Value of Neurologist Involvement in the US Health Care System: Evaluating Effectiveness in Economic and Patient Outcomes Analyses

David van der Goes
American Academy of Neurology
07/01/2013 – 06/30/2014

Description:

We propose that a neurologist adds value to the care of patients with neurological diseases by improving the outcomes of these disorders. Value can be measured in cost-savings in direct and indirect health care costs and in health-related quality of life. We build on our expertise in health economics modeling of neurological interventions in hypothetical models and with outcomes extracted from analysis of large public datasets. In Dr. van der Goes’ submission (with Dr. John Ney) to the 2013 AAN national conference, it is shown that neurologists substantially and significantly improve emergency, hospital and home-health care utilization and costs in four classes of chronic neurological illness using free public survey data. Dr. van der Goes is already familiar with most publicly available datasets that can be used to study the economics of neurology. Dr. van der Goes has manuscripts in various stages of publication reflecting the usage of free public datasets, but feel that the next step is analysis of outcomes of a large administrative claims dataset with adequate sample size to power main and subgroup analyses in a cohort over time.

This research will produce estimates of the economic and outcomes based value of neurologists and interventions in common neurological disorders. The work will focus on several key areas in neurology – dementia, epilepsy, parkinsonism, stroke, and pain. Additionally, this research will investigate the impact of reimbursement changes on the practice of neurology.

Research Plan:

In this proposal, we will analyze a nationally representative longitudinal administrative claims dataset (Market Scan) for cost outcomes of health care utilization for patients who received neurologist care versus other specialties and primary care. We will have access to approximately 51 million covered persons for 4 years, including both private and public payers. The Market Scan data allows for analysis of children, working-age people, and older populations; we can cover all areas of neurology.

Aim 1: Identify a cohort of patients with neurological diseases in a nationally representative dataset, while controlling for disease severity.
Challenge: Neurologist involvement in care suggests greater disease severity.
Approach: We will apply novel statistical techniques including propensity score matching and instrumental variables to identify cases that received neurologist care and controls that did not.
Impact: This approach will overcome one of the essential problems of determining costs of neurological care, where patients with more severe diseases have greater costs, and neurologist care is a marker for more severe disease.

Aim 2: Determine meaningful outcomes for neurological patients.
Challenge: Persons with neurological illnesses often live a normal lifespan, but are chronically debilitated. Approaches based on mortality may not be accurate or useful.
Approach: We will follow persons with neurological diseases in a longitudinal dataset over a number of time points, looking at associated health care events and claims over time, with and without neurologist involvement in care. Both counts of events and cost of these events
will be analyzed.
Impact: By examining health care utilization events and costs, we will inform economic models of neurological care including cost-consequence, budget-impact, and cost-benefit analyses for patients, third-party payers, and policy makers at the regional and national levels.

Aim 3: Evaluate the effect of neurologist care relative to other physicians.
Challenge: Neurologists overlap in procedures and expertise on specific neurological conditions, and many neurological patients may only see primary care or non-neurologist specialties for their conditions.
Approach: We will look at both overall meaningful outcomes as specified in Aim2 for neurologists relative to other physicians; but also look specifically at procedures and diseases which are shared with other specialties such as sleep studies (pulmonary) and nerve conductions (physiatry), and illnesses such as dementia (geriatrics) and pain (anesthesia, psychiatry).
Impact: This will increased the impact of Aim 2, and further emphasize the advantages of neurologist expertise in particular diseases and procedures.

Reports:

One major paper to be submitted to the Journal of the American Medical Association, the New England Journal of Medicine, the Annals of Internal Medicine, or the American Journal of Managed Care

Second major paper to be submitted to a top Health Economics Journal such as Health Affairs, Health Services Research, Journal of Health Economics, Medical Care Research and Review or the Journal of Economic Perspectives.

Due on June 30, 2014