Published Ahead of Print on April 17, 2015 as 10.1212/WNL.0000000000001589
CONTEMPORARY ISSUES
The practice of neurology Looking ahead by looking back
Steven P. Ringel, MD
Correspondence to Dr. Ringel: [email protected]
ABSTRACT
Over the last 50 years, there have been many improvements in therapy for individuals with neurologic disorders. Simultaneously, the complexity and cost of care have increased. The delivery of neurologic services is inefficient. The needs of both patients and neurologists are not being optimally addressed. Although greater attention is on the quality, safety, and value of the care, there remains a need for fundamental redesign in the way neurologic services are provided. The future practice of neurology will likely be interdisciplinary and provide both easy access and efficient coordination of services. No matter what changes in financing of health care are adopted, focus needs to be on reducing health care costs. Patients seeking neurologic care will expect seamless, innovative, and cost-effective services and to be active participants in their care. The proposed modifications address current demands and advocate for prospective innovative solutions. The changes proposed to improve care for patients will simultaneously make the careers of neurologists more gratifying and less stressful. Neurology® 2015;84:1–5 GLOSSARY MS 5 multiple sclerosis.
Fifty years ago, I began to learn about the nervous system in medical school and set in motion my career as an academic neurologist. With countless new discoveries and an aging population, I have seen the complexity and cost of neurologic care increase dramatically. I am now able to provide patients more accurate diagnoses and a broader range of treatments. But I have also encountered many unintended consequences: time pressures, fragmentation in care, suboptimal communication, burdensome regulations, professional burnout, and financial anxiety.1,2 It is a daily struggle for me to integrate the many demands of today’s health care delivery system to allow me to care for my patients optimally. The ultimate goal of the next generation of neurologists will be to craft strategies that provide all our neurologic patients the tripartite goal of improved care, improved patient experience, and lower costs. The many neurologic advances we enjoy today came about because of the creativity, adaptability, and self-discipline of practitioners. Those attributes are needed more than ever as we examine the weaknesses and deficiencies in today’s health care environment and commit to improving the neurologic care we provide. Protecting practice styles that were relevant in the past is a futile strategy that only enhances personal dissatisfaction. In this essay, I describe transformations in the delivery of health care I anticipate. To put my personal predictions in context, I first describe both beneficial and adverse changes I have seen in the practice of neurology over the last several decades. I also highlight some changes the Department of Neurology at the University of Colorado has implemented to facilitate some of the changes ahead. Early in my career, I participated in studies to examine the practice patterns of Colorado’s private and academic neurologists in a systematic way. My colleagues and I demonstrated that the vast majority of outpatient consultations were for conditions associated with the scope of primary care: headaches, back and neck pain, seizures, and unexplained symptoms. These topics received little emphasis in neurology training programs. Only 19% of patients had more classic From the Department of Neurology, University of Colorado Denver. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the author, if any, are provided at the end of the article. © 2015 American Academy of Neurology
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
1
neurologic diagnoses and remained under the care of their neurologists after a year. The majority of these patients received diagnostic testing even though the initial diagnosis changed in only a small fraction of cases.3–5 These early studies taught me the value of community-based research if we are to understand what works best for our patients. I also came to appreciate the unqualified support of my neurologic colleagues and their willingness to learn and adapt. Working with the American Academy of Neurology, we began to monitor changing trends in the demography, practice profile, and attitudes of US neurologists, information that over time has guided recommendations.6–8 As today’s neurologists have experienced managed care, outcomes research, limits on price and volume, diagnostic and treatment restraint, divestiture of ownership in health care facilities, malpractice reform, and increased use of preventive services, these changes have all become part of the changing practice of neurology.9,10 Quality and safety concerns received little attention earlier in my career but are a major focus today. A variety of organizations and government programs first encouraged and subsequently required documentation and promotion of high-quality care. These efforts have resulted in an explosion of quality information.11–13 Today’s neurologists must participate in quality and performance improvement efforts for maintenance of board certification. However, many of today’s quality measures are not standardized, so that neurologists are confused about the appropriate data elements to monitor. Many departments of neurology are developing research and training programs in all aspects of health care delivery using the same model that produced successful basic researchers.14–16 This effort is directed at improving the quality, safety, and value of neurologic services and now typically includes patients’ perspectives. Under the Affordable Care Act, there are incentives for reengineered care delivery models and for more effective strategies for bringing scientific discoveries to the bedside. The impact of discovery and health system reform over my career has, on balance, been positive, but for patients with neurologic 2
