In a First, Medicare Coverage Is Authorized for Alzheimer's
March 31, 2002
NY Times
WASHINGTON, March 30 - The Bush administration, in a major change, has authorized Medicare
coverage for the treatment of Alzheimer's disease, which afflicts nearly four
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."
Mr.
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, 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," Ms. 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," Ms. 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.
Mr.
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,
Ms. 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,"
Ms. 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 8 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."
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."
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."
Back to Top
| 
