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    Kim Blasingame, FACMPE

    Editor’s note: This article was adapted from a Fellow paper submitted toward fulfillment of the requirements for Fellowship in the American College of Medical Practice Executives. Learn more:
    Physician practices and health systems across the nation are experiencing growing competition for neurologists and neurology trained advanced practice providers (nurse practitioners and physician assistants).

    The U.S. government projects a 19% shortage in the neurology workforce by 2025. The model used to make this projection assumed — against evidence — that supply and demand were balanced in 2013. They were not.

    The generally accepted standard of care for wait time to see a neurologist is two weeks. The 2012 national average neurologist reported patient wait time for first appointment was 35 days. In 2016, the average wait time to see a Parkinson’s disease specialist was more than two months, with one-third of centers reporting wait times greater than three months. Online research reveals countless individual reports of appointment wait times of many months for the most common neurologic conditions.

    Factors on both sides of the supply and demand equation contribute to this imbalance.

    One little understood but fundamental cause of supply constraints in the physician workforce is an outdated system of government incentives. This is compounded by changes in neurology workforce demographics and expectations.

    With the birth of Medicare in 1965, the U.S. government became involved in physician supply. Policymakers took a forward-thinking approach to health insurance for the growing population of Americans over 65 who did not have access to private insurance.

    The Medicare program included temporary funding for graduate medical education (GME) to help train physicians to provide care to the newly insured. This GME funding was intended to be temporary, but it increased over the next 30 years, as did the supply of trained physicians. In 1997, amid concern for the financial impact of this program, the number of funded training institutions and positions was essentially frozen at 1996 levels.

    Annually, $15 billion of taxpayer dollars now support GME positions for primary care and specialties nationally, and Medicare remains the largest source of funding.

    Since 1996, there have been unprecedented advances in technology and treatment in the field of neurology. Also during this period, the site of care for most healthcare services continued to change. GME funding and the site of training did not.

    While the site of care for most healthcare services shifted away from teaching hospitals, training dollars did not. The structure of the government GME funding system discourages teaching hospitals from using training sites outside the hospital to better prepare physicians for practicing medicine after training.

    As a result, physicians who will enter the workforce to practice in sites of care outside the hospital are trained in the hospital. They are poorly prepared for a world in which payers demand that physicians keep patients out of the hospital to control costs. This creates a skills gap in the transition from training to practice. The neurology workforce, already restricted by funding policy, is made less productive by the difficult transition from training to practice. Productivity is further affected by changes in the workforce itself.

    Millennial neurologists have different work-life priorities than older neurologists. Consequently, they work fewer hours and see fewer patients, which diminishes their impact.

    The increase in women entering the physician workforce reflects our changing culture, but is another factor reducing supply. Many in this growing population of female physicians continue to be the primary provider of child care and family care, despite their professional position. As a result, they work fewer hours and see fewer patients.  

    The aging and retiring Baby Boomer neurology workforce compounds the shortage. As the supply of Baby Boomer neurologists declines, neurology groups and health systems pay higher compensation to younger neurologists for fewer hours of work. While the work-life balance shifts and compensation for young neurologists increases, the challenges of delivering neurological care increase as well.

    One solution to the neurologist shortage is innovation through the use of advanced practice providers (APPs). APPs, including nurse practitioners and physician assistants, are an integral part of primary care and other specialty teams.

    In neurology, this proven approach is impeded by a lack of training incentives, fee-for-service payer policies, negative attitudes by neurologists toward the team care approach, force of habit in the practice of neurology and delayed adoption by the American Academy of Neurology (AAN).

    Further, recruiters report that APPs with neurology experience are even more difficult to recruit than neurologists. The root causes of the APP shortage, however, are less complex. Of the $15 billion spent each year on GME, none is allocated to GME funding for APPs. The direct consequence is a corresponding lack of formal neurology training programs for APPs. Nationally, there is only one known neurology GME program for APPs. That program has only two positions; not enough to staff that health system’s demand for these clinicians. Here again, the incentive model has not adapted to the changes in healthcare — in this case the increasing need for APPs.

