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Neurology Advocacy 2.0: After Sustainable Growth Rate Repeal

Neurology Advocacy 2.0: After Sustainable Growth Rate Repeal On April 16, 2015, the Medicare Access and Children’s Health Insurance Program Reauthorization Act, known as MACRA,1 was signed into law. The following week, the American Academy of Neurology held its annual meeting where many neurologists openly questioned: “What now?” Repeal of the Medicare Sustainable Growth Rate (SGR) formula, as part of MACRA, is historic. The SGR formula was enacted in 1997 and designed to reduce health care costs by calculating what sustainable growth within the system would be and reducing physician reimbursement if it exceeded that rate. However, such cuts (typically in the double digits) were vigorously opposed by the physician community. As a result, during the past 12 years, Congress intervened 17 times with a temporary halt to the SGR cuts. These last-minute fixes were costly to taxpayers, required a substantial lobbying effort by organizations such as the American Academy of Neurology, and caused significant uncertainty among health care professionals. Repealing the SGR required a sustained effort by the entire physician community for more than a decade. Resolution of the SGR issue provides a significant opportunity for neurologists to focus on other issues, including advocating for better recognition of cognitive care services, improving the practice of neurology, and strengthening the neuroscience pipeline. Stabilization of Medicare payments improves the practice of neurology, but significant hurdles remain. The challenges include those associated with an evaluation and management (E/M)–based specialty. For the neurologist, the current system continues to disincentivize the thoughtful and complete care required to treat a patient with a neurologic disease. Many of our patients have chronic conditions, and management of those conditions requires labor-intensive time. In addition, with the aging population, the demand for neurologists is increasing and fewer trainees are pursuing the field.2 As the practice environment evolves, neurologists must acclimate to succeed in a value-based system. Our advocacy efforts need to focus on optimizing opportunities for neurologists and other cognitive specialists providing E/M-based care. Several approaches may be taken to optimize opportunities. In the first approach, increased recognition of care coordination may help neurologists. The existing chronic complex care management code has too many requirements to benefit most neurologists. Increasing the rate and liberalizing the use of this code may help neurologists obtain appropriate reimbursement for the non–face-to-face efforts required to care for their patients. In the second approach, E/M codes should undergo an overall revaluation. Not all level 5 visits are created equal. Requesting that the Centers for Medicare & Medicaid Services study the E/M codes might value the time and efforts required for the better diagnosis and management of neurologic disease. We need to pursue all available avenues to increase and incentivize E/M-based care, regardless of specialty. In addition, as MACRA unfolds, we will continue to advocate for neurology as an E/M-based specialty in need of support to care for those patients with complex and chronic illnesses. The funding and support of neuroscience research is also critically important. The support for such work remains very low and challenges those individuals attempting to cure patients. For example, care for individuals with Alzheimer disease (AD) costs more than $250 billion dollars annually; care for individuals with cancer, $157 billion dollars annually.3-5 However, in fiscal year 2014, within the National Institutes of Health (NIH), Congress directed more than $5 billion dollars to cancer research and $862 million to AD or stroke research.6 Convincing neurology residents to pursue a career in research is challenging; maintaining neuroscience research is equally challenging, with historically low funding paylines for researchers. This situation is paradoxical to the opportunities that novel imaging techniques, high-throughput sequencing, and other technologies afford researchers. These opportunities and challenges require us to redouble our efforts to increase research funding for neuroscience. These efforts require 2 approaches. First, we must continue to address the challenges detailed above in an effort to broadly increase NIH funding. As background, NIH funding is provided through the appropriations process, which begins in the US House of Representatives. Typically, the President provides the House a draft budget, and the House and Senate generate their own budgets. These budgets are large and complex, and changing the budget dramatically for any single item (eg, NIH funding) is difficult. For efforts such as these to be successful, they will require a true groundswell of support from physician and patient organizations. Given the varied interests of patient organizations and physicians, fractures by disease research priorities limit these