The Future of Alzheimer's Care in America

How Patient Demand and Health Care System Capacity Could Affect the Delivery of Alzheimer's Disease–Modifying Treatments

The widespread availability of effective disease-modifying therapies (DMTs) would be a breakthrough in slowing the progression of early-stage Alzheimer’s disease to later stages of dementia.

However, even as DMTs become more widely available throughout the United States, the delivery of these therapies will depend on patient demand and provider supply—both of which are influenced by such factors as cost and reimbursement, stigma, trust in providers, access to care, provider training, and health care system infrastructure.

To assess how these factors could affect wait times and the number of patients treated with Alzheimer’s disease DMTs if such therapies become widely available, RAND researchers have simulated a selected set of possible scenarios under specific—and uncertain—conditions in the United States.

Using county-level population and health care system capacity data, projections of health care system capacity, and assumptions about patient demand at clinical steps, this tool allows users to explore the simulation and examine the relative impact of varying patient uptake and capacity—and how these factors interact to influence the delivery of Alzheimer’s disease DMTs.

Visualizing the State of Alzheimer's Care Today

Select a health care measure below to view how it differs by county.

Data unavailable for the following counties: Chugach, AK; Copper River, AK; Greater Bridgeport, CT; Naugatuck Valley, CT; and Tolland, CT.

Key Findings

  • There is substantial variation in health care system capacity across the United States to detect, diagnose, and treat early-stage Alzheimer’s disease with DMTs.
  • The estimated wait times and the number of patients treated are sensitive to patient uptake of cognitive assessment.
  • Estimated average wait times vary by state and can be three times longer in rural areas compared with urban areas.
  • Care models that enable primary care practitioners to diagnose and evaluate patients for treatment eligibility would make the biggest impact on reducing wait times for specialists and increasing the number of people treated during the 2025–2044 time period in our analysis. Improved triage of patients using blood-based biomarker tests could further reduce caseloads for specialists.
  • Widespread delivery of Alzheimer’s disease DMTs will require a combination of strategies to communicate the value of detection and treatment to patients, integrate PCPs into the detection and diagnosis pathway, and address capacity disparities across the United States.

About This Tool

This tool illustrates how patient uptake and health care system capacity will affect the delivery of Alzheimer’s disease DMTs. In the model used in this tool, patients move through detection, diagnosis, and treatment phases based on the assumed uptake and health care system capacity devoted to the clinical activity, and patients move through disease states organized by transition probabilities from the literature.

The tool expands and updates prior work by examining the role of primary care and geographic variation in capacity across the United States. The simulation results in this tool are not meant to predict what will actually happen with treatment delivery in the future, which will depend on coverage and reimbursement decisions. Rather, the simulation results illustrate a selected set of possible scenarios to demonstrate the relative impact of varying patient uptake and capacity and how these factors interact to influence the delivery of Alzheimer’s disease DMTs.

This research was funded by Genentech and carried out within the Access and Delivery Program in RAND Health Care.

RAND Health Care, a division of the RAND Corporation, promotes healthier societies by improving health care systems in the United States and other countries. We do this by providing health care decisionmakers, practitioners, and consumers with actionable, rigorous, objective evidence to support their most complex decisions. For more information, see www.rand.org/health-care, or contact:

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Data Sources

This simulation uses 2020 county-level population data from the U.S. Census Bureau as the baseline population.

The primary source of data for health care system capacity in the model is the Area Health Resources File (AHRF) 2021–2022, which includes 2020 county-level data on the health care workforce and health facilities. For PET scanners, the simulation uses the AHRF data on the distribution of PET scanners in hospitals in each county, and we benchmark to the total number of PET scanners in all settings. For infusions, the simulation assumes that infusions would be administered by RNs and LPNs.

See RR-A2643-1 for details on the data and approach.

Definitions

Average wait time:
The average amount of time waited for a given service among people who sought the service in the specified time period.
Biomarker test:
A test to measure a biological process. For Alzheimer’s disease, biomarker tests include neuroimaging such as PET, testing cerebrospinal fluid (CSF), and testing blood for the presence of proteins consistent with Alzheimer’s disease pathology. Blood-based biomarker tests could be conducted in primary care settings to improve the triage of patients with MCI due to Alzheimer’s disease.
Dementia specialist:
A neurologist, geriatrician, or geriatric psychiatrist.
Disease-modifying therapy (DMT):
A treatment that slows the progression of disease.
Infusion treatment:
Intravenous administration of a treatment directly to the bloodstream over a period of time.
Mild cognitive impairment (MCI):
An early stage of memory loss or other loss of cognition; this may be due to Alzheimer’s disease or other causes.
Overall average wait time:
The sum of average wait times across the four services studied. Sometimes increasing the capacity of one service can counterintuitively increase the overall wait time because it creates longer wait times at downstream services.
Patients treated:
The number of patients with MCI due to Alzheimer's disease who started infusion treatment in the specified time period. Sometimes increasing the capacity of one service can counterintuitively decrease the number of patients treated. This can create longer wait times at downstream services during which disease progresses and patients may no longer be eligible for treatment.
Patient uptake of cognitive assessment:
The level of patients who seek a brief cognitive assessment (a short evaluation for cognitive impairment using a structured assessment tool).
Positron emission tomography (PET):
An amyloid PET scan is a diagnostic imaging procedure used to detect the presence of amyloid plaques in the brain.
Primary care practitioner (PCP):
A primary care physician (general family medicine, general practice, and general internal medicine; excluding general pediatrics and hospital residents) or a nurse practitioner or physician assistant who works in a primary care setting.
Providers for diagnosis and treatment management based on protocolized evaluations:
The types of providers (PCPs, dementia specialists) who evaluate and diagnose patients with MCI due to Alzheimer’s disease and who manage and monitor their treatment with Alzheimer’s disease DMTs.
Share of MCI population who choose to visit a dementia specialist:
The share of patients with MCI (as determined by a score on a structured assessment tool) who are referred to a dementia specialist and seek care with a dementia specialist.
Share of PCP visits for cognitive assessment:
The share of all visits to PCPs that include cognitive assessments.