Dr Joseph BergerJoseph Berger, MD
A topic of conversation among some multiple sclerosis (MS) specialists has been the lack of adequate resources for an increased number of patients. Recent estimates have suggested that in the US alone, there are 1 million patients with MS, with only about 1500 neurologists who can provide the proper care needed—only 500 of which are specialized in MS.

At the Americas Committee for Treatment and Research in MS (ACTRIMS) Forum in Dallas, Texas, Joseph Berger, MD, spoke with NeurologyLive about this issue and some of the factors he believes may be responsible for getting to this point. The professor of neurology at the Hospital of the University of Pennsylvania and the chief of the Multiple Sclerosis Division at the Perelman School of Medicine discussed the importance of institutions recognizing the value a comprehensive MS clinic can provide not only to the patients but the institution itself.

He noted the need for a shift in the current compensation models to better assess the value that MS specialists provide in such a labor-intensive, time-intensive discipline.

NeurologyLive: How does the issue of not being adequately resourced come about for these physicians?

Joseph Berger, MD: The issue arises because, at many institutions, I would posit, the MS neurologists in the MS center, those people providing care to MS patients, are not recognized for the value they are contributing to the institution. If one were to look at the revenue that is being generated by the provision of MS care, you will find that there are many different streams that enhance the financial well-being of the institution. This includes if you provide the drugs through your pharmacy and if you have a specialty pharmacy. If you're providing the infusions—and this is particularly true if you're an institution operating under a Medicare 340b—there is a significant profit that is generated by the institution because of the provision of those drugs. If the imaging studies, which we do with great regularity, are being done at your institution; if the referrals to physical therapy, occupational therapy, the neurologists, the ophthalmologist etc., are all returning; and in addition, the laboratory testing—either the laboratory testing done at the time of the initial diagnosis and the laboratory testing done as a consequence of the monitoring—and the electrophysiologic studies are being done at your institution, all of these contribute to the contribution margin for the MS center and it is a significant stream of revenue.

At my own institution, it now exceeds the amount of money for the institution that is being generated by spine surgery. In fact, in the aggregate, if you take all the neurology subspecialties—stroke, Parkinson disease and other movement disorders, epilepsy, etc.—and you look at what they contribute to the institution, it is dwarfed by what MS contributes at the institution. Therefore, we have been successful in arguing for additional support. But in addition to the support, I think that the MS expert needs to be compensated appropriately as well because within institutions, the MS neurologists, historically, have been compensated the way a general neurologist is. Not like an epileptologist and not like the neuromuscular expert or the others. Yet, the revenue that they generate, relative to compensation, far exceeds those disciplines. If we're going to attract people into the discipline and make sure that they are satisfied with what it is that they do, you have to pay them adequately.

My latest, I would say, schtick—apart from the science of MS—is ensuring that we have the resources and the personnel to keep our patients healthy. It's a very labor-intensive discipline, and as a consequence of being a labor-intensive discipline where your value is assessed, in most institutions, by relative value units (which are extremely difficult to generate when you are in this labor-intensive discipline) the compensation models have to change. I just start with that.

What can MS neurologists, or physicians in general, do to help combat this challenge of compensation?

One of the problems that we have in medicine is that you're not taught business in medical school. You're simply not taught business, and as a consequence most physicians—the overwhelming majority—even people that are in roles of authority like department chairs and division chiefs, don't understand even the vocabulary of business that an administration within a medical institution uses.

The very first thing that people have to do is to educate themselves about the vocabulary and about what their worth is and what it is that they're contributing over and above the well-being of their patients—which is of critical importance and what we're here for. Over and above that, they need to know what it is that they're doing, and then they have to look at their own models and say, “What do I need to provide the highest level of care to my patients?” As I said, there are certain things that are fundamental. Those things are: to have adequate administrative support, to have adequate nursing support, to have pharmaceutical support, to have social work support, and to have the therapists that are proximate to your clinic. Those things are critically important. In answer to your question, people have to look at their own individual setup and determine what's best for them and what it is that they need in order to provide that high level of care.

With the average MS patient who first comes to your office, it’s critically important to spend a lot of time with them because history is essential. We still do physical examinations as MS neurologists. That's not true of all neurologists, by the way. If you’re practicing headache, or you're practicing epilepsy, and a patient comes back to see you a second or third or fourth time, it's not that critical that you do a careful physical examination. But for the MS neurologist, it's critical, and that can be time-consuming, to do a comprehensive neurologic examination.

This time doesn't translate necessarily into relative value units. It's much more efficient to see 6 headache patients in an hour than 1 MS patient in an hour, and when the institution is looking only at our RVUs and saying, “Well, the MS neurologist isn't generating very many RVUs…” wait a minute. Look at what they contribute to the overall health of the institution. Very frequently, the institutions are reluctant to share that information with the practitioner, and the practitioner has no idea. In fact, my own experience was that. That was true, and I did back-of-the-envelope calculations which turned out to be pretty much on target. They were published and following their publication, the institution started releasing the data. But I had practiced in a state, the state of Kentucky, for 20 years that was a sunshine state and that information was shared. Not only did you get that information from the Dean at monthly meetings on neuroscience service lines as a department chair, but you could tell anybody’s salary by simply going online. There has to be some more openness, more dialogue, between the administration and MS practitioners. There's got to be more support for MS centers.