Today’s neurologists already work with midlevel providers (nurse practitioners and physician assistants), and a few even provide remote consultation using telemedicine, 2 relatively new innovations. Overwhelmed by the financial and regulatory burden of private practice, younger neurologists are joining large health systems that manage the complex operational requirements in today’s practice environment. To meet patient demand, these systems are expanding clinic hours and requiring neurologists to provide ambulatory consultation into the evenings and on weekends.
Comment: The changing practice of neurology and a look to the future John F. Kennedy said “Change is the law of life. And those who look only to the past or present are certain to miss the future.” The article by Ringel1 reflects on the evolution of neurologic practice over several decades, how the profession has tracked changes in neurologists’ practice environment, and the enormous, “disruptive” changes the specialty faces looking forward. It is particularly timely given a recent report on the relatively high prevalence of burnout symptoms among neurologists.2 A major change driver facing neurologists is the Affordable Care Act, with its rollout of policies that turn financial incentives for care delivery completely upsidedown. The comfortable situation of being paid for care quantity under fee-forservice models is changing to payment for care for a given population and meeting quality targets, putting financial risk on the delivery system and providers. Neurology needs many more evidence-based, team care coordination models,3 experience in implementing them and estimating costs/savings, and active voices in decisionmaking regarding deployment of these multidisciplinary models within our practice settings. Envisioning the changes that technology will bring and the radically different skill set it will require is daunting. Facts about the nervous system once diligently memorized can now be retrieved with point-of-care handheld devices. The value neurologists will bring is creating and using tools to optimize clinical judgments— based on evidence that is ever-increasingly individualized with genomic and other predictor data—and effectively eliciting patient preferences through communication of comprehensible risk/benefit information. Electronic medical record systems plaguing us today should become powerful decision support tools with embedded software apps (http://web1.johnshopkins.edu/onemagazine/fall-winter-2014/category/ features/rx-disruption/). Finally, advances in diagnostics and therapeutics should expand neurologists’ workforce options, as neurohospitalists, as company-based teleneurologists, and on multidisciplinary quality improvement teams within health care systems, continually incorporating these advances into neurologic practice. Change for neurologists is inevitable and well under way. 1. 2. 3.
Ringel SP. The practice of neurology: looking ahead by looking back. Neurology 2015;84:2086–2091. Sigsbee B, Bernat JL. Physician burnout: a neurologic crisis. Neurology 2014;83: 2302–2306. Vickrey BG, Mittman BS, Connor KI, et al. The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med 2006;145:713–726.
Barbara G. Vickrey, MD, MPH From the Department of Neurology, University of California, Los Angeles; and the VA Greater Los Angeles Healthcare System, CA. Study funding: No targeted funding reported. Disclosure: B.G. Vickrey receives grant support from NIH/National Institute of Neurological Disorders and Stroke 1U54NS081764 and R37NS031146, the VA Health Services Research and Development Service, California Community Foundation, and UniHealth Foundation; has received consulting income and travel support from Genentech; received travel support from EMD Serono; and received consulting income from Indiana University for participation in Data Safety Monitoring Boards for several NIH trials. Go to Neurology.org for full disclosures.
2090
Neurology 84
Integrated models of care have the potential to meet the needs of patients and will allow neurologists to focus their time more efficiently and effectively. As these models are put in place, neurologists will have legitimate concerns about greater financial risk. No neurologist wants to be in a situation where despite achieving favorable safety, quality, and utilization performance measures, a contract with an insurer is financially detrimental. Whether a system or an individual neurologist is involved in payment negotiations, stop loss provisions and more comprehensive data systems will be needed to track resource use and outcomes for patients with specific neurologic disorders. Our success requires that we become involved and advocate for humanistic, scientifically sound care for patients with chronic neurologic disorders. Rather than focus on the weakness and defects of current strategies, we need to embrace changes that correct these deficits. This tall order no doubt requires ingenuity, flexibility, resources, and commitment, but it is one that is attainable. AUTHOR CONTRIBUTIONS Steven P. Ringel: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and final approval.
STUDY FUNDING No targeted funding reported.
DISCLOSURE S. Ringel receives a stipend from the AAN as editor of Neurology Today. Go to Neurology.org for full disclosures.
Received September 15, 2014. Accepted in final form December 30, 2014.
REFERENCES 1. Ringel SP, Swash M. Money and medicine: a problem that won’t go away. Neurology 2009;72:766–768. 2. Ringel SP. Practicing medicine vs. pushing paper. Health Aff 2011;30:1200–1202. 3. Franklin GM, Ringel SP, Nelson LM, DeLapp C. Neurology practice patterns in Colorado. Neurology 1987;37: 287–289. 4. Ringel SP, Franklin GM, DeLapp C, Boyko EJ. Cross sectional comparative study of private and academic outpatient neurologic practices in Colorado. Neurology 1988; 38:1308–1314. 5. Franklin GM, Ringel SP, Jones M, Baron A. A prospective study of principal care among Colorado neurologists. Neurology 1990;40:701–704. 6. Ringel SP. Future neurology workforce: the right kind and number of neurologists. Neurology 1996;46: 897–900.
