NEUROGENESIS
Career Development in Neurology: Focus on Health Policy Pushpa Narayanaswami, MBBS, DM, FAAN
N
ational health expenditures in the United States were $2.7 trillion in 2011, comprising nearly 18% of the gross domestic product.1 The increasing, unsustainable costs of health care are a major focus of legislative and regulatory policies to reduce costs, promote care coordination, and enhance outcomes. These policies in turn drive resource allocation in medicine, both academic (eg, research funding) and in practice (eg, physician reimbursements). The past few years have seen several policy and regulatory changes that affect neurologists. The impact on practice of these policy changes, such as the recent reimbursement cuts for nerve conduction studies/electromyography, is obvious. Their impact on academic neurology also is substantial, but tends to be less conspicuous. Consequently, knowledge of health care systems and health policy is emerging as an important facet of neurology. Expertise in this area helps neurologists to influence policy effectively and ensure that challenges specific to neurology are recognized when policies are developed and implemented. There are increasing opportunities for neurologists to receive formal training and develop careers in health policy. This article reviews the place of health policy in academic neurology.
Role of Health Policy in Academic Neurology The World Health Organization defines health policy as “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.”2 As far back as 2002, former Secretary of State Colin Powell emphasized the partnership between science and policy decisions, going so far as to say that “American science must enlighten American statecraft.”3,4 Effective leadership
is essential, even critical, to ensure that health care policy takes into account the multifaceted, complex nature of health care delivery. In a charter on medical professionalism, several medical professional organizations jointly recommended physician involvement to “improve the healthcare system for the welfare of society.”5 Public policy is a complex area that involves knowledge of the legislative process and understanding of both how policies are developed and how to effectively influence them. Neurologists have to participate in the process to effectively influence policy decisions that affect our patients. Because some degree of training in health policy is essential to accomplish this, basic health policy literacy and an understanding of health care systems should be possessed by all neurologists to enable effective participation in health care reform. Ideally, health policy should be assimilated into the training of physicians, perhaps as early as in the medical school curriculum, but certainly during residency. However, health policy education may be less than optimal; in the 2007 Medical Student Graduation Questionnaire, medical students consistently reported feeling that the time devoted to health care systems education was insufficient, in contrast to their satisfaction with training in clinical care.6 In a 2010 survey of medical school administrators, 58% stated that their programs provided too little health policy education.7 Patel and colleagues suggest that for health care reform to have its greatest impact, a core program in health policy education should be adopted by medical schools and residency programs, focusing on 4 domains: health care systems and principles, health care quality and safety, value and equity, and health politics and law.8 The decision by the Accreditation Council for Graduate Medical Education (ACGME)
View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.24315 Received Aug 11, 2014, and in revised form Nov 19, 2014. Accepted for publication Nov 20, 2014. Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA Additional supporting information can be found in the online version of this article.
C 2014 American Neurological Association V 1
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to include systems-based training (cost-effectiveness and risk–benefit analyses, patient safety curricula, and quality improvement) as requirements of neurology residency training underscores the trend toward incorporating health policy and health systems literacy in training.9 However, at the present time, ACGME mandates focus primarily on patient safety and quality improvement initiatives. Training programs with limited resources may therefore be forced to restrict health policy training to these topics. From the broader perspective, quality and safety initiatives are only one aspect of health policy. Development and implementation of quality measures are a major initiative of the Centers for Medicare and Medicaid Services (CMS), which uses them in its quality improvement, public reporting, and pay-for-performance programs.10 To ensure that quality measures accurately evaluate neurologic care, neurologists must be involved in their development. To do so, they should understand how quality measures fit into health care delivery models. Hence, safety and quality initiatives should be part of a curriculum that ensures competency in the basics of health policy, encompassing legislative and regulatory processes that affect health care delivery and systems. There also is increasing federal recognition and support for health services research to inform future policies. The American Recovery and Reinvestment act of 2009 allotted $1.1 billion to support comparative effectiveness research.11 Directed by the Affordable Care Act, the Patient Centered Outcomes Research Institute (PCORI) was established to stimulate comparative clinical effectiveness research that helps patients make informed health care decisions.12 In the September 2013 funding cycle, 71 projects were funded, totaling $114 million.13 At the level of clinical practice, payment policies and physician reimbursements are a moving target. Value-based payment systems incentivizing high-quality care, wherein value is defined as health outcomes achieved per dollar spent, are the practice models of the future.14,15 For neurology, this requires the development of relevant and reliable outcome measures and means for evaluating cost-effectiveness of interventions, which brings one full circle to the impetus for research in health policy. Thus, all academic neurologists are impacted by health policy and its direct impact on health care systems, regardless of their primary focus. This close relationship between clinical practice, which is driven by health policy, which in turn should be informed by research, places a responsibility on academic neurologists to foster health services research and influence policy.
