As we know, dementia diagnosis in the US is awful. Few doctors are trained to diagnosis and we are left wondering who is a diagnosis expert. Clinical competency requires fellowship training, one which few doctors pursue these fellowships. "The amyloid imaging task force decided the answer is a geriatrician, neurologist or psychiatrist who devotes a “substantial proportion” of practice to diagnosing and caring for adults with cognitive problems. That proportion, we suggested, should be at least 25% of patient contact. There aren't a lot of doctors who meet this criterion."
There is a strong financial disincentive for doctors to not specialize in dementia care. Doctor visits are long but the fees (determine by Medicare and insurance companies) are low. Doing dementia only care isn't financially feasible for private practices. no wonder so many doctors who work in the field are university researchers or work for non-profits that get some of their income outside of insurance payments and user fees.
"Among the biggest drivers of physicians' salaries are the drugs, tests and procedures they prescribe. The more they prescribe, the more they get paid. These incentives are hardwired into the healthcare system. The 1965 legislation that created Medicare wasn’t written to develop a system to care for older adults and to pay doctors to deliver quality care. Concerns about socialized medicine stifled those progressive ideas. Instead, Medicare was designed to pay 1965 doctors to practice 1965 medicine on their patients. The system was driven by the volume, not the value, of care."
But some good news.
"Multiple well-designed studies demonstrate that an accurate diagnosis and care plan benefit both patients and their caregivers, delaying, for example, the need for nursing home placement. So let’s start paying for that."
"Medicare is beginning to pay for innovations that use the principles of geriatric medicine to care for complex patients, and among the patients targeted to receive comprehensive primary care are patients with dementia. Just last month, Medicare also agreed to pay doctors to diagnose and create a care plan for patients with cognitive impairment."
"These are small steps, but they’re steps forward. I worry though that the politics of “repealing Obamacare” will knock us backwards, but I have to have hope that, in time, doctors will have more skills and time to properly work up and treat patients with memory problems, and so I’ll stop hearing about how memory loss can cause diarrhea."
This change in the Medicare law explains a cognitive care plan meeting for my wife last week. During the meeting the doctor said that this is something new her clinic is doing because Medicare now allows for re-examination of diagnosis twice a year. I later read the Forbes article and it clicked that what I read about is being quickly adopted by my wife's clinic. We hope that Thursday's meeting will result in improved care for my wife. And I hope we will see better dementia care in the US over time.
The Forbes article was written by Jason Karlawish is a Professor of Medicine, Medical Ethics and Health Policy, and Neurology at the University of Pennsylvania.
I'm not sure how well this will translate for us in the trenches, especially in smaller communities.
I think about paying for a medicare supplement for my husband (already pay for Part B but never used it) so I can get a non-VA doctor, maybe one that would care more about the both of us. I am envious when ones here talk about how their spouses doctor also is worried about them. I have tried to change my primary to the senior clinic Kadlec has because in the 4 years since my doctor put me on wellbutrin he has never once asked me how I am doing. I thought maybe at the senior clinic where they treat a lot of dementia it might be different. I was told I was not sick enough for the clinic! He should be sick enough to get in to one of their doctors.
It can be the beginning of a more long term change that will make it economically viable for doctors to specialize in dementia care. You are correct that most people will not see changes in the short run.
It also pointed out to me one reason it is so hard to get a dementia dx. So few doctors are familiar with any dementia and there are strong economic incentives for doctors to stay away from dementia care.
I know that my partner's neurologist treated her for her seizure disorder, but refused to diagnose "dementia" of any sort because that meant "it was all over". With my life experience I knew we were in the midst of dementia, it was the reason I was going with her to doctor appointments. I also knew that we were at the beginning of a new journey together and that it was far from being "all over" for us. What he meant, but did not explain, was that it was all over for him - nothing more he could do. A little narrow sighted do you think?
Without help from him I got the help that my partner and I needed to see our way through to the end of what was a long journey. But I always thought what happens to people who do not have my life experience of working with the elderly and dealing with dementia?