Opinion
VIEWPOINT
Daniel Gold, DO Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland. David E. NewmanToker, MD, PhD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Joshua M. Sharfstein, MD Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Corresponding Author: Joshua M. Sharfstein, MD, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room 484, Baltimore, MD 21205 (joshua [email protected]). jamaneurology.com
Neurology and the Affordable Care Act The Affordable Care Act is reshaping US health care. Major expansions in access have allowed millions of Americans to gain health coverage. New models of care delivery and payment are leading to fundamental shifts in outpatient and inpatient treatment. As specialists and diagnosticians, neurologists should understand the basics of this legislation and take advantage of opportunities on behalf of patients. As a result of the Affordable Care Act, more Americans than ever are covered by health insurance. As of March 2015, 28 states and the District of Columbia have expanded Medicaid to cover families with income up to 133% of the federal poverty line. All states are covered by insurance exchanges that offer access to subsidized private coverage up to 400% of the poverty line. From 2012 to 2014, millions of Americans have taken advantage of these opportunities, and the number of uninsured in the United States has decreased from 37 to 29 million.1 Although trends in the use of specialty services are not yet available, newly insured Americans should have greater access to neurologists than those who are uninsured. This is good news. In the setting of acute illness, such as stroke, seizure, or neuroinfectious disease, speedy access to neurological care saves lives. In the context of nebulous symptoms, the more expeditious the neurologic evaluation, the more timely the diagnosis. For example, neurologists are best able to differentiate epileptic from nonepileptic seizures, to separate stroke mimics from actual strokes, and to discern potentially life-threatening causes of headache and dizziness. Patients with chronic neurological disease faced special challenges prior to the passage of the Affordable Care Act and are in a position to gain significantly from the law’s benefits. For example, among patients with multiple sclerosis, one study2 found that concern over access to treatment was associated with “depression, anxiety, fatigue, sleep disturbance, pain interference, social function, and perceived cognitive functioning.” Researchers also found that uninsured and underinsured patients with migraine were more likely to be cared for in emergency departments and less likely to receive appropriate abortive and prophylactic therapy.3 The new law establishes a benchmark of comprehensive coverage and prohibits discrimination against individuals with preexisting conditions. Since passage, the number of Americans who have missed needed care because of financial barriers has decreased by 16 million.1 Patients with chronic neurological disease often need access to costly but meaningful therapies, including the disease-modifying drugs for multiple sclerosis, triptans for migraines, and immunoglobulin therapy or chemotherapy for a variety of autoimmune conditions. It will be important to monitor access to these therapies, as well as the involvement of neurologists in patient-
centered decision making and monitoring for significant adverse effects. Similar to its substantial effect on coverage, the Affordable Care Act has brought profound change to health care delivery and payment. In ways large and small, the law has accelerated the shift away from feefor-service reimbursement to models that reward outcomes and quality. Examples of new models include patient-centered medical homes (which reward primary care physicians for high-quality management of patients with chronic illness), accountable care organizations (which allow health care organizations to take responsibility for the care and cost of large populations), and bundled rates (which provide a set fee for specialists for the management of specific conditions). These changes have important implications for neurologists. Neurology is a cognitive specialty in which invasive procedures are infrequent, so most of the clinical care involves sharing diagnostic and therapeutic knowledge with patients. Most neurologists pride themselves on their bedside diagnostic skills. It is no secret, however, that fee-for-service payment systems create financial incentives to perform more diagnostic tests. As a result, many diagnostic tests for neurological disorders are overused, adding billions of dollars to annual US health care costs.4,5 The push toward value-based payment offers the promise of incentives to “do less” yet still “get it right,” with financial penalties resulting from bouncebacks and complications. For neurology, this new approach offers the hope of rewarding the more efficient and effective use of diagnostic tests and reflecting the importance of delivering bedside expertise to patients. For example, in a bundled or capitated payment system, a neurologist capable of correctly diagnosing and effectively treating migraine in a patient with new headache, without the use of an expensive imaging study, might be able to share in the savings. In addition, shifting the emphasis to quality outcomes could alleviate excessive burdens for physicians related to documentation and coding. Fully realizing the benefits of the Affordable Care Act for neurologists and their patients requires navigating around several obstacles. Competition between health plans is a hallmark of the Affordable Care Act. If plans lower costs by supporting the quality of care and negotiating effectively with drug and device companies for lower prices, patients can benefit without changes in access to care. However, if plans attempt to lower costs by reducing specialty access and limiting access to needed drugs, patients may be harmed. Establishing transparency in health care professional networks through websites such as Maryland Health Connection (https: //providersearch.crisphealth.org/) is important for monitoring access to specialty care. Increasingly, health (Reprinted) JAMA Neurology June 2015 Volume 72, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
623
Opinion Viewpoint
plans are adopting formulary exclusions as an approach to reducing costs; because of the chance that critical therapies may be excluded, this is a trend that requires close oversight.6 Changes to health care payment require oversight as well. If payments are bundled or capitated solely by chronic disease (eg, diabetes mellitus) and treatment (eg, hip replacement), then the benefit for diagnostic accuracy in health care will be minimal. By contrast, if payments are bundled by symptoms or presenting problems, then incentives will encourage accurate, efficient diagnosis.7 For example, a bundled rate for the management of stroke would leave untouched current incentives for the excessive use ARTICLE INFORMATION
REFERENCES
Published Online: April 20, 2015. doi:10.1001/jamaneurol.2015.0083.