efforts. Nonetheless, we continue to support an overall increase to NIH funding. Other federal organizations that support neuroscience research, including the Department of Defense and the Centers for Disease Control and Prevention, are also subject to the appropriations process and require yearly efforts at least to renew current support. The second approach is to identify specific research areas or focuses in an effort to increase research funding in a more targeted fashion. A recent example is the Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative.7 The BRAIN Initiative was introduced in 2013 with the goal of developing the next generation of technologies and thereby understanding brain function and disease. This initiative has several aspects for support that are appealing, including private sector investment and the collaborative work of several funding agencies (eg, the NIH, Department of Defense). The American Academy of Neurology continues to advocate for full funding of this important initiative through the annual appropriations process. From an advocacy standpoint, this approach is simpler because it is directed at a specific initiative and making the connection between the funding to the treatment of brain diseases is easy. Another example is the AD “bypass budget” initiative.8 This unique initiative would allow the NIH to determine the optimal funding level needed for AD research that is not subject to the annual budget process. This approach is the most sustainable and direct effort to influence research in a specific disease area. This effort will require a sustained and coordinated advocacy effort among those patient organizations and other professional organizations, such as the American Academy of Neurology, to bring this initiative to fruition. New opportunities using a targeted funding approach include the 21st Century Cures Act,9 which is a broad-ranging bill but which specifically supports increased surveillance of neurologic diseases, such as Parkinson disease and multiple sclerosis. Many of our recent successes in supporting neuroscience research funding have come as the result of a more targeted approach. This tactic is challenging for neurologists given the wide range of diseases we treat. The balance of opportunities to further the research in specific areas such as AD while striving to strengthen funding for overall neuroscience research is of critical importance. The costs and prevalence of neurologic disease in the United States justify a greater investment in the institutions and individuals conducting neuroscience research. Conclusions In the end, post-SGR advocacy will center on improving the recognition and value for E/M-based health care professionals and increasing the support for neuroscience research through a variety of approaches. We hope that these efforts will improve access to neurologists, strengthen the profession of neurology, and further the treatments that the neurologist is able to offer. Back to top Article Information Corresponding Author: Nicholas E. Johnson, MD, Department of Neurology, University of Utah, 15 N 2030 St E, Room 2260, Salt Lake City, UT 84112 (nicholas.johnson@hsc.utah.edu). Published Online: December 21, 2015. doi:10.1001/jamaneurol.2015.2666. Conflict of Interest Disclosures: Dr Johnson reported serving as an associate editor for Neurology: Genetics; receiving grant 1K23NS091511-01 from the National Institutes of Health; and receiving research support from Biogen Idec, Ionis Pharmaceuticals, the Muscular Dystrophy Association, and Valerion Therapeutics. No other disclosures were reported. References 1. Medicare Access and CHIP Reauthorization Act of 2015. HR 2, 114th Congress (2015). https://www.govtrack.us/congress/bills/114/hr2. Accessed November 8, 2015. 2. Sigsbee B. The income gap: specialties vs primary care or procedural vs nonprocedural specialties? Neurology. 2011;76(10):923-926.PubMedGoogle ScholarCrossref 3. Centers for Disease Control and Prevention. Healthy aging.http://www.cdc.gov/aging/aginginfo/alzheimers.htm. Updated March 5, 2015. Accessed July 10, 2015. 4. Centers for Disease Control and Prevention. Stroke frequently asked questions (FAQs).http://www.cdc.gov/stroke/faqs.htm. Updated February 19, 2015. Accessed July 10, 2015. 5. National Cancer Institute. Cancer prevalence and cost of care projections.http://costprojections.cancer.gov. Accessed July 10, 2015. 6. US Department of Health and Human Services. Estimates of funding for various research, condition, and disease categories (RCDC).http://www.report.nih.gov/categorical_spending.aspx. Published February 5, 2015. Accessed July 10, 2015. 7. Insel TR, Landis SC, Collins FS. Research priorities: the NIH BRAIN Initiative. Science. 2013;340(6133):687-688. PubMedGoogle ScholarCrossref 8. National Institute on Aging. Bypass budget proposal for fiscal year 2017. https://www.nia.nih.gov/alzheimers/bypass-budget-fy2017. Accessed November 10, 2015. 9. 21st Century Cures Act. HR 6, 114th Congress (2015). https://www.govtrack.us/congress/bills/114/hr6. Accessed November 8, 2015. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Neurology American Medical Association

