Creator: Help Dementia Editorial Team
Published: 2026-04-11T23:41:24

Reviewed by the Help Dementia Editorial Team — our editors review every article for accuracy against guidance from the National Institute on Aging, the Alzheimer’s Association, and peer-reviewed sources.

Healthcare system sits at the center of this dementia and brain health question.

The healthcare system is not yet adequately prepared for the demand that disease-modifying Alzheimer’s treatments will create. With lecanemab and donanemab now approved worldwide and demonstrating efficacy in slowing cognitive decline in early-stage patients, the U.S. healthcare infrastructure faces substantial, documented challenges in screening, diagnosing, and treating patients quickly enough to make these medications available at scale.

Research from RAND and academic medical centers shows that current capacity—from diagnostic testing to specialist availability to treatment coordination—falls significantly short of what will be needed in the coming years. The core problem is not the availability of effective medications, but rather the fundamental limitations in how Americans access the diagnostic pathway to receive them. A patient with early memory concerns today faces bottlenecks at nearly every step: getting a primary care provider who recognizes early cognitive decline, accessing cognitive assessment, obtaining the specialized testing required to confirm amyloid pathology, and finding a qualified care coordinator to manage ongoing treatment. These gaps exist today, before treatment demand has fully emerged, suggesting the system will struggle substantially as more patients seek access to these disease-modifying therapies.

Why Diagnostic Bottlenecks Threaten Access to New Alzheimer’s Treatments
Coverage Access and the Equity Crisis Embedded in Current Approval
The Integration Gap Between Primary Care and Specialist-Driven Diagnosis
Workforce Limitations and the Shortage of Cognitive Specialists
Medication Access and Infusion Capacity
Regional Disparities and Rural Healthcare System Deficits
Future Outlook and the Closing Window for Preparedness
Conclusion

Why Diagnostic Bottlenecks Threaten Access to New Alzheimer’s Treatments

The most critical constraint identified by healthcare systems researchers is the capacity for amyloid-targeting therapy confirmation testing. Lecanemab and donanemab both require evidence of amyloid pathology in the brain, confirmed through either cerebrospinal fluid (CSF) analysis via spinal tap or positron emission tomography (PET) imaging. The U.S. healthcare system currently lacks sufficient capacity in both modalities to screen and confirm the number of patients who will need this testing once treatment demand increases. CSF analysis expansion is explicitly identified in preparedness assessments as necessary infrastructure that must be developed.

Consider the practical reality: A 65-year-old with subjective cognitive decline visits her primary care physician in a mid-sized U.S. city. The doctor recognizes the concern and wants to refer her for evaluation, but the local neurology practice has a 4-month waiting list, and no CSF testing capacity exists at the regional hospital. The patient’s best option is to travel 200 miles to a major medical center—an option unavailable to many. This scenario, repeated across the country, exemplifies why preparedness remains inadequate. The RAND Corporation’s assessment found that many regions lack even basic infrastructure for early identification and diagnostic confirmation.

Why Diagnostic Bottlenecks Threaten Access to New Alzheimer's Treatments

Coverage Access and the Equity Crisis Embedded in Current Approval

Even where diagnosis is possible, treatment access remains restricted by insurance coverage and regional policies. Disease-modifying Alzheimer’s therapies are currently limited in many countries and regions, often restricted to those with adequate insurance coverage or living in healthcare systems that have adopted public payment policies. In the United States, Medicare coverage policies remain complex and restrictive in some circumstances, while many commercial insurers maintain high barriers to entry. The equity implications are stark. A patient in San Francisco with excellent insurance coverage and access to a major academic medical center may be diagnosed and treated within months of symptom onset.

A rural patient in Mississippi with Medicare alone may never gain access to these therapies, regardless of their medical need. Worse, some healthcare systems have delayed systematic screening efforts because they lack confidence in their ability to deliver treatment to those diagnosed positive. This creates a perverse incentive structure: if you cannot afford or access treatment, you may not be offered diagnosis either. The coverage landscape remains fragmented globally, with some European countries offering earlier and broader access than the United States—a situation that contradicts the notion of the U.S. healthcare system being any kind of leader in Alzheimer’s treatment preparedness.

The Integration Gap Between Primary Care and Specialist-Driven Diagnosis

A major finding across preparedness research is the lack of integration between primary care providers and specialist assessment for cognitive decline. Primary care physicians—the first line of contact for most patients with early memory concerns—have limited training in cognitive screening, little time to conduct proper assessment, and often lack established referral pathways to specialists. Meanwhile, the specialists capable of performing comprehensive cognitive evaluation and amyloid confirmation testing are concentrated in urban academic medical centers and are already overwhelmed. This gap creates a fundamental system dysfunction.

A Medicare patient visits her family medicine doctor with complaints of forgetting appointments and losing her keys more often than before—classic early cognitive symptoms. The physician, seeing her briefly, may attribute this to normal aging or stress and not refer her further. Weeks or months later, when the patient or her family finally pursues specialist evaluation, more cognitive decline has occurred, and the narrow window for disease-modifying treatment efficacy has narrowed or passed. Research on site readiness for Alzheimer’s treatment found that the most under-resourced component of the pathway was this initial screening and triage function in primary care, alongside the training and tools needed for mid-level providers (nurse practitioners, physician assistants) to identify and coordinate early cognitive evaluation.

