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The American Journal of Managed Care August 2019
Late Diagnosis of Hepatitis C Virus Infection, 2014-2016: Continuing Missed Intervention Opportunities
Anne C. Moorman, MPH; Jian Xing, PhD; Loralee B. Rupp, MSE; Stuart C. Gordon, MD; Mei Lu, PhD; Philip R. Spradling, MD; Joseph A. Boscarino, PhD; Mark A. Schmidt, PhD; Yihe G. Daida, PhD; and Eyasu H. Teshale, MD; for the CHeCS Investigators
Current Evidence and Controversies: Advanced Practice Providers in Healthcare
Erin Sarzynski, MD, MS; and Henry Barry, MD, MS
From the Editorial Board: Elizabeth Mitchell
Elizabeth Mitchell
Passive Social Health Surveillance and Inpatient Readmissions
Nnadozie Emechebe, MPH; Pamme Lyons Taylor, MBA, MHCA; Oluyemisi Amoda, MHA, MPH; and Zachary Pruitt, PhD
The Adoption and Spread of Hospital Care Coordination Activities Under Value-Based Programs
Larry R. Hearld, PhD; Nathaniel Carroll, PhD; and Allyson Hall, PhD
The Potential Impact of CAR T-Cell Treatment Delays on Society
Julia Thornton Snider, PhD; Michelle Brauer, BS; Rebecca Kee, BA; Katharine Batt, MD, MSc; Pinar Karaca-Mandic, PhD; Jie Zhang, PhD; and Dana P. Goldman, PhD
Pediatric Codeine Prescriptions in Outpatient and Inpatient Settings in Korea
Dajeong Kim, MS; Inmyung Song, PhD; Dongwon Yoon, PharmD; and Ju-Young Shin, PhD
Access to Chiropractic Care and the Cost of Spine Conditions Among Older Adults
Matthew A. Davis, PhD, DC, MPH; Olga Yakusheva, PhD; Haiyin Liu, MA; Joshua Tootoo, MS; Marita G. Titler, PhD, RN; and Julie P.W. Bynum, MD, MPH
Tools to Improve Referrals From Primary Care to Specialty Care
Varsha G. Vimalananda, MD, MPH; Mark Meterko, PhD; Molly E. Waring, PhD; Shirley Qian, MS; Amanda Solch, MSW; Jolie B. Wormwood, PhD; and B. Graeme Fincke, MD
Influence of Out-of-Network Payment Standards on Insurer–Provider Bargaining: California’s Experience
Erin L. Duffy, PhD, MPH
Currently Reading
Cost of Dementia in Medicare Managed Care: A Systematic Literature Review
Paul Fishman, PhD; Norma B. Coe, PhD; Lindsay White, PhD; Paul K. Crane, MD, MPH; Sungchul Park, PhD; Bailey Ingraham, MS; and Eric B. Larson, MD, MPH

Cost of Dementia in Medicare Managed Care: A Systematic Literature Review

Paul Fishman, PhD; Norma B. Coe, PhD; Lindsay White, PhD; Paul K. Crane, MD, MPH; Sungchul Park, PhD; Bailey Ingraham, MS; and Eric B. Larson, MD, MPH
A systematic review of the literature reporting the cost of dementia among Medicare managed care plans found a limited and dated body of evidence.

Objectives: We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD) within private Medicare managed care plans.

Study Design: A systematic review of all studies published in English reporting original empirical analyses of direct costs for older adults with ADRD in Medicare managed care.

Methods: All papers indexed in PubMed or Web of Science reporting ADRD costs within Medicare managed care plans from 1983 through 2018 were identified and reviewed.

Results: Despite the growth in Medicare managed care enrollment, only 9 papers report the costs of care for individuals with ADRD within these plans, and only 1 study reports data less than 10 years old. This limited literature reports wide ranges for ADRD-attributable costs, with estimates varying from $3738 to $8726 in annual prevalent costs and $8938 to $38,794 in 1-year immediate postdiagnosis incident costs. Reviewed studies also used varied study populations, case and cost ascertainment methods, and analytic methods, making cross-study comparisons difficult.

Conclusions: The expected continued growth in Medicare managed care enrollment, coupled with the large and growing impact of ADRD on America’s healthcare delivery and finance systems, requires more research on the cost of ADRD within managed care. This research should use more consistent approaches to identify ADRD prevalence and provide more detail regarding which components of care are included in analyses and how the costs of care are captured and measured.

