Medicare Mandates Cognitive Screening, But Do PCPs Have the Tools to Act Confidently?

As a geriatrician, I see the significant gap between what policies intend and the reality in practice, and it’s not always what you expect. We measure blood pressure, weight, and cholesterol without hesitation. These screenings are effective because they are routine, but also because they provide clear data that helps providers make fast, crucial decisions. A blood pressure reading of 180/110 requires immediate action and primary care providers have the tools and the confidence to respond. 

Medicare’s requirement for cognitive assessment in annual wellness visits is well-meaning. However, it has an unintended consequence. Unlike other areas of health we ask PCPs to measure, providers are expected to spot cognitive decline without having the precise tools they need to act with confidence, resulting in systemic inefficiencies that clog the entire system. 

The confidence crisis hidden in plain sight 

Every three seconds, a new case of dementia is diagnosed worldwide. What happens next for these patients relies entirely on the healthcare system they encounter. I’ve seen how, despite good intentions, our flawed system fails these patients regularly. They come to my office after months of uncertainty, having been referred by their primary care providers. These are the doctors who know them best. The ones who first noticed the warning signs, yet felt they had to refer rather than take action themselves. 

And it’s not because of a lack of competence. It’s because of a lack of confidence. Particularly, a lack of confidence in the data they collect and how to turn it into actionable care. 

Imagine this scenario: During an annual wellness visit, a longtime patient scores 26 on the MoCA. That’s technically considered a “normal” score, but it’s down from a score of 28 two years ago. Their primary care provider notices this decline, but has limited insight into what’s driving it. Is this just normal aging? Signs of mild cognitive impairment? Worth monitoring? Worth doing a more fulsome work-up against? The patient and their family are worried, but the data is unclear. 

Faced with uncertainty, possibly coupled with the weight of having to deliver a diagnosis with potentially life-changing implications, most providers take the safer route: they refer to a specialist. This is a reasonable response given the situation, but it leads to a cascade of unintended consequences. 

The hidden cost of low-confidence referrals

To see a neurologist, the average wait is 34 days. For nearly one in five patients, it’s three months or more. But these are just the statistics. What the numbers don’t show is that many of these referrals aren’t from complex cases needing specialist expertise. Instead, they’re from primary care providers who lack confidence in their cognitive assessment data. These providers already know how to identify cognitive decline and use screening tools. They’ve cared for their patients for years and understand their baselines, family dynamics, and overall health better than any specialist probably could. What they lack isn’t clinical judgment; it’s the precise measurements that create confidence in their clinical decision making. 

When a provider checks blood pressure and finds that it’s high, they don’t hesitate to act. They adjust medications, recommend lifestyle changes, or formulate a monitoring plan on the spot. They know time is of the essence and they can move quickly because they trust their data. But when that same provider notices cognitive changes and only has blunt screening tools or patient-reported concerns to rely on, their often immediate recourse is a referral. That’s not because the case is complex; it’s because their tools don’t provide detailed enough insights to act on. 

The efficiency we’re losing 

This gap in confidence is hurting the efficiency of our system. It worsens due to the overwhelming demands placed on primary care providers during annual wellness visits. PCPs are expected to pack a lot into these very short appointments: preventive screenings, chronic disease management, medication reviews, lifestyle counseling, and cognitive assessments. With only 15-20 minutes to cover everything, it’s understandable for providers to feel that gathering the detailed data needed for a confident cognitive assessment isn’t feasible at the point of care. 

And so begins a vicious cycle: lacking time and tools for thorough cognitive evaluations, PCPs default to specialist referrals, even for cases they might otherwise manage. The result? Specialists like me spend significant time evaluating patients whose cognitive concerns could be handled, at least initially, in their primary care providers office. But only if those providers had more thorough assessment tools that also met the speed of evaluation required. 

And for patients with actually complex neurological conditions – they also feel the impact. They’re left waiting longer for expert care because the system is overwhelmed with cases that don’t actually necessitate that level of specialization. So we end up failing everyone: PCPs feel stressed and under-equipped, patients face unnecessary delays and anxiety, and specialists like me are diverted from the complex cases that could truly benefit from my focus and timely expertise. 

