Opinion
VIEWPOINT
Joseph B. Martin, MD, PhD Department of Neurobiology, Harvard Medical School, Boston, Massachusetts. Hamilton Moses III, MD The Alerion Institute and Alerion Advisors, LLC, North Garden, Virginia; and Johns Hopkins University School of Medicine, Baltimore, Maryland.
Corresponding Author: Joseph B. Martin, MD, PhD, Department of Neurobiology, Harvard Medical School, 220 Longwood Ave, Goldenson Bldg, Room 542, Boston, MA 02115 (joseph_martin@hms .harvard.edu). jamaneurology.com
Planning the Future of Neurology Crisis or Opportunity Perennially, senior observers discuss the forces affecting neurology and their impact (real or imagined) on science, clinical practice, training, economics, and the people required to deliver the best care.1-3 The thrust of these commentaries is that although neurology reflects the general pressures facing US academic medical institutions (and the tensions within them), our specialty must confront fundamental questions about our value and sustainability. Indeed, neurology is a microcosm of all current uncertainties in medicine. Today, academic neurology has before it several choices, each having very different implications for its future. What are the fundamental issues that we must consider? First, health care delivery in the United States is undergoing the most radical changes since the introduction of Medicare 50 years ago. There is unprecedented attention to population health, prevention, global budgets for care, rewards for measured quality, expanded access, and affordability. These changes are due to legislation, consolidation of hospitals and medical groups, the blending of care provision with insurance, and newly empowered patients as consumers. The fragmentation of care within the United States is seen as a major source of our unfavorable morbidity and mortality rates when compared with other developed countries, with care regarding neurology, human immunodeficiency virus/AIDS, and cancer being notable exceptions. These forces imply fewer choices for patients and physicians alike, and that (paradoxically) care may be not as available or be of the quality patients have come to expect, even as insurance coverage is expanded. The result is a tension between these emerging forces. Reconciling them is the chief challenge of the current era.4 Second, despite remarkable advances in neuroscience and in defining biological mechanisms, there have been few new treatments, particularly for the growing burden of chronic diseases associated with aging. Consequently, large pharmaceutical companies have reduced investment in psychiatric and neurologic disorders owing to the failures of clinical trials of drugs that looked promising in early development. Small pharmaceutical companies have not filled that vacuum.5,6 Third, institutions are isolating research from patient care, using separate budgets, locations, and staff in order to permit each to focus more effectively on 1 mission. Examples include the Broad Institute, the Allen Center, and similar institutes at Johns Hopkins University, the University of Michigan, and Cornell University. In parallel, clinical service lines, which de-emphasize traditional departments, encompass neurologic, neurosur-
gical, imaging, and critical care. Whether these changes will accomplish their intended aims will not be known for a decade or more. Fourth, chronic conditions (all causes) produce 84% of total US costs. Neurological and psychiatric diseases account for 25% of total costs, with both growing rapidly at 12% per year.4 In an era of measurable outcomes, particularly those that emphasize mortality while neglecting disability, neurology’s incremental costs will not necessarily be perceived by health care systems or insurers as commensurate with its added value. While a role will continue for uncommon diseases (particularly neuromuscular diseases, multiple sclerosis, and rare degenerative diseases), it is likely that other clinicians will provide care for most patients with stroke, dementia, or even epilepsy. Parkinson disease is emblematic, in that less than half of patients see a neurologist during their lifetime, even though superior outcomes and lower total cost result from these consultations.7 Fifth, all of these factors affect training because they will determine how many and what kind of neurologists are needed, and they will dictate their necessary grounding in basic neuroscience, health services research, and other clinical specialties. Calls to separate payment for residencies from clinical fees, and research training from grants, and to emphasize primary care will be especially challenging for neurology. Finally, as compared with cancer, cardiovascular disease, and genetics (for which about half of the known heritable diseases affect the nervous system), neurology rarely speaks with 1 voice in the corridors of power. It is striking that cardiologists and cardiac surgeons or medical and surgical oncologists jointly chart the future of their fields, working with the National Institutes of Health, industry, Medicare, and insurers, yet neurology is eclipsed in such discussions by critical care, radiology, psychiatry, and geriatrics in diseases squarely within our domain.