Current Health Policy Issues in Neurology The controversial Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010.16 2
This act is the single most important piece of legislation to impact health care services in the United States since Medicare was introduced in 1965.17 In June 2012, the Supreme Court of the United States ruled that the ACA is constitutional, and set the wheels in motion for its implementation. A recent review evaluated the impact of this ruling on neurology.18 However, the constitutionality of various aspects of the ACA continues to be challenged in federal courts. The executive branch of the US government (the Department of Health and Human Services, which administers CMS) is charged with the responsibility of interpreting and executing the law. As implementation of the ACA proceeds, some issues of concern to the practice of neurology already have been identified during the CMS rule-making process. These include the exclusion of neurologists from (1) the “primary care bonus,” which seeks to recognize and incentivize “cognitive care” as opposed to “procedural services”19; and (2) the Medicaid “bump,” which seeks to reimburse physicians who treat Medicaid patients at Medicare rates.20 In both instances, the exclusion of neurology despite inclusion of all subspecialties of internal medicine was due to CMS interpretation of the appropriate specialties on the basis of their certification boards, and not on the type of practice, cognitive versus procedural. Alternative payment models such as “patient centered medical homes” and “accountable care organizations” are predicted to be the future of health care delivery; these models incorporate a network of physicians, other providers, and hospitals to assume the responsibility for the cost and quality of care of a population of patients.21 The role of the neurologist in these models remains to be defined. Although these are primarily issues that affect clinical practice, they directly impact academic neurologists whose focus is clinical care, because most academic centers bill for reimbursement of clinical services in a “private practice” model. Physician payment reform to permanently repeal the flawed sustainable growth rate formula (SGR) continues to be the effort of lobbying by the medical community. Another issue that is relevant to subspecialties such as neurology is telemedicine, which is rapidly emerging as a practice model. Malpractice liability, reimbursement, and licensure across state borders are important policy issues that affect the practice of telemedicine. At the state level, sports concussion is a prominent legislative issue. All 50 states have adopted the 3 central elements of the Zachary Lystedt Law first passed by the state of Washington in 2009: education of coaches and parents, immediate removal from play/practice if a concussion is suspected, and clearance to play by a neurologist or properly trained physician. States continue to Volume 00, No. 00
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refine and implement other regulations to improve player safety. In the research realm, federal funding for the National Institutes of Health (NIH) has been a target of budget cuts. The planned increase in NIH federal funding between 1998 and 2003 resulted in NIH appropriations of about $27.1 billion in 2003. This has since remained flat, or slightly declined, with 2013 appropriations equaling about $29.3 billion.22 Adjusted for inflation, the 2014 funding target of $29.9 billion is nearly 25% below the 2003 funding. Policy decisions do not always have a foundation in scientific research. Some policies are driven by the passionate voices of strong lobbies. The legalization of cannabis for medical purposes in 22 states and the District of Columbia is one such issue.23 Others, such as management of sports concussion, telemedicine, and diagnosis and management of traumatic brain injury in our veterans, are hot issues in the press, which may drive policies despite the lack of concrete research data upon which to base these policies. If academic physicians have a duty to advocate for policies that have a sound basis in research, do they then have a responsibility to develop the research and gather the data that will inform public policy for the good of society at large? In a recent study of the faculty of the Department of Medicine, University of California, San Francisco, higher faculty rank was significantly associated with health policy involvement.24 The reasons for this may vary. Lack of formal training or mentorship at early career levels may preclude health policy involvement. As academicians become established in their research careers, they may branch off into health policy as a logical extension of translating the results of their research into policy, or because they have the credibility to advise policy makers and are invited into the health policy arena as an offshoot of their research. At the level of professional organizations, there has been a growing awareness of the need to be involved in shaping health policy. The American Academy of Neurology (AAN) established the Center for Health Policy (CHP) in 2000 in response to the increasing role of policy makers and third party payers in determining how neurologists practice. The 3 major divisions of the CHP are Government Relations, Practice, and Medical Economics and Management, which address health policy issues at the legislative, regulatory, and payer levels. The CHP and the Washington, DC office of the AAN, established in 2005, closely monitor and address legislative and regulatory issues of relevance to neurology. The AAN also actively recruits member neurologists with opportunities for advocacy training—the Donald M. Palatucci Advocacy Leadership Forum (PALF) and NeurolMonth 2014
ogy on the Hill (NOH) programs—and public policy fellowships, all aimed at bringing neurologists into direct contact with the legislative branch of the US government to influence health policy.25 NOH is an annual program in which member neurologists visit Washington, DC. They receive updates on current policy issues and gain insights about the workings of Congress from CHP staff, congressional leaders, and consultants. They are trained to deliver their message on priority issues, which they then carry to their legislators. For many neurologists, NOH is their first hands-on experience with the political process. Over the years, several legislative successes have resulted from this direct contact, such as funding for the Veterans Administration epilepsy centers of excellence. The AAN joined others in successfully advocating for additional funding of $122 million for Alzheimer disease for FY2014. This is the largest ever increase in federal funding for Alzheimer research and care programs. Other successes are not as easy to achieve, and lobbying continues. An increase in NIH funding and SGR repeal have been consistent “asks” over the years. Although both the primary care bonus and the Medicaid “bump” programs implemented as part of the ACA are slated to end over the next 2 years, they remain the subject of extensive lobbying on the Hill to educate policy makers about the concept of “cognitive care” so that future payment models will take into consideration the services provided rather than arbitrary board certification designations.
