April 2018

 

Most of these articles leave the impression that dementia is an expensive condition but fail to explain why. However, if dementia is so expensive, why did CMS eliminate the HCC Risk Adjustment Score* for dementia in 2014? 

 

It turns out that dementia on its own is not expensive. Because there is no cure for dementia and also no way to slow its progression (e.g., drugs like Namenda and Aricept have limited benefits) a person who is generally healthy and living with dementia does not require more medical care—because none exists. In fact, CMS announced in 2014** that “many of the costs directly associated with dementia are not Medicare Part A and B costs.” Thus, while dementia clearly has a devastating impact on quality of life, caregiver burden and family dynamics, CMS is unprepared to support higher reimbursement for the medical expenses of patients living solely with dementia. 

 

But wait, does that mean that the numbers reported in all of those published articles are incorrect? Not exactly; but the reasons given for why dementia is expensive are often not fully explained. 

 

The medical cost of dementia are exceptionally high when a person living with dementia is also unable to self-manage their other chronic conditions, for example, CHF, diabetes or COPD. Persons living with dementia are often unable to accurately report their symptoms, follow their physicians’ instructions, and have stressed and inexperienced family members who provide support. These are the reasons why patients with dementia much more likely to go to the emergency room, be admitted to the hospital and utilize more post-acute care (e.g., skilled nursing or home health). Experts agree that many of the causes for higher and more expensive utilization of healthcare services of those with dementia are preventable in the home. 

 

The truth is that dementia is a significant “multiplier” on the costs of chronic conditions, similar to the known multiplier effect that depression has on costs. Managing any chronic condition is two to three times more expensive in the presence of dementia.  In a typical Medicare population, 10% of patients have dementia or are cognitively impaired and drive more than 25% of total annual healthcare expenditures – the vast majority of which are in Part A and B cost categories.  If health plans and providers understood this reality, they’d be lobbying CMS for a reinstatement of the HCC codes for dementia, as a multiplier.  They’d also be aggressively seeking ways to help multi-chronic patients with dementia manage their chronic conditions, for example, by empowering a family caregiver to provide better care (this is what we do at Ceresti, www.ceresti.com).  

 

Imagine if it were possible to reallocate the billions that can be saved by providing better care for those with dementia, to research aimed at finding a cure. Everybody would benefit.

 

* Risk Adjustment and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Centers for Medicare and Medicaid Service (CMS) to adjust Medicare Advantage health plan payment at the patient level. HCC risk adjustment is largely based on the enrollee health status and their demographic characteristic.

 

** Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter (April 1, 2013)

 

What are Chronic Conditions?

Chronic conditions are medical conditions that are persistent and require regular monitoring, management or treatment. The 10 most common chronic conditions that impact seniors are:

 

1) Hypertension (High Blood Pressure)

2) High Cholesterol

3) Arthritis

4) Ischemic/Coronary Heart Disease

5) Diabetes

6) Chronic Kidney Disease

7) Heart Failure

8) Depression

9) Alzheimer’s Disease and Dementia

10) Chronic Obstructive Pulmonary Disease

 

In some cases, the onset of a chronic condition can be prevented through incorporation of lifestyle habits like a healthy diet and exercise.  However, in other cases, one may be genetically predisposed to the condition. In either scenario, once someone has been diagnosed with a chronic condition, regular medical and lifestyle management are required to appropriately maintain the course of one’s health.    

 

How are Chronic Conditions are Managed?

When trying to understand the management of chronic conditions, we typically reference “best practices” and “evidence-based interventions.” While there are a variety of strategies and goals healthcare providers can recommend to their patients, there are commonalities among most of these approaches.

 

For example, medication adherence is common to all chronic care management strategies.  Whether referring to hypertension, diabetes or depression, taking medications as prescribed is essential. Other common self-management functions include maintaining a particular diet, getting the appropriate amount of exercise, proper sleep hygiene and monitoring of vitals/labs/weight.         

 

Multiple Chronic Conditions: 1 + 1 ≠ 2

Chronic conditions are not simply additive in either complexity and cost. If someone is suffering from diabetes, hypertension and chronic kidney disease, it is not enough to just manage each condition individually. Not only do the conditions interact and exacerbate each other, but the management strategies and treatments do as well. The relative severity of each of these conditions also impacts the overall management approach, highly personalized and often complex care plans are necessary to account for these individual nuances.        

 

What happens with Dementia?

Alzheimer’s Disease and other forms of dementia are commonly age-related conditions, primarily impacting the oldest segments of the population. While the cognitive and behavioral challenges associated with dementia are significant, the consequences on other chronic conditions are perhaps even more dire.  

 

Self-management of chronic conditions can be severely compromised with dementia, where medication adherence and following a care plan can be impossible for the patient. Even conditions that are typically well managed, like hypertension, can become a major issue for someone with dementia. The inability to fully participate in chronic care management severely confounds the challenges associated with dementia, unfortunately accounting for tremendous morbidity in seniors in today (the fastest growing segment of the US population).

It wasn’t always that way for Renee.  As the primary caregiver for her husband Tom who was diagnosed with multiple chronic conditions, that meant managing his health needs and daily activities in addition to her own. Renee often felt stressed and anxious about the requirements of caring for Tom at home.  By working with Ceresti’s coaching, education and support program, she was able to develop the skills and confidence needed to provide Tom with the best possible care and alleviate the stress associated with her role as his caregiver.