The Choices Different models for academic neurology can be envisioned. Each has implications for the physician’s role, organization, economics, and training. In the context of the present considerations, we consider primarily the academic department or institute and the mission to advance our field. Option 1: The Neurological Consultant
Clinical neurologists could emphasize high-value, shortduration, intermittent relationships with patients, as is practiced in Canada and Europe or in some US academic neurology departments. Diagnosis, manage-
(Reprinted) JAMA Neurology February 2015 Volume 72, Number 2
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 05/31/2015
141
Opinion Viewpoint
ment of rare diseases, and uncommon manifestations of common conditions would be emphasized. Value would be judged by the patients’ perceived benefits and the degree to which management is changed. Insurers should expect to pay a premium for those services, given that neurology’s role would be limited. Under this scenario, an important responsibility for the neurologist lies in interpreting clinical implications of emerging neuroscience for a particular patient or family, which is often problematic for other physicians. Continuing care would be provided only for a limited number of diseases, which are primarily neurological and having relatively few effects on other organ systems, such as amyotrophic lateral sclerosis, multiple sclerosis, and epilepsy. Medical genetics, another field in which scientific discoveries are occurring rapidly but that other fields view as arcane, is evolving in this direction. Option 2: Comprehensive Care
The neurologist would assume primary responsibility for all conditions affecting the nervous system, both common and uncommon. This model requires strong grounding in general medicine, pediatrics, and psychiatry and expanded responsibility in rehabilitation, palliative and end-of-life care, and behavior. This model lends itself to patients with dementia, stroke, or Parkinson disease and to patients with a primary neurological condition that eclipses others, such as head trauma, mental retardation, or autism. Value would be judged by measures now being applied to populations, using aggregate cost, access, quality, and safety. This role is analogous to that of the AIDS specialist or medical oncologist, as they have evolved over the past 2 decades. ARTICLE INFORMATION
academic neurology: report of the Long Range Planning Committee of the American Neurological Association. Ann Neurol. 1996;39(6):693-699.
Published Online: December 1, 2014. doi:10.1001/jamaneurol.2014.3448. Conflict of Interest Disclosures: None reported. REFERENCES 1. Martin JB. Whither neurology? N Engl J Med. 1984;311(16):1048-1050. 2. Griffin JW, Griggs RC, Barchi R, Schneck SA, Moses H III. Opportunities and challenges in
142
Is a choice among the options necessary? The organizational implications and financial investments required of each of these functions are considerable. Organizing for a consultant’s role is very different than organizing for chronic care, making a choice unavoidable. Moreover, little guidance can be obtained from Medicare or private insurers because they (thus far) have not articulated their preferences for neurologists’ responsibilities, having concentrated on mental health, addiction, cardiovascular disease, musculoskeletal disease, and cancer, despite the high rate of cost growth of neurological conditions. Therefore, neurology has an opportunity to influence the integrated health care system as it adapts to an aging populace, as it develops a growing awareness of the burden of neurological disease, and as it assumes financial responsibility for large groups of patients. The challenge for neurology is to rise to this opportunity. Whichever option a particular neurologist, clinical group, or academic department chooses, it must articulate a renewed intention to care for those with neurological illness and their families. This commitment implies several things. First, we must be accessible and deliver demonstrable value. Second, we must be scientifically rigorous and not overpromise, either clinically or in the laboratory. Third, we must rethink our training in general medicine or pediatrics, psychiatry, rehabilitation, and palliative care. Fourth, we must realize that the long-term health of neurology requires us to define new roles within the maelstrom of changes in medicine. Finally, it is readily apparent that these driving forces and choices will affect in major ways the type and numbers of neurological trainees we prepare for the neurological workforce. 5. Moses H III, Martin JB. Biomedical research and health advances. N Engl J Med. 2011;364(6):567-571.
3. Pedley TA. Neurology at a crossroads: opportunities and challenges. JAMA. 2014;311(16): 1611-1612.
6. Moses H, Matheson DHM, Cairns-Smith S, Palisch C, George BP, Dorsey ER. The anatomy of medical research: US and international comparisons. JAMA. In press.
4. Moses H III, Matheson DHM, Dorsey ER, George BP, Sadoff D, Yoshimura S. The anatomy of health care in the United States. JAMA. 2013;310(18): 1947-1963.
7. Dorsey ER, George BP, Leff B, Willis AW. The coming crisis: obtaining care for the growing burden of neurodegenerative conditions. Neurology. 2013;80(21):1989-1996.