Neurology 84
diseases, the benefit of increased longevity and more treatment options can easily get lost in the day-to-day chaos that runs hand in hand with modern medical care.17 Not uncommonly, my patients are elderly and incapacitated with multiple diseases that require simultaneous care from several different physicians. In the compressed time available, too often communication with other specialists is inadequate and allows insufficient time to educate patients satisfactorily about the management of their illness. It is common for me to treat patients who have received mixed messages from various providers and are confused and anxious. For people with advanced neurologic disease, a host of community services, psychosocial support, and palliative care is needed. While these services may be available, we do not yet have convenient systems in place to offer this assistance. In addition to educational and infrastructure system obstacles, patients constantly worry that they will spend all of their savings on health care. Total medical costs when I started medical school were a fraction of what they are today. Payer sources have dramatically changed. Almost half of all patients’ health care is now paid by government programs. Government and private insurers are increasingly shifting financial burden to the patient. Facing higher copayments, deductibles, and tiered pricing for medications, patients are often noncompliant with medications because they simply cannot afford them. It is a sad fact to recognize that many patients spend a greater percentage of their disposable income on medical care today than on housing, food, or clothing. Despite the Affordable Care Act, which provides health insurance to many people previously uninsured, access to neurologic services remains difficult, particularly for disadvantaged populations. Privately insured patients often are restricted to health care panels that reduce provider choice, and an increasing number of neurologists are turning away patients when the reimbursement they receive does not meet their expenses. Many patients aggressively seek medical cures, an expectation that is a direct result of the many advances medicine has seen in the last few decades. Stem cells and targeted genetic therapies that block or correct aberrant
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
coding are examples of promising approaches to neurodegenerative diseases, but there are many obstacles to overcome before we will see benefit from these methods. Similarly, precision medicine may in the future allow neurologists to avoid detrimental therapies in individuals who have specific mutations, but there are countless other factors that result in variable responses to our treatment recommendations including disease characteristics, comorbidities, patient preferences, and adherence to what we prescribe. Although I continue to advocate for research that will produce such improved outcomes, I have learned to accept that the human body is a fallible machine that ultimately wears down. Even with previously unimaginable scientific discoveries on the horizon, I recognize that patients benefit as much or more from traditional supportive services as they do from curative approaches that often produce unintended harmful side effects. What do I see evolving in neurologic care in the future? There are glaring needs that must be addressed to correct today’s dysfunctional health care system. A well-functioning system has to support better coordination of services, greater patient education and participation in care, increased patient access, and reduction in health care costs and bureaucracy. Ideally, a patient seeking neurologic care will expect a seamless journey that provides innovation, teamwork, and value.15 Primary care physicians have provided leadership in developing effective models of integrated care such as the patient-centered medical home. Reimbursed a fixed amount rather than a fee for each service provided, these models emphasize care coordination and communication and include data systems to document high-quality, cost-effective care. To establish the reimbursement fixed amount effectively, the model requires understanding the extent of illness within the population served so that resources can be allocated based on need. I anticipate that future health care funding will favor capitation models that limit spending. Neurologists will likely organize or participate in provider networks that offer cost-effective, multidisciplinary care for patients with chronic neurologic illness. These approaches will require
a change in culture and structure of our current neurologic practices, which are fragmented, staffed to provide acute (incident) care, and pay too little attention to self-management needs of chronically ill patients.18 Because office staff focus on managing access and patient flow, the responsibility for planning care, counseling, and follow-up are not sufficiently delegated. By default, these important functions fall to the neurologist or midlevel provider who is severely pressed for time. Information necessary for organizing or planning care is not readily available and often becomes a lower priority for a busy clinician. This lack of organization and information reinforces the focus on immediate symptoms and physiologic abnormalities. All too often neurologists reach for quick empirical pharmacologic remedies rather than spending the time to educate and reassure a stressed patient and family. To try to address these concerns, our neuromuscular patients complete a depression survey (Patient Health Questionnaire) at