Am J Manag Care. 2019;25(8):e247-e253
Takeaway Points
  • Despite the growth in Medicare managed care enrollment, only 9 studies have reported the cost of Alzheimer disease and related dementias (ADRD) among private health plans now providing care to one-third of Medicare beneficiaries.
  • Estimates of annual ADRD incremental costs among managed care plans vary widely, with annual prevalent and incident costs ranging from $3738 to $8726 and $8938 to $39,794, respectively.
  • The extant literature has limited policy relevance to the cost of ADRD among managed care plans due to studies being out of date and reflecting divergent populations and research methods.
As of 2018, estimates suggest that 5.4 million individuals have Alzheimer disease and related dementias (ADRD) in the United States, of whom 96% are 65 years or older.1 If current prevalence rates and population trends continue, the number of older Americans with ADRD will more than double by midcentury, with projections of 11 million to more than 13 million2,3 individuals with diagnosed ADRD by 2050. Ensuring adequate resources for the health and social services required for a growing population with diagnosed and treated ADRD is a priority for the United States and other countries around the world4; this has led to a growing demand for analyses of the costs of the social, human, and health services required to provide adequate care for cognitively impaired older adults.1,4

Analyses of the direct medical care costs among older adults with ADRD in the United States have relied primarily on diagnostic and healthcare use data from claims submitted by providers and facilities to CMS for services provided through the Medicare and Medicaid programs. This reliance on claims has resulted in most cost evidence for ADRD being based on the experience of the Medicare fee-for-service (FFS) program. Although Medicare beneficiaries have had the option of enrolling in private managed care insurance plans since 1983 when Congress created the Medicare Part C program—later transformed into the Medicare+Choice program, now Medicare Advantage (MA)—relatively little research has been conducted on the costs of ADRD among older adults within these plans.

The limited focus on ADRD costs within managed care plans has been largely driven by 2 factors. First, MA plans were not required to provide detailed diagnostic and health service use information to CMS until 2013,5 so MA-specific research required investigators to obtain data from individual health plans rather than from a single, national source. Second, enrollment in Medicare managed care plans had been consistently low—between 10% and 15% of eligible adults—for most of the program’s first 25 years.6 Thus, estimates that relied exclusively on data from Medicare FFS were presumed to produce reliable estimates of national care costs because of the relatively small numbers of older adults who chose to enroll in private managed care plans.

The limited attention that the cost of ADRD within Medicare managed care has received in the extant scientific literature was first highlighted by Rice and colleagues in 2001.7 In discussing the need for private Medicare plans to better understand and develop strategies to address treatment for the growing number of older adults with ADRD, Rice et al7 identified only 1 published paper that estimated the costs of ADRD within Medicare managed care. At that time, 15% of those eligible for Medicare (or 6.2 million individuals) were enrolled in private managed care plans.6 In the almost 20 years following the review published by Rice et al, enrollment in Medicare managed care has increased to 33% of all those eligible (or 19 million individuals). Further, Medicare managed care enrollment is forecast to rise to 41% of eligible individuals by 2027, continuing a steady shift away from FFS Medicare.6

Considering the impact that ADRD is likely to have as a driver of health service use and cost among older adults, and the increasing role that managed care plays in health service delivery for this population, we conducted a systematic review of the evidence on the direct medical care costs of ADRD within Medicare managed care. Our goal is to document the evidence of the costs of ADRD within Medicare managed care, identify potential gaps in the evidence base, and propose a research agenda to address these gaps.


We conducted a systematic review of the scientific literature that reports the direct medical care costs of ADRD for the United States within Medicare’s managed care program based on studies reported in either the PubMed or Web of Science citation indices. We included all studies published in English that reported original empirical analyses of either total healthcare costs or key components of costs (eg, inpatient services, skilled nursing care). Although the Medicare managed care program began in 1983, our search did not restrict the years in which papers were published and included papers published from 1983 through 2018. Candidate papers for this review were identified using search terms used in previous literature reviews of ADRD costs, which included combinations of the following terms: “Medicare and managed care,” “Medicare + Choice,” “Medicare Part C,” or “Medicare Advantage” with “Alzheimer’s,” “Alzheimer’s disease,” “dementia,” or “ADRD,” and “economic,” “cost,” “expenditures,” or “spending.” Two members of the study team reviewed the title of each paper to determine relevance for our analysis and then the abstracts of remaining studies to ensure that each met inclusion criteria before identifying the papers for which full reviews were to be conducted. Finally, we reviewed the citation lists for the papers that met all study inclusion criteria, as well as 2 previously published systematic reviews on ADRD cost,8,9 to ensure that our search criteria did not overlook any previously cited studies. Disagreements regarding the set of papers included in the final review were addressed by the entire study team.

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