What will the future of neurology look like? Will neurologists in private practice fare better by signing up for accountable-care organizations? What stake does neurology have in the quality-reporting movement and systems? Is there a future for private independent practice? What can neurologists learn from online patient communities? Neurology Today asked four leaders in the field — who led a session on these and related topics at the last AAN annual meeting — to offer their perspectives.
Their comments are excerpted below. To hear more of the conversation, follow the links to our podcast interviews.
DR. BRUCE H. COHEN: WHERE WILL NEUROLOGISTS FIT IN WITH ACOS?
Under the Medicare Shared Savings Program, the Centers for Medicare & Medicaid Services will pay an ACO a maximum fixed dollar amount per year for every contracted member. The ACO must provide all medical services (or arrange for services provided outside of the ACO) and meet certain quality standards. With this model, the ACO takes a risk: if it spends more than the contracted maximum, it will lose money. If it spends less, the ACO will split the savings with Medicare. Thus, financial success comes from providing high quality care at the lowest cost, not from generating high revenue.
Bruce H. Cohen, MD, professor of pediatrics and director of neurology in the NeuroDevelopmental Science Center at Akron Children's Hospital in Ohio, thinks accountable-care organizations are going to be with us for the next few years, maybe longer. “No one knows where this is going to end up, but the federal government announced contracts with another 100 ACOs this summer. So, the government and the ACOs are going to give this a fair try.
“As we move to an ACO model, we are going to all be looking at how to deliver services more efficiently, not more units of service. We will probably be more valuable to our employer if we are a jack-of-all-trades who is able to take care of 90 percent of the patients 90 percent of the time than a highly-skilled epilepsy specialist or some other subspecialist.
“This is a totally different paradigm for medical care as we are used to thinking that seeing more patients will improve our bottom line. In the ACO model, the winner is the group of health care providers that can deliver the highest quality care. The devil in the details is providing that care using efficient but comprehensive services, without skimping on safety and quality.
“We traditionally have thought about ‘the bad guy’ as the insurance company that denies hospitalizations for migraine therapy or repeated spine MRIs — but with the ACO model, that could change. The ACO will define the diagnostic and therapeutic decisions that have been the purview of the faceless insurance company.
“The neurologist who is going to be the most valuable to the ACO will be the clinician who can see a lot of patients efficiently, communicate well with patients and with colleagues, and deliver personalized medical care.
“You can say, ‘That's what we're doing now.’ We may be sort of doing that in some ways, and not, in others. The currency in many neurology departments right now is how many papers you are publishing, how subspecialty-focused you are, and how many protocols you have open for experimental design…. Even though you may only be treating 10 patients a year under these experimental protocols, it gives you a reputation that you are a super subspecialist.
“As you think about how ACOs may change the payment model, ask yourself this question: If you are the neurology chairman trying to juggle a department and have the choice between hiring a jack-of-all trades clinical neurologist or the fourth neurologist whose primary job will be to read EEGs and attend in the Epilepsy Monitoring Unit, which neurologist will you hire?
“One of the key things people ought to take away from this is to make yourself indispensable — to your boss, your colleagues, and to your patients. You want the internists in town to think of you as their go-to neurologist. Because when it comes referral time, they're going to be one of your main customers.”
TUNE IN, LISTEN UP: How will the ACO movement affect your practice? Here, Bruce H. Cohen, MD, professor of pediatrics and director of neurology in the NeuroDevelopmental Science Center at Akron Children's Hospital in Ohio, discusses the implications: http://bit.ly/rCBryX.
DR. CONSTANTINE MOSCHONAS: SHIFTS IN HOSPITAL PRACTICE COULD BODE WELL FOR NEUROLOGY
Every trend in health care payment and delivery is pointing toward keeping patients out of hospital inpatient beds as much as possible, said Constantine Moschonas, MD, director of Four Peaks Neurology in Scottsdale, AZ. And it is why he thinks neurologists are well-positioned to succeed, regardless of what payment and delivery models emerge.
“The future is going to be more rewarding for the kind of work that we do. In neurology, we deal with a very delicate organ that is poorly understood and highly complex. So it takes a lot of time on our part to get to the core of what's going on and to manage it.
“A lot of the neurologic conditions tend to be long-lived. And what neurologists demonstrate is their ability to stay in for the entire race. They manage the chronic dementia patients, and those with Parkinson's disease. These diseases require a lot of physician-patient interaction. And as medicine is changing, people will start to understand — and they do already — that if neurologists do their job really well, they will keep these patients with chronic conditions out of hospitals and out of institutions — by, for example, helping them prevent breaks and falls — and these strategies will be cost-effective in the long run.
“There will be a change in the hospital model itself. Hospitals in the future are not going to be rewarded for simply filling their beds. Neurohospitalists will increasingly take over at the hospital, allowing independent neurologists to be truly office-based.
“As neurologists become more office-based, they are going to have the opportunity to take care of individual patients in their home setting. That is going to be a model of the future, especially in dealing with chronic illness, because the hospitals are not going to be rewarded when a patient comes to their institution repeatedly. In fact, they are going to be penalized. What's going to end up happening is that the neurologist who follows these patients and keeps them at home and not in an institution, is going to be rewarded because that is a more cost-effective way of taking care of these people.”
