When Lawrence Samkoff, M.D., speaks on Capitol Hill, legislators pay closer attention for much the same reason his own patients do. Joining 48 fellow neurologists from around the country in Washington this May, Dr. Samkoff lobbied not just as a physician but also as a patient. Since he has cerebral palsy, he understands what patients “go through on a day-to-day basis” and can convey the unique importance of comprehensive neurological exams.
“We talk to patients, examine them, spend time with them, make an assessment, devise a plan,” he says, defining what neurologists refer to as cognitive services. “With a new patient, I'll spend an hour and a half talking with them and examining them. If you cut down that time, you cut corners for efficiency and sacrifice quality for quantity.”
Failure to conduct these detailed cognitive assessments can result in oversights with serious consequences: In the office of Sen. Dianne Feinstein (D-Calif.) during the “Neurology on the Hill” lobbying day sponsored by the American Academy of Neurology (AAN), Dr. Daniel Giang, chairman of neurology at California's Loma Linda University, told the senator's aides about a patient who'd been to two emergency rooms without a correct diagnosis; another neurologist reported seeing a patient who'd been told in an ER that he had a migraine. In both cases, the patients suffered serious strokes.
“The whole services picture is screwed up,” says Dr. Samkoff, a neurologist at New York's Rochester General Hospital. “Neurology relies on cognitive exams. The problem with our current system is that it's more attuned to acute care than chronic care. Insurance companies pay for tests and testing; reimbursements are made for a much greater percentage of these than for cognitive services. The value of cognitive services is under-recognized in favor of more extensive testing associated with MRIs or other sophisticated diagnostic tools.”
A 2005 AAN survey and report supports his observations, finding that while insurance payments for the cognitive exams and in-office consultations with neurologists are dropping drastically, payments for tests and medical procedures are skyrocketing. The result: diminishing access to neurologists and declining patient care quality for serious neurological disorders.
“If a patient has limited access to neurologists, neurological diseases will go untreated, under-treated or mismanaged for longer periods of time,” Dr. Samkoff says. “As doctors, neurologists are under pressure to spend less time with patients, and are finding it increasingly difficult to speak with patients to the extent that good care requires.
“Our major issue as a group was ensuring patient access to a neurologist. We're taking care of chronically disabled patients in many instances who need a tremendous amount of care. No one recognizes that. Under the current system, neurologists are finding it difficult to provide these services.”
The message he and his colleagues left in 116 congressional offices: “If patients don't have adequate access to neurologists, primary care physicians and other physicians would have to do some unnecessary testing, since neurologists wouldn't be available,” he says. “More potential would exist for a misdiagnosis or a delayed diagnosis.”