Pursuing an Academic Career in Public Policy The extent of public policy involvement among academic neurologists and the effect of this involvement on their career development are unclear. Many who work in health policy have taken circuitous, ill-defined routes and stumbled serendipitously upon this aspect of medicine. There is not a clear career path for medical students and residents who express an interest in health policy. Potential barriers to involvement in health policy and advocacy start with the inadequacy of formal training in medical school and during residency or fellowship. Mentorship is not easily identified. There may be a perception among some senior academic neurologists that policy is synonymous with politics and is irrelevant, perhaps even counterproductive, to research and teaching. This may deter younger faculty and residents from pursuing health policy. Resources through professional organizations such as the AAN are not easily accessible. Health policy is outside the comfort zone of many physicians, who may be intimidated by the prospect of interfacing with legislators or officials of regulatory agencies. Time and distance are 3
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practical constraints, as travel to the state capital or Washington, DC may be necessary. In the previously mentioned study, about onefourth of the faculty of the Department of Medicine, University of California, San Francisco participated in 1 of 3 policy-related activities: policy-related research, expert advice to government officials, or advocacy in collaboration with organizations.24 Extramural funding for this involvement most often was available to those who were involved in public policy–related research; almost half of this funding was for projects involving direct work with policy makers or community-based organizations. The authors make a case for identifying public policy expertise among academic faculty, establishing mentorship opportunities, and incorporating work in public policy into the promotions process.24 The Viste Neurology Public Policy Fellowship (NPPF), cosponsored by the AAN, American Neurologic Association (ANA), and Child Neurology Society (CNS), was the first attempt to foster the development of neurologists interested in a career in heath policy. Fellows spent a year in Washington, DC as part of a congressional staff office or committee, or in the executive branch. They helped draft legislation; engaged in the policy process; worked with constituents, lobbyists, and congressional staff; participated in hearings and sessions related to health care policy; and attended meetings sponsored by the NIH, Congressional Research Service, and Library of Congress. Fellows subsequently have held leadership positions in the AAN; one holds a position at CMS. Of the 15 neurologists who have completed the NPPF since its inception in 1995, 5 are in academic practice. From my conversations with some of them, the effect of their public policy work on career development is difficult to define (Supplementary Table). Their expertise in health policy is recognized, but no uniform process for formal incorporation of this expertise into their roles in education is apparent. An effect of health policy expertise on the promotions process is similarly difficult to ascertain.
research. This comprehensive 2-year fellowship, sponsored by the AAN, George Washington University, ANA, and CNS, will include training at the George Washington University School of Public Health and Health Services to obtain a Master of Science (MS) degree in Health Policy, comprising a 48-credit course including a Master’s thesis. Fellows will maintain their clinical skills with rotations at local hospitals and obtain practical experience in health policy by working with one of the sponsoring organizations to attend issue briefings and meetings at congressional offices, other federal agencies, or the AAN Government Relations Committee (GRC).26 The expectation is that the fellows will submit a career development award toward the end of their MS training. Karen Spencer from Boston Children’s Hospital is the first fellow, and began her training in July 2014. This fellowship heralds a new breed of academic neurologist with early career formal training and commitment toward an academic career in health policy. The eventual aim is to establish an ongoing program of formal fellowship training with mentoring opportunities to develop a career path in health policy. Another training opportunity is the Robert Wood Johnson Foundation Health Policy Fellowship.27 The Robert Wood Johnson Clinical Scholars Program, distinct from the Fellowship, offers a postresidency Master’s degree in health services and health policy research.28 Master’s degrees in Public Health or in Public Policy may be available as part of K-awards during fellowships, although these programs may lack the practical legislative experience that is the strength of public policy fellowships. For neurologists who have completed training, or when formal fellowships are not feasible, there are other avenues. The advocacy programs of the AAN-PALF and NOH- which provide training, networking opportunities, and informal mentorship, are examples.29,30 Serving on committees such as the AAN GRC also provides similar opportunities. Funding opportunities through PCORI and the Agency for Healthcare Research and Quality (AHRQ) encourage research in health services, which in turn influences health policy.
