Hospitals, primary care practices and other healthcare providers are split over whether Medicare will pay them enough to cover dementia patients at home as part of a new pilot.
Nearly 100 providers began enrolling patients July 1 in the Centers for Medicare and Medicaid Services’ Guiding an Improved Dementia Experience model, known as GUIDE. Another 300 others will begin enrolling patients in the program on July 1, 2025. Some participants that previously provided comprehensive wrap-around services for dementia patients at home said getting a monthly care management payment for each fee-for-service beneficiary will cover costs they had been absorbing. But others aren’t sure the reimbursement will be enough to scale up programs or cover the cost of care for these complex patients.
Related: CMS to test dementia care model for caregivers, patients
CMS is testing the GUIDE program for eight years to see if it can contain the spiraling costs of care for Alzheimer’s disease and dementia patients, which are expected to balloon from $345 billion in 2023 to nearly $1 trillion by 2050, according to the Centers for Disease Control and Prevention. Many of those patients cycle through hospitals and emergency departments for a variety of conditions.
Providers in the pilot deliver a variety of home-based healthcare services, including primary care, care navigation by social workers and community health workers and a 24/7 support hotline. The program also offers education, training and respite services to unpaid caregivers.
Medicare reimbursement for the program ranges from $150 a month for less complex patients to $390 a month for moderate to highly complex patients during their first six months in the program. After that, monthly rates fall by about half for established patients. Spending for caregiver respite services is capped at $2,500 a year.
The monthly payments should cover the costs for Rush University Medical Center in Chicago to provide comprehensive care to dementia patients at home and support for their caregivers, said Dr. Elizabeth Davis, associate chief medical officer for community health equity. The Chicago-based hospital system will enroll around 80 patients in GUIDE by the end of this year and up to 200 by next July.
Rush has been providing home-based care and wrap-around services to some dementia patients for several years through the primary care program Rush at Home and Rush Senior Care, which provides geriatric care and counseling services. While fee-for-service Medicare pays for some services, such as home-based primary care, it doesn’t pay for social workers or community health workers, according to Davis, who leads Rush at Home. She said before GUIDE, the health system relied on philanthropy to plug reimbursement holes for those patients.
“This will literally help us make ends meet,” Davis said. “We don’t want margin and mission to be opposed. We want them to be aligned and GUIDE helps us align our mission and our margin.”
However, some providers just ramping up new programs aren’t sure Medicare's pay will cover the cost of comprehensive home-based services and caregiver support that CMS envisioned. New York-based Weill Cornell Medicine, which will launch GUIDE next year, is among them.
The health system will provide some services through its home care unit and will need to hire a number of staff, including nurse practitioners and social workers, according to Dr. Matthew Fink, Weill Cornell Medicine neurology chair. Fink said setting up the program will be a heavy lift and, although he thinks it will benefit dementia patients, he is not sure the payment rate is enough to cover the program’s costs.
“We are going to move ahead with it anyway because we think it is very important and is the right thing to do," Fink said. "We’ll have to worry about the adequacy of the reimbursement at a later time.”
EmpowerMe Wellness CEO Joshua Stevens also said he isn’t sure the payment rate will be sufficient to cover dementia patients enrolled in GUIDE. The St. Louis, Missouri-based company provides wellness visits, care coordination, therapy and pharmacy services to older adults at about a thousand onsite clinics at senior living facilities.
Stevens thinks the pilot will provide valuable data to both CMS and private insurers on the actual costs to care for a patient population that is expected to double from approximately 7 million people to nearly 14 million over the next 30 years. He said that could encourage private payers to find ways bundle those services in a cost-effective way.
“It makes things much less abstract and it might allow them to underwrite the opportunity to partner with us in a way that is much less risky for them,” Stevens said.