Neurology is at a turning point. After decades of limited progress, new disease-modifying therapies (DMTs) for neurodegenerative diseases such as Alzheimer's disease and many other diseases are finally entering the market. While some still question the clinical benefits and safety risks of DMT, Biogen (Leqembi) and Eli Lilly's (Kisunla) new Alzheimer's treatments are just two examples of long-awaited scientific breakthroughs.
However, with new treatments approved and many others in the pipeline, we face a critical question: Are our health care systems ready to deliver them effectively and sustainably?
For now, the answer is no. But this gap represents a significant opportunity for innovation. We are approaching a unique convergence point where neurology will become top of mind across the entire healthcare ecosystem, requiring bold new approaches to how care is delivered and paid for.
Nursing Services: Unmet Coordination Opportunities
The increasing availability of neurodegenerative DMTs creates an opportunity for health systems to improve the economics of high-priority but low-margin neurology service lines that have traditionally been underpinned by procedure volume. These therapies require seamless, end-to-end operational and clinical workflows to properly identify eligible patients, provide education, deliver treatment, measure treatment effectiveness, and monitor side effects.
Both Leqembi and Kisunla are administered by infusion, so hospital pharmacy collaboration and infusion clinic capabilities are key requirements to deliver the treatment. Frequent imaging is also critical to monitor safety events and adjust treatment. This requires imaging availability and appropriate classification based on the results. Finally, if patients seek emergency care due to side effects during treatment, the ED path must be configured to route these patients accordingly.
Administration and monitoring of these therapies require new access points and a high degree of cross-sector collaboration. The healthcare system currently lacks a coordinated infrastructure and orchestration layer, creating gaps that hinder the delivery of potentially life-changing treatments and the appropriate management of serious risks for those receiving treatment. The field is ripe for innovation and collaboration opportunities for powerful models that integrate existing workflows with the delivery of these new therapies.
Payments: the need for sustainability
The promise of DMT is huge, but it comes at a cost. Historically, payers have seen Neurology as a relatively low priority condition set. Most want to close the gap between access to neurology and neurology as a spending category. However, Leqembi costs an estimated $26,000 per year — and that doesn't include any follow-up care, testing or monitoring. Spending on specialty treatments will put additional margin pressure on payers and reinforce the need for more sustainable ways to pay for neurodegenerative disease care.
Some view the CMS GUIDE model as a signal of innovation in payment models tailored for Medicare beneficiaries with dementia. While GUIDE is a means of coordinated, collaborative care that improves outcomes and reduces avoidable high-cost services, it no The true gateway to value-based care (VBC) in neurology. GUIDE has no clear, quantified cost-savings goals or even a way to measure them.
VBC in neurology faces incredible complexity due to cost savings, even more so than other specialty VBC models. One reason is that patients with neurodegenerative diseases rarely present to the emergency room or hospital with a neurological diagnosis. For example, patients with dementia and worsening cognitive decline may experience unexplained falls or injuries, acute infections, or complications of chronic disease. Although the outcome is inextricably linked to an underlying dementia diagnosis, when this patient presents to the emergency room, they are understandably admitted with an acute condition rather than dementia.
Although VBC in neurology is complex, it is not unsolvable. Indeed, more formal care pathways and DMTs create opportunities for neurology VBC providers and facilitators to more clearly realize the value they drive. Value can come from proactively and appropriately identifying patients eligible for treatment, optimizing costly monitoring and imaging requirements, and improving skills and leveraging other care team members for less complex cases. These levers not only provide downstream cost savings but also support a workforce with limited capabilities.
The path forward for neurology care and payment
The availability of new therapies provides health systems with the opportunity to improve the economics of their neurology service lines. However, the market lacks the infrastructure and support layer to support the new workflows required. This includes addressing diagnostic bottlenecks, identifying and triaging eligible patients, and managing ongoing care and follow-up. Increased demand and the silver tsunami will increase pressure on neurology to better utilize advanced practice providers. Finally, these models should be ready to adapt to the increased pace of innovation. For example, improved biomarkers could ultimately reduce the need for imaging and new drug formulations.
As for building more sustainable payment models, many more dominoes will need to fall for the market to mature for innovation. More approved DMTs must enter the market, which increases costs for payers and forces them to pay more attention. Care pathways must continue to mature, bringing more certainty to outcomes without the need for long and expensive journeys to care. Finally, larger platforms are needed to bring together the very fragmented market of neurologists, creating space to test and scale risk-sharing arrangements that individual practices cannot manage alone.
New solutions (or treatments) bring new challenges. But new challenges create new opportunities. Innovators and entrepreneurs who build on the current momentum in neurology and prepare to expand their offerings will be able to transform neurology and the lives of its most important stakeholders: patients and their caregivers.
Photo: Khanisorn Chaokla, Getty Images
Adeyoola “Yoola” Adeniji brings experience in healthcare providers and digital health startups to LRVHealth's investment team. She has worked in operations at Cohere Health, a digital health startup focused on automating administrative affairs in healthcare, and held roles at Mass General Brigham (formerly Partners Healthcare), where she co-led the implementation of electronic health records and training for population health programs and primary care practices. As a partner at LRVHealth, Yoola helps source and support all aspects of corporate investments, from due diligence to execution. Yoola earned her MBA from the Yale School of Management, where she was commencement speaker and a Consortium Fellow and Forté Fellow. She graduated magna cum laude from the University of Florida with a bachelor's degree in health education and a minor in communication studies.
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