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Treating Multiple Sclerosis: The Healthcare Provider Perspective

Web Exclusives - In the News

The treatment of multiple sclerosis (MS) involves pharmacotherapy to treat disease progression, symptoms, and acute exacerbations. Patients may also engage in a number of nonpharmacologic interventions, such as physical and occupational therapy.

Optimally, patients with MS are treated using an interdisciplinary approach, which may involve a number of different healthcare providers (HCPs) in patient care. Generally the neurologist leads the treatment team, and may refer services to physical therapists, physiatrists, occupational therapists, and other allied health professionals on a patient-specific basis. In addition, some neurology practices employ nurse practitioners and physician assistants to assist with patient care. Other health system professionals, such as pharmacists and case managers, may also become involved in patient care. Because of the psychosocial aspect of MS, and the fact that many patients suffer from concomitant depression, mental health professionals may be members of the treatment team. Finally, there are a number of advocacy and support organizations that provide valuable resources to patients seeking to empower themselves in managing their illness.

Although all of these stakeholders are committed to providing the best possible patient care, their professional orientation, training, and philosophies toward treatment may differ. For example, neurologists focus on reducing relapses and limiting disease progression, whereas mid-level providers are more aware of patient symptoms and psychosocial issues. Rehabilitative specialists focus on nonpharmacologic approaches to treatment. Misaligned perspectives and lack of coordination may lead to missed opportunities to optimize care, as expressed by the following two panelists of the MS roundtable:

  • Physical therapist: “In general, I have to say that neurologists are very slow to refer the patients to physical therapy in general. We see more referrals from the MS society and other providers than neurologists. But usually, if there's a significant decline in function through the relapse and so on, then we may see a physical therapy referral.”
  • Nurse practitioner: “While the world has changed in terms of relapse management and disease modification, symptom management has always been a mainstay, and I don’t think we should lose sight of that. I think that one of the big problems that we have today is that there’s such a focus on those expensive disease- modifying therapies that many patients are falling by the wayside in terms of those important symptoms, such as walking, bowel, bladder, fatigue, cognition, using drugs that we know have worked.”

HCPs at the MS roundtable noted that there is substantial variability in the services available to patients with MS, depending on geography and the practice-specific level of care integration. As a result, smaller, community-based neurology practices, particularly those in rural areas, may not have the same access to the range of multidisciplinary clinicians and support services as larger, multiprovider, urban-based practices.

The clinical course of MS can be highly variable and involves management of disease progression as well as symptoms. As a result, the treatment of MS is complex. Because of this complexity, many neurologists consider the treatment of MS in general, and symptom management in particular, to be an art as well as a science. Neurologists and other members of the treatment team frequently rely on patient self-report and clinician/ patient interaction to inform treatment decisions. Because of the interpatient and intrapatient variability in disease course and treatment response, regimens are often tailored to the needs of the individual patient. In other words, MS does not lend itself to a one-size-fits-all treatment approach.

In addition to the variability in the treatment of MS, the neurology community is fragmented. By and large, state neurology societies conduct their activities independent of the American Academy of Neurology. There are few consensus guidelines regarding disease-modifying therapies, and even fewer regarding symptom management. Furthermore, there is a lack of objective, universally accepted metrics available to measure functional status for some symptoms.

Because of the complexity of the treatment of MS and the inherent unpredictability of the disease, coupled with the special nature of the clinician/patient relationship, the course of treatment may vary over time, and successful treatment of MS can be difficult to quantify. As a nurse practitioner at the roundtable stated, “Nothing exists by itself in MS—it’s a very complicated disease—and it becomes a very costly disease for the caregiver. The time required is extraordinary, if you really want to do a good job.”

Payers are reacting to the increasing cost of the MS category, and as a result, neurologists and other treatment team clinicians are being forced to consider treatment in a broader context. HCPs are increasingly being impacted by business considerations in healthcare, primarily in the form of utilization management strategies implemented by third-party insurers. Because of their patient-centered focus, HCPs have difficulty understanding what value means to payers. A neurologist at the roundtable commented, “I know what patient value is. I think [HCPs] can all figure out what patient value means to us. I still don’t know what value is to [payers].”

Prior authorization (PA) is the most frequently used utilization management tool in treating MS. In the PA process, HCPs are asked to provide clinical justification before the insurer agrees to pay the cost of a prescription drug or a medical procedure.

Although most HCPs acknowledge the rising cost of healthcare and understand the rationale for PA implementation, they contend that the process is cumbersome and sometimes interferes with patient care. The HCPs represented on the roundtable panel expressed their desire for consistent, streamlined PAs, without superfluous or irrelevant questions, that adequately take into account their professional judgment and experience. HCPs may have a few or many payers whose PA requirements are different, which creates an additional challenge. Perhaps above all, HCPs seek to understand payer expectations so they can respond to utilization management requests in an appropriate, timely manner. Payer expectations may pose a particular challenge for smaller, community-based practices that may not have the resources or the infrastructure to keep abreast of changing requirements by multiple health plans. In the words of a neurologist on the panel, discussing the PA for an agent to treat walking impairment, “It would be useful if the PA criteria were completely transparent. On the initial PA [forms] that we receive, it doesn’t specify that we need to reassess patients after X months. That information needs to be on the form. And if we have any questions, we need open lines of communication with payers.”

In the end, HCPs state that their primary responsibility is to the patient. In that sense, they have a concrete goal, whereas payers represent broader societal and fiscal concerns. These concerns are more difficult to elucidate and describe, and are often driven by health policy at the state and federal levels.

By and large, the neurology professionals represented on the panel recognized the need to rein in healthcare spending, noting that the costs are increasingly being passed on to patients, not all of whom have the ability to pay, even if they are insured. In this regard, they are open to compromise with the payer community. Although there may be disagreement on the best way to support appropriate utilization of healthcare services, HCPs acknowledge that there must be systems in place to mitigate the burden of increasing healthcare costs on the patient in particular and on society in general.

Overview
Multiple Sclerosis Disease State Review
Treating Multiple Sclerosis: The Healthcare Provider Perspective
Management of the Multiple Sclerosis Category: An Increasing Focus for Payers

Achieving Consensus between Healthcare Providers and Payers

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Last modified: August 30, 2021