of 0.21 percent. Hospitals where more than 18 percent of Medicare patients were low income had an average penalty more than twice that, 0.45 percent.

"Income is still an important … variable in explaining variation in readmissions," the commission said. It recommended that in future years, when determining penalties, Medicare compare a hospital's readmission rates to those of hospitals with comparable numbers of poor patients. Penalties can be a drain on safety net hospitals, many of which operate on slim profits or at a loss.

The Centers for Medicare & Medicaid Services did not comment on the MedPAC recommendations. In the past, officials have noted that after years of holding steady, the national hospital readmission rate last year dipped below 18 percent.

But MedPAC warned that if the penalty formula remains unchanged many hospitals will continue to get penalized in future years even if they reduce readmissions because they will be judged on how they compare to the entire industry. MedPAC proposed that Medicare set target readmission rates for hospitals each year and exempt from penalties those that succeed.

"These are all steps in the right direction," said Dr. Ashish Jha, a Harvard School of Public Health researcher who first documented the unevenness of the penalties. “MedPAC is thinking smartly about this and they're looking at the evidence coming and making changes to the metrics."

Changing the program, however, might not be easy. Medicare officials have said that many details were spelled out in the 2010 law, making them difficult to change in light of deep partisan divisions in Congress.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

http://www.kaiserhealthnews.org/Stories/2013/June/14/medpac-hospital-readmissions-poor-congress.aspx