ARTICLE IN BRIEF
An analysis funded by the AAN found that while care for chronic conditions by neurologists costs more than care by other physicians, outcomes tend to be better.
Care by a neurologist for chronic conditions may cost more up front, but it can help reduce emergency department visits, hospitalizations, and medical problems such as infections and fractures, according to an analysis of a large insurance claims database published in the December 23 online edition of Neurology.
The study also found that patients seen by neurologists for chronic neurologic diseases such as multiple sclerosis (MS), Parkinson's disease (PD), or epilepsy are more likely to get disease-modifying treatments than patients who don't see neurologists.
The new study, funded by the AAN, comes amid growing pressure on physicians and other health care providers to demonstrate that their services provide value from both a monetary and outcomes standpoint.
“When we [neurologists] are involved with care, the costs of that care are a little bit more, but at the same time the outcomes are substantially better and the quality of care is better,” said John P. Ney, MD, MPH, the study's lead author and staff neurologist at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA.
The study is part of an ongoing AAN effort to quantify the value of neurologist care. “Aggregation of health care information in large administrative claims databases presents an opportunity to assess the effect of specialist physicians on downstream usage of health resources related to the disease they treat,” the researchers wrote. “Payers, from the US Government to [third-party] private insurers and employers, are looking to this kind of big data analysis to inform coverage decisions, regulatory actions, and policymaking decisions.”
The study used a proprietary claims dataset maintained by Optum, Inc., a health care consulting firm, which contains payment information for people covered by commercial insurance, as well as by Medicare and Medicare supplemental insurance.
The dataset uses software to determine “episodes of care” for persons with specific conditions. The researchers focused on claims for the years 2010 to 2012 for 10 neurologic disorders: Alzheimer's disease, amyotrophic lateral sclerosis, autism, developmental delay, stroke (as defined by a stroke hospitalization), dementia, epilepsy, migraine headache, MS, and PD.
In the first phase of their study, the researchers analyzed insurance payments related to office-based or outpatient face-to-face encounters and calculated total cost of care and whether it was provided by a neurologist or non-neurologist; the differences were not adjusted for demographics or disease severity. The costs included claims for doctor's visits, pharmaceuticals, and testing.
Among other findings on direct health care costs, the researchers reported:
- Total allowed payments over a given calendar year were higher for all 10 neurologic conditions when a neurologist provided care compared to when a neurologist was not involved.
- Payments were twice as high when neurologists provided care for MS patients ($13,428 versus $6,704 for non-neurologists) and about 25 percent higher in the case of Alzheimer's ($2,486 versus $1,995) or acute stroke ($20,578 versus $16,455).
- Payments were about 40 percent higher with neurologist involvement in migraine ($834 versus $502) or epilepsy ($1,854 versus $1,098).
BETTER LONG-TERM OUTCOMES
The results may have looked like an argument against neurology if the investigators had only analyzed attributable direct health care expenditures for neurologic conditions, said Dr. Ney. But a different story emerged when the researchers considered factors such as adverse events, hospitalizations, and emergency department visits.
“Neurologist ambulatory care is associated with decreased adverse events and usage of acute and post-acute health care resources,” they concluded. In addition, all-cause hospitalizations were less common for patients seen by a neurologist, which “suggests neurologist visits may have beneficial effects even outside of the treated neurological disorder.”
When neurologists were involved in care, for example, MS patients had fewer urinary tract infections and decubitis ulcers; MS and PD patients experienced fewer pneumonias and less major depression; and PD patients used less home health agency care.The researchers did not attach dollar amounts to the differences in utilization of acute and post-acute care, but they plan to do so in future research, Dr. Ney said.
The study also focused on the use of disease-specific treatments and screenings. For most of the conditions, neurologists seemed to improve care through the use of therapies considered to be optimal treatments. For example, MS patients were more likely to be given immunotherapy; stroke patients with atrial fibrillation were more likely to be given anticoagulants; epilepsy patients were more likely to get deep brain stimulation; and those with Parkinson's were more likely to get dopaminergic therapies.
Having a neurologist involved made no obvious difference in some cases. For instance, “yearly ophthalmologic screening and liver function and blood count testing in MS (if using immune therapies), physical and occupational therapy for PD, and medication compliance rates in epilepsy and MS were not substantially different or slightly worse in the group with identified neurologist care,” the study found.
The researchers said it was not surprising that costs were higher with neurologist care, noting that the goal of health care is “not to provide care at zero or net negative expenditure, but rather to improve health and quality of life at acceptable costs.”
The study did have limitations. The authors noted that it could not adequately adjust for differences in the severity of patients' conditions, and absent information on all acute care expenditures (including those outside the episode treatment groups), it was impossible to say how much money may have been saved. Also, while it makes sense that seeing a neurologist and using disease-specific therapies would lead to higher quality of care and better outcomes, the study was not designed to prove that hypothesis.
In an editorial accompanying the study in the same edition of Neurology, Lyell K. Jones Jr., MD, FAAN, an associate professor of neurology at the Mayo Clinic in Rochester, MN, and Marc R. Nuwer, MD, PhD, FAAN, a professor of neurology at the University of California, Los Angeles David Geffen School of Medicine, wrote that the researchers had “taken an important early step in quantitative measurement of the value our specialty provides at a population level.
“Studies such as these can be used to encourage policymakers to design appropriate incentives to preserve access to neurologic care,” they said.
Robert Kropp, MD, FAAN, who serves on the AAN's Medical Economics Committee, told Neurology Today that it has been hard for some specialty groups, including neurologists, to quantify an answer to the question, “Are we really making a difference?”
“I think the study answers that question in the affirmative,” said Dr. Kropp, a former practicing child neurologist who is vice president for clinical transformation, accountable care solutions for Aetna.
Gregory J. Esper, MD, FAAN, vice chair of the AAN Medical Economics Management Committee, said the study provides a “good foundation” for the Academy's goal to better objectively define the value of neurologist care.
“Value has three components: quality, patient satisfaction, and cost,” said Dr. Esper, an associate professor of neurology and vice chair for clinical affairs at Emory University. “This study shows that neurologists create value when they are involved in patient care, which is proven by the higher quality of care [they provide], a lower number of adverse events, and a reduction in the use of expensive hospital resources such as emergency departments and readmissions.”
He said that while neurologists no doubt want to be better reimbursed for their services, patients also deserve access to the very best care.
Elaine C. Jones, MD, FAAN, a neurologist with a solo practice in Bristol, RI, and chair of the AAN Payment Policy Subcommittee, said that while it would have been nice if the study had proved that money was saved with neurologist care, the findings reflect the reality that “when you do the best thing for the patient, it can cost more up front.”
Dr. Jones said she believes that “neurology has been kind of forgotten” in the stiff competition for health care dollars. The AAN and neurologists themselves [are recognizing a] need to better make the case that “neurologists bring value to the table.” If a patient's disease is well managed and complications are avoided, “we are saving on hospital costs and nursing home costs,” she said.
Dr. Kropp said the findings could be useful not only at a policy level, for advocating for improved reimbursement for neurologists, but could also be helpful for neurologists wanting to prove the added value they could bring to a “clinically integrated network” of physicians.
The findings should also be personally reassuring to neurologists, Dr. Kropp said. “It used to be we treated one patient at a time and each encounter provided a limited view of how I was doing overall. Now that we are in the realm of population health, physicians can see that when they treat groups of similar patients in a certain way, that is beneficial.”
EXPERTS: ON COSTS AND OUTCOMES WITH NEUROLOGIST CARE