Physicians Lack Time, Tools for Medicare's Cognitive Screening Benefit

Primary care physicians have one more item on their to-do lists: screening for cognitive impairment among Medicare beneficiaries.

Under section 4103 of the Affordable Care Act, Congress added a new benefit that provides full coverage for an Annual Wellness Visit for all Medicare beneficiaries. The visit is designed not as an annual physical, but as a preventive checkup, where the physician can design and update a long-range care plan and monitor the patient’s individual risk factors. As part of this visit, physicians are required by Medicare to assess the patient’s cognitive function using a combination of direct observation and patient and family reports.

But 1 year after the new Medicare benefit went into effect, Jan. 1, 2011, physicians aren’t spending a lot of time performing cognitive screening. Part of the reason is that they aren’t performing these annual wellness visits all that often.

"If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done."

"A lot of patients don’t ask for that exam, at least not in our neck of the woods," said Dr. Eric Tangalos, an internist and professor of medicine at the Mayo Clinic in Rochester, Minn.

And he said physicians aren’t likely to suggest scheduling the Medicare Annual Wellness Visit starting at age 65, because some of the testing doesn’t have much clinical relevance that would aid in the care of patients. "The science behind an annual wellness examination is minimal," he said.

Another problem with the exam requirements is that the provider must develop a personalized prevention plan that includes a written screening schedule for the next 5-10 years. That requirement is not only time consuming, but could be difficult for practices that don’t use electronic health records, Dr. Tangalos said.

But if the Medicare Annual Wellness Visit does become more common, physicians and other providers are likely to need more guidance on what to do as part of the cognitive screening. Officials at the Centers for Medicare and Medicaid Services have instructed providers to assess cognitive function based on their direct observation, the patient’s own reports, and information from family members, friends, and caregivers. But they haven’t recommended any specific screening instruments or set other parameters for the testing.

CMS turned to the National Institute on Aging (NIA) to look into the issue. Officials at the NIA have been working on the project for the last year, meeting with experts and evaluating published brief cognitive screening instruments. Some of the issues they are looking at include the cost of the screens and how long they take to perform, said Molly Wagster, Ph.D., chief of the Behavioral and Systems Neuroscience of Aging Branch at the NIA. They are also looking into whether the screening instruments are valid and reliable and if they are appropriate for racial and ethnic minority groups.

NIA officials also are considering whether it makes sense to conduct the assessments in a targeted way. For example, they are looking at whether or not individuals aged 65 to 75 should be automatically screened and what risk factors might be appropriate in triggering a formal screening test. NIA officials expect to complete their work this year, Dr. Wagster said.

Dr. Tangalos, who also serves as codirector for education at the Mayo Alzheimer’s Disease Research Center, said he doesn’t view routine cognitive impairment screening among 65-year-olds as beneficial because the incidence of disease is still low in that age group. Dr. Tangalos prefers to focus on at-risk populations, such as anyone moving into an assisted living facility, or moving from their home to another city. "Those things just don’t happen by accident," he said. "That, by definition, is someone at risk."

Prioritizing patients for screening based on age and other risk factors makes sense, said Dr. Howard Fillit, executive director of the Alzheimer’s Drug Discovery Foundation. The organization has been a proponent of including the cognitive assessment in the annual wellness visit, but Dr. Fillit, who is a geriatrician, said they also understand that the busy primary care physician is being asked to do a lot of things in that exam. It may make sense to screen patients annually starting around age 70 or 75 instead, he said, when the exponential increase in prevalence makes it a greater priority within the wellness exam.

The CMS language requiring cognitive impairment screening in the annual wellness exam is fairly vague, Dr. Fillit said, which gives physicians some leeway in whether or not to do formalized screening in every patient receiving the exam. If a patient is 65 years old, plays tennis everyday, continues to run a business, and his wife has no concerns about his memory, that’s probably not the best candidate for performing a cognitive impairment screen, he said.

Time is likely to be the biggest problem for primary care physicians trying to add cognitive screening to their exams, said Dr. David Knopman, professor of neurology at the Mayo Clinic in Rochester, Minn. "If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done," he said.