Training Opportunities for Neurologists What career development advice is available for neurologists interested in health policy? If possible, formal training in some aspect of health policy is desirable. Other specialties such as internal medicine and emergency medicine have recognized the need for formal training in health policy, to ensure that research drives health policy. Over the past 2 years, the NPPF fellowship has been extensively reorganized and formalized into a new Health Policy Research Fellowship designed specifically to prepare neurologists for an academic career in health policy 4
Incorporating Health Policy into Neurology Departments A framework for career development in heath policy and health care systems research has been recommended31 that recognizes 3 intersecting focus areas of a career in health systems improvement: research, policy, and management. Examples of research include comparative effectiveness and health services research. Examples of policy include advocacy and government relations. There is overlap between these areas. For instance, health services Volume 00, No. 00
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research is intertwined with policy when the research informs future policies. Policy execution in turn closely involves management. At the intersection of research and management is implementation science, which studies the factors that influence the uptake of research findings into routine health care at clinical, organizational, and policy levels.31 Most academic centers recognize 3 cornerstones of an academic medical career: clinical expertise, education, and research. If health policy is on its way to becoming a subspecialty in neurology, should it be the fourth cornerstone in an academic medical career? An introduction to health policy should be a basic requirement for medical students. During residency, this should be augmented by information about health policy issues relevant to neurology. Quality and safety initiatives are an integral part of many medical centers. Encouraging neurology residents and faculty to participate in hospital-wide quality improvement efforts is a starting point for developing interests in health policy. Collaborations with other departments that have a health policy division will facilitate the development of such a division within neurology departments. Although health policy is a field that crosses subspecialty lines, the creation of a formal division within neurology departments will provide credibility to this budding area and encourage its growth. To establish such a division, it is important to actively identify faculty members who have an interest and expertise in health policy. This division should be tasked with the responsibility of developing curricula, and training and mentoring residents and fellows, and would logically combine the interrelated facets of health services research and health policy. Recognition of health policy work in the promotions process will encourage neurologists to pursue it as an academic career.
Potential Conflicts of Interest
4.
US Department of State. Remarks at the National Academy of Sciences annual meeting. 2002. Available at: http://2001–2009.state. gov/secretary/former/powell/remarks/2002/9874.htm, accessed on June 12, 2014.
5.
ABIM Foundation. American Board of Internal Medicine; ACPASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243–246.
6.
Patel MS, Lypson ML, Davis MM. Medical student perceptions of education in health care systems. Acad Med 2009;84:1301–1306.
7.
Mou D, Sarma A, Sethi R, Merryman R. The state of health policy education in U.S. medical schools. N Engl J Med 2011;364:e19.
8.
Patel MS, Davis MM, Lypson ML. Advancing medical education by teaching health policy. N Engl J Med 2011;364:695–697.
9.
Accreditation Council for Graduate Medical Education. The Neurology Milestone Project. December 2013. Available at: http:// www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/Neurology Milestones.pdf, accessed on June 5, 2014.
10.
Centers for Medicare and Medicaid Services. Quality measures. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/QualityMeasures/index.html?redirect5/ QUALITYMEASURES/, accessed on September 23, 2014.
11.
The American Recovery and Reinvestment Act. 2009. Available at: http://www.recovery.gov/arra/About/Pages/The_Act.aspx, accessed on June 5, 2014.
12.
Patient Centered Outcomes Research Institute. 2010. Available at: http://www.pcori.org/about-us/mission-and-vision/, accessed on June 5, 2014.
13.
PCORI’s latest funding cycle: what our new awards say about the research community—and us. 2013. Available at: http://www. pcori.org/blog/pcoris-latest-funding-cycle-what-our-new-awardssay-about-the-research-community-and-/, accessed on June 12, 2014.
14.
Lee TH. Putting the value framework to work. N Engl J Med 2010; 363:2481–2483.
15.
Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA 2007;297:1103–1111.
16.
The Affordable Care Act. Available at: http://www.whitehouse. gov/healthreform/healthcare-overview, accessed on June 1, 2014.
17.
Social Security History. Available at: http://www.ssa.gov/history/ ssa/lbjmedicare1.html, accessed on June 1, 2014.
18.
Jones EC. Supreme Court decision on the Affordable Care Act: what does it mean for Neuology. Neurol Clin Pract 2013;3: 61–66.
19.
Summary information regarding Medicare’s Primary Care Incentive Payment Program (PCIP). 2014. Available at: http://www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLN MattersArticles/downloads/se1109.pdf, accessed on June 15, 2014.
20.
Qs & As on the increased Medicaid payment for primary care: CMS 2370-F. 2012. Available at: http://www.medicaid.gov/AffordableCareAct/Provisions/Downloads/Q-andA-Managed-CareIncreased-Payments-for-PCPs.pdf, accessed on June 12, 2014.
