Medicare will now cover Alzheimer's patients
The New York Times
WASHINGTON -- The Bush administration, in a major
change, has authorized Medicare coverage for the treatment of Alzheimer's
disease, which afflicts nearly 4 million Americans and is expected to grow to
epidemic proportions with the aging of the population.
The new policy means that Medicare beneficiaries
can no longer be denied reimbursement for the costs of mental health services,
hospice care or home health care just because they have Alzheimer's.
In the past, many claims were automatically denied
on the assumption that treatment was futile because people with Alzheimer's were
incapable of any medical improvement. Now, federal officials say, new studies
show that people with Alzheimer's can often benefit from psychotherapy, physical
and occupational therapy and other services.
"This is great news for people with Alzheimer's
disease and other dementias," said Stephen R. McConnell, chief executive of the
Alzheimer's Association. "The new policy should eliminate a form of
discrimination against millions of people."
Neither federal officials nor advocates for the
elderly provided estimates of the cost of the new policy. Experts said the
direct cost to Medicare could be several billion dollars a year. But, they said,
some of the cost could be offset by savings elsewhere in Medicare and Medicaid,
because the new services will enable patients to live longer on their own, with
greater ability to function.
The policy is set forth in a memorandum sent late
last year from the government to the companies that review and pay Medicare
claims. These companies have just begun to put the change into practice.
The government gave no public notice of the new
policy, but it has already made a difference in the lives of some people with
Alzheimer's. Some patients have received benefits that were once denied, and
some medical practitioners have secured payment for services that Medicare once
refused to cover.
The companies that review claims for the
government, under federal contracts, are known as Medicare carriers. Most of
them had programmed their computers to reject claims for people with Alzheimer's
and other types of dementia. The new policy bans such computer software
instructions and says contractors cannot deny claims simply because a person has
Alzheimer's.
"Throughout the course of their disease," the
memorandum says, "patients with dementia may benefit from pharmacologic,
physical, occupational, speech-language and other therapies."
Patients' advocates, including the Alzheimer's
Association and the American Bar Association, had supplied the government with
dozens of research studies providing scientific evidence that such therapies
were effective.
The government said it changed its policy because
doctors and psychologists can now often diagnose Alzheimer's in its early
stages, when patients are most likely to derive significant benefits from
treatment and therapy. While there is no cure for Alzheimer's, staving off its
worst effects can prolong a relatively normal life and save money.
It is not clear why the government did not
publicize the new policy. Some officials apparently did not want to acknowledge
that the old policy was, in effect, biased against people with Alzheimer's. When
asked, a Medicare official said the change was not announced because "we saw it
mainly as a technical matter for Medicare carriers."
McConnell of the Alzheimer's Association estimated
that 10 percent of people over 65 and nearly half of those over 85 had
Alzheimer's, a brain disorder that causes loss of memory, changes in personality
and behavior, and a decline in thinking abilities.
Under the policy, Medicare will pay for more
therapy and outpatient services. Dr. Steven T. DeKosky, a neurologist who
directs the Alzheimer's Disease Research Center at the University of Pittsburgh,
said these services would "keep people out of nursing homes," avoiding costs
that would otherwise be borne by the government and by patients or their
families.
Kim A. Warchol, an occupational therapist in
Itasca, Ill., who specializes in the treatment of people with Alzheimer's, said
the new policy had major implications for patients, their spouses and their
children.
"People with Alzheimer's will be able to live at
home longer and avoid institutionalization," Warchol said. "Caregivers often
assume that people with Alzheimer's are helpless. But we focus on their
remaining physical and mental abilities, the things they can still do, and we
find that many patients can perform activities of daily living if we provide
appropriate cues or reminders of how to get started."
Margaret P. Norris, an associate professor of
psychology at Texas A&M University, said that while Alzheimer's was
irreversible and incurable, patients with mild to moderate forms of the disease
could benefit from psychotherapy to help them cope with loss of memory and with
feelings of depression and anxiety.
"We encourage patients to keep a notebook full of
important information, like the names of their grandchildren, which they might
forget," Norris said. "In later stages of Alzheimer's disease, it's common for
patients to yell and scream and become aggressive. That may be because the
environment is too noisy and distracting. We can sometimes modify the patient's
behavior by changing the environment."
The impact of the new policy is illustrated by the
experience of Jenni Lee Robins, 58, of Winter Haven, Fla., who used it to get
treatment for her father, Harry H. Baker.
Baker, 78, has had Alzheimer's for eight years.
After he was hospitalized and admitted to a nursing home last year, he received
physical therapy, but it was ended after the nursing home concluded that his
condition would not improve. He was hospitalized this year for pneumonia.
After learning of the new policy from a local
chapter of the Alzheimer's Association, Robins used it to ensure that her father
got "all the appropriate therapies" -- physical, occupational and respiratory.
"Daddy has improved tremendously because of the
therapies Medicare now covers," Robins said. "He is in better condition now than
before he went into the hospital this year. After eight days in the hospital, he
lost the ability to walk, forgot how to walk. But after nine weeks of physical
therapy, he can walk again."
People with Alzheimer's live an average of eight to
10 years after the condition is diagnosed.
Dr. Paula E. Hartman-Stein, a clinical psychologist
and founder of the Center for Healthy Aging in Kent, Ohio, said: "Previously, in
many parts of the country, if a person had a diagnosis of dementia, the Medicare
carrier would just arbitrarily, as a blanket policy, not cover psychological
services. The new policy breaks down one of the major barriers to providing
mental health services to elderly people."
Dr. Hartman-Stein said she had many patients with
Alzheimer's or other types of dementia who "do very well in the psychotherapy
groups I run."
Christina A. Metzler, director of federal affairs
at the American Occupational Therapy Association, said the new policy was
"tremendously significant" for patients.
"In the past," she said, "a diagnosis of
Alzheimer's could prevent a patient from getting Medicare coverage for therapy
to treat other conditions -- a broken hip, a broken wrist or a stroke. If a
diagnosis of Alzheimer's showed up anywhere on the claim, Medicare tended to
deny payment."
The new policy was adopted after two years of
lobbying by the Alzheimer's Association and the American Bar Association's
Commission on Legal Problems of the Elderly.
Leslie B. Fried, a lawyer at the commission, used
the Freedom of Information Act to get copies of the local rules used by Medicare
carriers in deciding whether to pay claims. These documents, she said, showed
that "people with Alzheimer's were often being denied medically necessary
services."
With Alzheimer's, as with any other illness, health
care providers seeking payment from Medicare must show that their services are
medically necessary.
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