The improved survival rate and cost-effectiveness of a 7-day continuous subcutaneous insulin infusion set.

AIMS: The purpose of this article is to compare the insulin cost-savings of the Medtronic Extended Infusion Set (or EIS, a.k.a. Extended Wear Infusion Set) designed and labeled for up to 7-day use with rapid-acting insulins to the current standard of care, 2- to 3-day infusion sets. METHODS: There are three major improvements (reducing insulin waste, plastic waste, and adverse events) with the extended duration of infusion set wear. This analysis focuses on cost savings from reduced insulin wastage during set changes. Studies published on insulin infusion set survival and EIS clinical trial data (NCT04113694) were used to estimate device lifetime performance using a Markov chain Monte Carlo model, including the assessment of adverse effects and device failure. Total costs associated with infusion set change or failure were systematically found in published literature or estimated based on physical usage, and the direct impact on insulin costs was calculated. RESULTS: Based on the model and clinical data, EIS users can expect to change their infusion sets about 75 fewer times than standard set users each year. The costs related to unrecoverable insulin during an infusion set and reservoir change in the US were estimated to range from $19.79 to $22.48, resulting in approximately $1324 to $1677 in annual cost-savings for the typical user from minimizing insulin wastage. LIMITATIONS: The study only assessed devices used within a monitored setting, that is, clinical trials. In addition, the variability associated with healthcare standards and costs and individual treatment variability including insulin dosages, contribute to the uncertainties with the calculations. CONCLUSIONS: Our analysis demonstrates that by extending the duration of infusion set wear, there may be substantial cost savings by reducing insulin wastage.

Quantitative EEG in attention-deficit/hyperactivity disorder: A companion payment policy review for clinicians and payers.

Quantitative EEG measurement of the scalp vertex theta/beta ratio (TBR) is marketed as a tool for use in the evaluation of patients who may have attention-deficit/hyperactivity disorder (ADHD). The American Academy of Neurology (AAN) recently assessed the literature about this tool. The assessment urged caution, considering that the TBR remains an investigational research tool at this time. This perspective comments further on that assessment and its rationale, and recommends a perspective for the clinician and payer.

Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Payment policy perspectives.

This article is presented as a companion to the American Academy of Neurology guideline update on the use of botulinum neurotoxin (BoNT) for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache. Whereas the guideline update provides clarity on the efficacy of different BoNT-branded preparations for the 4 listed indications, this companion piece identifies ambiguities in the evidence for efficacy among various brand names for a given clinical indication, their dosing equivalencies, as well as different clinical indications. This article provides guidance and background information to reduce obstacles for third party payment, especially when uncertainties exist and levels of evidence are lower.

Clinical perspectives on medical marijuana (cannabis) for neurologic disorders.

The American Academy of Neurology published an evidence-based systematic review of randomized controlled trials using marijuana (Cannabis sativa) or cannabinoids in neurologic disorders. Several cannabinoids showed effectiveness or probable effectiveness for spasticity, central pain, and painful spasms in multiple sclerosis. The review justifies insurance coverage for dronabinol and nabilone for these indications. Many insurance companies already cover these medications for other indications. It is unlikely that the review will alter coverage for herbal marijuana. Currently, no payers cover the costs of herbal medical marijuana because it is illegal under federal law and in most states. Cannabinoid preparations currently available by prescription may have a role in other neurologic conditions, but quality scientific evidence is lacking at this time.

Complementary and alternative medicine in multiple sclerosis: Payment policy perspectives.

This article identifies payment policy perspectives of the American Academy of Neurology's guideline on complementary and alternative medicine (CAM) in multiple sclerosis (MS). The guideline is a reliable repository of information for advocating or not recommending certain CAM treatments in MS. It eases the burden of searching for information on each separate CAM treatment. It frequently emphasizes the need for patient counseling. To provide such generally undervalued, but needed, cognitive services, neurologists could use advanced practice providers and patient-friendly visual aids during or between visits. They should also rely on evaluation and management codes that recognize time spent predominantly on counseling or coordination of care. The guideline's categorization of probable effectiveness of certain therapies will not influence coverage decisions because payers do not generally cover CAM therapies.

Diagnosis and treatment of limb-girdle and distal dystrophies: Payment policy perspectives.

