The Minnesota Cognitive Acuity Screen (MCAS) and LTCI

What do Coca Cola’s secret recipe, Colonel Sander’s 11 herbs and spices, and the Minnesota Cognitive Acuity Screen have in common?  Each has propelled its company to a position of industry dominance by virtue of a fiercely-protected patent.  The business of geriatric medicine has employed a battery of nearly 40 similar tests, where the quality of a cognitive screen can mean the difference between policy acceptance or denial, an insurer losing multimillion dollar bets, and of personalized treatment plans horribly miscalculated.

So imagine the LTCI industry’s readiness to adopt a screen that could deliver on this promise: “98.1% effectiveness in determining the presence or absence of mild to moderate cognitive impairment”.  That day occurred in the Summer of 2000, when the MCAS debuted.  A product developed and patented by Nation’s CareLink (today known as Univita), the Minnesota Cognitive Acuity Screen has been licensed for use by more than 33 LTCI insurers since its debut, and administered nearly 1/2 million times.

Agents find it difficult, if not impossible, to get their hands on the actual test questions or answer key questions.  Without too much sleuthing we find the Minnesota Cognitive Acuity Screen takes 15 – 20 minutes either in person or over the phone, and focuses on 9 key areas (Orientation, Attention, Delayed Word Recall, Comprehension, Repetition, Naming, Computation, Judgment, and Verbal Fluency).  Among the strengths of the MCAS are its speed of administration, sensitivity to even the earliest signs of mild impairment, and its ability to discern between the various sub-types of non-Alzheimer’s dementias which may comprise 20 – 25% of all cognitive impairments.

Surprisingly, the Alzheimer’s Association itself gives the MCAS only a lukewarm endorsement.  To understand the criticism, one must understand the critic: advocacy groups and researchers are most concerned with diagnosis, mitigation, and cure.  Underwriters and insurers are pre-occupied with risk assessment.  From these perspectives, each stakeholder views the Minnesota Cognitive Acuity Screen a bit differently.

Wary of home-testing in general, the Alzheimer’s Association labels the MCAS a “commercial” rather than “clinical” application, and seems equally leery over the maker’s recommendation for an annual re-test (at $95/each), when there is no scientific basis given for this claim.  On the other hand, with 40 other cognitive screens to choose from, the market seems to have settled the debate over the ubiquitous Minnesota Cognitive Acuity Screen to the satisfaction of the insurers, who have everything to lose by choosing this product.  Cognitive claims are among the industry’s lengthiest and most ruinous, so any underwriting tool which can successfully shape the risk pool, continually prove itself in the field, let alone pay for itself, will survive.

I’ve tried Coke, and Kentucky Fried Chicken, but it’s tempting to wonder how one might perform if given the chance to audit the MCAS?  Some producers have been old enough when they applied for their own LTCI that they can share their experiences.

In my case, I just had to be in the wrong place at the right time.

It was a foggy, cool Saturday afternoon, and I had the occasion to set-up a doctor’s appointment outside of normal business hours.  I pulled into the parking lot of the building and was immediately met by a flannel-clad fellow standing beside his beaten red pickup truck.  In one hand he held a cigarette, in the other the reins of two adorable chihuahuas.  Before I entered the building, I stopped to pet the shivering dogs and struck-up a light conversation with the guy.  Turns out he was trying to get them to gobble their medicine out of the bowls sitting on the pavement: I shared that I’m having the same problem with a cat of ours.  I say goodbye and run up the stairs into the building, where I’m forced to wait in a common area until my appointment begins.

In one corner of the foyer sits a professional-looking woman– clipboard in hand, briefcase at her side– steadily and calmly posing questions to a woman in her late 50’s who looks a bit bewildered.  No sooner do I hear a question or two about “orientation to time and place” than my hair stands up and I recognize what I’m witnessing.  Could this be the legendary Minnesota Cognitive Acuity Screen?  I know this lobby should not have been occupied on a Saturday but for my surprise appearance…

Quiet as a turning page, I slip into a chair as far away as I can, embarrassed to be there, but fascinated just the same.  For obvious reasons, carriers are loathe to reveal the exact content of these tests to producers, fearful we will coach our applicants.  As I sat there in total silence, I wanted so badly to text someone, or take notes, but instead I had to commit to memory everything I heard and wait nearly 90 minutes until I could drive to my office and transcribe my mental notes– irony if there ever was.

