We appreciate the opportunity to comment on the proposed regulations regarding the initial preventive

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www.alz.org Washington 202 393 7737 phonePublic Policy Office 2109 facsimile 1319 F Street, NW, Suite 710 Washington, DC 20004-1106 September 24, 2004 Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1429 – P P.O. Box 8012 Baltimore, Maryland 21244-8012 Re: CMS File Code – 1429-P: Comments on Revision to Payment Policies Under Physician Fee Schedule for 2005 ents on Section 611 – Initial Preventive Physical Examination Dear Sir or Madam: The Alzheimer's Association appreciates the opportunity to comment on the Initial Preventive Physical Examination pursuant to Section 611 of the Medicare Prescription, Drug, Improvement and Modernization Act of 2003 (MMA), published in the federal register on August 5, 2004. The Alzheimer's Association is the premier source of information and support for the 4.5 million Americans with Alzheimer's disease. Through its national network of chapters, it offers a broad range of programs and services for people with the disease, their families, and caregivers and represents their interests on Alzheimer-related issues before federal, state, and local government and with health and long term care providers. The largest private funder of Alzheimer research, the Association has committed nearly $150 million toward research into the causes, treatment, prevention, and cure of Alzheimer's disease. In its proposed regulations, ...

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• Publié par: Neveng
• Nombre de lectures: 17
• Langue: English

Extrait

www.alz.org

Washington

202 393 7737

phone

Public Policy Office

202 393 2109

facsimile

1319 F Street, NW, Suite 710

Washington, DC

20004-1106

September 24, 2004

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Attention: CMS-1429 – P

P.O. Box 8012

Baltimore, Maryland 21244-8012

Re: CMS File Code – 1429-P:

Comments on Revision to Payment Policies Under Physician Fee Schedule for 2005

Comments on Section 611 – Initial Preventive Physical Examination

Dear Sir or Madam:

The Alzheimer's Association appreciates the opportunity to comment on the Initial Preventive

Physical Examination pursuant to Section 611 of the Medicare Prescription, Drug,

Improvement and Modernization Act of 2003 (MMA), published in the federal register on

August 5, 2004. The Alzheimer's Association is the premier source of information and support

for the 4.5 million Americans with Alzheimer's disease. Through its national network of

chapters, it offers a broad range of programs and services for people with the disease, their

families, and caregivers and represents their interests on Alzheimer-related issues before

federal, state, and local government and with health and long term care providers

.

The largest

private funder of Alzheimer research, the Association has committed nearly $150 million

toward research into the causes, treatment, prevention, and cure of Alzheimer's disease.

In its proposed regulations, the Centers for Medicare and Medicaid Services (CMS) proposes to

interpret the term, “Initial Preventive Physical Examination” to include a “review of the

individual’s comprehensive medical and social history” and a “review of the individual’s

functional ability and level of safety.” The Alzheimer’s Association believes that both of these

assessments should include questions that would identify Medicare beneficiaries with possible

Alzheimer’s disease or other dementias. Individuals identified through this process would need

a follow-up diagnostic evaluation, which is already covered by Medicare.

Specific Recommendations

We recommend the following revisions to the proposed regulations and implementation of this

new benefit:

1. In §410.16(a)(1), the provision should be revised as follows:

“Review of the individual’s comprehensive medical and social history,

including

memory problems.”

With regard to Section §410.16(a)(1), in the review of the individual’s comprehensive medical

and social history, beneficiaries should be asked whether they have memory problems severe

enough to interfere with their ability to carry out routine daily activities. This question can be

asked in-person. Alternatively, many physicians have a printed questionnaire that lists

important medical conditions and is presented to the patient (or family member or other proxy

informant) at the time of the first visit or mailed to the patient to be completed ahead of time.

The condition “severe memory problems” can be easily added to the list. Since 1998, Kaiser

Permanente has used a health status questionnaire for its elderly Medicare enrollees that

includes the question, “Do you have any of the following health conditions?” and lists “severe

memory problems” as one of 18 conditions.

1

Approximately 5% of Kaiser enrollees (or their

proxy informant) give a positive response to this question, and these individuals have been

shown to be very likely to have cognitive impairment or dementia.