JAMA Neurology February 2015 Volume 72, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 05/31/2015
jamaneurology.com
VIEWPOINT
Joseph B. Martin, MD, PhD Department of Neurobiology, Harvard Medical School, Boston, Massachusetts. Hamilton Moses III, MD The Alerion Institute and Alerion Advisors, LLC, North Garden, Virginia; and Johns Hopkins University School of Medicine, Baltimore, Maryland.
Corresponding Author: Joseph B. Martin, MD, PhD, Department of Neurobiology, Harvard Medical School, 220 Longwood Ave, Goldenson Bldg, Room 542, Boston, MA 02115 (joseph_martin@hms .harvard.edu). jamaneurology.com
Planning the Future of Neurology Crisis or Opportunity Perennially, senior observers discuss the forces affecting neurology and their impact (real or imagined) on science, clinical practice, training, economics, and the people required to deliver the best care.1-3 The thrust of these commentaries is that although neurology reflects the general pressures facing US academic medical institutions (and the tensions within them), our specialty must confront fundamental questions about our value and sustainability. Indeed, neurology is a microcosm of all current uncertainties in medicine. Today, academic neurology has before it several choices, each having very different implications for its future. What are the fundamental issues that we must consider? First, health care delivery in the United States is undergoing the most radical changes since the introduction of Medicare 50 years ago. There is unprecedented attention to population health, prevention, global budgets for care, rewards for measured quality, expanded access, and affordability. These changes are due to legislation, consolidation of hospitals and medical groups, the blending of care provision with insurance, and newly empowered patients as consumers. The fragmentation of care within the United States is seen as a major source of our unfavorable morbidity and mortality rates when compared with other developed countries, with care regarding neurology, human immunodeficiency virus/AIDS, and cancer being notable exceptions. These forces imply fewer choices for patients and physicians alike, and that (paradoxically) care may be not as available or be of the quality patients have come to expect, even as insurance coverage is expanded. The result is a tension between these emerging forces. Reconciling them is the chief challenge of the current era.4 Second, despite remarkable advances in neuroscience and in defining biological mechanisms, there have been few new treatments, particularly for the growing burden of chronic diseases associated with aging. Consequently, large pharmaceutical companies have reduced investment in psychiatric and neurologic disorders owing to the failures of clinical trials of drugs that looked promising in early development. Small pharmaceutical companies have not filled that vacuum.5,6 Third, institutions are isolating research from patient care, using separate budgets, locations, and staff in order to permit each to focus more effectively on 1 mission. Examples include the Broad Institute, the Allen Center, and similar institutes at Johns Hopkins University, the University of Michigan, and Cornell University. In parallel, clinical service lines, which de-emphasize traditional departments, encompass neurologic, neurosur-
gical, imaging, and critical care. Whether these changes will accomplish their intended aims will not be known for a decade or more. Fourth, chronic conditions (all causes) produce 84% of total US costs. Neurological and psychiatric diseases account for 25% of total costs, with both growing rapidly at 12% per year.4 In an era of measurable outcomes, particularly those that emphasize mortality while neglecting disability, neurology’s incremental costs will not necessarily be perceived by health care systems or insurers as commensurate with its added value. While a role will continue for uncommon diseases (particularly neuromuscular diseases, multiple sclerosis, and rare degenerative diseases), it is likely that other clinicians will provide care for most patients with stroke, dementia, or even epilepsy. Parkinson disease is emblematic, in that less than half of patients see a neurologist during their lifetime, even though superior outcomes and lower total cost result from these consultations.7 Fifth, all of these factors affect training because they will determine how many and what kind of neurologists are needed, and they will dictate their necessary grounding in basic neuroscience, health services research, and other clinical specialties. Calls to separate payment for residencies from clinical fees, and research training from grants, and to emphasize primary care will be especially challenging for neurology. Finally, as compared with cancer, cardiovascular disease, and genetics (for which about half of the known heritable diseases affect the nervous system), neurology rarely speaks with 1 voice in the corridors of power. It is striking that cardiologists and cardiac surgeons or medical and surgical oncologists jointly chart the future of their fields, working with the National Institutes of Health, industry, Medicare, and insurers, yet neurology is eclipsed in such discussions by critical care, radiology, psychiatry, and geriatrics in diseases squarely within our domain.
