Local advocacy is imperative when coverage for dementia patients is needed

                                    The National Psychologist  January/February 2001, Vol. 10  No 1, P. 14

By Paula Hartman-Stein, Ph.D.

Despite trends to increase restrictions for payment of psychological services for Medicare patients diagnosed with dementia, there is hope that necessary psychological and rehabilitation care will be covered in the future.


A rule to that effect became part of Medicare policy in Connecticut on Dec. 19, but other carriers in the country have not yet demonstrated intentions to emulate Connecticut.


However, Leslie Fried, an attorney and associate director of the American Bar Association’s (ABA) Commission of Legal Problems of the Elderly, noted that local advocacy groups made it happen there.  She emphasized the importance of local involvement by groups who want services for dementia patients to continue.


It took a year of negotiations with United Health Care, the Medicare carrier in Connecticut, to loosen coverage for psychological and rehabilitation services.  (United Health Care has since been replaced by another carrier in Connecticut, First Coast Service Options.)


Fried explained that because there is no cure for Alzheimer’s disease, Medicare carriers frequently deny services that would treat symptoms and potentially improve functioning for these patients.


In November 1999 United Health Care proposed a medical review policy that severely restricted payment of services for dementia patients. The diagnosis of Alzheimer’s disease or other causes of dementia would have automatically prohibited payment for psychiatric services, including psychotherapy as well as physical, occupational, and speech therapy. This was done whether the patient was in the earliest detectable stage or in the most severe stage.


Fried said that almost all of the Medicare carriers have a local medical review policy on psychiatry and psychology which restricts services to patients with dementia.


In Connecticut, local providers, including geriatric psychiatrists and the local Alzheimer Association, sent information about these policy changes to the ABA Commission. After their attorney became involved, the local medical director suddenly became willing to talk to providers about evidence-based clinical practices. Fried explained that there were several rounds of proposed drafts and eventually what was adopted was agreeable to the providers.


Now that the  new policy has taken effect, clinicians in Connecticut must show medical necessity for their treatment, but the services are not automatically excluded for dementia patients as they previously had been.


One major goal of the ABA Commission is to try and get the carrier to all individual assessment of each person and decide whether they should have coverage. “It should be decided individually, not just based upon a diagnosis,” according to Fried.


The major goal of local medical review policies is to prevent overutilization of services Paid by Health Care Financing administration (HCFA). “I think that HCFA has given unfettered authority to the local Medicare carriers without any oversight,” said Fried. Although she acknowledges that the process is a slow one, she said, “we are trying to educate medical directors and HCFA staff that Alzheimer’s disease is a progressive illness.”


Early diagnosis of dementia can result in proper medical and psychosocial treatment for both the patient and the caregiver. The ABA commission is concerned that clinicians may be hesitant to properly diagnose dementia if Medicare carriers automatically prohibit payment of services.


Fried advised that “given the weight and impact of the local medical review policies, all provider associations should have somebody watching the proposed policy changes.” Fried is available to review local Medicare policies or proposed changes and can be contacted at friedl@staff.abanet.org.


On a related issuer, the Office of the Inspector General is reported to have written a document stating that mental health services in nursing homes have been over utilized with the implication that local Medicare carriers are to scrutinize mental health practices more closely.  The OIG report is to be made public in January.  An earlier report outlining abuses of mental health practices in nursing homes was presented by the OIG in 1996.


Paula Hartman-Stein, Ph.D. is a clinical psychologist specializing in geropsychology in Kent, Ohio. In 1998 she edited Innovative Behavioral Healthcare for Older Adults: A Guidebook for Changing Times. Her seminars are available in archive version through the Fielding Institute. She can be reached through her website, www.centerforhealthyaging.com.

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