To do the screening properly, Dr. Knopman said physicians need to set aside enough time to perform the standardized screening tests and to speak with an informant, usually a spouse or adult child who knows the patient well. He advises practices to arrange in advance to have the informant present whenever a cognitive assessment is being performed.

Dr. Jacobo Mintzer, professor of neuroscience at the Medical University of South Carolina, Charleston, and chair of the scientific advisory committee at the Alzheimer’s Foundation of America, said he thinks that as time goes on cognitive impairment screening will become a standard part of the exam for all older adults, much like a blood pressure check. "At some point it becomes part of the basic consult that the patient receives," he said.

But not all primary care physicians will be comfortable diagnosing and treating dementia patients, he said, just as some physicians prefer to refer patients for cardiology conditions. His advice: "Know what you don’t know."

Dr. Marwan Sabbagh, a geriatric neurologist and director of the Banner Sun Health Research Institute in Sun City, Ariz., agrees that many primary care physicians aren’t comfortable making a diagnosis of Alzheimer’s disease, disclosing that diagnosis, and recommending treatment. The problem, he said, is that there just aren’t enough neurologists to go around.

There is a shortage of general neurologists, but when it comes to subspecialist neurologists who are specially trained to deal with issues of aging, the situation is even worse. The United Council for Neurologic Subspecialties have developed a certification pathway for geriatric neurologists and more fellowships in dementia and geriatric neurology are being created, Dr. Sabbagh said, but it will take years for those efforts to produce more physicians trained to care for dementia patients. "There is a huge gap," he said.

Primary care physicians have one more item on their to-do lists: screening for cognitive impairment among Medicare beneficiaries.

Under section 4103 of the Affordable Care Act, Congress added a new benefit that provides full coverage for an Annual Wellness Visit for all Medicare beneficiaries. The visit is designed not as an annual physical, but as a preventive checkup, where the physician can design and update a long-range care plan and monitor the patient’s individual risk factors. As part of this visit, physicians are required by Medicare to assess the patient’s cognitive function using a combination of direct observation and patient and family reports.

But 1 year after the new Medicare benefit went into effect, Jan. 1, 2011, physicians aren’t spending a lot of time performing cognitive screening. Part of the reason is that they aren’t performing these annual wellness visits all that often.

"If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done."

"A lot of patients don’t ask for that exam, at least not in our neck of the woods," said Dr. Eric Tangalos, an internist and professor of medicine at the Mayo Clinic in Rochester, Minn.

And he said physicians aren’t likely to suggest scheduling the Medicare Annual Wellness Visit starting at age 65, because some of the testing doesn’t have much clinical relevance that would aid in the care of patients. "The science behind an annual wellness examination is minimal," he said.

Another problem with the exam requirements is that the provider must develop a personalized prevention plan that includes a written screening schedule for the next 5-10 years. That requirement is not only time consuming, but could be difficult for practices that don’t use electronic health records, Dr. Tangalos said.

But if the Medicare Annual Wellness Visit does become more common, physicians and other providers are likely to need more guidance on what to do as part of the cognitive screening. Officials at the Centers for Medicare and Medicaid Services have instructed providers to assess cognitive function based on their direct observation, the patient’s own reports, and information from family members, friends, and caregivers. But they haven’t recommended any specific screening instruments or set other parameters for the testing.

CMS turned to the National Institute on Aging (NIA) to look into the issue. Officials at the NIA have been working on the project for the last year, meeting with experts and evaluating published brief cognitive screening instruments. Some of the issues they are looking at include the cost of the screens and how long they take to perform, said Molly Wagster, Ph.D., chief of the Behavioral and Systems Neuroscience of Aging Branch at the NIA. They are also looking into whether the screening instruments are valid and reliable and if they are appropriate for racial and ethnic minority groups.

NIA officials also are considering whether it makes sense to conduct the assessments in a targeted way. For example, they are looking at whether or not individuals aged 65 to 75 should be automatically screened and what risk factors might be appropriate in triggering a formal screening test. NIA officials expect to complete their work this year, Dr. Wagster said.

Dr. Tangalos, who also serves as codirector for education at the Mayo Alzheimer’s Disease Research Center, said he doesn’t view routine cognitive impairment screening among 65-year-olds as beneficial because the incidence of disease is still low in that age group. Dr. Tangalos prefers to focus on at-risk populations, such as anyone moving into an assisted living facility, or moving from their home to another city. "Those things just don’t happen by accident," he said. "That, by definition, is someone at risk."