1. Collins SR, Rasmussen PW, Doty MM, Beutel S. The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. http://www.commonwealthfund.org /~/media/files/publications/issue-brief/2015/jan /1800_collins_biennial_survey_brief.pdf?la=en. Commonwealth Fund issue brief. Published January 2015. Accessed January 15, 2015.
Conflict of Interest Disclosures: Dr Sharfstein served as secretary of the Maryland Department of Health and Mental Hygiene and as chair of the board of the Maryland Health Benefit Exchange from 2011 to 2014. Dr Newman-Toker is a board member of the Society to Improve Diagnosis in Medicine, with interests in misdiagnoses; has received support from the National Institutes of Health (grant U01 DC013778-01A1) and has a grant pending as principal investigator that is related to work regarding neurologic diagnoses; and had received honoraria from Janssen and SunPharma, as well as multiple academic institutions in the United States and abroad. No other disclosures are reported.
VIEWPOINT
Joseph R. Berger, MD Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Corresponding Author: Joseph R. Berger, MD, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3 W Gates, Philadelphia, PA 19104 (joseph.berger @uphs.upenn.edu). 624
of imaging for patients with possible stroke symptoms. However, a bundled rate for a patient with a chief symptom of dizziness or vertigo would incentivize making the correct inner ear diagnoses without brain imaging. This would likely drive the use of proven clinical decision rules and enhance the value of bedside neurological diagnosis. As the nation’s health care system evolves, there should be greater demand for the full range of clinical services and expertise of neurologists. The Affordable Care Act offers neurologists unique opportunities to improve care delivery, clinical quality, and health outcomes.
2. Jones SM, Amtmann D. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol. 2014;59(3):354-359. 3. Wilper A, Woolhandler S, Himmelstein D, Nardin R. Impact of insurance status on migraine care in the United States: a population-based study. Neurology. 2010;74(15):1178-1183.
4. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011. 5. Burke JF, Skolarus LE, Callaghan BC, Kerber KA. Choosing Wisely: highest-cost tests in outpatient neurology. Ann Neurol. 2013;73(5):679-683. 6. Smolinski I. Specialty formulary exclusions gaining traction. Morning Consult website. http://morningconsult.com/2015/01/specialty -formulary-exclusions-gaining-traction/. Published January 6, 2015. Accessed January 18, 2015. 7. Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? a health economics perspective. BMJ Qual Saf. 2013;22(suppl 2):ii11-ii20.
Political Correctness of Medical Documentation Having relocated to a new academic institution, I was certain that I would have to learn some new things but revising how I wrote the history and physical examinations of my patients was hardly anticipated. The template I used was largely unchanged in more than 4 decades and it had served me well. While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated. The history and physical examination started with the following description: “This 36-year-old, righthanded, African American man presents to office…” Commencing the report with this descriptive detail provides a mental image of the patient to the reader. The argument my colleague proffered was that race, ethnicity, and country of origin are essentially of no value. Any person could have any illness. He made note of a fact that
I had appreciated in the short time that I have been at the new institution, namely, that few physicians or trainees included such elements in their histories. My immediate thought was that he was right. That evening, I recited verbatim the opening lines of the history to my wife who has a keen ear for anything that smacks of political incorrectness, whether it was regarding race, country of origin, sexual orientation, or other. Curiously, she appeared tone deaf to the issue of race, rather she corrected the grammar (she is an English-as-a-secondlanguage teacher). Her inability to consider the opening phrase, which includes a description of race, inappropriate was heartening. The more I reflected on the issue the more I considered these descriptions not only appropriate but, at times, critically important. There are 3 reasons to consider this to be the case: (1) certain illnesses are far more common in some races, ethnicities, or regions of the world; (2) depending on their genetics, some people may respond to medications differently; and (3) rich descriptions of the patient incorporating elements that may not be essential for diagnosis or management help the physician to recall the patient. With respect to the association of race/ethnicity and country of origin with illness, I will provide some ex-
JAMA Neurology June 2015 Volume 72, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
jamaneurology.com
VIEWPOINT
Daniel Gold, DO Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland. David E. NewmanToker, MD, PhD Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Joshua M. Sharfstein, MD Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Corresponding Author: Joshua M. Sharfstein, MD, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Room 484, Baltimore, MD 21205 (joshua [email protected]). jamaneurology.com