each visit. Their responses indicate how often we ignore or inadequately manage psychosocial distress. All neurologists can benefit from more effective strategies to educate patients in self-management of their illness. I envision future care of patients with chronic neurologic diseases will be provided according to an explicit plan, which includes regularly scheduled follow-up, systemic assessments, and attention to the self-management needs of patients. To implement these plans efficiently, neurologists will have to overcome protectionist attitudes regarding scope of work. Key care functions will be delegated to an interdisciplinary team of physicians and nonphysicians including midlevel providers, pharmacists, nutritionists, therapists, and caseworkers. In my hospital, our team-based stroke care spans multiple disciplines, eliminating at least one the many historical silos that permeate medicine.17 In our movement disorder and epilepsy clinics, where patients often receive multiple medications, pharmacists and nurses spend considerable time teaching patients about proper dosing, side effects, and the importance of medication compliance. We use information systems, particularly when available in realtime, to document compliance with protocols Neurology 84
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
3
and record outcomes. In our multiple sclerosis (MS) clinic, we use postvoid residuals obtained using ultrasound since unrecognized urinary retention frequently leads to urinary tract infections and MS exacerbations. Future neurologists will recognize that patients with chronic neurologic disease require more time, a broad array of resources, and closer follow-up, including telephone calls and even home visits. By efficiently delegating many of these tasks to a support team, neurologists will be less overwhelmed and burnout might decrease. Because our population is aging and more individuals will develop neurologic disease, more patients will seek neurologic services. These added system pressures will require creative solutions. As more of our population has become insured, a goal of the Affordable Care Act, the potential exists for the most disadvantaged populations to receive better care. Even today, the demand for neurologic services exceeds availability, so that in my department we have employed several new strategies. In our stroke and movement disorder clinics, we offer group visits to better educate patients and to improve their access to multidisciplinary neurologic services. We also provide ambulatory palliative care services that focus on relieving symptoms that diminish quality of life: depression, fatigue, pain, and disrupted sleep. Our hospice program emphasizes that decline and death can be managed and need not be perceived as failure. As payment for services becomes less episode-based, neurologists will need to evaluate the cost benefit of all their recommendations and put greater emphasis on standards of care.1 If we no longer underestimate and undervalue the benefit of providing behavioral health care to our patients, I anticipate that more comprehensive counseling services will result in less use of other more costly and less effective health care services. Perhaps the most challenging hurdle for neurologists will be defining and using tests and treatments cost-effectively. To accomplish cost reductions, neurologists need data that demonstrate the value of all diagnostic and treatment recommendations.15 Most of our current payment systems have perverse incentives that motivate providers to recommend 4
Neurology 84
more rather than efficient services. In our neuromuscular clinic, we developed data systems to determine the frequency of positive test results for patients seen with peripheral neuropathies. Not surprisingly, we identified disparate approaches to diagnosis by each provider, so we developed a standardized, more cost-effective testing algorithm that all now use. Convenient decision analyses, coupled with tracking outcomes, will allow neurologists to refine testing and treatment recommendations for populations of patients. It is misleading and unwise to imply that all diagnostic and treatment decisions can be reduced to algorithms since a patient’s individual choices and response to treatment vary. Randomized controlled therapeutic trials determine if a treatment is beneficial for a population of patients, but often fail to describe which individuals had the best response and how much treatment diversity was present. Future studies will have to include information on the range in response so neurologists can select the best therapeutic option. This redesign should include comparisons of alternative therapeutic approaches, more patient engagement, shared decision-making, and transparency around the quality and safety of each option. Future restructuring that offers better coordination of care, patient education, access to services, and cost reduction may be accomplished first in larger neurologic practices that can aggregate patients with similar needs. The same approaches can be adapted to solo or smaller group practices. Many hospitals in urban or rural settings are becoming part of larger health systems that can share interdisciplinary resources with neurologists. If neurologists do not have access to such systems, another option will be to participate in consortia that use electronic patient registries, share quality data, and provide effective strategies for process improvement and cost containment. Further investment in information technology and clinical decision support will enable neurologists to develop accurate accountability measures that reflect patient preferences, diversity of risk, individual adverse effects, and responsiveness to treatment. Change is easier to accept and less disruptive when incrementally implemented.