21.
American Academy of Neurology. Accountable care organizations. 2014. Available at: https://www.aan.com/practice/new-paymentand-delivery-models/accountable-care-organizations/, accessed on June 12, 2014.
22.
The NIH almanac: appropriations (section 2). Available at: http:// www.nih.gov/about/almanac/appropriations/part2.htm, accessed on September 24, 2014.
23.
White House. Answers to frequently asked questions about marijuana. 2014. Available at: http://www.whitehouse.gov/ondcp/ frequently-asked-questions-and-facts-about-marijuana#legalization, accessed on June 12, 2014.
Nothing to report.
References 1.
Centers for Medicare and Medicaid Services. 2013 CMS statistics. Available at: http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/CMS-Statistics-ReferenceBooklet/Downloads/CMS_Stats_2013_final.pdf, accessed on September 23, 2014.
2.
World Health Organization. Health policy. Available at: http:// www.who.int/topics/health_policy/en/, accessed on June 3, 2014.
3.
US Department of State. Remarks at reception to announce the 2004–2005 winners of the First Jefferson Science Fellowships. 2004. Available at: http://2001–2009.state.gov/secretary/former/ powell/remarks/32864.htm, accessed on June 12, 2014.
Month 2014
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24.
Jacobs DB, Greene M, Bindman AB. It’s academic: public policy activities among faculty members in a department of medicine. Acad Med 2013;88:1460–1463.
25.
Zecavati N, Song S, Farmer JG. Emerging subspecialties in neurology: public policy fellowships. Neurology 2011;77:e85–e87.
26.
27.
6
28.
Robert Wood Johnson Foundation. Clinical Scholars. 2014. Available at: http://rwjcsp.unc.edu/, accessed on June 24, 2014.
29.
American Academy of Neurology. Palatucci Advocacy Leadership Forum. 2014. Available at: https://www.aan.com/public-policy/palatucci-advocacy-leadership-forum/, accessed on June 12, 2014.
American Academy of Neurology. Neurology Health Policy Research Fellowship. 2013. Available at: https://www.aan.com/public-policy/ health-policy-research-fellowship/, accessed on June 5, 2014.
30.
American Academy of Neurology. Neurology on the Hill. 2014. Available at: https://www.aan.com/public-policy/neurology-on-thehill/, accessed on June 12, 2014.
Robert Wood Johnson Foundation. Health Policy Fellows. 2014. Available at: http://healthpolicyfellows.org/home.php, accessed on June 12, 2014.
31.
Ackerly DC, Parekh A, Stein D. Perspective: a framework for career paths in health systems improvement. Acad Med 2013;88: 56–60.
Volume 00, No. 00
Career Development in Neurology: Focus on Health Policy Pushpa Narayanaswami, MBBS, DM, FAAN
N
ational health expenditures in the United States were $2.7 trillion in 2011, comprising nearly 18% of the gross domestic product.1 The increasing, unsustainable costs of health care are a major focus of legislative and regulatory policies to reduce costs, promote care coordination, and enhance outcomes. These policies in turn drive resource allocation in medicine, both academic (eg, research funding) and in practice (eg, physician reimbursements). The past few years have seen several policy and regulatory changes that affect neurologists. The impact on practice of these policy changes, such as the recent reimbursement cuts for nerve conduction studies/electromyography, is obvious. Their impact on academic neurology also is substantial, but tends to be less conspicuous. Consequently, knowledge of health care systems and health policy is emerging as an important facet of neurology. Expertise in this area helps neurologists to influence policy effectively and ensure that challenges specific to neurology are recognized when policies are developed and implemented. There are increasing opportunities for neurologists to receive formal training and develop careers in health policy. This article reviews the place of health policy in academic neurology.
Role of Health Policy in Academic Neurology The World Health Organization defines health policy as “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.”2 As far back as 2002, former Secretary of State Colin Powell emphasized the partnership between science and policy decisions, going so far as to say that “American science must enlighten American statecraft.”3,4 Effective leadership
is essential, even critical, to ensure that health care policy takes into account the multifaceted, complex nature of health care delivery. In a charter on medical professionalism, several medical professional organizations jointly recommended physician involvement to “improve the healthcare system for the welfare of society.”5 Public policy is a complex area that involves knowledge of the legislative process and understanding of both how policies are developed and how to effectively influence them. Neurologists have to participate in the process to effectively influence policy decisions that affect our patients. Because some degree of training in health policy is essential to accomplish this, basic health policy literacy and an understanding of health care systems should be possessed by all neurologists to enable effective participation in health care reform. Ideally, health policy should be assimilated into the training of physicians, perhaps as early as in the medical school curriculum, but certainly during residency. However, health policy education may be less than optimal; in the 2007 Medical Student Graduation Questionnaire, medical students consistently reported feeling that the time devoted to health care systems education was insufficient, in contrast to their satisfaction with training in clinical care.6 In a 2010 survey of medical school administrators, 58% stated that their programs provided too little health policy education.7 Patel and colleagues suggest that for health care reform to have its greatest impact, a core program in health policy education should be adopted by medical schools and residency programs, focusing on 4 domains: health care systems and principles, health care quality and safety, value and equity, and health politics and law.8 The decision by the Accreditation Council for Graduate Medical Education (ACGME)
View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.24315 Received Aug 11, 2014, and in revised form Nov 19, 2014. Accepted for publication Nov 20, 2014. Department of Neurology, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA Additional supporting information can be found in the online version of this article.