The Integration Gap Between Primary Care and Specialist-Driven Diagnosis

Workforce Limitations and the Shortage of Cognitive Specialists

The healthcare system does not have sufficient cognitive specialists, neuropsychologists, and memory care specialists to evaluate, diagnose, and manage the projected number of patients who will pursue treatment with lecanemab and donanemab. The U.S. already faces shortages of behavioral neurologists and geriatric specialists. Expanding capacity by training new specialists takes years, yet patient demand for these treatments is rising now. This creates a workforce constraint that no amount of pharmaceutical development can overcome. Consider a realistic timeline: A primary care clinic identifies 50 patients with possible cognitive decline among its 10,000 patients.

All 50 need referral to cognitive specialists for further workup. The nearest qualified neurologist is accepting new patients only every three months and has a six-month waiting list. Even if that neurologist sees five patients per week, they cannot accommodate a 50-patient surge from a single primary care practice. Now multiply this across the nation. The solution involves training mid-level providers as care coordinators and cognitive screeners—a shift that requires curricula development, supervision infrastructure, and billing policy changes. None of these exist yet at scale. The alternative is a rationing system, where only the most severe cases or most insistent patients receive evaluation and treatment, contrary to the intention of early intervention.

Medication Access and Infusion Capacity

The logistics of delivering disease-modifying Alzheimer’s treatments introduces another preparedness gap often overlooked. Lecanemab requires intravenous infusion every two weeks for 18 months. Donanemab requires monthly infusions. Administering hundreds of thousands of infusions across the U.S. healthcare system requires substantial capacity expansion in outpatient infusion centers, satellite clinics, and potentially home health services. The infrastructure exists in urban oncology centers, but cognitive decline affects patients in rural areas and suburbs where infusion capacity is sparse.

A warning worth noting: The infusion regimen itself creates a barrier to adherence. A patient in a rural area who must drive 90 minutes each way for a biweekly infusion faces a practical burden that urban patients do not. Missed infusions interrupt the treatment course and reduce efficacy. Some healthcare systems have begun deploying mobile infusion units or exploring home-based IV therapy, but these are not standard practice and face reimbursement barriers. The U.S. healthcare system has not systematically planned or funded the expansion of infusion capacity needed for these treatments.

Regional Disparities and Rural Healthcare System Deficits

Preparedness is not uniform across the United States. Urban academic medical centers in major metropolitan areas have begun developing infrastructure for early Alzheimer’s detection and treatment, with memory clinics, cognitive assessment capacity, and CSF testing available. Rural and small-town healthcare systems have virtually none of this. A patient with cognitive decline in rural Kansas or West Virginia has no realistic pathway to diagnosis and treatment with available disease-modifying therapies, not because the medications are unavailable, but because the diagnostic and delivery infrastructure is absent. The RAND Corporation’s assessment of U.S.

healthcare system preparedness explicitly flagged regional variation as a major source of inequity. Some states have begun funding initiatives to expand cognitive assessment capacity and train primary care providers in dementia screening. Others have made little progress. This creates a geographic lottery in which a patient’s access to Alzheimer’s treatment depends largely on their zip code. Closing this gap requires sustained funding, workforce development incentives, and policy changes at state and federal levels—none of which are currently adequate.

Future Outlook and the Closing Window for Preparedness

The good news is that the healthcare system has time to prepare—but that window is narrowing. Demand for these treatments will accelerate as more patients learn about efficacy, more physicians understand the diagnostic pathway, and insurance coverage expands. The next two to three years represent a critical period for building capacity. This requires concrete investments: funding for primary care provider training, expanding CSF and PET imaging capacity, establishing care coordinator pathways, and developing infusion network infrastructure in underserved areas.

Some forward-looking health systems have already begun this work, recognizing that preparedness requires proactive investment. Others remain in a reactive posture, assuming demand will emerge slowly enough that they can adapt incrementally. The evidence suggests otherwise. Successful preparedness will separate healthcare systems and regions that invested early from those that did not, likely amplifying existing health disparities unless federal and state policies mandate equitable capacity expansion.

Conclusion

The healthcare system is not adequately prepared for the treatment demand that approved disease-modifying Alzheimer’s therapies will create. The bottlenecks are well-documented: insufficient diagnostic capacity, limited specialist availability, integration gaps in primary care, inadequate workforce training, and regional inequities in infrastructure. These are not insurmountable problems, but they require acknowledged, targeted, and sustained investment. For patients and families facing early cognitive decline, the immediate lesson is clear: Do not wait passively.

Seek evaluation from a neurologist or cognitive specialist now, before demand overwhelms the system further. For healthcare systems and policymakers, the lesson is equally clear: preparedness requires action today, not promises of future adaptation. The medications are ready. The question is whether the healthcare system will be.