Neurology Advocacy 2.0: After Sustainable Growth Rate Repeal

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American Medical Association
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Copyright © 2016 American Medical Association. All Rights Reserved.
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2168-6149
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2168-6157
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10.1001/jamaneurol.2015.2666
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Abstract

On April 16, 2015, the Medicare Access and Children’s Health Insurance Program Reauthorization Act, known as MACRA,1 was signed into law. The following week, the American Academy of Neurology held its annual meeting where many neurologists openly questioned: “What now?” Repeal of the Medicare Sustainable Growth Rate (SGR) formula, as part of MACRA, is historic. The SGR formula was enacted in 1997 and designed to reduce health care costs by calculating what sustainable growth within the system would be and reducing physician reimbursement if it exceeded that rate. However, such cuts (typically in the double digits) were vigorously opposed by the physician community. As a result, during the past 12 years, Congress intervened 17 times with a temporary halt to the SGR cuts. These last-minute fixes were costly to taxpayers, required a substantial lobbying effort by organizations such as the American Academy of Neurology, and caused significant uncertainty among health care professionals. Repealing the SGR required a sustained effort by the entire physician community for more than a decade. Resolution of the SGR issue provides a significant opportunity for neurologists to focus on other issues, including advocating for better recognition of cognitive care services, improving the practice of neurology, and strengthening the neuroscience pipeline. Stabilization of Medicare payments improves the practice of neurology, but significant hurdles remain. The challenges include those associated with an evaluation and management (E/M)–based specialty. For the neurologist, the current system continues to disincentivize the thoughtful and complete care required to treat a patient with a neurologic disease. Many of our patients have chronic conditions, and management of those conditions requires labor-intensive time. In addition, with the aging population, the demand for neurologists is increasing and fewer trainees are pursuing the field.2 As the practice environment evolves, neurologists must acclimate to succeed in a value-based system. Our advocacy efforts need to focus on optimizing opportunities for neurologists and other cognitive specialists providing E/M-based care. Several approaches may be taken to optimize opportunities. In the first approach, increased recognition of care coordination may help neurologists. The existing chronic complex care management code has too many requirements to benefit most neurologists. Increasing the rate and liberalizing the use of this code may help neurologists obtain appropriate reimbursement for the non–face-to-face efforts required to care for their patients. In the second approach, E/M codes should undergo an overall revaluation. Not all level 5 visits are created equal. Requesting that the Centers for Medicare & Medicaid Services study the E/M codes might value the time and efforts required for the better diagnosis and management of neurologic disease. We need to pursue all available avenues to increase and incentivize E/M-based care, regardless of specialty. In addition, as MACRA unfolds, we will continue to advocate for neurology as an E/M-based specialty in need of support to care for those patients with complex and chronic illnesses. The funding and support of neuroscience research is also critically important. The support for such work remains very low and challenges those individuals attempting to cure patients. For example, care for individuals with Alzheimer disease (AD) costs more than $250 billion dollars annually; care for individuals with cancer, $157 billion dollars annually.3-5 However, in fiscal year 2014, within the National Institutes of Health (NIH), Congress directed more than $5 billion dollars to cancer research and $862 million to AD or stroke research.6 Convincing neurology residents to pursue a career in research is challenging; maintaining neuroscience research is equally challenging, with historically low funding paylines for researchers. This situation is paradoxical to the opportunities that novel imaging techniques, high-throughput sequencing, and other technologies afford researchers. These opportunities and challenges require us to redouble our efforts to increase research funding for neuroscience. These efforts require 2 approaches. First, we must continue to address the challenges detailed above in an effort to broadly increase NIH funding. As background, NIH funding is provided through the appropriations process, which begins in the US House of Representatives. Typically, the President provides the House a draft budget, and the House and Senate generate their own budgets. These budgets are large and complex, and changing the budget dramatically for any single item (eg, NIH funding) is difficult. For efforts such as these to be successful, they will require a true groundswell of support from physician and patient organizations. Given the varied interests of patient organizations and physicians, fractures