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
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. 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. 7. Bernat JL, Ringel SP, Vickrey BG, Keran C. Attitudes of US neurologists concerning the ethical dimensions of managed care. Neurology 1997:49:4–13. 8. Ringel SP, Vickrey BG, Keran CM, Bieber J, Bradley WG. Training the future neurology workforce. Neurology 2000;54:480–484. 9. Holloway RG, Ringel SP, Bernat JL, Keran CM, Lawyer BL. US neurologists: attitudes on resource allocation. Neurology 2000;55:1492–1497. 10. Ringel SP. Can neurologists survive or thrive with health care reform. Ann Neurol 1993;33:441–444. 11. Ringel SP, Vickrey BG. Measuring quality of care in neurology. Arch Neurol 1997;54:1329–1332. 12. Holloway RG, Ringel SP. Narrowing the evidence-practice gap: strengthening the link between research and clinical practice. Neurology 1998;50:319–321. 13. Ringel SP, Vickrey BG, Schembri M, Kravitz RL. Neurologists’ assessment of their ability to provide high quality care. Neurology 2003;61:612–615. 14. Ringel SP. The future of academic neurology: a Colorado perspective. Ann Neurol 1990;27:100–102. 15. Holloway RG, Ringel SP. Getting to value in neurological care: a road map for academic neurology. Ann Neurol 2011;69:909–918. 16. Ringel SP, Steiner JF, Vickrey BG, Spencer SS. Training clinical researchers in neurology: we can do better. Neurology 2001:57:388–392. 17. Ringel SP, Hughes SR. Evidence-based medicine, critical pathways, practice guidelines and managed care: reflections on the prevention and care of stroke. Arch Neurol 1996;53:867–871. 18. Ringel SP. Teaching rounds and change. Neurology 2009; 72:2049–2051.
Neurology 84
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
5
The practice of neurology: Looking ahead by looking back Steven P. Ringel Neurology published online April 17, 2015 DOI 10.1212/WNL.0000000000001589 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/early/2015/04/17/WNL.0000000000 001589.full.html
Supplementary Material
Supplementary material can be found at: http://www.neurology.org/content/suppl/2015/04/17/WNL.000000000 0001589.DC1.html
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.
CONTEMPORARY ISSUES
The practice of neurology Looking ahead by looking back
Steven P. Ringel, MD
Correspondence to Dr. Ringel: [email protected]
ABSTRACT
Over the last 50 years, there have been many improvements in therapy for individuals with neurologic disorders. Simultaneously, the complexity and cost of care have increased. The delivery of neurologic services is inefficient. The needs of both patients and neurologists are not being optimally addressed. Although greater attention is on the quality, safety, and value of the care, there remains a need for fundamental redesign in the way neurologic services are provided. The future practice of neurology will likely be interdisciplinary and provide both easy access and efficient coordination of services. No matter what changes in financing of health care are adopted, focus needs to be on reducing health care costs. Patients seeking neurologic care will expect seamless, innovative, and cost-effective services and to be active participants in their care. The proposed modifications address current demands and advocate for prospective innovative solutions. The changes proposed to improve care for patients will simultaneously make the careers of neurologists more gratifying and less stressful. Neurology® 2015;84:1–5 GLOSSARY MS 5 multiple sclerosis.
