Substantial barriers exist in timely detection of cognitive impairment, especially Alzheimer disease and related dementias (ADRD), impeding effective care planning and coordination among providers, patients and caregivers.1,2 To address these challenges, on January 1, 2017, Medicare began reimbursing clinicians for a comprehensive clinical visit for patients with cognitive impairment. Reimbursement requires cognition-focused evaluation, identification of caregivers and caregiver needs, and development, revision, or review of an Advance Care Plan.3,4 We provided the first assessment of the use of the new cognitive assessment and care planning (CACP) codes in the first 2 years of their introduction.
The study was approved by the institutional review board of Weill Cornell Medical College. Informed consent was not obtained because only deidentified secondary data were used. We followed the Strengthening the Reporting of Observational Studies in Epidemiology () reporting guideline.
We conducted a retrospective cross-sectional study using a 20% nationwide random sample of Medicare Part A and B claims and Medicare Beneficiary Summary File. Our study population included Medicare fee-for-service patients aged 65 years or older as of 2017 who were continuously enrolled in Medicare Part A and B between 2017 and 2018, or until death if they died during this period. Use of CACP was identified using Current Procedural Terminology code G0505 in 2017 and 99483 in 2018. We assessed the prevalence of patients with CACAP claims. Because patients with ADRD were the primary recipients of CACP, we stratified the claims by whether the patients had a diagnosis of ADRD in either 2017 or 2018 that had been identified by using the ADRD chronic condition indicator in the Medicare Beneficiary Summary File. Among patients with ADRD, we used multivariable logistic regression analysis to identify patient characteristics associated with having CACP in either 2017 or 2018. Patient characteristics included: age (ie, 65-74 years, 75-84 years, 鈮�85 years), gender, race, region of residence (ie, South, Midwest, West, Northeast), dual eligibility for Medicare and Medicaid, income quartile, and number of non-ADRD chronic conditions.5锘� P values were calculated using 2-sided t test, with .05 as the level of significance. Statistical analyses were performed from August 2020 to March 2021. SAS version 9.4 (SAS Institute) was used for all data analyses.
Our study population included 5鈥�980鈥�271 Medicare patients, and 895鈥�726 of the patients (15.0%) had ADRD and 8355 of the patients (0.14%) had at least 1 CACP claim in either 2017 or 2018 (Table 1). Among patients with ADRD, 390鈥�116 (43.5%) were aged 85 years or older, 358鈥�500 (40.0%) resided in the South, 234鈥�638 (26.2%) were Medicaid eligible, and 565鈥�042 (63.1%) had at least 5 chronic conditions other than ADRD (Table 2).
Among ADRD patients, 5796 patients (0.65%) had a CACP claims in either 2017 or 2018. The proportion patients with CACP claims increased from 2017 to 2018 for patients with ADRD and without ADRD (2017: patients with ADRD, 2619 [0.29%]; patients without ADRD, 1274 [0.03%]; 2018: patients with ADRD, 3639 [0.41%]; patients without ADRD, 1511 [0.03%]), and 688 (8.23%) who received any CACP services received them in both 2017 and 2018.
In an adjusted analysis, patients who were aged 85 years or older (odds ratio [OR] 0.69; 95% CI, 0.64-0.74), resided in the Midwest relative to the South (OR, 0.42; 95% CI, 0.38-0.46), and were eligible for Medicaid (OR, 0.59; 95% CI, 0.55-0.63) were associated with lower odds of having a CACP claim (Table 2). Patients were associated with higher odds of having CACP if they resided in the West relative to South, were in a higher income quartile, and had more chronic medical conditions.
There was a very low uptake of CACP claims in the first 2 years after its introduction, with disparities by patient age, number of chronic conditions, region, and income. Patients who are older may encounter more challenges in fulfilling the comprehensive evaluation required by CACP, and providers may prioritize CACP among those with more chronic conditions. Furthermore, providers in rural areas or small practices may be less likely to be aware of these codes, which may disproportionately affect patients in more remote geographic areas or patients with a lower socioeconomic status.6 However, it is possible that providers were billing components of the CACP service under separate reimbursement codes. Because of data limitations, we were unable to examine Medicare Advantage patients or include more recent years. However, our study suggests that increasing provider awareness of the new CACP service is important, perhaps through targeted continuing medical education at the facility level which may also address institution-specific challenges in billing CACP.
Accepted for Publication: July 15, 2021.
Published: September 17, 2021. doi:10.1001/jamanetworkopen.2021.25725
Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2021 Li J et al. 糖心vlog Open.
Corresponding Author: Jing Li, PhD, Assistant Professor, Department of Population Health Sciences, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065 (jil2033@med.cornell.edu).
Author Contributions: Dr Li had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Li, Mitchell.
Acquisition, analysis, or interpretation of data: Li, Andy.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: Li.
Statistical analysis: Li, Andy.
Obtained funding: Li.
Supervision: Li, Mitchell.
Conflict of Interest Disclosures: Dr Li reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.
Funding/Support: Dr Li was supported by grant K01AG066946 from the National Institute on Aging of the National Institutes of Health.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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