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Where Neurologists Are, What Services Are Used, Where More Care Is Needed

Article In Brief

There is an uneven distribution of neurologists across the US, although the prevalence of neurologic conditions is relatively similar in different areas of the country. Telemedicine and more cross-collaboration among physician specialties could help address some of the deficits in access to care, experts said.

The distribution of neurologists across the US is very uneven, even though the prevalence of neurologic conditions is fairly similar in different parts of the country, according to a study that was published online on December 23 in Neurology.

The study looked at geographic differences in supply and demand for neurologic services across the US. Among its findings, there was a nearly fourfold difference between the regions with the lowest and highest density of neurologists; metropolitan areas had a greater supply of neurologists than rural communities.

The study, based on 2015 Medicare data, found that patients, regardless of where they lived, were likely to see a neurologist for complex conditions such as Parkinson's disease (PD) and multiple sclerosis (MS). That trend did not hold true for other neurologic conditions, such as headache or dementia.

“The neurologic conditions don't seem to change across the United States, but whether someone with a neurologic problem sees a neurologist does differ in different parts of the country,” said study coauthor Brian Callaghan, MD, MS, FAAN, associate professor of neurology at the University of Michigan.

The demand for neurologic care is expected to increase even more as the population ages, he noted, while a significant shortage of neurologists to meet the need has been predicted. The growing list of therapies for neurologic conditions such as MS and epilepsy will also heighten the need for expertise that may go beyond the scope of many primary care practitioners.

While the issue of uneven distribution of physicians, including neurologists, is not new, the authors said they hoped the additional data in their study “provide insight for policymakers when considering strategies in matching the demand for neurologic care with the appropriate supply.”

The COVID-19 pandemic has revealed one possible solution—a wider use of telemedicine, Dr. Callaghan said. The growing use of advanced practice providers in neurology, including nurse practitioners and physician assistants, also is starting to help improve access to neurologic care, he added.

The new study, which was proposed and funded by the AAN Health Services Research Subcommittee, noted that neurologists comprise about 2 percent of physicians in the US, a percentage that has held steady for the past decade.

“Geographic variability in neurologist supply may influence whether or not a neurologist is involved in the care of a patient with a neurologic disorder or symptom,” the paper said. “Variability in neurologists and whether this variability is associated with involvement in care has not been evaluated in detail.”

Study Design

To explore the issue, the researchers used a random 20 percent national sample of the 2015 fee-for-service Medicare carrier file. The file contains data on medical services (diagnosis codes and procedures) as well as information on the provider, including specialty and practice location.

The researchers also obtained patient demographic information, including age and sex, and place of residence from the Medicare beneficiary summary file. The analysis included 2.1 million adult Medicare-insured patients with at least one office-based evaluation/management (E/M) visit with a primary diagnosis of a neurologic condition in 2015.

The analysis divided the country into 306 areas known as “Hospital Referral Regions” (HRRs) to examine geographic variations by lowest neurologist density quintile to highest density quintile.

The study identified 13,627 neurologists, who provided care to Medicare beneficiaries during the study period. Neurology density by HRR ranged from 9.7 per 100,000 Medicare beneficiaries in the lowest neurologist density quintile to 43.1 per 100,000 beneficiaries in the highest density quintile. The mean number of E/M visits per neurologist was 512, with a range of 668 (lowest density quintile) to 335 (high-density quintile). Neurologists in the high-density areas, which tend to be near urban areas and academic medical centers, may have teaching or research duties in addition to their clinical practices, the study noted.

Nearly one-third of patients who were Medicare beneficiaries had at least one visit for a neurologic condition—a number that was fairly consistent across the country. The most common conditions were back pain, sleep disorders, and peripheral neuropathy. The least common were MS, other central nervous system disorders (often mild cognitive impairment), and Parkinson's disease (PD).

On average, 23.5 percent of patients with a neurologic condition had at least one E/M visit to a neurologist. The proportion of patients seen by a neurologist gradually increased across all quintiles, from 20.6 percent in the lowest neurologist density quintile to 27 percent in the regions with the highest density of neurologists.

Overall, more than 80 percent of patients with complex conditions such as MS and PD saw a neurologist, with not much difference in that pattern of care from the regions with the lowest density of neurologists compared to the highest density.

In contrast, the proportion of Medicare patients getting care from a neurologist for neurologic conditions such as stroke, headache, epilepsy, and peripheral neuropathy was fairly modest, to begin with, but rose incrementally as the density of neurologists increased. For instance, in low-density areas, 25.8 percent of patients with a stroke diagnosis saw a neurologist compared with 31.2 percent of patients in high-density areas. For headache, the proportion went from 32.6 percent to 35.7 percent as neurologist density increased.

The study did not address whether patients who saw a neurologist had more favorable outcomes than those who saw a primary care doctor or another non-neurologist, a question that Dr. Callaghan said needs to be addressed in future research.

“Neurologists [at current levels] will never be able to take care of all the neurologic care that is needed in this country,” Dr. Callaghan said, though he and other experts said there could be better access to neurology expertise through enhanced partnering with primary care physicians and use of technology that brings expertise to patients in remote areas.