Fifty years ago, I began to learn about the nervous system in medical school and set in motion my career as an academic neurologist. With countless new discoveries and an aging population, I have seen the complexity and cost of neurologic care increase dramatically. I am now able to provide patients more accurate diagnoses and a broader range of treatments. But I have also encountered many unintended consequences: time pressures, fragmentation in care, suboptimal communication, burdensome regulations, professional burnout, and financial anxiety.1,2 It is a daily struggle for me to integrate the many demands of today’s health care delivery system to allow me to care for my patients optimally. The ultimate goal of the next generation of neurologists will be to craft strategies that provide all our neurologic patients the tripartite goal of improved care, improved patient experience, and lower costs. The many neurologic advances we enjoy today came about because of the creativity, adaptability, and self-discipline of practitioners. Those attributes are needed more than ever as we examine the weaknesses and deficiencies in today’s health care environment and commit to improving the neurologic care we provide. Protecting practice styles that were relevant in the past is a futile strategy that only enhances personal dissatisfaction. In this essay, I describe transformations in the delivery of health care I anticipate. To put my personal predictions in context, I first describe both beneficial and adverse changes I have seen in the practice of neurology over the last several decades. I also highlight some changes the Department of Neurology at the University of Colorado has implemented to facilitate some of the changes ahead. Early in my career, I participated in studies to examine the practice patterns of Colorado’s private and academic neurologists in a systematic way. My colleagues and I demonstrated that the vast majority of outpatient consultations were for conditions associated with the scope of primary care: headaches, back and neck pain, seizures, and unexplained symptoms. These topics received little emphasis in neurology training programs. Only 19% of patients had more classic From the Department of Neurology, University of Colorado Denver. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the author, if any, are provided at the end of the article. © 2015 American Academy of Neurology
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
1
neurologic diagnoses and remained under the care of their neurologists after a year. The majority of these patients received diagnostic testing even though the initial diagnosis changed in only a small fraction of cases.3–5 These early studies taught me the value of community-based research if we are to understand what works best for our patients. I also came to appreciate the unqualified support of my neurologic colleagues and their willingness to learn and adapt. Working with the American Academy of Neurology, we began to monitor changing trends in the demography, practice profile, and attitudes of US neurologists, information that over time has guided recommendations.6–8 As today’s neurologists have experienced managed care, outcomes research, limits on price and volume, diagnostic and treatment restraint, divestiture of ownership in health care facilities, malpractice reform, and increased use of preventive services, these changes have all become part of the changing practice of neurology.9,10 Quality and safety concerns received little attention earlier in my career but are a major focus today. A variety of organizations and government programs first encouraged and subsequently required documentation and promotion of high-quality care. These efforts have resulted in an explosion of quality information.11–13 Today’s neurologists must participate in quality and performance improvement efforts for maintenance of board certification. However, many of today’s quality measures are not standardized, so that neurologists are confused about the appropriate data elements to monitor. Many departments of neurology are developing research and training programs in all aspects of health care delivery using the same model that produced successful basic researchers.14–16 This effort is directed at improving the quality, safety, and value of neurologic services and now typically includes patients’ perspectives. Under the Affordable Care Act, there are incentives for reengineered care delivery models and for more effective strategies for bringing scientific discoveries to the bedside. The impact of discovery and health system reform over my career has, on balance, been positive, but for patients with neurologic 2
Neurology 84
diseases, the benefit of increased longevity and more treatment options can easily get lost in the day-to-day chaos that runs hand in hand with modern medical care.17 Not uncommonly, my patients are elderly and incapacitated with multiple diseases that require simultaneous care from several different physicians. In the compressed time available, too often communication with other specialists is inadequate and allows insufficient time to educate patients satisfactorily about the management of their illness. It is common for me to treat patients who have received mixed messages from various providers and are confused and anxious. For people with advanced neurologic disease, a host of community services, psychosocial support, and palliative care is needed. While these services may be available, we do not yet have convenient systems in place to offer this assistance. In addition to educational and infrastructure system obstacles, patients constantly worry that they will spend all of their savings on health care. Total medical costs when I started medical school were a fraction of what they are today. Payer sources have dramatically changed. Almost half of all patients’ health care is now paid by government programs. Government and private insurers are increasingly shifting financial burden to the patient. Facing higher copayments, deductibles, and tiered pricing for medications, patients are often noncompliant with medications because they simply cannot afford them. It is a sad fact to recognize that many patients spend a greater percentage of their disposable income on medical care today than on housing, food, or clothing. Despite the Affordable Care Act, which provides health insurance to many people previously uninsured, access to neurologic services remains difficult, particularly for disadvantaged populations. Privately insured patients often are restricted to health care panels that reduce provider choice, and an increasing number of neurologists are turning away patients when the reimbursement they receive does not meet their expenses. Many patients aggressively seek medical cures, an expectation that is a direct result of the many advances medicine has seen in the last few decades. Stem cells and targeted genetic therapies that block or correct aberrant
