New Clues, Same Access Challenges for Alzheimer’s Patients

October 29, 2015

by Amanda Conschafter, blog editor

Recent research has yielded new clues about the early indicators of Alzheimer’s disease, raising hopes for breakthrough treatments to slow the degenerative disease. According to findings published in Science this month, grid cells – the neurons charged with brain navigation – function differently in patients with a genetic predisposition toward Alzheimer’s. Research like this could contribute to more targeted Alzheimer’s medications in coming decades. But can current health plan structures accommodate access to breakthrough medications for the nations’ growing population of Alzheimer’s patients?

Exceptional in its reach and impact, Alzheimer’s and dementia are the cause of death for one in three seniors. The costs of caring for Alzheimer’s and dementia patients is expected to reach $1.1 trillion by 2050. And, according to one source, that cost now overshadows the price of treating patients with cancer or heart disease. Thus, researchers are under pressure to not only identify clues about Alzheimer’s cause but also to translate these findings into meaningful options for patients.

Current Alzheimer’s Treatment Options

At present, medications called cholinesterase inhibitors are commonly used to treat mild or moderate Alzheimer’s. These drugs temporarily prevent symptom worsening and can also control behavioral symptoms. A handful of other medications are FDA approved to treat moderate or severe Alzheimer’s. They typically work to delay symptoms or allow patients to maintain daily functioning, such as using the restroom independently, for several more months. Patients and their families remain hopeful that future medical therapies will offer find a way to permanently eradicate or more significantly delay symptoms.

High Out-of-pocket Costs for Seniors

In the meantime, some seniors with Alzheimer’s struggle to get the care they need. Half of people on Medicare had annual incomes of less than $23,500 in 2013. Yet a 2014 report from the Kaiser Family Foundation found that Medicare beneficiaries with Alzheimer’s disease have high out-of-pocket costs, spending an average of $8,305 out of pocket in 2010. More than four in 10 beneficiaries with Alzheimer’s disease were in the report’s top quartile of total out-of-pocket spending in 2010.

This spending is driven largely by long-term care facility costs. It also reflects the number of premiums seniors must pay, the report noted. Beneficiaries generally pay a premium for both Medicare Part B (physician services) and Part D (prescription drug coverage). Some pay an additional premium for Medigap or some form of private supplemental insurance.

Coverage Challenges, Narrow Formularies & Utilization Management Barriers

Unlike most health plans, Medicare does not cap the amount of out-of-pocket payments required of its beneficiaries. Thus, as advanced medications do emerge, access challenges spurred by high out-of-pocket spending requirements may grow into a more significant problem. Drug formulary make-up and utilization management techniques could also complicate matters. Currently, Medicare does not cover all Alzheimer’s drugs, limits the number of pills allowed for certain medications, and requires step therapy or “fail first” on several brand-name medications. Some therapies also require prior authorization before the patient can access them.

Thus, Alzheimer’s patients and advocates face a knotty question: When rigorous research finally yields revolutionary medicine, will the long-awaited therapies be accessible to patients?

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