Neurology and the Affordable Care Act The Affordable Care Act is reshaping US health care. Major expansions in access have allowed millions of Americans to gain health coverage. New models of care delivery and payment are leading to fundamental shifts in outpatient and inpatient treatment. As specialists and diagnosticians, neurologists should understand the basics of this legislation and take advantage of opportunities on behalf of patients. As a result of the Affordable Care Act, more Americans than ever are covered by health insurance. As of March 2015, 28 states and the District of Columbia have expanded Medicaid to cover families with income up to 133% of the federal poverty line. All states are covered by insurance exchanges that offer access to subsidized private coverage up to 400% of the poverty line. From 2012 to 2014, millions of Americans have taken advantage of these opportunities, and the number of uninsured in the United States has decreased from 37 to 29 million.1 Although trends in the use of specialty services are not yet available, newly insured Americans should have greater access to neurologists than those who are uninsured. This is good news. In the setting of acute illness, such as stroke, seizure, or neuroinfectious disease, speedy access to neurological care saves lives. In the context of nebulous symptoms, the more expeditious the neurologic evaluation, the more timely the diagnosis. For example, neurologists are best able to differentiate epileptic from nonepileptic seizures, to separate stroke mimics from actual strokes, and to discern potentially life-threatening causes of headache and dizziness. Patients with chronic neurological disease faced special challenges prior to the passage of the Affordable Care Act and are in a position to gain significantly from the law’s benefits. For example, among patients with multiple sclerosis, one study2 found that concern over access to treatment was associated with “depression, anxiety, fatigue, sleep disturbance, pain interference, social function, and perceived cognitive functioning.” Researchers also found that uninsured and underinsured patients with migraine were more likely to be cared for in emergency departments and less likely to receive appropriate abortive and prophylactic therapy.3 The new law establishes a benchmark of comprehensive coverage and prohibits discrimination against individuals with preexisting conditions. Since passage, the number of Americans who have missed needed care because of financial barriers has decreased by 16 million.1 Patients with chronic neurological disease often need access to costly but meaningful therapies, including the disease-modifying drugs for multiple sclerosis, triptans for migraines, and immunoglobulin therapy or chemotherapy for a variety of autoimmune conditions. It will be important to monitor access to these therapies, as well as the involvement of neurologists in patient-
centered decision making and monitoring for significant adverse effects. Similar to its substantial effect on coverage, the Affordable Care Act has brought profound change to health care delivery and payment. In ways large and small, the law has accelerated the shift away from feefor-service reimbursement to models that reward outcomes and quality. Examples of new models include patient-centered medical homes (which reward primary care physicians for high-quality management of patients with chronic illness), accountable care organizations (which allow health care organizations to take responsibility for the care and cost of large populations), and bundled rates (which provide a set fee for specialists for the management of specific conditions). These changes have important implications for neurologists. Neurology is a cognitive specialty in which invasive procedures are infrequent, so most of the clinical care involves sharing diagnostic and therapeutic knowledge with patients. Most neurologists pride themselves on their bedside diagnostic skills. It is no secret, however, that fee-for-service payment systems create financial incentives to perform more diagnostic tests. As a result, many diagnostic tests for neurological disorders are overused, adding billions of dollars to annual US health care costs.4,5 The push toward value-based payment offers the promise of incentives to “do less” yet still “get it right,” with financial penalties resulting from bouncebacks and complications. For neurology, this new approach offers the hope of rewarding the more efficient and effective use of diagnostic tests and reflecting the importance of delivering bedside expertise to patients. For example, in a bundled or capitated payment system, a neurologist capable of correctly diagnosing and effectively treating migraine in a patient with new headache, without the use of an expensive imaging study, might be able to share in the savings. In addition, shifting the emphasis to quality outcomes could alleviate excessive burdens for physicians related to documentation and coding. Fully realizing the benefits of the Affordable Care Act for neurologists and their patients requires navigating around several obstacles. Competition between health plans is a hallmark of the Affordable Care Act. If plans lower costs by supporting the quality of care and negotiating effectively with drug and device companies for lower prices, patients can benefit without changes in access to care. However, if plans attempt to lower costs by reducing specialty access and limiting access to needed drugs, patients may be harmed. Establishing transparency in health care professional networks through websites such as Maryland Health Connection (https: //providersearch.crisphealth.org/) is important for monitoring access to specialty care. Increasingly, health (Reprinted) JAMA Neurology June 2015 Volume 72, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
623
Opinion Viewpoint
plans are adopting formulary exclusions as an approach to reducing costs; because of the chance that critical therapies may be excluded, this is a trend that requires close oversight.6 Changes to health care payment require oversight as well. If payments are bundled or capitated solely by chronic disease (eg, diabetes mellitus) and treatment (eg, hip replacement), then the benefit for diagnostic accuracy in health care will be minimal. By contrast, if payments are bundled by symptoms or presenting problems, then incentives will encourage accurate, efficient diagnosis.7 For example, a bundled rate for the management of stroke would leave untouched current incentives for the excessive use ARTICLE INFORMATION
REFERENCES
Published Online: April 20, 2015. doi:10.1001/jamaneurol.2015.0083.
