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Viewpoint |

Medical Insurance Coverage and Alzheimer Disease

Carol F. Lippa, MD1
[+] Author Affiliations
1Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
JAMA Neurol. 2015;72(11):1231. doi:10.1001/jamaneurol.2015.2147.
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This Viewpoint explores ways in which medical insurance coverage in the United States should better approach costs associated with Alzheimer disease.

Heart disease and cancer are the 2 leading causes of nonaccidental death in American individuals. Recent studies suggest that Alzheimer disease (AD) is underreported and ranks third.1 Today, more than 5 million Americans have AD.2 In 2010, the costs associated with AD and related dementias approached $215 billion.3 By 2050, that number is estimated to reach $1.2 trillion unless disease-modifying interventions are developed.

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AAlzheimers Disease Update form New York
Posted on October 28, 2015
David HOffman
New York State Department of Health; UAlbany School of Public Health Department of Health Policy Management and Behavior
Conflict of Interest: None Declared
Response to Dr Carol Lippa: Medical Insurance Coverage and Alzheimer Disease; JAMA Neurol. 2015; :1-2. doi: 10.1001/jamaneurol.2015.2147

Dr. Lippa describes challenges of caring for people with Alzheimer’s disease or other dementias (AD/D). Policymakers are increasingly engaging on this issue on all levels. Significant improvements have occurred in recent years for families and patients with AD/D (1). Most of the 5 million people with dementia are age 65 or older (2) and eligible for Medicare and Social Security. Most are enrolled prior to onset; there is no special application process for AD/D. Medicare covers many AD/D diagnostic services, although requirements for pre-authorizations vary by Part B plan.
The focus and cost driver for caring for people with AD/D, is long-term services and supports (LTSS), assistance with everyday activities such as bathing, dressing, meals, or managing money. Individuals with AD/D need more of these services than other older adults (3). This care, far beyond custodial care, is mostly provided by family and friends estimated at 17.9 billion hours annually (4). When families use paid providers, costs are high: Home care, 8 hours/day costs an average of $58,400 annually (5).
Eligible families do have access to some assistance. Medicaid provides coverage for health care and LTSS for people with AD/D who have low income/ assets, or who “spend down” to eligibility. Protections exist for families, specifically for their homes and some assets. In all states, nursing home care is available to Medicaid recipients who need that level of care. Most state Medicaid programs covers home and community-based services (HCBS) including personal care by paraprofessionals, states may limit the number and type of beneficiaries eligible for these services, as well as the range of services provided, and thus may have waiting times. Some HCBS providers are available through the Aging Network (for information, see eldercarelocator.gov).
State action is called for too, under Governor Cuomo’s leadership, New York is now implementing the largest state initiative ever. This $25 million effort will expand a set of evidenced-based services to more people than ever before and we are also committed to evaluating and sharing results for future health policy development.
The National Advisory Council on Alzheimer’s Disease (6) annually makes recommendations to the HHS Secretary and Congress addressing AD/D. I’ve been honored to serve on this group for the past four years, chairing the LTSS Committee. Our recommendations include adequate reimbursement, specialized training, a lead agency in every state, support for caregivers, and increasing funding for LTSS (7). Council meetings are quarterly, webcast, and open, with time for public comments.
Not long ago, AD/D was hidden and barely recognized in policy. Through national efforts and leadership in many states, we are beginning to ease the burden on people with AD/D and their families. I encourage anyone interested in advancing this effort to reach out to their local Alzheimer’s Association, contact me, or submit a comment to the Advisory Council on Alzheimer’s Research, Care, and Services. While our research colleagues work to find a cure, we need providers, families and advocates to work to ensure that loved ones with dementia get the best care possible.

David Hoffman, Director, Bureau of Community Integration and Alzheimers Disease
New York State Department of Health, Office of Health Insurance Programs
Clinical Associate Professor, Department of Health Policy Management and Behavior
UAlbany School of Public Health
One Commerce Plaza, Suite 1605
Albany, New York 12210

Hoffman, D. (2015). Looking At The Future of Alzheimer’s Disease Policy. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2015/07/14/looking-at-the-future-of-alzheimers-disease-policy/.
2 An estimated 200,000 people in the United States have early-onset dementia, which begins before age 65. These people often have a difficult time getting Social Security Disability Insurance and subsequently Medicare coverage. The Affordable Care Act, but removing the ban on denials for pre-existing conditions, is expected to ensure that some of these patients have health insurance coverage.
3 Kasper, J.D., Freedman, V.A., Spillman, B.C. (2014). Disability and Care Needs of Older Americans by Dementia Status: Findings from the 2011 National Health and Aging Trends Study. Prepared for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy, at Table 9. Retrieved from http://aspe.hhs.gov/daltcp/reports/2014/NHATS-DS.cfm.
4Alzheimer’s Association. 2015 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. 2015; 11(3): 332+.
5 MetLife Mature Market Institute. (2012). Market Survey of Long-Term Care Costs. Retrieved from https://www.metlife.com/assets/cao/mmi/publications/studies/2012/studies/mmi-2012-market-survey-longterm-care-costs.pdf.
6 http://aspe.hhs.gov/national-alzheimers-project-act
7 http://aspe.hhs.gov/national-alzheimers-project-act#Advisory Council Recommendations

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