Limb-girdle muscular dystrophies (LGMDs) and distal dystrophies are a diverse group of genetically heterogeneous myopathies characterized by an evolving and often confusing nomenclature. Though rare as a group, they are commonly seen in neuromuscular clinics and occasionally in general neurology clinics, and are frequently a source of diagnostic dilemma. A recent evidence-based guideline by the American Academy of Neurology provides a comprehensive analysis of the clinical phenotypes, diagnostic approach, and management principles of the LGMDs and associated disorders. There remain many unanswered questions regarding the role of radiologic and genetic testing, cardiorespiratory screening, and physical therapy in managing these patients. This payment policy article suggests potential solutions to challenging coverage scenarios that result from incomplete or conflicting evidence.

Practice patterns for intraoperative neurophysiologic monitoring.

OBJECTIVE: The professional practice of intraoperative monitoring (IOM) has evolved over the past 30 years. This report describes the field's current state and how site of service affects practice. METHODS: A survey queried American Academy of Neurology IOM neurologist members about their IOM volume, case type, duration, numbers of simultaneous cases, and location of the monitoring physician. RESULTS: Physicians located locally typically monitored fewer cases annually and simultaneously compared to physicians who monitored from remote locations. Physicians at remote locations monitored proportionally more spine procedures, whereas physicians who monitored locally monitored more intracranial procedures and a greater variety of cases. CONCLUSIONS: The remote monitoring practice model is different from local models in annual volume, simultaneous cases, work per case, and types of cases.

Vagus nerve stimulation in the treatment of epilepsy: Payment policy perspectives.

This article is presented as a companion to the recent American Academy of Neurology (AAN) guideline update on use of vagus nerve stimulation (VNS) for treating epilepsy. The guideline update reaffirms the efficacy of VNS for intractable epilepsy. Whereas it upholds the value of VNS for its originally approved indications, the guideline reminds us of existing evidence gaps and unmet research needs. This companion identifies ambiguities in the definition of intractable epilepsies and discusses the use of VNS in children under age 12 years and in persons with intellectual disabilities (mental retardation). Many payers require prior authorization and fulfillment of criteria for coverage of VNS. This article provides guidance and background information to reduce obstacles for coverage, especially where uncertainties exist and levels of evidence are lower.

Practice and payment trends in neurology in 2012.

This article describes practice and payment trends among neurologists. Data from the 2012 Practice and Payment Trends survey were compared to results from the 2010 Medical Economics survey. Both surveys were sent to a random sample of 1,000 US practicing neurologists, with a response rate of 32%. Since 2010, there has been an 8% increase in the percent of neurologists working in academic medical centers. Nearly half of neurologists reported working for a hospital-affiliated practice. Wait times have increased 40% for a new patient visit. Only 19% of neurologists indicated procedures as the primary focus of their practice. New delivery models have not yet gained traction with neurologists but the majority (>80%) of neurologists currently use electronic health records in their practice.

Payment reform and the changing landscape in medical practice: Implications for neurologists.

The growth in health care spending in the United States, though slowed in the last few years, remains unsustainable. Since higher health care spending does not correlate with most measures of improved patient outcome, there are new attempts to define "value" in health care as the ratio of quality to cost. This article reviews newer proposed models for provider payment and organization and their possible effects on neurologic practice.

An analysis of AAN's evidence-based guideline for IVIg use in neurologic disorders: Provider impact and payer perspectives.

Health insurers look for reliable, published evidence such as evidence-based guidelines put forth by medical specialty societies to craft their coverage policies. These guidelines generate both beneficial and controversial consequences on policies. Coverage policies aim to address the most typical clinical presentations. The American Academy of Neurology guideline for IV immunoglobulin strengthens the case for coverage when it is used to treat Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy. The guideline is less likely to strengthen coverage for several other diagnoses with lower levels of evidence. The responsibility to clarify specific situations when patient need falls outside of what is considered to be routine evaluation or treatment rests heavily on the physician. Advice on appealing an unfavorable coverage decision is also provided to the reader.

The AAN's role in the development of health insurer coverage policy.

Scientific, evidence-based clinical practice guidelines (CPGs) differ from coverage/policy statements. The latter incorporate values and priorities and translate evidence into human benefit. They assist provider and payer decisions, and abide by extant laws and regulations. Payers have set internal processes for balancing and integrating the intent of CPGs into their coverage/payment policies. Recently, however, their efforts to reach out to respected medical specialty societies for input are increasing. In response, the American Academy of Neurology (AAN) has taken the following steps: 1) it is reacting to, and providing input to, payer requests for policy reviews; 2) it is taking a proactive approach by developing AAN guideline companion documents that describe potential provider impacts and policy implications; and 3) it is commencing an initiative to write its own template policies. This new involvement has met with initial positive outcomes. The AAN will continue to expand efforts to fulfill a growing need in this area.