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
coding are examples of promising approaches to neurodegenerative diseases, but there are many obstacles to overcome before we will see benefit from these methods. Similarly, precision medicine may in the future allow neurologists to avoid detrimental therapies in individuals who have specific mutations, but there are countless other factors that result in variable responses to our treatment recommendations including disease characteristics, comorbidities, patient preferences, and adherence to what we prescribe. Although I continue to advocate for research that will produce such improved outcomes, I have learned to accept that the human body is a fallible machine that ultimately wears down. Even with previously unimaginable scientific discoveries on the horizon, I recognize that patients benefit as much or more from traditional supportive services as they do from curative approaches that often produce unintended harmful side effects. What do I see evolving in neurologic care in the future? There are glaring needs that must be addressed to correct today’s dysfunctional health care system. A well-functioning system has to support better coordination of services, greater patient education and participation in care, increased patient access, and reduction in health care costs and bureaucracy. Ideally, a patient seeking neurologic care will expect a seamless journey that provides innovation, teamwork, and value.15 Primary care physicians have provided leadership in developing effective models of integrated care such as the patient-centered medical home. Reimbursed a fixed amount rather than a fee for each service provided, these models emphasize care coordination and communication and include data systems to document high-quality, cost-effective care. To establish the reimbursement fixed amount effectively, the model requires understanding the extent of illness within the population served so that resources can be allocated based on need. I anticipate that future health care funding will favor capitation models that limit spending. Neurologists will likely organize or participate in provider networks that offer cost-effective, multidisciplinary care for patients with chronic neurologic illness. These approaches will require
a change in culture and structure of our current neurologic practices, which are fragmented, staffed to provide acute (incident) care, and pay too little attention to self-management needs of chronically ill patients.18 Because office staff focus on managing access and patient flow, the responsibility for planning care, counseling, and follow-up are not sufficiently delegated. By default, these important functions fall to the neurologist or midlevel provider who is severely pressed for time. Information necessary for organizing or planning care is not readily available and often becomes a lower priority for a busy clinician. This lack of organization and information reinforces the focus on immediate symptoms and physiologic abnormalities. All too often neurologists reach for quick empirical pharmacologic remedies rather than spending the time to educate and reassure a stressed patient and family. To try to address these concerns, our neuromuscular patients complete a depression survey (Patient Health Questionnaire) at each visit. Their responses indicate how often we ignore or inadequately manage psychosocial distress. All neurologists can benefit from more effective strategies to educate patients in self-management of their illness. I envision future care of patients with chronic neurologic diseases will be provided according to an explicit plan, which includes regularly scheduled follow-up, systemic assessments, and attention to the self-management needs of patients. To implement these plans efficiently, neurologists will have to overcome protectionist attitudes regarding scope of work. Key care functions will be delegated to an interdisciplinary team of physicians and nonphysicians including midlevel providers, pharmacists, nutritionists, therapists, and caseworkers. In my hospital, our team-based stroke care spans multiple disciplines, eliminating at least one the many historical silos that permeate medicine.17 In our movement disorder and epilepsy clinics, where patients often receive multiple medications, pharmacists and nurses spend considerable time teaching patients about proper dosing, side effects, and the importance of medication compliance. We use information systems, particularly when available in realtime, to document compliance with protocols Neurology 84
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
3
