Neurology is at a turning point. After decades of limited progress, new disease-modifying treatments (DMTs) for neurodegenerative conditions like Alzheimer’s and many others are finally reaching the market. While some still question the clinical benefits and safety risks of DMTs, new Alzheimer’s therapies from Biogen (Leqembi) and Eli Lilly (Kisunla) are just two examples of long-awaited scientific breakthroughs.
Yet, with new therapies being approved, and many others in the pipeline, we face a critical question: Is our healthcare system prepared to deliver them effectively and sustainably?
Right now, the answer is no. But that gap represents a major opportunity for innovation. We are approaching a unique convergence point where neurology will become top-of-mind across the healthcare ecosystem, requiring bold new approaches in how we deliver and pay for care.
Care delivery: The unmet opportunity for orchestration
The increasing availability of neurodegenerative DMTs creates an opportunity for health systems to improve the economics of a high priority but low margin neurology service line traditionally buoyed by procedural volume. These therapies demand seamless, end-to-end operational and clinical workflows to properly identify eligible patients, provide education, deliver therapeutics, measure treatment efficacy, and monitor side effects.
Leqembi and Kisunla are both administered via infusion, so hospital-pharmacy collaboration and infusion clinic capacity are key requirements to deliver treatment. Frequent imaging is also critical to monitor for safety events and adjust treatment. This requires imaging availability and appropriate triage based on results. Lastly, if a patient seeks emergency care for side effects while on treatment, ED pathways must be configured to route these patients accordingly.
The administration and monitoring of these therapies require new access points and a high degree of cross-department collaboration. The healthcare system currently lacks a coordinated infrastructure and orchestration layer, resulting in gaps that hinder the delivery of potentially life-changing treatments and the appropriate management of serious risks for those undergoing treatment. The opportunity for innovation and partnership in this space is ripe for robust models that integrate existing workflows with the delivery of these new therapies.
Payment: The need for sustainability
The promise of DMTs is tremendous, but it comes at a price. Historically, payers have viewed neurology as a relatively low-priority condition set. Most have looked to improve gaps in neurology access versus addressing neurology as a category of spend. However, Leqembi is estimated to cost as much as $26K annually – and that’s before any follow-up care, testing, or monitoring. Specialty therapeutic spend will introduce additional margin pressures for payers and reinforce the need for more sustainable ways to pay for neurodegenerative care.
Some look to the CMS GUIDE model, which is tailored to Medicare beneficiaries with dementia, as a signal for payment model innovation. While GUIDE is a means to coordinated, collaborative care that can improve outcomes and lower avoidable, high-cost services, it is not a true on-ramp to value-based care (VBC) in neurology. GUIDE has no explicit, quantified cost savings targets, or even methods for measurement.
VBC in neurology faces incredible complexity with the attribution of cost savings, even more so than other specialty VBC models. One reason is because patients with a neurodegenerative condition are rarely admitted to the ED or hospital with a neurological diagnosis. For example, a patient with dementia and worsening cognitive decline may experience an unexplained fall or injury, acute infection, or chronic disease complications. Though the outcome and underlying dementia diagnosis are inextricably linked, when this patient presents to the ED, they will understandably be admitted for the acute condition, not dementia.
While VBC in neurology is complicated, it is not unsolvable. In fact, more formalized care pathways and DMTs create the opportunity for neurology VBC providers and enablers to be more pointed in the value they drive. Value can be derived from proactively and appropriately identifying eligible patients for treatment, optimizing for costly monitoring and imaging requirements, and upskilling and leveraging other care team members for less complex cases. These levers not only save downstream costs but also support a capacity constrained workforce.
The path forward for neurology care and payment
The delivery of new therapeutics represents an opportunity for health systems to improve the economics of their neurology service line. Yet the market lacks infrastructure and enablement layers to support the new workflows required. This includes addressing the diagnostic bottleneck, identifying and triaging eligible patients, and managing ongoing care and follow-up. Increased demand and the silver tsunami will amplify pressure on neurology to better leverage advanced practice providers. And lastly, these models should be ready to adapt as the pace of innovation increases. For example, improved biomarkers could eventually lessen the need for imaging and new drug formulations.
As for building more sustainable payment models, a few more dominoes need to fall to ripen the market for innovation. More approved DMTs must come to market, increasing costs for payers and forcing them to heighten their focus. Care pathways must continue to mature, bringing more certainty to outcomes without a long and costly care odyssey. Finally, larger platforms will need to bring a very fragmented market of neurologists together, creating space to test and scale risk-sharing arrangements that individual practices could not manage alone.
With new solutions (or treatments) come new challenges. But new challenges create new opportunities. Innovators and entrepreneurs who are building on the momentum taking place in neurology right now, and preparing to scale their offerings, will be in a position to transform neurology and the lives of the most important stakeholders: patients and their caregivers.
Photo: Khanisorn Chaokla, Getty Images
Adeyoola “Yoola” Adeniji brings experience from both the healthcare provider and digital health startup world to LRVHealth’s investment team. She worked in operations at Cohere Health, a digital health startup automating administrative transactions within healthcare, and held roles at Mass General Brigham (formerly Partners Healthcare), where she co-led electronic health record implementation and training for population health programs and primary care practices. As an associate at LRVHealth, Yoola helps source and support all aspects of the firm’s investments, from due diligence through execution. Yoola earned her MBA at Yale School of Management, where she was the class graduation speaker, as well as a Consortium Fellow and Forté Fellow. She graduated summa cum laude from the University of Florida with a B.S. in Health Education and minor in Communication Studies.
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