     The AAN only recently began supporting the addition of APPs to the neurology care team. With one known exception, physician training in neurology takes place in teaching programs that do not include APPs.

    Neurologists are not trained to work in teams with APPs, and APPs are not formally trained to work in neurology. Although the U.S. government projects substantial growth in APP presence in neurology by 2025, there will still be a shortage.

    The neurology workforce supply is constrained by many factors including government policy, advances in neurological care, demographic changes, failure to innovate and changing clinician work-life balance expectations are limiting growth in the supply of neurology patient care. But it is the convergence with another force — demand expansion — that is creating the perfect storm.

    Demand expansion in neurology is more straightforward than supply constraints. As the growth of the neurology workforce is constrained, advances in treatment for neurological conditions and longer life expectancy increase the demand for neurology services.

    As life expectancy increases, more people develop neurological conditions. Parkinson’s disease, stroke, Alzheimer’s and other types of dementia are significantly more common in the elderly than in the general population.

    Further increasing demand for neurology, advances in treatment mean clinicians can offer patients more options, which takes more time, both in direct patient care and in clinician education. For example, the demand for sub-specialized neurology services increases with the complexity of treatment options. The greatest concentration of neurologists equipped and trained to deliver these advanced treatments are Millennials. If they work fewer hours and take more time with patients than their predecessors, the workforce shortage is amplified.

    As demand increases, practice leadership teams must consider how to change the way neurology services are delivered. The right solutions will provide the right care at the right time in the right place. Prospective changes relate to primary care, behavioral health, and growing the care team.

    Primary care

    Primary care providers (PCPs) play an important role in the care team of every neurology patient. Effective collaboration with primary care is central to reducing demand on the neurology workforce. Unfortunately, primary care training, patient volume expectations and a myriad of other modern-day practice challenges often leave PCPs without the tools and resources to manage patients with chronic neurological conditions.

    PCPs must develop the skills needed to identify and make the most appropriate referrals to neurology and to resume management of stable neurology patients. Referring too late can make treatment less effective, while referring inappropriately increases cost, delays care and increases patient wait times.

    PCPs may not be sufficiently trained to identify and make the most appropriate neurology referrals. Neurology rotations are limited, and usually elective, in primary care GME programs for medical students and residents. This affects the effectiveness of the neurologist’s role in the care team.

    Primary care GME programs must include neurology as part of a larger plan to focus primary care training from the point of entry into medical school. Programs must offer specific, predictive, demand-based numbers of primary care and specialist medical school positions. Under this plan, programs would remove surgery and obstetrics rotations from the primary care curriculum, replacing them with rotations in the cognitive specialties, including rheumatology, gastroenterology, endocrinology, infectious disease and neurology. This focused program will better prepare PCPs to care for an aging population.

    As important as this change may be, it will take seven years to improve primary care physician training and impact the workforce and then decades to change it.

    In the interim, neurologists and PCPs must collaborate more effectively to facilitate successful return of stable patients from neurology to primary care. Neurologists must provide a long-term patient management plan to the PCP and provide the education and support needed to execute it. PCPs must lobby for payment for the neurologist’s time to provide this support and to participate in quarterly care team meetings to monitor the success of the long-term patient care plan. Compensation for the neurologist’s collaboration with the PCP will result in more robust patient care, as the neurologist’s office would otherwise find it difficult to dedicate its limited resources pro bono.

    Behavioral health

    The most common comorbidities in neurology are in behavioral health, which is outside the scope of practice of a PCP. In particular, depression and anxiety complicate neurological conditions. Addressing these complications improves lives and reduces demand on the neurology workforce.

    The first step is to screen all neurology patients for depression and anxiety. Currently available EHR and patient portal technology can be used to reliably deliver these screenings without increasing workload on clinicians and staff.

    It will take time and resources to select and implement the screenings, and to create the workflow to prompt patient participation and present actionable results to the clinician. Neurology practices that want to see patients over 65 without being subjected to a government-imposed financial penalty already have the most expensive and effective tools at their disposal. They don’t need new resources to screen for depression and anxiety. They need to make better use of the resources they have by effectively utilizing their EHR software.

