American Academy of Neurology (AAN) president and leading lecturer, Timothy A. Pedley, MD, Columbia University’s College of Physicians and Surgeons, New York, New York, USA, delivered the 2015 Presidential Lecture, focusing on challenges currently faced by neurologists and the opportunities these challenges create. According to Dr Pedley, neurologists are facing an unparalleled number of challenges that adversely impact the field. The AAN has taken steps to address these challenges with the aim of promoting the highest-quality patient-centered neurological care, while enhancing member career satisfaction.

The rapid advances in basic and clinical neuroscience leading to new therapies for controlling and even curing neurologic disease have been exciting. Examples include monoclonal antibody therapies for multiple sclerosis, endovascular thrombectomy for acute ischemic stroke, and new interventions for previously untreatable brain tumors. The advent of neurological intensive care units and epilepsy monitoring units has greatly improved the outcomes of critically ill and therapeutically complex patients. At the same time, many aspects of neurology practice do not fit well in a health care system that bases reimbursement on procedural interventions with outcomes that can be clearly measured within a relatively short timeframe.

The first challenge faced by neurologists is the urgent need for payment reform. The US health care system is unaffordable and inequitable. The United States now spends almost 18% of its gross domestic product on health care [OECD. Health at a Glance 2013: OECD Indicators. OECD Publishing. http://dx.doi.org/10.1787/health_glance-2013-en. Accessed April 29, 2015], with a per capita cost of $8508, higher than any other country in the world [Davis K et al. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. June 2014]. Despite this, the United States ranks last among industrialized countries in health care quality and outcome measures according to one international study, which also included Australia, Canada, France, Germany, New Zealand, Norway, Sweden, Switzerland, The Netherlands, and United Kingdom. Measures in this study included the quality of care (effective, safe, coordinated, and patient-centered care), cost-related issues, timeliness of care, efficiency, equity, and healthy lives.

The United States lags in adopting information technology and developing national policies promoting quality improvement. Additionally, nonphysician clinicians such as nurse practitioners, physician assistants, and other physician extenders are underutilized. The most notable difference between the United States and the other countries is the lack of universal health insurance coverage in the United States. According to Dr Pedley, it is not possible to make system-wide changes that promote access to care, implement preventive strategies, and assure equity in prevention and treatment strategies for the entire population without universal health insurance coverage.

The Centers for Medicare and Medicaid Services (CMS) and other major payers are placing increasing emphasis on value-based physician payment reform. New requirements are changing many of the previous rules and methods for most billing practices. The AAN has developed resources to assist members in adjusting to the new requirements, including webinars, courses, videos, and publications addressing key topics such as Accountable Care Organizations, bundled payments, and independent practice associations.

The AAN must assist neurologists, especially those in small practices and not part of an Accountable Care Organization, large medical specialty center, or multispecialty clinic, whose resources are most strained by the shift from payment for specific volumes of services to value-based reimbursement for episodes of care. The AAN can assist in developing quality measures and collecting data demonstrating the validity and value of those measures. An important step is developing a clinical data registry (the AAN’s is called the Axon Registry) to answer questions about treatments and procedures, practice patterns, and patient outcomes. The data should assist in identifying gaps in care, and ways to improve quality and outcomes and decrease costs; demonstrate the value of neurologists; and assist in meeting regulatory reporting requirements.

As the complexity of neurology increases, more neurologists are developing expertise in one or more subspecialties and participating in subspecialty societies. Although most of these neurologists have remained members of AAN, the society is concerned about losing members as this trend increases. Dr Pedley believes that AAN should expand and strengthen partnerships with subspecialty societies. He proposed that AAN create a Council of Neurological Subspecialty Societies (CNSS), modeled on the existing Council of Medical Specialty Societies and Council of Specialty Societies. An exploratory meeting between the AAN and neurological subspecialty societies was held in 2014 to explore options for promoting greater interactions and the general support for this concept.

The growing shortage of neurologists is a major challenge. An AAN-supported study reported an 11% neurologist shortage in 2012 and predicted an increased shortfall of 19% by 2025 [Dall TM et al. Neurology. 2013]. One way to meet this challenge is to promote the integration of advanced practice providers (APPs), including nurse practitioners, physician assistants, and advanced practice nurses, into neurology practices and hospital services. The AAN board has approved a workgroup recommendation to conduct a targeted membership drive to recruit more neurology APPs and to develop special education tracks and materials for APPs beginning with the 2015 annual meeting.

Neurologists have one of the highest rates of burnout among physicians. Burnout limits neurologists’ ability to demonstrate the value of their practice and affects their career satisfaction. Burnout is characterized by low personal assessment, decreased work effectiveness, depersonalization, and emotional exhaustion [Sigsbee B, Bernat JL. Neurology. 2014]. Choice of specialty, personality type, practice setting, and types of patients are among factors associated with burnout. The AAN president-elect has made neurologist burnout a high priority and co-chairs a committee to study neurologist burnout and potential mitigation strategies.

Many neurologists are dissatisfied with the American Board of Medical Specialties’ maintenance of certification (MOC) requirements, particularly Part 4, the component dedicated to improvement in practice. MOC implementation is a significant challenge for AAN, but patients and regulatory bodies must be assured that AAN members are professionally current. It is essential for neurologists to remain up-to-date regarding neuroscience, disease pathophysiology, diagnostic modalities, and therapeutic interventions. According to Dr Pedley, it is unfortunate that the emphasis has been on certification rather than maintenance of competence. The AAN hopes to work with the American Board of Psychiatry and Neurology to develop meaningful and acceptable modifications of, or alternatives to, existing MOC requirements. Dr Pedley concluded that as neurologists, they must demonstrate to patients and families that they remain current on changing knowledge and skills as the time from their initial training becomes more distant.