C 2014 American Neurological Association V 1
ANNALS
of Neurology
to include systems-based training (cost-effectiveness and risk–benefit analyses, patient safety curricula, and quality improvement) as requirements of neurology residency training underscores the trend toward incorporating health policy and health systems literacy in training.9 However, at the present time, ACGME mandates focus primarily on patient safety and quality improvement initiatives. Training programs with limited resources may therefore be forced to restrict health policy training to these topics. From the broader perspective, quality and safety initiatives are only one aspect of health policy. Development and implementation of quality measures are a major initiative of the Centers for Medicare and Medicaid Services (CMS), which uses them in its quality improvement, public reporting, and pay-for-performance programs.10 To ensure that quality measures accurately evaluate neurologic care, neurologists must be involved in their development. To do so, they should understand how quality measures fit into health care delivery models. Hence, safety and quality initiatives should be part of a curriculum that ensures competency in the basics of health policy, encompassing legislative and regulatory processes that affect health care delivery and systems. There also is increasing federal recognition and support for health services research to inform future policies. The American Recovery and Reinvestment act of 2009 allotted $1.1 billion to support comparative effectiveness research.11 Directed by the Affordable Care Act, the Patient Centered Outcomes Research Institute (PCORI) was established to stimulate comparative clinical effectiveness research that helps patients make informed health care decisions.12 In the September 2013 funding cycle, 71 projects were funded, totaling $114 million.13 At the level of clinical practice, payment policies and physician reimbursements are a moving target. Value-based payment systems incentivizing high-quality care, wherein value is defined as health outcomes achieved per dollar spent, are the practice models of the future.14,15 For neurology, this requires the development of relevant and reliable outcome measures and means for evaluating cost-effectiveness of interventions, which brings one full circle to the impetus for research in health policy. Thus, all academic neurologists are impacted by health policy and its direct impact on health care systems, regardless of their primary focus. This close relationship between clinical practice, which is driven by health policy, which in turn should be informed by research, places a responsibility on academic neurologists to foster health services research and influence policy.
Current Health Policy Issues in Neurology The controversial Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010.16 2
This act is the single most important piece of legislation to impact health care services in the United States since Medicare was introduced in 1965.17 In June 2012, the Supreme Court of the United States ruled that the ACA is constitutional, and set the wheels in motion for its implementation. A recent review evaluated the impact of this ruling on neurology.18 However, the constitutionality of various aspects of the ACA continues to be challenged in federal courts. The executive branch of the US government (the Department of Health and Human Services, which administers CMS) is charged with the responsibility of interpreting and executing the law. As implementation of the ACA proceeds, some issues of concern to the practice of neurology already have been identified during the CMS rule-making process. These include the exclusion of neurologists from (1) the “primary care bonus,” which seeks to recognize and incentivize “cognitive care” as opposed to “procedural services”19; and (2) the Medicaid “bump,” which seeks to reimburse physicians who treat Medicaid patients at Medicare rates.20 In both instances, the exclusion of neurology despite inclusion of all subspecialties of internal medicine was due to CMS interpretation of the appropriate specialties on the basis of their certification boards, and not on the type of practice, cognitive versus procedural. Alternative payment models such as “patient centered medical homes” and “accountable care organizations” are predicted to be the future of health care delivery; these models incorporate a network of physicians, other providers, and hospitals to assume the responsibility for the cost and quality of care of a population of patients.21 The role of the neurologist in these models remains to be defined. Although these are primarily issues that affect clinical practice, they directly impact academic neurologists whose focus is clinical care, because most academic centers bill for reimbursement of clinical services in a “private practice” model. Physician payment reform to permanently repeal the flawed sustainable growth rate formula (SGR) continues to be the effort of lobbying by the medical community. Another issue that is relevant to subspecialties such as neurology is telemedicine, which is rapidly emerging as a practice model. Malpractice liability, reimbursement, and licensure across state borders are important policy issues that affect the practice of telemedicine. At the state level, sports concussion is a prominent legislative issue. All 50 states have adopted the 3 central elements of the Zachary Lystedt Law first passed by the state of Washington in 2009: education of coaches and parents, immediate removal from play/practice if a concussion is suspected, and clearance to play by a neurologist or properly trained physician. States continue to Volume 00, No. 00