2

2. With regard to §410.16(a)(3), in the review of the individual’s functional ability and level of

safety,” beneficiaries (or their family member or other proxy informant) should be asked about

specific daily activities that are likely to be affected by loss of memory, executive function, and

other cognitive abilities and likely to have important safety implications. Two such questions

are:

•

Do you get lost while walking or driving in familiar places?

•

Do you have difficulty (or need help with) taking medications according to

instructions?

These questions can be easily added to other questions about functional ability that will be

included in the Initial Preventive Physical Examination and will provide important information

about cognitive status and safety risks that are highly relevant for physicians and other health

care providers.

Reasons for using the approach above rather than screening with a brief mental status

questionnaire

Brief mental status tests are frequently used for research and often recommended for use in

clinical evaluation of elderly people. These tests generally show acceptable to high accuracy

for dementia when they are used in samples that include only people who have previously been

determined to have either dementia or normal cognition and exclude people with delirium,

mental illness, mental retardation, and other acute and chronic conditions that could affect their

cognition. When used in general population samples and general medical settings where these

1

Brody KK, Johnson RE, Ried LD, Carder PC, Perrin N. A comparison of two methods for identifying frail Medicare-

aged persons.

J Am Geriatrics Soc

. 2002;50:562-569.

2

2

Crooks VC, Buckwalter JG, Petitti DB. Usefulness of a single question in a self-report questionnaire for identifying

persons with possible dementia: comparisons with other screening measures of cognitive impairment and dementia.

Presentation at the Annual Meeting of the Gerontological Society of America, Nov. 18, 2001; Chicago, IL.

3

other conditions have not been excluded, mental status test results are much less accurate and

result in many false positives, especially for people who are less educated, foreign born, or for

whom English is a second language.

For these reasons, the three consensus groups that have considered the use of brief mental

status tests to screen for cognitive impairment or dementia in population samples and general

medical settings have not recommended their use for this purpose.

3,4,5

In 2003, the U.S.

Preventive Services Task Force concluded that “current evidence does not support routine

screening of patients in whom cognitive impairment is not otherwise suspected.”

6

All three consensus groups and the U.S. Preventive Services Task Force recommend that health

care providers learn about and follow up on signs of possible dementia and respond to concerns

expressed by the patient, family members, and other knowledgeable informants. The U.S

Preventive Services Task Force concluded (some of this is also quoted above):

“Although current evidence does not support routine screening of patients

in whom cognitive impairment is not otherwise suspected, clinicians

should assess cognitive function whenever cognitive impairment or

deterioration is suspected, based on direct observation, patient report, or

concerns raised by family members, friends, or caretakers.”

7

Approximately 2% of people who are 65 years old have Alzheimer’s disease or other

dementias. These individuals are much more likely to have vascular dementia than Alzheimer’s

disease. The Alzheimer’s Association believes that the approach we propose will provide a

more accurate identification of individuals with potential Alzheimer’s disease or other

dementias. Beneficiaries identified during the initial preventive physical examination would

then require a comprehensive diagnostic evaluation for Alzheimer’s disease or other dementias.

We appreciate the opportunity to comment on the proposed regulations regarding the initial

preventive physical examination. The Alzheimer’s Association is ready to work with you, and

to assist in identifying appropriate clinical experts, to assure early identification of beneficiaries

with possible Alzheimer’s disease or dementia. Please feel free to contact Leslie B. Fried,

Director of the Association’s Medicare Advocacy Project, [phone] to further discuss

these matters.

Sincerely,

Bonnie Hogue

Leslie B. Fried

Director, Federal and State Policy

Director, Medicare Advocacy Project

3

Brodaty H, Clarke J, Ganguli M, et al. Screening for cognitive impairment in general practice: toward a consensus.

Alzheimer Dis Assoc Disord.

1998;12:1-13.

4

Costa PT, Williams TF, Somerfield M, et al. Recognition and initial assessment of Alzheimer's disease and related

dementias: clinical practice guideline. Rockville, MD: US Dep. of Health and Human Services, Agency for Health Care

Policy and Research: 1996.

5

Patterson JS, Gass DA. Screening for cognitive impairment and dementia in the elderly.

Can J Neurol Sci

. 2001;

28(suppl.):S42-S51.

6

U.S. Preventive Services Task Force.

Screening for Dementia,Recommendations and Rationale,

p. 2, accessed Sept.

14, 2004 at http://www.ahrq.gov/clinic/3rduspstf/dementia/dementrr.htm

.

7

Id.