Paying for Dementia care
Mary Ann Forciea MD
Clinical Professor of Medicine
Division of Geriatric Medicine
University of Pennsylvania Health System
Goals of this workshop
• Increased awareness of financial challenges
during the course of a dementia illness
• Increased awareness of quality measures for
dementia care
– incentives/penalties as they apply to:
• Sites of care
• Individual practitioners
Possible concerns about costs of
dementia care
• Time required to meet needs of patient or
caregiver
• Payment options for interprofessional team
members
• Unfamiliarity with
Medicare/Medicaid/insurers special programs
How much is the annual cost of care
for a patient with dementia?
• Office care
– Co pays, transport, attendant, meds
• Home care
– Attendant
• Pay
• Missed wages of family caregivers
– Home modification
• NH care
– Self pay
– Medicaid issues
• Hospice
Task 1 – Estimates of Costs of Care
• Write down your estimate of annual cost of
care for a patient/family with moderate
dementia for:
– Share of costs covered by Medicare
– Out of pocket costs, or
– caregiver cost
How much is the annual cost of care
for a patient with dementia?
• Office care
– Co pays, transport, attendant, meds
• Home care
– Attendant
• Pay
• Missed wages of family caregivers
– Home modification
• NH care
– Self pay
– Medicaid issues
• Hospice
Categories for dementia care
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Medicare 8%
Nursing home 22%
Informal (unpaid)home care 48%
Paid home care 11%
Out of pocket spending 11%
Yearly cost per person with dementia
in 2010 dollars
• Care purchased
– Out of pocket
– Medicare
– Formal Home Care
– Nursing home
6,194
2,752
5,678
13.876
• Informal home care
– Replacement cost
• TOTAL
27,789
56,290
How can health care professionals
help?
• Better attention to the primary care needs of the
patient with a dementing illness will improve:
– Quality of life of patients
– Quality of life of caregivers
– Cost
• Decreased hospital/ER use
• End of life care
• “much of health care for dementia patients is
reactive and unsystematic, rather than proactive
and planned” Odenheimer
Models to influence primary care
• Reimbursement (time)
– Medicare coding
• New models
• Group visits
• Medical Homes
• System Integrations (ACOs)
• Quality Improvement/Performance Measures
Challenges: Quality Measures
• Definition of quality care
– National
• Specialty societies
• “neutral” entities (non profit consortia)
– Local:
• experts/teams of leaders
• Source of data
– Evidence base
– Expert opinion
• Ease of data collection
Quality measures for dementia care
• Clinical care ‘items’ which should be offered to
all patients within a disease category
– “Quality assessment” indicators
• Payers: Medicare, private insurers
• Certifiers: Joint commission, Medicare, State
Departments of Health, Practitioner certification
agencies
• Systems
– Facilities
– Individual practitioners
Impact on practice
• Resource for individual practitioner
– Good linkage to EMR
• Guide for facility/system for resource
allocation
• Behavior change
– “Pay for performance”
• Incentives
• Penalties
Task 2: Quality Measure for Dementia
Care
• Form groups of 3 with neighbors
• You have been named to your health system’s IP
quality assurance panel as a representative of
your discipline.
• You are working with a mini-team to plan a
quality audit of a group of primary care practices
• For a medical office caring for a patient who has
been diagnosed already with dementia,
– Agree on 3 clinical services/care items which should
be documented in the chart in a 12 month period
Debrief
• List:
PCQI (AMA) Quality Measure:
Dementia Care
• AMA convened a workgroup panel (20102011, final report Oct 2011):
– MDs (neurology, psychiatry, geriatrics, primary
care), Nursing, Rehab Med
– Review of existing guidelines and supporting data
bases of information
– Series of meetings to define/refine
Final Measures
• 10 measures of quality care in 3 domains:
– Dementia subtyping and staging
– Assessment and management of behavioral
symptoms
– Caregiver education, assessment, assistance
• Data available through chart audits
Measure set: Domain 1 – dementia
staging (Measures 1, 2, 3)
• 1: Patients with dementia who were staged:
– Mild, mod, severe
– GDRS
– Fast
• 2: Cognition assessed and/or reviewed
annually
• 3: Functional status assessment annually
FAST scale grading
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FAST SCALE ADMINISTRATION
The FAST scale is a functional scale designed to evaluate patients at the more
moderate-severe stages of dementia
when the MMSE no longer can reflect changes in a meaningful clinical way. In the
early stages the patient may be
able to participate in the FAST administration but usually the information should
be collected from a caregiver or,
in the case of nursing home care, the nursing home staff.
The FAST scale has seven stages:
1 which is normal adult
2 which is normal older adult
3 which is early dementia
4 which is mild dementia
5 which is moderate dementia
6 which is moderately severe dementia
7 which is severe dementia
Fast: instructions
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FAST stage 1 is the normal adult with no cognitive decline.
FAST stage 2 is the normal older adult with very mild memory loss. (MCI)
Stage 3 is early dementia. Here memory loss becomes apparent to co-workers and family. The
patient may be unable to remember names of persons just introduced to them.
Stage 4 is mild dementia. Persons in this stage may have difficulty with finances, counting money,
and travel to new locations. Memory loss increases. The person's knowledge of current and recent
events decreases. ( early IADL issues)
Stage 5 is moderate dementia. In this stage, the person needs more help to survive. They do not
need assistance with toileting or eating, but do need help choosing clothing. The person displays
increased difficulty with serial subtraction. The patient may not know the date and year or where
they live. However, they do know who they are and the names of their family and friends(severe
IADL issues).
Stage 6 is moderately severe dementia. The person may begin to forget the names of family
members or friends. The person requires more assistance with activities of daily living, such as
bathing, toileting, and eating. Patients in this stage may develop delusions, hallucinations, or
obsessions. Patients show increased anxiety and may become violent. The person in this stage
begins to sleep during the day and stay awake at night (ADL Issues).
Stage 7 is severe dementia. In this stage, all speech is lost. Patients lose urinary and bowel control.
They lose the ability to walk. Most become bedridden and die of sepsis or pneumonia.
FAST sub staging
• 7a. Speech ability limited to the use of a single
intelligible word in an average day
• 7b. Ambulatory ability lost (cannot walk
without personal assistance).
• 7c. Ability to sit up without assistance lost
(e.g., the individual
• 7d. will fall over if there are no lateral rests
[arms] on the chair).
• e. Loss of the ability to smile.
Dementia Quality Measure
Domain 2: Behavioral symptoms
• 4. Assessment for neuropsychiatric symptoms
• 5. Intervention for neuropsychiatric
symptoms
• 6. Screened for depression
Dementia Quality Measure
Domain 3 - Caregiving
• 7. Caregivers or patients counseled for safety
• 8. Counseling/assessment of driving risk
• 9. End of life counseling:
– Goals of care documentation
– Proxy identification/review (within 2 yrs. of
diagnosis)
• 10. Caregivers
– Education
– Sources of additional support
Task 3
• You are asked to design a QI project for your
site related to dementia care
– Which performance measure would you choose to
focus on in your own practice site?
• Debrief in your mini group
• Big debrief
Summary
• Patients with dementia and their
families/caregivers have a long journey to
travel
• Dementia care elements should not be
overshadowed by acute or comorbid illness
care
• Performance (quality) measures may be a tool
to influence care
– And hopefully reward quality practice