Innovations and Challenges in Screening for Alzheimer Disease: Ken Cohen, MD, FACP

Early detection is critical in addressing Alzheimer disease (AD), yet most older adults have never received a cognitive screening, says Ken Cohen, MD, FACP, executive director of translational research, Optum Health. Digital tools, biomarkers, and value-based care models can help address this screening gap.

This transcript has been lightly edited; captions were auto-generated.

Transcript

Can you discuss the value of expanding screening for AD among seniors and what initiatives Optum is taking to broaden access?

The value is clear to both patients and the health care system. Interestingly, about 60% of patients have never had cognitive screening, so we are not providing the service that we need to provide. Patients perceive value in terms of if they were diagnosed with cognitive decline, they overwhelmingly support that they would make changes in their health behaviors—working on things like diet, exercise, and other nonpharmacologic methods that have been shown to improve cognitive function. There is value, from a patient perspective, to screening.

They also acknowledge that they would have changes to their advance care planning, financial planning, and family counseling—so there are lots of reasons patients are interested in screening. And as I mentioned, almost two-thirds of them have never been screened.

What we're doing at Optum now is that virtually all of our patients have an annual wellness visit—well in excess of 85%. We have always encouraged cognitive screening as part of that exam, but we’ve now really ramped that up so that it’s a mandatory part of the process. Our physicians and advanced practitioners are screening all seniors—those over the age of 65 or those who have noted cognitive decline, either by the patient or the caregiver—with simple primary care screening tools. Most of us are using the Mini-Cog or the MMSE [Mini-Mental State Examination].

If either of those are positive, we will move on to more definitive screening tools, such as the Montreal Cognitive Assessment or the St. Louis University Cognitive Assessment. If we define that patients have significant cognitive impairment based on those tools, they then move into a whole treatment algorithm. The screening really has been significantly ramped up just within the past year.

Why do you think this gap in screening access and utilization continues to persist?

A lot of it has to do with how we pay for services. If you look at a fee-for-service model—which is most Medicare and commercial health plans—there is no reimbursement for screening. More importantly, in terms of care management, there really isn’t robust reimbursement in most situations. Certainly not in Medicare, unless you’re part of the new GUIDE [Guiding an Improved Dementia Experience] model. There’s no reimbursement for all of the support systems required to treat a patient with Alzheimer disease. For both of those reasons, I think screening has been less than optimal.

It’s one area where value-based care has really demonstrated superiority. At Optum, we have about 5 million seniors in full value-based care models, where we have full accountability for their cost and quality of care. There, you’re not being paid fee-for-service, and we have data showing that a comprehensive care management program for patients with Alzheimer’s is actually cost-saving—reducing hospitalizations and overall medical costs.

We have an incentive to pay upfront for the infrastructure to provide those wraparound services, because we’re given the full budget for the patient. I think a lot of it really does have to do with how providers are reimbursed. We know that in our fully accountable value-based care model, for example, we do 82% more annual wellness visits compared to traditional Medicare fee-for-service. I think much of this comes down to the payment mechanisms.