Prioritizing patients for screening based on age and other risk factors makes sense, said Dr. Howard Fillit, executive director of the Alzheimer’s Drug Discovery Foundation. The organization has been a proponent of including the cognitive assessment in the annual wellness visit, but Dr. Fillit, who is a geriatrician, said they also understand that the busy primary care physician is being asked to do a lot of things in that exam. It may make sense to screen patients annually starting around age 70 or 75 instead, he said, when the exponential increase in prevalence makes it a greater priority within the wellness exam.

The CMS language requiring cognitive impairment screening in the annual wellness exam is fairly vague, Dr. Fillit said, which gives physicians some leeway in whether or not to do formalized screening in every patient receiving the exam. If a patient is 65 years old, plays tennis everyday, continues to run a business, and his wife has no concerns about his memory, that’s probably not the best candidate for performing a cognitive impairment screen, he said.

Time is likely to be the biggest problem for primary care physicians trying to add cognitive screening to their exams, said Dr. David Knopman, professor of neurology at the Mayo Clinic in Rochester, Minn. "If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done," he said.

To do the screening properly, Dr. Knopman said physicians need to set aside enough time to perform the standardized screening tests and to speak with an informant, usually a spouse or adult child who knows the patient well. He advises practices to arrange in advance to have the informant present whenever a cognitive assessment is being performed.

Dr. Jacobo Mintzer, professor of neuroscience at the Medical University of South Carolina, Charleston, and chair of the scientific advisory committee at the Alzheimer’s Foundation of America, said he thinks that as time goes on cognitive impairment screening will become a standard part of the exam for all older adults, much like a blood pressure check. "At some point it becomes part of the basic consult that the patient receives," he said.

But not all primary care physicians will be comfortable diagnosing and treating dementia patients, he said, just as some physicians prefer to refer patients for cardiology conditions. His advice: "Know what you don’t know."

Dr. Marwan Sabbagh, a geriatric neurologist and director of the Banner Sun Health Research Institute in Sun City, Ariz., agrees that many primary care physicians aren’t comfortable making a diagnosis of Alzheimer’s disease, disclosing that diagnosis, and recommending treatment. The problem, he said, is that there just aren’t enough neurologists to go around.

There is a shortage of general neurologists, but when it comes to subspecialist neurologists who are specially trained to deal with issues of aging, the situation is even worse. The United Council for Neurologic Subspecialties have developed a certification pathway for geriatric neurologists and more fellowships in dementia and geriatric neurology are being created, Dr. Sabbagh said, but it will take years for those efforts to produce more physicians trained to care for dementia patients. "There is a huge gap," he said.

Primary care physicians have one more item on their to-do lists: screening for cognitive impairment among Medicare beneficiaries.

Under section 4103 of the Affordable Care Act, Congress added a new benefit that provides full coverage for an Annual Wellness Visit for all Medicare beneficiaries. The visit is designed not as an annual physical, but as a preventive checkup, where the physician can design and update a long-range care plan and monitor the patient’s individual risk factors. As part of this visit, physicians are required by Medicare to assess the patient’s cognitive function using a combination of direct observation and patient and family reports.

But 1 year after the new Medicare benefit went into effect, Jan. 1, 2011, physicians aren’t spending a lot of time performing cognitive screening. Part of the reason is that they aren’t performing these annual wellness visits all that often.

"If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done."

"A lot of patients don’t ask for that exam, at least not in our neck of the woods," said Dr. Eric Tangalos, an internist and professor of medicine at the Mayo Clinic in Rochester, Minn.

And he said physicians aren’t likely to suggest scheduling the Medicare Annual Wellness Visit starting at age 65, because some of the testing doesn’t have much clinical relevance that would aid in the care of patients. "The science behind an annual wellness examination is minimal," he said.

Another problem with the exam requirements is that the provider must develop a personalized prevention plan that includes a written screening schedule for the next 5-10 years. That requirement is not only time consuming, but could be difficult for practices that don’t use electronic health records, Dr. Tangalos said.