Expert Commentary

“I do think the new tool that has helped us bridge the gap is telemedicine,” said W. David Freeman, MD, FAAN, professor of neurology and co-director of stroke at the Mayo Clinic in Jacksonville, who was not involved with the study. He said the Mayo Clinic has 30 telestroke sites across the country.

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“I think we have to introduce neurology early in the pipeline. We have to work with institutions to develop ways to provide exposure to students.”—DR. MIA T. MINEN

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“The neurologic side effects of COVID is one example of why access to neurologists is critical.”—DR. ALLISON BRASHEAR

While the value of telestroke services is well accepted, he pointed out that it's less clear if enthusiasm (and insurance reimbursement) for telemedicine for other neurologic conditions will remain as strong once the pandemic ends.

Dr. Freeman said electronic medical records are also allowing for better communication between neurologists and primary care providers that patients may see on a more regular basis. The growing role of nurse practitioners and physician assistants trained in neurologic care is also helping expand neurologist's reach, he added.

While there are some neurologic conditions that can be managed well by primary care providers, Dr. Freeman said, others “need to be outsourced and sent to a neurologist.”

“Stroke is definitely one. I think MS is another because, in the last 10 years, there are so many different drugs to offer patients. Those drugs have side effects and need careful monitoring,” Dr. Freeman said.

The study does not address whether there should be more residency training slots for neurologists as a means to increase patient access. It also does not make specific suggestions on what new programs or incentives might encourage doctors to set up practice in rural and small-town communities that may be underserved.

Allison Brashear, MD, MBA, FAAN, a neurologist and dean of University of California, Davis School of Medicine, said: “As our population ages, it is really incumbent upon the country to train more neurologists and to make sure those neurologists are found throughout the country.”

“We want to attract individuals in medicine who have a strong commitment to their community” to practice, Dr. Brashear said. She noted that Northern California, for instance, is one region that could benefit from having more neurologists.

“We want to attract individuals who want to go back to their community” to practice medicine,” Dr. Brashear said, adding, Northern California, for instance, is one region that could benefit from having more neurologists.

While the number of residency training positions is tied to Medicare funding, Dr. Brashear said UC Davis now funds an added slot in neurology to help address unmet needs for neurology expertise.

“The neurologic side effects of COVID-19 is one example of why access to neurologists is critical,” she said.

John P. Ney, MD, MPH, FAAN, medical director of specialty and acute care at the VA Medical Center in Bedford, MA, and assistant professor of neurology at Boston University, said that while the new study on neurologist distribution is well-done and descriptive, it was not designed to assess whether patients who saw a neurologist had better outcomes than those who didn't.

Dr. Ney said previous research has established that “not all patients with a neurologic condition will see a neurologist on an annual basis.” For example, about 10 to 15 percent of people with dementia see a neurologist annually, usually to establish the diagnosis.

“The question is whether getting a neurologist involved would make a difference in cost or outcomes,” he said. The same could also be asked about low back pain. “It's not clear what a neurologist would offer versus a pain specialist versus a primary care doctor.”

In conditions such as MS and epilepsy, where there are many drugs to choose from and then manage, the advantage of seeing a neurologist is very evident, he said.

Dr. Ney said more outcomes-focused research is needed to document the value provided by neurologists. “We do provide value in terms of quality of life, but a lot of that goes unmeasured in administrative claims data,” he said.

Mia T. Minen, MD, FAAN, associate professor of neurology and population health and chief of headache research at NYU Langone Health, said headache care is an example of neurologic care that can often be managed by primary-care providers.

“The vast majority of headache patients don't need to be followed by a headache specialist,” Dr. Minen said. The American Headache Society's “First Contact” program, for example—for which she serves on the advisory board—is an educational resource for family physicians, internists, and others on how to diagnose and treat migraine and other headache conditions. She said complicated cases that aren't resolved can be referred to a neurologist.

Dr. Minen said that as the field of neurology looks to the future, it needs to build a better pipeline that will help increase the strength of the neurology workforce. In an article published online on December 8 in Neurology, Dr. Minen and coauthors said there should be increased opportunities at the undergraduate level for neurology research and clinical care.

While the number of neuroscience programs has grown around the country, the focus tends to be on basic science rather than patient-oriented topics, she noted.

She encourages neurologists doing research to take on undergraduate students. “I think we have to introduce neurology early in the pipeline,” Dr. Minen said. “We have to work with institutions to develop ways to provide exposure to students.”

Disclosures

Dr. Callaghan receives support from DynaMed and from medical-legal consultation, including the Vaccine Injury Compensation Program. Drs. Freeman and Brashear had no relevant disclosures.

Link Up for More Information

• Chieh Lin C, Callaghan BC, Burke JF, et al. Geographic variation in neurologist density and neurologic care in the United States https://n.neurology.org/content/early/2020/12/23/WNL.0000000000011276. Neurology 2020; Epub Dec 23.
    • Minen MT, Szperka CL, Cartwright MS, Well RE. Building the neurology pipeline with undergraduate students in research and clinical practice https://n.neurology.org/content/early/2020/12/08/WNL.0000000000011351. Neurology 2020; Epub 2020 Dec 8.