and record outcomes. In our multiple sclerosis (MS) clinic, we use postvoid residuals obtained using ultrasound since unrecognized urinary retention frequently leads to urinary tract infections and MS exacerbations. Future neurologists will recognize that patients with chronic neurologic disease require more time, a broad array of resources, and closer follow-up, including telephone calls and even home visits. By efficiently delegating many of these tasks to a support team, neurologists will be less overwhelmed and burnout might decrease. Because our population is aging and more individuals will develop neurologic disease, more patients will seek neurologic services. These added system pressures will require creative solutions. As more of our population has become insured, a goal of the Affordable Care Act, the potential exists for the most disadvantaged populations to receive better care. Even today, the demand for neurologic services exceeds availability, so that in my department we have employed several new strategies. In our stroke and movement disorder clinics, we offer group visits to better educate patients and to improve their access to multidisciplinary neurologic services. We also provide ambulatory palliative care services that focus on relieving symptoms that diminish quality of life: depression, fatigue, pain, and disrupted sleep. Our hospice program emphasizes that decline and death can be managed and need not be perceived as failure. As payment for services becomes less episode-based, neurologists will need to evaluate the cost benefit of all their recommendations and put greater emphasis on standards of care.1 If we no longer underestimate and undervalue the benefit of providing behavioral health care to our patients, I anticipate that more comprehensive counseling services will result in less use of other more costly and less effective health care services. Perhaps the most challenging hurdle for neurologists will be defining and using tests and treatments cost-effectively. To accomplish cost reductions, neurologists need data that demonstrate the value of all diagnostic and treatment recommendations.15 Most of our current payment systems have perverse incentives that motivate providers to recommend 4
Neurology 84
more rather than efficient services. In our neuromuscular clinic, we developed data systems to determine the frequency of positive test results for patients seen with peripheral neuropathies. Not surprisingly, we identified disparate approaches to diagnosis by each provider, so we developed a standardized, more cost-effective testing algorithm that all now use. Convenient decision analyses, coupled with tracking outcomes, will allow neurologists to refine testing and treatment recommendations for populations of patients. It is misleading and unwise to imply that all diagnostic and treatment decisions can be reduced to algorithms since a patient’s individual choices and response to treatment vary. Randomized controlled therapeutic trials determine if a treatment is beneficial for a population of patients, but often fail to describe which individuals had the best response and how much treatment diversity was present. Future studies will have to include information on the range in response so neurologists can select the best therapeutic option. This redesign should include comparisons of alternative therapeutic approaches, more patient engagement, shared decision-making, and transparency around the quality and safety of each option. Future restructuring that offers better coordination of care, patient education, access to services, and cost reduction may be accomplished first in larger neurologic practices that can aggregate patients with similar needs. The same approaches can be adapted to solo or smaller group practices. Many hospitals in urban or rural settings are becoming part of larger health systems that can share interdisciplinary resources with neurologists. If neurologists do not have access to such systems, another option will be to participate in consortia that use electronic patient registries, share quality data, and provide effective strategies for process improvement and cost containment. Further investment in information technology and clinical decision support will enable neurologists to develop accurate accountability measures that reflect patient preferences, diversity of risk, individual adverse effects, and responsiveness to treatment. Change is easier to accept and less disruptive when incrementally implemented.
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
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. 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. 7. Bernat JL, Ringel SP, Vickrey BG, Keran C. Attitudes of US neurologists concerning the ethical dimensions of managed care. Neurology 1997:49:4–13. 8. Ringel SP, Vickrey BG, Keran CM, Bieber J, Bradley WG. Training the future neurology workforce. Neurology 2000;54:480–484. 9. Holloway RG, Ringel SP, Bernat JL, Keran CM, Lawyer BL. US neurologists: attitudes on resource allocation. Neurology 2000;55:1492–1497. 10. Ringel SP. Can neurologists survive or thrive with health care reform. Ann Neurol 1993;33:441–444. 11. Ringel SP, Vickrey BG. Measuring quality of care in neurology. Arch Neurol 1997;54:1329–1332. 12. Holloway RG, Ringel SP. Narrowing the evidence-practice gap: strengthening the link between research and clinical practice. Neurology 1998;50:319–321. 13. Ringel SP, Vickrey BG, Schembri M, Kravitz RL. Neurologists’ assessment of their ability to provide high quality care. Neurology 2003;61:612–615. 14. Ringel SP. The future of academic neurology: a Colorado perspective. Ann Neurol 1990;27:100–102. 15. Holloway RG, Ringel SP. Getting to value in neurological care: a road map for academic neurology. Ann Neurol 2011;69:909–918. 16. Ringel SP, Steiner JF, Vickrey BG, Spencer SS. Training clinical researchers in neurology: we can do better. Neurology 2001:57:388–392. 17. Ringel SP, Hughes SR. Evidence-based medicine, critical pathways, practice guidelines and managed care: reflections on the prevention and care of stroke. Arch Neurol 1996;53:867–871. 18. Ringel SP. Teaching rounds and change. Neurology 2009; 72:2049–2051.
Neurology 84
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
5
The practice of neurology: Looking ahead by looking back Steven P. Ringel Neurology published online April 17, 2015 DOI 10.1212/WNL.0000000000001589 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/early/2015/04/17/WNL.0000000000 001589.full.html
Supplementary Material
Supplementary material can be found at: http://www.neurology.org/content/suppl/2015/04/17/WNL.000000000 0001589.DC1.html
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.
