INTER-SOCIETY COLLABORATION IS THE WAVE OF THE FUTURE
Several months ago, members of the Neurology Today editorial board were invited to name one or two major clinical or basic science advances for an AAN Foundation listing of research progress in 2002.
I suggested two advances that are not “scientific,” but could be every bit as important to the practice of neurology – now and in the future. One is the publication of coding and billing guidelines for electromyography (EMG) and nerve conduction studies. The other is a work in progress: practice guidelines for peripheral neuropathy.
Why do I consider these two initiatives to be noteworthy? They involve the coordinated and cooperative efforts of more than one medical specialty society – and, therefore, can be a model for developing clinical guidelines that will achieve higher levels of acceptance by health care providers and insurers than guidelines authored by single societies or third party payers.
Neurologists frequently perform electromyography (EMG) and nerve conduction studies, but there has been nationwide variability in CPT coding because traditional coding references are ambiguous. Coding and billing guidelines for EMG and nerve conduction studies were published last April in the CPT Assistant, a monthly newsletter of the American Medical Association (AMA). The guidelines clarify proper use of these codes.
CLINICAL CONCERNS OF PROVIDERS
I believe that publication of these guidelines is a landmark in clinical practice. The AMA and the Centers for Medicare and Medicaid Services (CMS) endorsed principles developed by both the American Association of Electrodiagnostic Medicine (AAEM) and the AAN. They adopted a policy written by specialty societies whose members perform the tests, rather than by the AMA itself or some non-medical consultants. Too many guidelines are proprietary, driven by financial considerations of the payer, and unacceptable to physicians. Our policy is fundamentally different – it is driven by clinical concerns of the providers. We hope all payers adopt these recommendations!
Development of our guidelines began in 1993 when the AAEM was asked to respond to Indiana Medicare's restrictive policies concerning electrodiagnostic medicine. At the time, there were no national standards for the proper performance of these tests, which were done in large numbers and consumed large sums of money spent by Medicare and other insurers.
The AAEM figured that a properly designed policy could spread nationwide if it was fair and reasonable. Forty-three experts – neurologists and physiatrists – convened in Chicago in 1994 to generate national recommendations. I helped coordinate that meeting.
We followed procedures established by John Ferguson, MD, a neurologist who directed the National Institutes of Health consensus conferences. In the absence of evidence-based medicine data, our goal was to achieve consensus. The AAEM revised and extended these guidelines over the next eight years in concert with the AAN and the American Academy of Physical Medicine and Rehabilitation (AAPMR).
Finally, after prolonged advocacy efforts, CMS and the AMA accepted our recommendations. They knew that these guidelines were needed, but did not have the resources to develop them themselves. CMS and the AMA adopted our policies because they were based on accepted state-of-the-art developmental standards and were as impartial and as evidence-based as possible.
GUIDELINES FOR PERIPHERAL NEUROPATHY
The development of practice guidelines for peripheral neuropathy – a work in progress – is another example of inter-society collaboration. The goal is to develop evidence-based clinical recommendations that can be endorsed officially by several societies.
The National Guideline Clearinghouse Web site (www.guidelines.gov) includes several instances in which one clinical condition is covered by multiple practice parameters created by different societies. The guidelines sometimes differ considerably from one another, leading to confusion among practitioners. Which ones should we follow? It would be ideal if the different societies could unite and endorse a single guideline for each condition.
The AAN has occasionally endorsed practice parameters from other organizations, such as the AAEM's carpal tunnel syndrome practice parameter (Neurology 2002;58:1589–1592). Usually, however, the AAN has been reluctant to adopt guidelines from other societies because the criteria used may differ substantially from those of the AAN in its own development process.
AAN guidelines are developed with the utmost rigor. The AAN guidelines development process is the “gold standard” for other organizations to model. For this reason, a joint AAN-AAEM-AAPMR task force was established in 2000 to develop guidelines that all three organizations would endorse. All agreed that the guidelines would follow the AAN criteria and would deal with aspects of diseases of the peripheral nervous system, which is the common ground for the three organizations.
Naturally, there have been obstacles, but the task force has already made substantial progress towards two papers, each of which will be published in the respective society journals. The first will be the “Evidence- and Consensus-Based Case Definition of Polyneuropathy for Clinical Research” and the second will be the “Practice Parameter for the Diagnosis and Evaluation of Polyneuropathy.” Just as with the electrodiagnostic medicine guidelines, we hope that the final recommendations will be adopted by other medical organizations and by third party payers.
In these days of a zero-sum Medicare budget, turf battles between and among health care providers are all too frequent. Sometimes, the battles degenerate into the sort of “he said, she said” dialogue heard in a divorce court. Fair resolution of these conflicts often requires the participation of a dispassionate third party.
When we spoke with the Health Care Financing Administration (the precursor to CMS) leaders several years ago about EMG practice issues, they were more receptive to our position when we stated that the AMA supported our stance. Endorsement by the AMA meant a lot because it was an established and respected medical organization that did not have a direct stake in the outcome. Only a few physician members of the AMA perform EMG studies.
WHAT WE CAN DO
What can we learn from these recent advances? We can follow procedures to ensure more widespread acceptance of AAN clinical practice recommendations and guidelines. The following road map may help:
- Develop the guidelines using the most up-to-date and rigorous criteria, ideally with the active input from, and ultimately the explicit endorsement of, related specialty societies.
- Obtain the support of other medical societies, especially the AMA.
- Present the guidelines to CMS and other third-party payers for adoption.
This model of inter-society collaboration should significantly improve how we practice neurology and how others view our specialty. The voice of neurologically-oriented physicians is greatly amplified when sister organizations band together. The synergy from inter-society cooperation will immensely aid our advocacy efforts aimed at our members, other physicians, government, health insurers, and the public.