Few care models manage Alzheimer's members

Although few models have emerged for managing care and costs of Alzheimer’s disease, some coordinated care models in limited use show promise. The aim is cost control while providing care that avoids or delays nursing home residency. Additional models are in development under the National Plan to Address Alzheimer’s Disease, released last year.

In 2012, the average annual per-person payment for health and long term care for Medicare beneficiaries over age 65 with Alzheimer’s and other dementias was $45,657-more than triple the average $14,452 payment for beneficiaries without the condition, according to the Alzheimer’s Assn.  Medicare and Medicaid pay 70% of care costs; the balance is covered through private insurance, out of pocket, or other payers.

The association estimates that aggregate costs for healthcare, long-term care, and hospice for Alzheimer’s and dementia patients will rise from $203 billion this year to $1.2 trillion by 2050.

Almost all Alzheimer’s patients-about 96%-are on Medicare, says Matthew Baumgart, senior director of public policy for the Alzheimer’s Assn. He estimates that 500,000 to 800,000 Alzheimer’s patients are enrolled in Medicare Advantage plans. There is very little data about Alzheimer’s-specific care models today, and he says that cost data can be hard to gather with Medicare Advantage’s capitated structure.

Initiatives under development by the National Alzheimer’s Plan-which was authorized by President Obama in 2011 and is managed by the Department of Health and Human Services-should help to provide more information as well as additional financial resources to fund the project. Coordinated care and treatment are just two of many goals; others include more research and services across multiple federal agencies, accelerating treatment development, and improving early diagnosis.

Annual health costs for Medicare beneficiaries with Alzheimer’s and other dementias who live in their communities averaged $26,869 per person in 2012, while the costs for those in a residential facility averaged $71,917, according to the association’s Facts & Figures report.

The Center for Medicare and Medicaid Innovation (CMMI) is testing payment and service delivery models to cut Medicare and Medicaid costs while maintaining or enhancing the quality of care for beneficiaries.

Although not Alzheimer’s/dementia-specific, some of the CMMI’s work could apply to Alzheimer’s and dementia care, including medical home models that use a team approach to provide care and improve healthcare quality and coordination, and the Independence at Home Demonstration, which tests a payment and services system with physicians and nurse practitioners coordinating home-based primary care with long-term services and support.

Managed care plans may hold the key to the best patient management as well as cost controls, since managed care is “a little ahead of the curve” with its coordinated care philosophy, Baumgart says. The approach is especially helpful in addressing the population’s needs, since more than 75% of Alzheimer’s patients have other chronic conditions, he says. Common comorbid conditions include coronary heart disease, diabetes and congestive heart failure, according to the Alzheimer’s Assn. 

There are only two Medicare Advantage Special Needs Plans (SNP) for individuals with dementia. Universal Health Care offers an HMO in 21 counties in Florida, and Medica Complete Solution offers an HMO in 22 counties in Minnesota.

Medica’s SNP was established in 2008 and now has 26 participants, says Julie Faulhaber, senior director, state public programs. Another plan in the state, the Minnesota Senior Health Options Plan, is a dual eligible plan with 9,600 participants. While there is no data on the total number of enrollees with dementia, Faulhaber believes it is a “significant number.”

The care coordination model for the two programs is similar, and each program is set up for either home or facility residency. In the home environment, care coordination staff are usually registered nurses or licensed social workers. They assess the patient and create and adjust a care plan.

For facility enrollees, a nurse practitioner is the primary care person, and a similar care plan is developed. In addition to healthcare, the programs provide services such as home-delivered meals for enrollees live at home and family support services to ensure health and safety.

“We are maintaining the programs with the money from state and federal governments, and that says it is working,” Faulhaber says.

Coordinated care is a logical approach to managing Alzheimer’s and dementia patients, since those enrollees often suffer from other chronic health problems, says Andrew Davis, vice president for the Center for Healthy Aging at Medica. Proper diagnosis is important for Alzheimer’s and dementia patients and cognitive assessment can be part of patient management where warranted.

 “Don’t think of dementia as a stand-alone disorder,” Davis says. “Think of it as part of the fabric of managing the beneficiary’s health.”

While these programs are small in scope, they represent possibilities that can help care for Alzheimer’s and dementia patients beyond the limitations of Medicare fee-for-service. Davis says in fee-for-service plans, there is not a lot of support for the patient and the family unless a physician is willing and able to help. It is “a missed opportunity that will affect treatment and drive costs,” he says.

One existing model that shows promise for managing both care and costs for Alzheimer’s patients is the non-profit Program of All-Inclusive Care for the Elderly (PACE). An estimated one-half of program participants have Alzheimer’s or some other dementia, says Robert Greenwood, vice president of public affairs for the National PACE Assn.

PACE provides comprehensive long-term services to Medicare and Medicaid enrollees that include healthcare, hospitalization and emergency care, as well as social support such as door-to-door transportation to and from day centers. The day centers are the hub of a PACE program serving as medically intensive facilities that provide health services, care coordination, nutrition, family services and administrative support. Some centers are adding separate activity rooms for those with cognitive disabilities.

Most PACE enrollees live at home; just 8% are in nursing homes, Greenwood says. If nursing home care becomes necessary, the cost is covered by PACE. A team of healthcare professionals meets daily to assess and coordinate care for the 150 to 180 participants at each center. Some PACE programs have over 1,000 enrollees in multiple centers, including San Francisco, Denver, and New York City. About half of the programs operate with more than one center.

There are 92 PACE programs in 29 states with 29,000 enrollees, Greenwood says.

PACE is a lower cost approach since providers are paid 85% of what the state would expect to pay for fee-for-service plan costs. Helping to sustain patients at home-the key goal of PACE-instead of in a facility also provides substantial savings.

Currently there are five FDA approved drugs to treat symptoms of Alzheimer’s disease. According to the Alzheimer’s Assn., new drugs in development aim to modify the disease process and halt its progression. There are no known preventive measures, so manage care’s task is to help coordinate care and social supports.

Drug       Brand Name       Approved For     FDA Approval

Donepezil             Aricept All stages              1996

Galantamine     Razadyne              Mild to moderate             2001

Memantine         Namenda             Moderate to severe        2003

Rivastigmine      Exelon   Mild to moderate             2000

Tacrine                   Cognex Mild to moderate             1993

Source: Alzheimer’s Association