The Choices Different models for academic neurology can be envisioned. Each has implications for the physician’s role, organization, economics, and training. In the context of the present considerations, we consider primarily the academic department or institute and the mission to advance our field. Option 1: The Neurological Consultant
Clinical neurologists could emphasize high-value, shortduration, intermittent relationships with patients, as is practiced in Canada and Europe or in some US academic neurology departments. Diagnosis, manage-
(Reprinted) JAMA Neurology February 2015 Volume 72, Number 2
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 05/31/2015
141
Opinion Viewpoint
ment of rare diseases, and uncommon manifestations of common conditions would be emphasized. Value would be judged by the patients’ perceived benefits and the degree to which management is changed. Insurers should expect to pay a premium for those services, given that neurology’s role would be limited. Under this scenario, an important responsibility for the neurologist lies in interpreting clinical implications of emerging neuroscience for a particular patient or family, which is often problematic for other physicians. Continuing care would be provided only for a limited number of diseases, which are primarily neurological and having relatively few effects on other organ systems, such as amyotrophic lateral sclerosis, multiple sclerosis, and epilepsy. Medical genetics, another field in which scientific discoveries are occurring rapidly but that other fields view as arcane, is evolving in this direction. Option 2: Comprehensive Care
The neurologist would assume primary responsibility for all conditions affecting the nervous system, both common and uncommon. This model requires strong grounding in general medicine, pediatrics, and psychiatry and expanded responsibility in rehabilitation, palliative and end-of-life care, and behavior. This model lends itself to patients with dementia, stroke, or Parkinson disease and to patients with a primary neurological condition that eclipses others, such as head trauma, mental retardation, or autism. Value would be judged by measures now being applied to populations, using aggregate cost, access, quality, and safety. This role is analogous to that of the AIDS specialist or medical oncologist, as they have evolved over the past 2 decades. ARTICLE INFORMATION
academic neurology: report of the Long Range Planning Committee of the American Neurological Association. Ann Neurol. 1996;39(6):693-699.
Published Online: December 1, 2014. doi:10.1001/jamaneurol.2014.3448. Conflict of Interest Disclosures: None reported. REFERENCES 1. Martin JB. Whither neurology? N Engl J Med. 1984;311(16):1048-1050. 2. Griffin JW, Griggs RC, Barchi R, Schneck SA, Moses H III. Opportunities and challenges in
142
Is a choice among the options necessary? The organizational implications and financial investments required of each of these functions are considerable. Organizing for a consultant’s role is very different than organizing for chronic care, making a choice unavoidable. Moreover, little guidance can be obtained from Medicare or private insurers because they (thus far) have not articulated their preferences for neurologists’ responsibilities, having concentrated on mental health, addiction, cardiovascular disease, musculoskeletal disease, and cancer, despite the high rate of cost growth of neurological conditions. Therefore, neurology has an opportunity to influence the integrated health care system as it adapts to an aging populace, as it develops a growing awareness of the burden of neurological disease, and as it assumes financial responsibility for large groups of patients. The challenge for neurology is to rise to this opportunity. Whichever option a particular neurologist, clinical group, or academic department chooses, it must articulate a renewed intention to care for those with neurological illness and their families. This commitment implies several things. First, we must be accessible and deliver demonstrable value. Second, we must be scientifically rigorous and not overpromise, either clinically or in the laboratory. Third, we must rethink our training in general medicine or pediatrics, psychiatry, rehabilitation, and palliative care. Fourth, we must realize that the long-term health of neurology requires us to define new roles within the maelstrom of changes in medicine. Finally, it is readily apparent that these driving forces and choices will affect in major ways the type and numbers of neurological trainees we prepare for the neurological workforce. 5. Moses H III, Martin JB. Biomedical research and health advances. N Engl J Med. 2011;364(6):567-571.
3. Pedley TA. Neurology at a crossroads: opportunities and challenges. JAMA. 2014;311(16): 1611-1612.
6. Moses H, Matheson DHM, Cairns-Smith S, Palisch C, George BP, Dorsey ER. The anatomy of medical research: US and international comparisons. JAMA. In press.
4. Moses H III, Matheson DHM, Dorsey ER, George BP, Sadoff D, Yoshimura S. The anatomy of health care in the United States. JAMA. 2013;310(18): 1947-1963.
7. Dorsey ER, George BP, Leff B, Willis AW. The coming crisis: obtaining care for the growing burden of neurodegenerative conditions. Neurology. 2013;80(21):1989-1996.
JAMA Neurology February 2015 Volume 72, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archneur.jamanetwork.com/ by a University of St. Andrews Library User on 05/31/2015
jamaneurology.com
