Optimizing MS Care Delivery Through Neurology and Pharmacy Partnerships: Kavita Nair, PhD

The integration of neurology and pharmacy services represents a critical opportunity to enhance multiple sclerosis (MS) care coordination and patient outcomes, Kavita Nair, PhD, professor in the department of neurology and the Center for Pharmaceutical Outcomes Research at the University of Colorado Anschutz Medical Campus. While many health systems have historically outsourced neurology services, this approach often leads to fragmentation that can delay treatment initiation and complicate the multidisciplinary care essential for managing MS.

In a conversation with The American Journal of Managed Care^® (AJMC^®), Nair discussed the trade-offs between outsourced and integrated neurology care, the impact of fragmentation on quality initiatives and care pathways, and the transformative role that neurology-trained pharmacists play in supporting shared decision-making, managing prior authorizations, coordinating infusions, and optimizing medication adherence for patients navigating the complex landscape of disease-modifying therapies.

This transcript was lightly edited for length and clarity.

AJMC: Many clinics have historically outsourced neurology services. What are the advantages and challenges of integrating neurology care into core health system practices?

Nair: With anything that's outsourced, you're kind of cutting off the arm from the body, so to speak. With outsourcing neurology, the advantage is that if you don't have a neurology practice, you can now bring a neurology practice. It fills a gap, especially in areas where recruiting neurologists becomes difficult. We estimate from neurology shortage assessments that we are always going to have a shortage of neurologists—not to the extent that is going to be critical like in some other fields, although with recent policy and visa issues, who knows? And there are some other advantages [to outsourcing]. There's flexibility, lower staffing costs, and the ability to maintain coverage for inpatient consults or general neurology needs. For MS, specifically a system that contracts for specialty expertise, there's certainly a cost advantage.

I think the trade-off in outsourcing that we come back to is fragmentation. MS is very specific; it touches almost every domain of the body. In addition, it affects an employed or employable population, so you're talking about employment implications: dealing with the employer and issues related to employment.

AJMC: How does this fragmentation impact quality initiatives and multidisciplinary care coordination?

Nair: Outsourced clinicians will not be fully embedded in a health system’s workflow, which includes the electronic medical record templates, the care pathway, order sets, and quality initiatives. We're trying to reduce the time to first dose for an infusion by making sure that our pathways within our health system are more efficient, and an outsourced neurology practice is not necessarily going to be embedded in that. If you're trying to reduce the time to the first dose, that outsourced neurology clinic or neurology physicians may not be able to take advantage of that.

MS is all about multidisciplinary coordination, so it can be harder to coordinate things like MRI protocols, for example. Before we came on this call, I was working to help someone get a referral to see our MS neurologist, and it's typically a month. And we're like, “Let's see how we can reduce this.” If it's outsourced, that becomes another layer I have to coordinate vs just needing the referral, then working with everybody in our system because the only outside factor is the referral.

Especially in hospital systems, we are also dealing with the site of care. Hospital-based infusion centers tend to have higher facility fees, so most payers will not pay for an infusion—after the first few infusions to make sure there are no safety issues—to be continually administered at a hospital; patients have to go to outside standalone infusion centers. If you have the treating neurologist at an academic center, then you have infusions at an external center already; that coordination happens. When you add a treating neurologist that's outsourced, you're adding an entirely different layer that also needs to be coordinated, and that will add to delays in getting the patient seen. Then let's assume the patient and the neurology provider and family decide the patient is going to get on an infusible medication. Now they have to coordinate with an infusion center. It just adds more and more delays. And the saying goes that “time is brain.” We want to treat early and treat aggressively.

Again, there are advantages in terms of contracting with something that already exists. You can move quickly, and you don't have to put up capital costs and staff build up and deal with everything. If you don't have something, absolutely, outsourcing is the way to go. But if you can bring in neurology—because it's not going away, and it’s not something that's temporary, and MS is affecting a growing swath of the population—those trade-offs need to be considered as well.

AJMC: How can partnerships between pharmacy and neurology help elevate MS care coordination and patient outcomes?

Nair: One of the areas I feel like neurology has kind of dropped the ball is exactly in this question. Other subspecialties—like cardiology, for example—have recognized that pharmacy really brings in a level of value and increases the return on investment in multiple ways. If you think about MS, how is MS treated? It's not a disease that's treated by surgery, primarily, or any kind of medical equipment. It's treated through disease-modifying agents. That's how we treat MS. We diagnose and we treat with disease-modifying agents, and there are over 20 agents.

It's also a disease that primarily affects women during their reproductive years, and it affects all domains—cognition, mobility, dexterity, urinary and bowel issues, all of it. And with the medications that women with MS take, such as birth control or medications related to pregnancy and childbirth, depression, hypertension, etc, how do you manage MS medications? When someone wants to get pregnant, is pregnant, is considering children, all of the above, who is the best person to supplement that? Neurologists are trained to treat MS, but a lot of things go on between someone being a teenager and reaching 55 years and above, because life happens. If you're a young woman, you might be on birth control. Does it affect the efficacy? And there are medication issues that need to be considered? What about other medications you're taking, including antidepressants or antibiotics? This is a disease that can affect a 21-year-old, and you’ve got to be compliant.

With the breadth of medications in that age range, who's the best person to counsel these patients and monitor them and say, “Hey, MD neurologist, they can’t really be on this disease-modifying therapy. But no worries, we've got other options, because they're on X, Y, and Z.” [A neurologist] is the best option.

I think the role of a neurology-trained pharmacist brings in so much value. On the front end, having a neurology-trained pharmacist in the clinic supplements and enhances the value of shared decision-making. A pharmacist can say to a patient, “You've made a decision to take this drug, now let’s talk about what happens next.” We’ve had patients ask what an infusion is like or what happens to them when they go to get an infusion. They ask about how long it takes, if they can bring their children, if they will feel pain, and more, because they’ve never had an infusion. They're young people, and if you've never had an infusion before, you have no idea. Having a pharmacist explain what that process entails is valuable.

MS medications are also all delivery systems. You have oral medications, you have self-injectables, you have infusions, and then you have self-injectables that can only be given in a physician's office. Even just explaining that process is something that pharmacists can help with.

In addition, we have prior authorization for almost all these medications, except the older medications, and just being able to work with the patient, because they’ve been diagnosed with this devastating disease and want to get on medication fast, but the prior authorization process takes time. You want to work with your health plan, and the best advocate for that is your neurologist-pharmacist. Even if the process takes a while, because that is the nature of things, someone who can keep you updated and remind you that even if you feel great right now, you can’t miss your infusions.

Patients also have to get vaccinated, and they have to get vaccinated at least 2 weeks before getting scheduled for the infusion. And the infusion centers are brimming with infusions, because almost all neurology drugs are infusions. When you add that to oncology, vitamin B₁₂, antibiotics, etc, it's not easy to say, “Oh, I need my infusion scheduled in 2 weeks, so pencil me in.” The infusion center will tell them to get in line. Pharmacists can coordinate and help the patients do all of those things, in addition to working with them to make sure that things are approved. I certainly don't want to give the impression that pharmacists are only good for prior authorization. A prior authorization for a specialty drug, an MS drug, or any neurology drug takes a level of tremendous expertise to say, “How do we craft it? What's the clinical rationale?” and that's the pharmacist.

If I had my way, I would say that every neurology/MS clinic needs to have a neurology-trained pharmacist. They will pay for themselves in 6 months. We finally got one after 10 years of lobbying, and their value is off the charts.