by disease research priorities limit these efforts. Nonetheless, we continue to support an overall increase to NIH funding. Other federal organizations that support neuroscience research, including the Department of Defense and the Centers for Disease Control and Prevention, are also subject to the appropriations process and require yearly efforts at least to renew current support. The second approach is to identify specific research areas or focuses in an effort to increase research funding in a more targeted fashion. A recent example is the Brain Research Through Advancing Innovative Neurotechnologies (BRAIN) Initiative.7 The BRAIN Initiative was introduced in 2013 with the goal of developing the next generation of technologies and thereby understanding brain function and disease. This initiative has several aspects for support that are appealing, including private sector investment and the collaborative work of several funding agencies (eg, the NIH, Department of Defense). The American Academy of Neurology continues to advocate for full funding of this important initiative through the annual appropriations process. From an advocacy standpoint, this approach is simpler because it is directed at a specific initiative and making the connection between the funding to the treatment of brain diseases is easy. Another example is the AD “bypass budget” initiative.8 This unique initiative would allow the NIH to determine the optimal funding level needed for AD research that is not subject to the annual budget process. This approach is the most sustainable and direct effort to influence research in a specific disease area. This effort will require a sustained and coordinated advocacy effort among those patient organizations and other professional organizations, such as the American Academy of Neurology, to bring this initiative to fruition. New opportunities using a targeted funding approach include the 21st Century Cures Act,9 which is a broad-ranging bill but which specifically supports increased surveillance of neurologic diseases, such as Parkinson disease and multiple sclerosis. Many of our recent successes in supporting neuroscience research funding have come as the result of a more targeted approach. This tactic is challenging for neurologists given the wide range of diseases we treat. The balance of opportunities to further the research in specific areas such as AD while striving to strengthen funding for overall neuroscience research is of critical importance. The costs and prevalence of neurologic disease in the United States justify a greater investment in the institutions and individuals conducting neuroscience research. Conclusions In the end, post-SGR advocacy will center on improving the recognition and value for E/M-based health care professionals and increasing the support for neuroscience research through a variety of approaches. We hope that these efforts will improve access to neurologists, strengthen the profession of neurology, and further the treatments that the neurologist is able to offer. Back to top Article Information Corresponding Author: Nicholas E. Johnson, MD, Department of Neurology, University of Utah, 15 N 2030 St E, Room 2260, Salt Lake City, UT 84112 (nicholas.johnson@hsc.utah.edu). Published Online: December 21, 2015. doi:10.1001/jamaneurol.2015.2666. Conflict of Interest Disclosures: Dr Johnson reported serving as an associate editor for Neurology: Genetics; receiving grant 1K23NS091511-01 from the National Institutes of Health; and receiving research support from Biogen Idec, Ionis Pharmaceuticals, the Muscular Dystrophy Association, and Valerion Therapeutics. No other disclosures were reported. References 1. Medicare Access and CHIP Reauthorization Act of 2015. HR 2, 114th Congress (2015). https://www.govtrack.us/congress/bills/114/hr2. Accessed November 8, 2015. 2. Sigsbee B. The income gap: specialties vs primary care or procedural vs nonprocedural specialties? Neurology. 2011;76(10):923-926.PubMedGoogle ScholarCrossref 3. Centers for Disease Control and Prevention. Healthy aging.http://www.cdc.gov/aging/aginginfo/alzheimers.htm. Updated March 5, 2015. Accessed July 10, 2015. 4. Centers for Disease Control and Prevention. Stroke frequently asked questions (FAQs).http://www.cdc.gov/stroke/faqs.htm. Updated February 19, 2015. Accessed July 10, 2015. 5. National Cancer Institute. Cancer prevalence and cost of care projections.http://costprojections.cancer.gov. Accessed July 10, 2015. 6. US Department of Health and Human Services. Estimates of funding for various research, condition, and disease categories (RCDC).http://www.report.nih.gov/categorical_spending.aspx. Published February 5, 2015. Accessed July 10, 2015. 7. Insel TR, Landis SC, Collins FS. Research priorities: the NIH BRAIN Initiative. Science. 2013;340(6133):687-688. PubMedGoogle ScholarCrossref 8. National Institute on Aging. Bypass budget proposal for fiscal year 2017. https://www.nia.nih.gov/alzheimers/bypass-budget-fy2017. Accessed November 10, 2015. 9. 21st Century Cures Act. HR 6, 114th Congress (2015). https://www.govtrack.us/congress/bills/114/hr6. Accessed November 8, 2015.

Journal

JAMA Neurology – American Medical Association

Published: Feb 1, 2016

Keywords: alzheimer's disease,health care reform,medicare,united states national institutes of health,neurology,neuroscience,reimbursement mechanisms,research support,advocacy

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