By John Mach, M.D.

In value-based care, we ask primary care providers to be quarterbacks—responsible for clinical outcomes, cost containment and patient experience. But when it comes to dementia, an important condition that by its nature can be a challenge to diagnose and difficult to manage, we’ve handed them the ball without a playbook.

Importance of Dementia in Value-Based Care

Dementia is one of the most expensive and complex conditions in Medicare. In 2025, health and long-term care costs for people living with Alzheimer's and other dementias are projected to reach $384 billion, with Medicare and Medicaid expected to cover $246 billion (64%) of this amount. Emerging drug treatments and their related monitoring tests are expensive, adding to future financial challenges. Importantly, there are 11 million unpaid family caregivers caring for their loved ones with dementia.

The Masked Burden of Dementia

Unlike diabetes or hypertension, dementia often hides in plain sight. In the 15-minute window of a typical office visit, patients can—and often do—mask symptoms. They compensate, fill in the blanks, outright deny problems or defer to caregivers who may be unsure of what to report and reluctant to raise issues of cognition during the visit. By the time dementia is formally diagnosed, years may have passed. During that time, patients and their caregivers fall through the cracks: no documented diagnosis, no care plan and no accurate risk adjustment.

Eighty percent of people with dementia have two or more chronic conditions. In the setting of dementia, acute exacerbations of chronic conditions often present with vague, non-specific symptoms leading to delayed recognition and missed opportunities for timely ambulatory treatment.  Such delays lead to avoidable inpatient care and its resultant iatrogenic harm to the patients  BMC Health Services Research

Delays in dementia recognition and responses to chronic condition exacerbation don’t just impact the patient. They directly affect provider performance in value-based arrangements because RAF scores are suppressed, and unnecessary ED visits and hospitalizations climb. Caregiver burden escalates, further leading to patient care challenges.

Primary Care Is Set Up to Miss This

The system doesn’t incentivize—or enable—primary care to manage dementia. Time constraints and reimbursement arrangements might all inhibit primary care practitioners from examining cognitive function more closely or addressing the myriad issues and concerns that arise with a new diagnosis of dementia. Limited access to appropriate specialty teams well-versed in dementia care is also likely a barrier. Despite being required, cognitive screening rates during Medicare Annual Wellness Visits remain low. According to a 2022 study in Health Affairs, fewer than 30% of Medicare beneficiaries received a structured cognitive assessment during their AWV.

Most providers aren’t trained to identify or manage dementia let alone handle the behavioral and logistical challenges that follow. And their clinics are not structured to meaningfully engage the family caregivers who provide the majority of dementia-related support.

Unlike most chronic conditions, dementia cannot be self-managed. Patients rely entirely on family caregivers to recognize symptoms, follow clinical guidance and coordinate care. But these family caregivers are often untrained, overwhelmed and unsupported. Without education, coaching and consistent reinforcement, they cannot fill the clinical gaps—and neither can primary care.

Doing Nothing Is Not Free

Many organizations have taken a wait-and-see approach to dementia. But let’s be clear: doing nothing is not free. In unmanaged populations, dementia is an invisible cost driver—contributing to medication mismanagement, ED overutilization and avoidable inpatient stays.

The good news? Medicare is funding solutions. Through the GUIDE model, CMS is investing in caregiver enablement and longitudinal support for dementia patients. For ACOs, Medicare Advantage plans and even Medicare Supplement carriers, this creates a no-cost, no-regret opportunity to address dementia without increasing burden on primary care teams.

The Path Forward: Partner With Purpose

To make dementia visible—and manageable—we must rethink how we support primary care. That means leveraging data to identify likely dementia patients, empowering caregivers before a crisis occurs and aligning with CMS-funded programs like GUIDE to deliver results at scale.

At Ceresti, we partner with value-based organizations to do exactly that. Our model doesn’t replace primary care—it enhances and unburdens it. We identify high-risk patients, activate their caregivers and deliver proven results: up to 44% fewer avoidable hospitalizations, improved RAF accuracy and sustained caregiver engagement that drives measurable outcomes.

And we don’t just promise performance—we guarantee it. We stand behind our program with a success-based approach that aligns our incentives with yours. If we don’t deliver impact, you don’t pay. It’s that simple.

Dementia is not going away. But with the right partner, it doesn’t have to be unmanageable. For organizations serious about improving outcomes and protecting margins, now is the time to lead.

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