    For treatment of patients with positive screenings for depression and anxiety, physicians may consider cognitive behavioral therapy (CBT). CBT is a highly effective treatment option that can be used to augment pharmacotherapy and in certain cases be the primary treatment itself. Treating these common neurological comorbidities will improve patient adherence, decrease disease burden and help practitioners address the primary medical concern. In concert, these benefits can help reduce the workload for neurologists and PCPs.

    Growing the care team

    Nothing will increase the productivity of neurologists in lowering costs, increasing access and delivering high-quality patient care more than leveraging the skills and time of APPs. But neurologists and APPs cannot meet all patient needs without a network of healthcare professionals on their team. This network includes the neuropsychologist, social worker, therapists from multiple disciplines and an emerging member of the team, the clinical pharmacist.  

    The role of the clinical pharmacist — filled by a PharmD (doctor of pharmacy) — in the care team is growing.  New treatments, particularly biological drugs with newly discovered mechanisms of action, have increased the complexity of medication management. The clinical pharmacist is trained to not only address patient safety but also efficacy of treatment. Both are of concern when PCPs and specialists prescribe different medications to the same patient without sufficient understanding of the implications.

    Neurology medications can be particularly complex; for example, biologic drugs used by neurologists to treat multiple sclerosis. Biologics are often administered by intravenous infusing in a healthcare facility. They are aggressive, effective and dangerous.

    The systems that alert prescribers to adverse drug interactions are not designed to include infusion drugs. The prescribing neurologist can manually add the drug to the local health record, but persistent interoperability challenges prevent this manually added data from being reliably shared with other members of the patient’s care team.

    Because infusion drugs are not electronically prescribed, they are not added to a pharmacy’s database.  The care team and even the retail or mail-order pharmacist — the last line of defense against medication error — are not privy to the drug interaction alerts when the most complex and dangerous drugs are prescribed by neurologists.

    The U.S. health system continues to struggle to deliver the right health information at the right time to the right people in the care team.  Interim steps are needed now.

    Neurology providers report spending up to and sometimes greater than 50% of their face-to-face patient visit time managing the medication plan. After the visit, clinical support staff may spend up to or sometimes greater than an hour per patient to ensure access to prescribed medications. Educating and assisting the patient in applying for financial assistance, obtaining insurance authorization, coordinating with clinicians to either appeal prescription benefit coverage denials or change the medication plan and searching for best drug price, are all part of ensuring access. Neurology providers spend even more time negotiating medication choices with other prescribers on the care team, which affects productivity.

    A recent study involving neurology demonstrates that a clinical pharmacist’s intervention helps prevent numerous drug-related problems not caught by the system or the provider. Even if interoperability improves and systems reliably alert prescribers to adverse drug interactions, without a clinical pharmacist on the care team, effective pharmaceutical management will still consume too much of the neurology provider’s time — or worse yet, not be addressed.

    Neurology teams that include a clinical pharmacist, however, can better educate patients about their medications and better collaborate with other prescribers. A clinical pharmacist’s knowledge across specialties is particularly valuable here, given the wide range of comorbid conditions common to neurology patients. In this setting, a clinical pharmacist is focused on comprehensive medication management for the patient. This care team member is not constrained by time to deliver an effective, coordinated, accessible medication plan intended for the treatment of a chronic neurological condition. Care teams that include a clinical pharmacist can also leverage pharmaceutical industry resources to better support both providers and patients.

    The neurology workforce shortage exists and will get worse without changes. Patient care will be affected. Most important, leaders must act now to expand the neurology care team with APPs and update physician and APP training programs and their funding. Overcoming the barrier to the use of telehealth will also make a significant difference in delivering the right neurology care, at the right time, in the right place, to growing populations – all with fewer neurologists. 

    Other practice managers can compare the neurology situation to their own and adapt plans, with attention to growing the care team with APPs. This will be particularly relevant to specialty practices.   

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