TUNE IN, LISTEN UP: What will independent practice entail in the future? Constantine Moschonas, MD, director of Four Peaks Neurology in Scottsdale, AZ, shares his vision for the future of patient-centered medical care: http://bit.ly/rCBryX.
DR. RICHARD M. DUBINSKY: WHY THE QUALITY REPORTING SYSTEM IS HERE TO STAY
Neurologists have been slow to participate in the federal government's Physician Quality Reporting System (PQRS), which has paid physicians a bonus on their Medicare payments if they successfully submitted quality measures since 2007. Failure to participate will get more expensive for physicians who do not report next year.
Richard M. Dubinsky, MD, MPH, program director for the neurology residency program at University of Kansas Medical Center, says neurologists need to prove they are providing high quality care even if the bonus or penalty does not make it financially worthwhile. Dr. Dubinsky, who chairs the Academy's Practice Improvement Subcommittee, believes a good first step is participating in PQRS.
“I tried it two years ago and we had administrative hurdles in trying to use CPT-2 codes. This year, I hope to participate using the National Parkinson's Foundation registry. At the moment, the amount of dollars involved is not that great, so I don't feel bad that we couldn't figure it out the last few years. But as the penalties start to come into effect, participation is going to be more and more important. And like any large program looking at administrative data, there are many hurdles to overcome to get it to work.
“The main payer for health care — the Centers for Medicare & Medicaid Services — is now demanding a value from the dollars that it is spending, and value is defined as quality divided by cost. So, as a profession, we need to measure the quality of care that we are providing to patients and their families and show that it either justifies the cost or that we can provide the same or better quality at a lower cost than other specialties. We're approaching 19 percent of GDP spent on health care, and it is no longer sustainable, so we need to practice much more cost-effective medicine as we care for our patients.
“Five years from now, I hope that we will have many evidence-based quality measures for neurologists developed by the AAN and others that will not only show that neurologists can provide quality care, but that we provide better quality care for patients with neurological diseases than other specialties.”
TUNE IN, LISTEN UP: How does neurology compare with other specialties in quality measurement? Richard M. Dubinsky, MD, MPH, program director for the neurology residency program at University of Kansas Medical Center, offers his assessment here of neurology's challenges — and its leadership: http://bit.ly/rCBryX.
DR. DANIEL HOCH: HOW ONLINE PATIENT COMMUNITIES CAN LEAD TO BETTER CARE
The Internet had barely emerged in 1993 when Daniel Hoch, MD, PhD, recognized the potential of connecting online with patients. That is the year he and a colleague started BrainTalk (braintalkcommunities.org), which grew to become a collection of more than 200 separate online support groups for neurology patients. Nearly 50,000 individuals posted messages — and 200,000 read postings — each month, making BrainTalk the largest online support research for neurology patients and their caregivers at its peak.
Dr. Hoch, a Harvard University professor, epilepsy specialist, and director of Digital Initiatives for the Benson Henry Institute for Mind Body Medicine at Massachusetts General Hospital, shares his thoughts about how health care information technology is making neurology care more patient-centered:
“We all recognize the problem with research findings that provide new knowledge that might be helpful for our patients. Any time you look at a randomized control trial, you think, ‘Is this going to work in the real world? Can it be generalized? Do the conditions of the study reflect real life so that we can use the results in a meaningful way?’
“Meanwhile, patients have a lot of information to share, but it is not available in a format that allows it to be analyzed to determine whether the information is useful.
“I believe there are ways to study patient-generated data that may not meet the criteria of Class I evidence but could be complementary to traditional clinical research. That can happen when patients share their individual data and organize it in a way that can be analyzed.
“This has already happened online at sites like Patients Like Me (patientslikeme.com), which allows patients with similar medical problems to find each other. Its largest community is comprised of patients with amyotrophic lateral sclerosis (ALS), where an example of this kind of patient-generated research occurred. A member of that group saw an abstract from a small pilot study that suggested lithium may be helpful in the treatment of ALS.
“Patients with ALS organized around the fact that some of them were taking or planned to take lithium. The staff of Patients Like Me gave them the tools to collect and organize data about their use of the medication and the impact. Before long, the group had a nice comparison of data from patients who had chosen to use lithium and those who had not.
“They rather quickly discovered that while lithium looked promising initially, it did not make a big difference for the course of the illness. They came to that conclusion based on this naturalistic experiment about the same time that the first patient was enrolled in the National Institutes of Health-funded clinical trial of lithium in ALS.”
TUNE IN, LISTEN UP: How and why should neurologists stay tuned to online patient communities? Daniel Hoch, MD, PhD, a Harvard University professor, epilepsy specialist, and director of Digital Initiatives for the Benson Henry Institute for Mind Body Medicine at Massachusetts General Hospital, discussed why listening to what patients have to say could promote research advances and improved care: http://bit.ly/rCBryX.
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