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Comment: The changing practice of neurology and a look to the future Barbara G. Vickrey Neurology 2015;84;2090 Published Online before print April 17, 2015 DOI 10.1212/WNL.0000000000001598 This information is current as of April 17, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/20/2090.full.html
References
This article cites 3 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/20/2090.full.html##ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): All Clinical Neurology http://www.neurology.org//cgi/collection/all_clinical_neurology All Health Services Research http://www.neurology.org//cgi/collection/all_health_services_research Decision analysis http://www.neurology.org//cgi/collection/decision_analysis Palliative care http://www.neurology.org//cgi/collection/palliative_care Quality of life http://www.neurology.org//cgi/collection/quality_of_life
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
Comment: The changing practice of neurology and a look to the future John F. Kennedy said “Change is the law of life. And those who look only to the past or present are certain to miss the future.” The article by Ringel1 reflects on the evolution of neurologic practice over several decades, how the profession has tracked changes in neurologists’ practice environment, and the enormous, “disruptive” changes the specialty faces looking forward. It is particularly timely given a recent report on the relatively high prevalence of burnout symptoms among neurologists.2 A major change driver facing neurologists is the Affordable Care Act, with its rollout of policies that turn financial incentives for care delivery completely upsidedown. The comfortable situation of being paid for care quantity under fee-forservice models is changing to payment for care for a given population and meeting quality targets, putting financial risk on the delivery system and providers. Neurology needs many more evidence-based, team care coordination models,3 experience in implementing them and estimating costs/savings, and active voices in decisionmaking regarding deployment of these multidisciplinary models within our practice settings. Envisioning the changes that technology will bring and the radically different skill set it will require is daunting. Facts about the nervous system once diligently memorized can now be retrieved with point-of-care handheld devices. The value neurologists will bring is creating and using tools to optimize clinical judgments— based on evidence that is ever-increasingly individualized with genomic and other predictor data—and effectively eliciting patient preferences through communication of comprehensible risk/benefit information. Electronic medical record systems plaguing us today should become powerful decision support tools with embedded software apps (http://web1.johnshopkins.edu/onemagazine/fall-winter-2014/category/ features/rx-disruption/). Finally, advances in diagnostics and therapeutics should expand neurologists’ workforce options, as neurohospitalists, as company-based teleneurologists, and on multidisciplinary quality improvement teams within health care systems, continually incorporating these advances into neurologic practice. Change for neurologists is inevitable and well under way. 1. 2. 3.
Ringel SP. The practice of neurology: looking ahead by looking back. Neurology 2015;84:2086–2091. Sigsbee B, Bernat JL. Physician burnout: a neurologic crisis. Neurology 2014;83: 2302–2306. Vickrey BG, Mittman BS, Connor KI, et al. The effect of a disease management intervention on quality and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med 2006;145:713–726.
Barbara G. Vickrey, MD, MPH From the Department of Neurology, University of California, Los Angeles; and the VA Greater Los Angeles Healthcare System, CA. Study funding: No targeted funding reported. Disclosure: B.G. Vickrey receives grant support from NIH/National Institute of Neurological Disorders and Stroke 1U54NS081764 and R37NS031146, the VA Health Services Research and Development Service, California Community Foundation, and UniHealth Foundation; has received consulting income and travel support from Genentech; received travel support from EMD Serono; and received consulting income from Indiana University for participation in Data Safety Monitoring Boards for several NIH trials. Go to Neurology.org for full disclosures.
2090
Neurology 84
Integrated models of care have the potential to meet the needs of patients and will allow neurologists to focus their time more efficiently and effectively. As these models are put in place, neurologists will have legitimate concerns about greater financial risk. No neurologist wants to be in a situation where despite achieving favorable safety, quality, and utilization performance measures, a contract with an insurer is financially detrimental. Whether a system or an individual neurologist is involved in payment negotiations, stop loss provisions and more comprehensive data systems will be needed to track resource use and outcomes for patients with specific neurologic disorders. Our success requires that we become involved and advocate for humanistic, scientifically sound care for patients with chronic neurologic disorders. Rather than focus on the weakness and defects of current strategies, we need to embrace changes that correct these deficits. This tall order no doubt requires ingenuity, flexibility, resources, and commitment, but it is one that is attainable. AUTHOR CONTRIBUTIONS Steven P. Ringel: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and final approval.
STUDY FUNDING No targeted funding reported.
DISCLOSURE S. Ringel receives a stipend from the AAN as editor of Neurology Today. Go to Neurology.org for full disclosures.
Received September 15, 2014. Accepted in final form December 30, 2014.
REFERENCES 1. Ringel SP, Swash M. Money and medicine: a problem that won’t go away. Neurology 2009;72:766–768. 2. Ringel SP. Practicing medicine vs. pushing paper. Health Aff 2011;30:1200–1202. 3. Franklin GM, Ringel SP, Nelson LM, DeLapp C. Neurology practice patterns in Colorado. Neurology 1987;37: 287–289. 4. Ringel SP, Franklin GM, DeLapp C, Boyko EJ. Cross sectional comparative study of private and academic outpatient neurologic practices in Colorado. Neurology 1988; 38:1308–1314. 5. Franklin GM, Ringel SP, Jones M, Baron A. A prospective study of principal care among Colorado neurologists. Neurology 1990;40:701–704. 6. Ringel SP. Future neurology workforce: the right kind and number of neurologists. Neurology 1996;46: 897–900.
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Comment: The changing practice of neurology and a look to the future Barbara G. Vickrey Neurology 2015;84;2090 Published Online before print April 17, 2015 DOI 10.1212/WNL.0000000000001598 This information is current as of April 17, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/20/2090.full.html
References
This article cites 3 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/20/2090.full.html##ref-list-1
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): All Clinical Neurology http://www.neurology.org//cgi/collection/all_clinical_neurology All Health Services Research http://www.neurology.org//cgi/collection/all_health_services_research Decision analysis http://www.neurology.org//cgi/collection/decision_analysis Palliative care http://www.neurology.org//cgi/collection/palliative_care Quality of life http://www.neurology.org//cgi/collection/quality_of_life
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