1. Collins SR, Rasmussen PW, Doty MM, Beutel S. The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. http://www.commonwealthfund.org /~/media/files/publications/issue-brief/2015/jan /1800_collins_biennial_survey_brief.pdf?la=en. Commonwealth Fund issue brief. Published January 2015. Accessed January 15, 2015.
Conflict of Interest Disclosures: Dr Sharfstein served as secretary of the Maryland Department of Health and Mental Hygiene and as chair of the board of the Maryland Health Benefit Exchange from 2011 to 2014. Dr Newman-Toker is a board member of the Society to Improve Diagnosis in Medicine, with interests in misdiagnoses; has received support from the National Institutes of Health (grant U01 DC013778-01A1) and has a grant pending as principal investigator that is related to work regarding neurologic diagnoses; and had received honoraria from Janssen and SunPharma, as well as multiple academic institutions in the United States and abroad. No other disclosures are reported.
VIEWPOINT
Joseph R. Berger, MD Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Corresponding Author: Joseph R. Berger, MD, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3 W Gates, Philadelphia, PA 19104 (joseph.berger @uphs.upenn.edu). 624
of imaging for patients with possible stroke symptoms. However, a bundled rate for a patient with a chief symptom of dizziness or vertigo would incentivize making the correct inner ear diagnoses without brain imaging. This would likely drive the use of proven clinical decision rules and enhance the value of bedside neurological diagnosis. As the nation’s health care system evolves, there should be greater demand for the full range of clinical services and expertise of neurologists. The Affordable Care Act offers neurologists unique opportunities to improve care delivery, clinical quality, and health outcomes.
2. Jones SM, Amtmann D. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol. 2014;59(3):354-359. 3. Wilper A, Woolhandler S, Himmelstein D, Nardin R. Impact of insurance status on migraine care in the United States: a population-based study. Neurology. 2010;74(15):1178-1183.
4. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011. 5. Burke JF, Skolarus LE, Callaghan BC, Kerber KA. Choosing Wisely: highest-cost tests in outpatient neurology. Ann Neurol. 2013;73(5):679-683. 6. Smolinski I. Specialty formulary exclusions gaining traction. Morning Consult website. http://morningconsult.com/2015/01/specialty -formulary-exclusions-gaining-traction/. Published January 6, 2015. Accessed January 18, 2015. 7. Newman-Toker DE, McDonald KM, Meltzer DO. How much diagnostic safety can we afford, and how should we decide? a health economics perspective. BMJ Qual Saf. 2013;22(suppl 2):ii11-ii20.
Political Correctness of Medical Documentation Having relocated to a new academic institution, I was certain that I would have to learn some new things but revising how I wrote the history and physical examinations of my patients was hardly anticipated. The template I used was largely unchanged in more than 4 decades and it had served me well. While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated. The history and physical examination started with the following description: “This 36-year-old, righthanded, African American man presents to office…” Commencing the report with this descriptive detail provides a mental image of the patient to the reader. The argument my colleague proffered was that race, ethnicity, and country of origin are essentially of no value. Any person could have any illness. He made note of a fact that
I had appreciated in the short time that I have been at the new institution, namely, that few physicians or trainees included such elements in their histories. My immediate thought was that he was right. That evening, I recited verbatim the opening lines of the history to my wife who has a keen ear for anything that smacks of political incorrectness, whether it was regarding race, country of origin, sexual orientation, or other. Curiously, she appeared tone deaf to the issue of race, rather she corrected the grammar (she is an English-as-a-secondlanguage teacher). Her inability to consider the opening phrase, which includes a description of race, inappropriate was heartening. The more I reflected on the issue the more I considered these descriptions not only appropriate but, at times, critically important. There are 3 reasons to consider this to be the case: (1) certain illnesses are far more common in some races, ethnicities, or regions of the world; (2) depending on their genetics, some people may respond to medications differently; and (3) rich descriptions of the patient incorporating elements that may not be essential for diagnosis or management help the physician to recall the patient. With respect to the association of race/ethnicity and country of origin with illness, I will provide some ex-
JAMA Neurology June 2015 Volume 72, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of Manitoba User on 06/16/2015
jamaneurology.com
