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Financial Pressures Not Novel to Academic Neurology, But New Health Reform Mandates Drive Change to Status Quo

Valeo, Tom

doi: 10.1097/01.NT.0000399615.64391.79
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Chairs of academic neurology departments discuss strategies to stay solvent and constrain health care costs in the setting of the new health reform law.

Academic neurology departments with their triple responsibilities of patient care, teaching, and research will be especially challenged by efforts to constrain the soaring cost of health care in the United States, but they're also well positioned to lead the way toward greater integration and efficiency, according to chairs of several prominent departments.

Currently, academic neurology departments face two imposing problems. First, cuts to the federal budget have constricted the flow of research dollars so drastically that 90 percent of proposals now fail to receive any support.

“So many quality projects are not getting funded,” said Christopher M. Gomez, MD, PhD, Albina Y. Surbis Professor and Chair of the department of neurology at the University of Chicago Medical Center. “Clinical and basic research are labor-intensive and very costly, and the more we know the more we know what we don't know. But on top of that there are now all these well-intentioned efforts at accountability and regulation to make sure what we pay for has value.”

Second, neurologists in academic settings face the same inadequate reimbursement that affects other physicians, but the problem is compounded for them because their clinical work competes with other obligations.

“It's extremely difficult — if not impossible — for academic neurologists to earn a salary based on seeing patients because they have all these other responsibilities — clinical service, teaching and training, directing research projects, participating on various committees and boards,” said William J. Weiner, MD, professor and chairman of the department of neurology at the University of Maryland School of Medicine and director of the Maryland Parkinson's Disease and Movement Disorders Center.

But faculty members and their hospital may be able to work out a mutually beneficial arrangement, added Dr. Weiner, a member of the Neurology Today editorial advisory board.

“The hospitals benefit from the expertise of neurologists, and neurology departments benefit because they get support for neurologists' salaries,” he said. “People have to think how we can team up with our hospitals to come up with something beneficial for patients, the hospital, and the neurology department.”

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Clifford B. Saper, MD, PhD, has developed just such an arrangement by having faculty neurologists provide general neurological services to Beth Israel Deaconess Medical Center in Boston, where he is chair of the department of neurology.

“In an area like ours where reimbursements are relatively low but fixed costs relatively high, it's almost impossible for a neurologist to be paid a competitive salary from seeing outpatients alone,” said Dr. Saper, James Jackson Putnam Professor of Neurology and Neuroscience at Harvard Medical School. “If the hospital wants patients to receive prompt neurological care, it must pay the neurologists properly for their time. We designed a subsidy that specifically encourages faculty members to see new patients with general neurology problems, which is always a problem in a medical center where everyone is a subspecialist. Basically I buy up time slots from the faculty, which I or my administrator can assign new patients to, and we buy up enough time slots that a patient who calls can be seen by a neurologist within two or three days. The hospital decided it would be in its best interest to take some of the money it receives for doing MRI scans, surgery, and admissions, and give it to the neurologists in this way. It solves the problem of patient access, and it's also how patients want to be seen.”

Patients may request a particular neurologist, Dr. Saper said, but then they have to wait longer. That hasn't posed a significant obstacle, however.

“Patients don't come in and say, ‘I want to see an expert on muscular disorders,’” he said. “They come in and say, I'm weak, and the neurologist on duty must figure out if it's stroke or MS or cerebellar degeneration, or PD, or myasthenia gravis. If the patient turns out to have MS, the next stop will be the MS clinic, but at least they'll have been seen promptly. They won't have to wait a couple of months (for the initial consult).”

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The changes that will come from the passage of the Patient Protection and Affordable Care Act may be disruptive and very challenging for academic neurology departments, but the ultimate goal of constraining health care costs through efficiency and accountability cannot be faulted, according to Robert G. Holloway, MD, MPH, professor of neurology and community and preventive medicine at the University of Rochester School of Medicine and Dentistry, and an associate editor of Neurology Today.

“We have to find ways to bend the cost curve, and we can participate in that by being prepared,” he said.



In an effort to help neurologists prepare he and Steven P. Ringel, MD, professor and director of the Neuromuscular Division at University of Colorado-Denver in Aurora, and editor-in-chief of Neurology Today, have collaborated on a “roadmap for academic neurology,” to be published in an upcoming issue of the Annals of Neurology.

In it they review some of the strategies specified by the new health care law for constraining the per-capita cost of health care, such as payment for quality performance, careful measurement of outcomes, comparative effectiveness research, value measurements, and bundled payments instead of individual reimbursement.

“It's a call to arms,” Dr. Holloway said of the paper. “We need to have more realistic expectations about what our treatments and tests can actually do for our patients, and we need the courage to confront and study this. We have to be brutally honest with ourselves and identify those high-cost tests and procedures that benefit us more than our patients and their families.”

The existing reimbursement system, which pays less for a physician's time than for doing procedures, is particularly unsuitable for the team approach that will dominate the future of medicine, according to John Mazziotta, MD, PhD, chair of the department of neurology at the David Geffen School of Medicine at the University of California-Los Angeles (UCLA), and director of the UCLA Brain Mapping Center.

“Physicians in cognitive specialties low in procedures don't get compensated very well,” he said. “So if you come and see me because you have a headache, and you say something that suggests the headache might be something more ominous, I can't explore that in a 7-minute office visit, so I'm going to send you for a scan. Instead of getting an extra $75 or $100 for a longer visit I send you for a $2,500 scan. What was saved by not compensating the physician for spending more time with a patient is lost on a test. Spending 25 minutes with a patient ultimately is cost-effective. It's a better value for the patient, and it will save the system money.”

“Academic medical centers, home for specialists of every type, are well-suited to a team approach, but only if they become big enough to demand a different form of reimbursement,” Dr. Mazziotta said.

“Now you get paid when people are sick,” he said. “There's no incentive to keep people well, and that has to change. One way would be for academic medical centers to become very large HMOs that take care of millions of patients. By taking care of so many people, with only a small number getting sick at any one time, your incentive is to keep people well. Families would subscribe and produce an annual revenue stream, and you would take on risk in exchange. If they get sick, you pay for their care. That way you'd have a cash flow other than reimbursement. Instead of responding to the economic environment, you could drive the economic environment.”



Bundled payments instead of individual reimbursements seems like an inevitable trend in the new health care environment to Ralph L. Sacco, MD, chairman of neurology at the Miller School of Medicine at the University of Miami.

“The menu-driven approach to reimbursement will change,” he said. “There will be more bundled payments going to systems of physicians collaborating to improve the quality of care for groups of patients. We also need to blend research with education and clinical work. For example, we need to motivate patients to become involved in clinical research and clinical trials. We can create disease-specific registries for collecting genetic information on patients that may be helpful to address future research questions. We already have that started at the University of Miami for stroke, movement disorders, Alzheimer's, and sleep disorder patients.”

In their forthcoming paper in the Annals of Neurology, Drs. Holloway and Ringel lay out changes that will affect physicians, but their focus, they say, is the improvement of health care in general.

“If we begin each discussion by considering how to preserve our salaries, our collective efforts to rethink health care delivery will fall short,” said Dr. Holloway. “We need to become courageous innovators who seek quality and value as we pursue new ways of organizing, delivering financing and evaluating the impact of neurological care. Simply put, the status quo cannot continue.”

©2011 American Academy of Neurology