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refine and implement other regulations to improve player safety. In the research realm, federal funding for the National Institutes of Health (NIH) has been a target of budget cuts. The planned increase in NIH federal funding between 1998 and 2003 resulted in NIH appropriations of about $27.1 billion in 2003. This has since remained flat, or slightly declined, with 2013 appropriations equaling about $29.3 billion.22 Adjusted for inflation, the 2014 funding target of $29.9 billion is nearly 25% below the 2003 funding. Policy decisions do not always have a foundation in scientific research. Some policies are driven by the passionate voices of strong lobbies. The legalization of cannabis for medical purposes in 22 states and the District of Columbia is one such issue.23 Others, such as management of sports concussion, telemedicine, and diagnosis and management of traumatic brain injury in our veterans, are hot issues in the press, which may drive policies despite the lack of concrete research data upon which to base these policies. If academic physicians have a duty to advocate for policies that have a sound basis in research, do they then have a responsibility to develop the research and gather the data that will inform public policy for the good of society at large? In a recent study of the faculty of the Department of Medicine, University of California, San Francisco, higher faculty rank was significantly associated with health policy involvement.24 The reasons for this may vary. Lack of formal training or mentorship at early career levels may preclude health policy involvement. As academicians become established in their research careers, they may branch off into health policy as a logical extension of translating the results of their research into policy, or because they have the credibility to advise policy makers and are invited into the health policy arena as an offshoot of their research. At the level of professional organizations, there has been a growing awareness of the need to be involved in shaping health policy. The American Academy of Neurology (AAN) established the Center for Health Policy (CHP) in 2000 in response to the increasing role of policy makers and third party payers in determining how neurologists practice. The 3 major divisions of the CHP are Government Relations, Practice, and Medical Economics and Management, which address health policy issues at the legislative, regulatory, and payer levels. The CHP and the Washington, DC office of the AAN, established in 2005, closely monitor and address legislative and regulatory issues of relevance to neurology. The AAN also actively recruits member neurologists with opportunities for advocacy training—the Donald M. Palatucci Advocacy Leadership Forum (PALF) and NeurolMonth 2014
ogy on the Hill (NOH) programs—and public policy fellowships, all aimed at bringing neurologists into direct contact with the legislative branch of the US government to influence health policy.25 NOH is an annual program in which member neurologists visit Washington, DC. They receive updates on current policy issues and gain insights about the workings of Congress from CHP staff, congressional leaders, and consultants. They are trained to deliver their message on priority issues, which they then carry to their legislators. For many neurologists, NOH is their first hands-on experience with the political process. Over the years, several legislative successes have resulted from this direct contact, such as funding for the Veterans Administration epilepsy centers of excellence. The AAN joined others in successfully advocating for additional funding of $122 million for Alzheimer disease for FY2014. This is the largest ever increase in federal funding for Alzheimer research and care programs. Other successes are not as easy to achieve, and lobbying continues. An increase in NIH funding and SGR repeal have been consistent “asks” over the years. Although both the primary care bonus and the Medicaid “bump” programs implemented as part of the ACA are slated to end over the next 2 years, they remain the subject of extensive lobbying on the Hill to educate policy makers about the concept of “cognitive care” so that future payment models will take into consideration the services provided rather than arbitrary board certification designations.
Pursuing an Academic Career in Public Policy The extent of public policy involvement among academic neurologists and the effect of this involvement on their career development are unclear. Many who work in health policy have taken circuitous, ill-defined routes and stumbled serendipitously upon this aspect of medicine. There is not a clear career path for medical students and residents who express an interest in health policy. Potential barriers to involvement in health policy and advocacy start with the inadequacy of formal training in medical school and during residency or fellowship. Mentorship is not easily identified. There may be a perception among some senior academic neurologists that policy is synonymous with politics and is irrelevant, perhaps even counterproductive, to research and teaching. This may deter younger faculty and residents from pursuing health policy. Resources through professional organizations such as the AAN are not easily accessible. Health policy is outside the comfort zone of many physicians, who may be intimidated by the prospect of interfacing with legislators or officials of regulatory agencies. Time and distance are 3
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practical constraints, as travel to the state capital or Washington, DC may be necessary. In the previously mentioned study, about onefourth of the faculty of the Department of Medicine, University of California, San Francisco participated in 1 of 3 policy-related activities: policy-related research, expert advice to government officials, or advocacy in collaboration with organizations.24 Extramural funding for this involvement most often was available to those who were involved in public policy–related research; almost half of this funding was for projects involving direct work with policy makers or community-based organizations. The authors make a case for identifying public policy expertise among academic faculty, establishing mentorship opportunities, and incorporating work in public policy into the promotions process.24 The Viste Neurology Public Policy Fellowship (NPPF), cosponsored by the AAN, American Neurologic Association (ANA), and Child Neurology Society (CNS), was the first attempt to foster the development of neurologists interested in a career in heath policy. Fellows spent a year in Washington, DC as part of a congressional staff office or committee, or in the executive branch. They helped draft legislation; engaged in the policy process; worked with constituents, lobbyists, and congressional staff; participated in hearings and sessions related to health care policy; and attended meetings sponsored by the NIH, Congressional Research Service, and Library of Congress. Fellows subsequently have held leadership positions in the AAN; one holds a position at CMS. Of the 15 neurologists who have completed the NPPF since its inception in 1995, 5 are in academic practice. From my conversations with some of them, the effect of their public policy work on career development is difficult to define (Supplementary Table). Their expertise in health policy is recognized, but no uniform process for formal incorporation of this expertise into their roles in education is apparent. An effect of health policy expertise on the promotions process is similarly difficult to ascertain.