But it doesn’t need to be an either/or situation. We don’t need to choose between primary care management and specialist referrals. I believe it is possible to have a system that empowers primary care providers to confidently manage what they can, using efficient, on-site tools that fit within the time limitations of real practice, while keeping specialist resources for cases that truly require advanced knowledge. 

What does confidence look like in practice 

Imagine instead: during that same annual wellness visit, the provider uses a precise cognitive assessment that provides detailed, domain specific data and the ability to benchmark performance and easily compare it year over year and to a normative database of health individuals. The patient’s scores indicate subtle but consistent decline across specific cognitive areas, along with clear risk stratification, actionable insights, and guided care plan creation. The provider now has a depth of data they can trust and the tools at their fingertips to create actionable next steps. 

With confidence, they can: 

● Start evidence-based interventions for modifiable risk factors 

● Develop targeted monitoring plans 

● Offer clear, data-supported guidance to patients and families 

● Reserve specialist referrals for cases showing significant concerns that need advanced evaluation 

This isn’t about replacing specialists; it’s about optimizing the entire system so each provider can operate at the top of their ability. 

When healthcare systems adopt this approach, efficiency spreads through every level of care. Primary care practices no longer need to rely as heavily on specialist referrals to help support every patient presenting with cognitive concerns. Instead, their referrals focus on cases that actually need specialist intervention. And trust me, specialists welcome this change because it means we can apply our expertise where it matters most instead of sifting through obvious cases. 

The financial impact of a better triage system is also significant. Fewer specialty care bottlenecks lead to shorter wait times and better use of resources. Improved documentation supports better reimbursement for cognitive health services. Medicare’s focus on value-based care suddenly benefits providers who show real outcomes through early detection and intervention. 

Beyond the system benefits, managing population health becomes feasible for the first time. Rather than waiting for crises, health systems can identify at-risk groups and act proactively. They can monitor outcomes, adjust protocols, and demonstrate a return on investment in cognitive health programs. 

More than economics: A case for human impact 

Maybe most importantly, the patient experience vastly improves. Instead of enduring months of worry and uncertainty, people leave appointments with a clear understanding of their cognitive health, specific steps to follow, and confidence that they are being monitored correctly. Families shift from panic to constructive involvement in care. 

Early detection and intervention delay nursing home placement by an average of two years. This represents millions in avoided costs. It also means reducing avoidable risks. Emergency department visits decline as cognitive issues that can lead to things like falls or missed medications are managed proactively rather than reactively. 

However, the true win isn’t financial — it’s families staying together longer, reduced stress on caregivers, and preserving the independence and dignity of patients. The entire system operates more smoothly and offers a better quality of life for the people it’s designed to serve. 

The tools already exist 

Through decades of practice, I’ve learned that the tools we use directly influence the care patients receive. Given the brain’s complexity, no area is this more true than in measurement of cognitive health. Scientifically validated, precise digital cognitive assessment technology is available today, providing the detailed, domain-specific results providers need to act with confidence. 

We don’t need radical changes to the system. We need to apply the same measurement principles that work for cardiovascular health to brain health: regular, precise, actionable assessments that build provider confidence and enable appropriate care at every level. 

An all-hands-on-deck approach 

The cognitive health crisis requires us to use our healthcare system’s full capacity efficiently. Primary care providers see patients regularly, understand their complete health stories, and are ideally suited to manage cognitive health — when they have the tools that inspire confidence instead of uncertainty. 

Having focused my career on aging and seeing its connection to cognitive health, I believe the solution is not about creating more referral pathways, but about building the measurement infrastructure that enables excellent primary care providers to act confidently on their observations. 

Expertise exists throughout our system. The tools to support it are available. What we need now is the commitment to ensure every provider — from primary care to specialists — has the specific data they need to deliver the right care at the right time, with confidence.

Photo: Jorg Greuel, Getty Images

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