Health care reimbursement is moving from volume-based fee-for-service to value-based systems. Value is defined as (quality + patient experience) divided by cost. This shift from volume to value is the central innovation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Both pathways of MACRA’s Medicare Quality Payment Program (QPP), the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs), preferentially reward high quality, low cost care.
Telehealth, which provides a means for long-distance clinical care, holds immense promise as a patient-centered care delivery model. This model has the potential to improve access to care in resource-limited settings (e.g., rural areas with few specialty providers) and for patients with limited mobility, transportation barriers, lack of caregivers and low funds. It may also improve the efficiency of a healthcare encounter by improving the timeliness and flexibility of visits. However, there are still several barriers to its widespread implementation. Beck and colleagues, through a randomized-controlled trial, test the feasibility and efficacy of adjunct telehealth visits with a movement disorders specialist compared to standard of care (as planned neurology visits) among participants with Parkinson’s disease to address one of these barriers. Namely, how does telehealth compare to what we currently do?
A challenge for the primary care medical home model (PCMH) is incorporating care from specialties. In this study, Elrashidi et al explored the impact of integrating a neurologist into the Mayo Clinic PCMH by comparing aspects of care delivered by the integrated neurologist with matched visits from the pre-integration time period. The integrated neurologist worked 0.6 FTE, had a staff of 3 FTE registered nurses, 3 clinical assistants, and a specified work plan — 3-4 scheduled patients per half day, in addition to curbsides, e-consults, follow-up, and additional acute same-day consults. Over a 12-month period of patient follow-up, patients seen by the integrated neurologist had fewer subsequent neurologist visits (0.62, p=0.001), EMGs (OR 0.64, p=0.009), and brain MRIs (0.60, p<0.001), but not total subsequent outpatient visits (0.92, p=0.21), ED visits (0.83, p=0.20), or hospitalizations (0.96, p=0.83) compared with the pre-integration visits. The integrated neurologist also did not lower the time to neurologist appointment (p=0.83), despite presumably reducing referrals because of curbsides and e-consults.
Health equity, as defined by The Robert Wood Johnson Foundation, means that “everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” The first step to obtaining equity in neurologic care is identifying health disparities, work that was recently undertaken by Altaf et al. This group of researchers analyzed the national state of equity in neurologic care using data from the 2006–2013 Medical Expenditure Panel Survey (MEPS), a nationally representative household survey, which queries medical conditions as well as medical expenditures, including outpatient and inpatient visits. After adjustment for socio-demographics, insurance status, health status, and self-reported neurologic diagnosis, the researchers found that black participants were nearly 30% less likely to see an outpatient neurologist and Hispanic participants were 40% less likely to see an outpatient neurologist compared to white participants.
Waldfogel et al performed a systematic review of pharmacotherapy for diabetic peripheral neuropathy pain. Similar to four previous systematic reviews, they conclude that serotonin reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and pregabalin are effective medications for this highly prevalent condition. In contrast to previous studies, they conclude that gabapentin is not effective while oxcarbazepine is effective.
Psychosis is a common problem in advancing Parkinson disease (PD). There are significant limitations of standard approaches of adjusting dopamine replacement therapies and using unconventional anti-psychotic agents such as clozapine and quetiapine. Pimavanserin is a promising addition to our therapeutic arsenal. Hawkins and Berman thoughtfully emphasize our relatively limited knowledge of pimavanserin clinical pharmacology. It was approved on the basis on 1 trial in a selected group of PD participants. Additional trials, particularly in PD dementia and Lewy body dementia subjects, and good post-marketing surveillance are needed to fully understand the utility of this agent.
In Introducing the Axon Registry, Sigsbee et al outline the rationale, structure, function, and challenges related to the AAN’s development of its own clinical quality data registry: the Axon Registry. Dr. Lyell K. Jones, co-author, answers some questions we had after reading the report.
In Feasibility of the Collection of Patient-Reported Outcomes in an Ambulatory Neurology Clinic, Moura et al describe the collection of patient reported outcome measures (PROMS) including the modified Rankin Scale (mRS), quality of life in epilepsy (QOLIE), and the PROMIS-10 physical and mental health scores. PROMIS is an NIH-sponsored initiative to promote the use of methods and measures for collecting outcomes. Moura et al collected the information directly from patients using iPads in the waiting room of a large, academic neurology clinic, and almost half of the more than 6000 patients participated. The authors take the ‘glass-half-full’ interpretation that the 49% participation rate indicates that data collection is feasible. However, the ‘glass-half-empty’ interpretation should also be considered because 51% of the subjects either declined or could not participate. The study also demonstrates that patients with English as their preferred language, who were married, privately insured, and attended general neurology clinic were more likely to participate. The authors correctly point out the potential for vulnerable populations to be left out if measures to increase their participation are not used. However, the biggest question remains: what data should be collected in ambulatory neurology clinics? Just because we can collect this data does not mean that we should. The resources needed to start collecting this type of data and the effort from physicians to review and interpret them is not trivial. Small and single neurology practices will find this effort even more daunting. Prior to engaging in efforts to collect large amounts of data from our neurology patients, we must have confidence that the information will not lead us astray and that there is utility of this information. Are we collecting this data for clinical or research reasons? Does the data positively impact patient care? Unfortunately, there is much to learn, but Moura et al have provided an essential first step.
In the article, Reducing costs while enhancing quality of care in MS, Kister and Corboy urge neurologists to do their part to improve the affordability of MS medications. The unaffordability of MS medications is driven by the outrageous prices that are in no way tied to the benefits these medications provide.
Healthcare innovations are frequently in the news and factors influencing care delivery are evolving at a fast pace. Most of what you hear though is not specific to neurology. The Innovations in Care Delivery section aims to fill this void. The initiation of this section by Bob Gross and Ray Dorsey demonstrates the commitment of the journal Neurology to publishing rigorous health services research aiming to describe, develop, test, implement, or evaluate the impact of the many organizational, behavioral, social, financial, and technological factors that influence neurologic care delivery, health, and well-being. Your submissions on these topics will be of strong interest here. This section also curates relevant articles, and utilizes blogs, podcasts, and interviews, to extend information and discussions on these important topics. The Innovations in Care Delivery section will also be a resource for collaboration and training. Soon, this site will maintain a list of data sources and persons experienced in using these. Available large databases create substantial opportunities for hypothesis generating research, and new discoveries about trends and the impact of healthcare delivery changes. Finally, we will work closely with the policy and practice sections of the American Academy of Neurology to keep you up-to-date on the most important issues regarding neurologic care delivery.