research. This comprehensive 2-year fellowship, sponsored by the AAN, George Washington University, ANA, and CNS, will include training at the George Washington University School of Public Health and Health Services to obtain a Master of Science (MS) degree in Health Policy, comprising a 48-credit course including a Master’s thesis. Fellows will maintain their clinical skills with rotations at local hospitals and obtain practical experience in health policy by working with one of the sponsoring organizations to attend issue briefings and meetings at congressional offices, other federal agencies, or the AAN Government Relations Committee (GRC).26 The expectation is that the fellows will submit a career development award toward the end of their MS training. Karen Spencer from Boston Children’s Hospital is the first fellow, and began her training in July 2014. This fellowship heralds a new breed of academic neurologist with early career formal training and commitment toward an academic career in health policy. The eventual aim is to establish an ongoing program of formal fellowship training with mentoring opportunities to develop a career path in health policy. Another training opportunity is the Robert Wood Johnson Foundation Health Policy Fellowship.27 The Robert Wood Johnson Clinical Scholars Program, distinct from the Fellowship, offers a postresidency Master’s degree in health services and health policy research.28 Master’s degrees in Public Health or in Public Policy may be available as part of K-awards during fellowships, although these programs may lack the practical legislative experience that is the strength of public policy fellowships. For neurologists who have completed training, or when formal fellowships are not feasible, there are other avenues. The advocacy programs of the AAN-PALF and NOH- which provide training, networking opportunities, and informal mentorship, are examples.29,30 Serving on committees such as the AAN GRC also provides similar opportunities. Funding opportunities through PCORI and the Agency for Healthcare Research and Quality (AHRQ) encourage research in health services, which in turn influences health policy.
Training Opportunities for Neurologists What career development advice is available for neurologists interested in health policy? If possible, formal training in some aspect of health policy is desirable. Other specialties such as internal medicine and emergency medicine have recognized the need for formal training in health policy, to ensure that research drives health policy. Over the past 2 years, the NPPF fellowship has been extensively reorganized and formalized into a new Health Policy Research Fellowship designed specifically to prepare neurologists for an academic career in health policy 4
Incorporating Health Policy into Neurology Departments A framework for career development in heath policy and health care systems research has been recommended31 that recognizes 3 intersecting focus areas of a career in health systems improvement: research, policy, and management. Examples of research include comparative effectiveness and health services research. Examples of policy include advocacy and government relations. There is overlap between these areas. For instance, health services Volume 00, No. 00
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research is intertwined with policy when the research informs future policies. Policy execution in turn closely involves management. At the intersection of research and management is implementation science, which studies the factors that influence the uptake of research findings into routine health care at clinical, organizational, and policy levels.31 Most academic centers recognize 3 cornerstones of an academic medical career: clinical expertise, education, and research. If health policy is on its way to becoming a subspecialty in neurology, should it be the fourth cornerstone in an academic medical career? An introduction to health policy should be a basic requirement for medical students. During residency, this should be augmented by information about health policy issues relevant to neurology. Quality and safety initiatives are an integral part of many medical centers. Encouraging neurology residents and faculty to participate in hospital-wide quality improvement efforts is a starting point for developing interests in health policy. Collaborations with other departments that have a health policy division will facilitate the development of such a division within neurology departments. Although health policy is a field that crosses subspecialty lines, the creation of a formal division within neurology departments will provide credibility to this budding area and encourage its growth. To establish such a division, it is important to actively identify faculty members who have an interest and expertise in health policy. This division should be tasked with the responsibility of developing curricula, and training and mentoring residents and fellows, and would logically combine the interrelated facets of health services research and health policy. Recognition of health policy work in the promotions process will encourage neurologists to pursue it as an academic career.
Potential Conflicts of Interest
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Nothing to report.
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