As the test unfolded without break, the interviewer was kind and gentle, but also uncompromising and unreadable.  It was agonizing enough watching this woman do poorly on the test, but the real kicker came when her husband entered halfway through the test and sat down next to her: the chihuahua guy from the parking lot! The nurse reminds him he can’t help her, but he’s fidgeting with his hat to keep his mouth shut. So he tells her to relax, take her time, and she keeps turning to him to make half-jokes/half-excuses.

Back at my office, here’s what I wrote down before I forgot:

  • What day comes after Monday?
  • What did you do last Friday?
  • Name 3 animals with tails (Her answer: “dog, cat, rat”)
  • Can you tell me what borders Washington State? (Her answer: “Oregon, Idaho… I give up.” (She knows there’s Canada, and water, but can’t grasp it)
  • Can you tell me why some people would say having friends is a good thing to have? (Her answer: “They’re not, they stab you in the back.”)
  • If you were lost in the forest in daytime, what would you do? (Her answer: “I’d follow the creek or river downstream.”)
  • If you were lost in a crowded mall, what would you do? (Her answer: “I’d be scared.”)
  • I’m going to list 8 words, then when I’m done I’d like you to repeat as many as you can remember: hippopotamus, frog, bicycle, brush, camel, toothpaste, light bulb, fork. (Her answer: “hippo, frog…hippo, frog…that’s all, I give up.”)
  • I’m going to list 3 words, then in 5 minutes I’m going to ask you to remember these 3 words and repeat them, all right?  The 3 words are: apple, dog, baseball.  [The interviewer then asked about 3 intervening questions, by no means was it 5 minutes, maybe 2 or 3 at most, and asked for the 3 words.]  (Her answer: “apple, dog.”)
  • Can you tell me why it costs more to live in the city than out in the country? (Her answer: “’Cause of the taxes to pay for schools and police and firefighters.”)
  • Do you recall how many other people were in this waiting room when we began?
  • Do you remember my name?
  • Can you name 5 major cities in the United States? (Her answer: “You mean like Seattle?” “Yes” “Seattle, San Francisco, Oklahoma City… that’s all.”)
  • What’s 35 + 47? (Answer: “I’d need a calculator!”)
  • All right, what’s 6 x 8? (Answer: “40?”)
  • Can you tell me 20 divided by 5? (Answer: “I was never very good at math!”)

I do believe there were some others which required her to generate some critical thought, such as “Can you tell me why it’s a good idea to get a license to drive a car?” or “Can you tell me why we pay taxes?”, but I’m not 100% positive I can remember the exact questions.  I also think there were some morality-based questions (e.g. “Can you tell me why we shouldn’t shoplift?”), while others only seemed to raise her ire (“That dang Obama just wants to take our money!”), at which point she and her husband would nod in agreement.  The interviewer was unflappable.

There’s an old saying, “Ignorance is Bliss”.  It would be too easy to think that refers to Mrs. Jane Doe whom I witnessed.  Instead, it speaks to the tragedy of cognitive impairment in general: this scourge that we hope to insure against, but only if we’re fortunate enough that people reach us in time.  If not, then to be that fly on the wall – as I was – is to be a witness to a slow-motion car crash.

I like to think that Mrs. Jane Doe was fortunate enough to ultimately be diagnosed with the 20 – 40% of “other” dementia syndromes with stranger names but better prospects.  In the meantime, knowing that the incidence of Alzheimer’s disease doubles every 5 years after age 65, let’s do everything we can as LTCI Professionals to make sure America is insured before tragedy strikes.

The Minnesota Cognitive Acuity Screen may be only one in a long line of continually-improving tools used by LTCI insurers.  While it’s helpful to know how and when it’s used, and what the screen is comprised of, the best use of the MCAS is on clients other than your own: that means we need to reach younger Americans.

Unlike Coca Cola or Kentucky Fried Chicken (no disrespect to those fine businesses), you should be proud that you work in an industry where you can wake up, go to work, and make a real difference in someone’s life today!  Good selling.

Stephen D. Forman

About Stephen D. Forman

A pioneer and leader in LTC insurance since 1974, LTCA has distinguished itself as one of the country's leading voices on this specialized topic. As Senior Vice-President, Stephen D. Forman has dedicated nearly two decades to this field, and is frequently sought for his expertise, appearing in such publications as "Kiplinger's Personal Finance", "Agents Sales Journal", and in the Congressional Research Service's confidential report to Congress on the CLASS Act. He can be reached at 800.742.9444 or