But if the Medicare Annual Wellness Visit does become more common, physicians and other providers are likely to need more guidance on what to do as part of the cognitive screening. Officials at the Centers for Medicare and Medicaid Services have instructed providers to assess cognitive function based on their direct observation, the patient’s own reports, and information from family members, friends, and caregivers. But they haven’t recommended any specific screening instruments or set other parameters for the testing.

CMS turned to the National Institute on Aging (NIA) to look into the issue. Officials at the NIA have been working on the project for the last year, meeting with experts and evaluating published brief cognitive screening instruments. Some of the issues they are looking at include the cost of the screens and how long they take to perform, said Molly Wagster, Ph.D., chief of the Behavioral and Systems Neuroscience of Aging Branch at the NIA. They are also looking into whether the screening instruments are valid and reliable and if they are appropriate for racial and ethnic minority groups.

NIA officials also are considering whether it makes sense to conduct the assessments in a targeted way. For example, they are looking at whether or not individuals aged 65 to 75 should be automatically screened and what risk factors might be appropriate in triggering a formal screening test. NIA officials expect to complete their work this year, Dr. Wagster said.

Dr. Tangalos, who also serves as codirector for education at the Mayo Alzheimer’s Disease Research Center, said he doesn’t view routine cognitive impairment screening among 65-year-olds as beneficial because the incidence of disease is still low in that age group. Dr. Tangalos prefers to focus on at-risk populations, such as anyone moving into an assisted living facility, or moving from their home to another city. "Those things just don’t happen by accident," he said. "That, by definition, is someone at risk."

Prioritizing patients for screening based on age and other risk factors makes sense, said Dr. Howard Fillit, executive director of the Alzheimer’s Drug Discovery Foundation. The organization has been a proponent of including the cognitive assessment in the annual wellness visit, but Dr. Fillit, who is a geriatrician, said they also understand that the busy primary care physician is being asked to do a lot of things in that exam. It may make sense to screen patients annually starting around age 70 or 75 instead, he said, when the exponential increase in prevalence makes it a greater priority within the wellness exam.

The CMS language requiring cognitive impairment screening in the annual wellness exam is fairly vague, Dr. Fillit said, which gives physicians some leeway in whether or not to do formalized screening in every patient receiving the exam. If a patient is 65 years old, plays tennis everyday, continues to run a business, and his wife has no concerns about his memory, that’s probably not the best candidate for performing a cognitive impairment screen, he said.

Time is likely to be the biggest problem for primary care physicians trying to add cognitive screening to their exams, said Dr. David Knopman, professor of neurology at the Mayo Clinic in Rochester, Minn. "If you don’t have a half an hour to obtain a history from an informant and do a mental status exam, it’s not going to get done," he said.

To do the screening properly, Dr. Knopman said physicians need to set aside enough time to perform the standardized screening tests and to speak with an informant, usually a spouse or adult child who knows the patient well. He advises practices to arrange in advance to have the informant present whenever a cognitive assessment is being performed.

Dr. Jacobo Mintzer, professor of neuroscience at the Medical University of South Carolina, Charleston, and chair of the scientific advisory committee at the Alzheimer’s Foundation of America, said he thinks that as time goes on cognitive impairment screening will become a standard part of the exam for all older adults, much like a blood pressure check. "At some point it becomes part of the basic consult that the patient receives," he said.

But not all primary care physicians will be comfortable diagnosing and treating dementia patients, he said, just as some physicians prefer to refer patients for cardiology conditions. His advice: "Know what you don’t know."

Dr. Marwan Sabbagh, a geriatric neurologist and director of the Banner Sun Health Research Institute in Sun City, Ariz., agrees that many primary care physicians aren’t comfortable making a diagnosis of Alzheimer’s disease, disclosing that diagnosis, and recommending treatment. The problem, he said, is that there just aren’t enough neurologists to go around.

There is a shortage of general neurologists, but when it comes to subspecialist neurologists who are specially trained to deal with issues of aging, the situation is even worse. The United Council for Neurologic Subspecialties have developed a certification pathway for geriatric neurologists and more fellowships in dementia and geriatric neurology are being created, Dr. Sabbagh said, but it will take years for those efforts to produce more physicians trained to care for dementia patients. "There is a huge gap," he said.