Expanding Precision Care for Alzheimer Disease, Multiple Sclerosis

Am J Manag Care. 2025;31(Spec. No. 15):SP1150

What do multiple sclerosis (MS) and Alzheimer disease have in common? They’re both neurological conditions that exact significant clinical, emotional, and financial tolls on patients and the health care system—and their management is being transformed by the availability of disease-modifying therapies, according to speakers at an Institute for Value-Based Medicine® event in Portland, Oregon, on October 21, 2025. The event, hosted by The American Journal of Managed Care®, featured speakers from Oregon Health & Science University, UW Medicine, and Providence, who discussed the need to keep patient access and value in mind as treatment toolboxes expand.

“Hopefully soon, there’ll be value-based assessments of symptomatic and rehabilitative strategies, because they in fact lead to better function. I wonder if we will shift from thinking of confirmed disability progression to thinking of improved functional outcomes as a frame shift, as a field.” — Rebecca Spain, MD, MSPH, FAAN, associate professor of neurology, Oregon Health & Science University | Image Credit: © Oregon Health & Science University

Advances in AD Care

The first speaker, Darla Chapman, DNP, ARNP, a nurse practitioner with University of Washington (UW) Medicine who specializes in neurology, began with an exploration of the new era in diagnosis and treatment of Alzheimer disease. With 2 disease-modifying drugs approved, lecanemab (Leqembi; Eisai Inc) and donanemab (Kisunla; Eli Lilly & Company), it’s now possible to clear some of the amyloid tangles in the brain that characterize Alzheimer disease, leading to a 25% to 35% slowing in cognitive decline for those with mild dementia.1,2 “What this really points out is that if we can modify pathology, we can change the trajectory of the disease,” Chapman said.

However, the need to act early in the disease course is complicated by persistent barriers to early diagnosis, both systemic and policy related. For instance, Medicare’s reimbursement of telemedicine recently reverted to prepandemic levels,3 and “when we have restrictions on telemedicine, it limits what we can do,” Chapman noted.

Considering the traditional pathways to diagnosis and treatment, which tend to be centralized at academic medical centers, a more democratic model is needed to expand access to screening and therapy, according to Chapman. This could be achieved by equipping primary care providers to perform screenings and order blood biomarker tests for patients with cognitive complaints and then refer them to neurology specialists for confirmatory scans. It will also be necessary to increase access to infusion centers and imaging modalities to meet the administration and monitoring requirements that intravenous disease-modifying therapies entail.

Future priorities include developing subcutaneous formulations for maintenance dosing to alleviate some of that infusion burden, as well as incorporating these agents into prevention strategies to act on preclinical markers of the disease. Still, the strides made in treating Alzheimer disease are worth celebrating. “I love having new tools to offer,” Chapman said. “We haven’t had much to offer patients for the longest time, and I think if we keep this momentum, we’re really going to be able to bring precision Alzheimer [disease] care to more sites of care and to every community.”

Operational Challenges and Early Detection

The next speaker, event chair Sophia Humphreys, PharmD, MHA, BCBBS, executive director of pharmacy at Providence, delved into the operational considerations of delivering these Alzheimer disease treatments. The 2 antiamyloid agents have similar indications but different mechanisms of action, so Providence’s formulary team is tasked with reviewing the class and drawing comparisons between them. Local pharmacists are an important component of this team, Humphreys said, because “we could look at clinical trials all day, but we would miss the complexity of the operations details.” Another key aspect is reimbursement, informed by 340B experts and drug contracting team members.

Best practices from Providence include performing board reviews for each prospective patient to assess their risk of complications and compare their characteristics against the established use criteria. Another tip is to ensure that Medicare patients are recorded in the registry so their treatment will be reimbursed, Humphreys advised. Finally, she emphasized the importance of communication among direct care teams, formulary experts, and pharmacists to answer any questions about delivering this new class of drugs to the right patients at the right time. “We want to identify these patients early so that we can offer this treatment, and early detection and early initiation of treatment are still key for us,” Humphreys concluded.

Defining and Optimizing Value in MS

With the advent of disease-modifying therapy, Alzheimer disease “feels like it’s where we were 20 years ago” in the field of MS, said Michelle H. Cameron, MD, PT, MCR, a professor in the Department of Neurology at Oregon Health & Science University. Her talk focused on defining value in MS care, which she explained varies by one’s perspective. Clinicians use validated scales to measure cognitive and functional domains, but patients are more concerned with the answers to their questions. “Can they chat with their grandkids? Can they have a job? Can they drive safely?”

MS has a wide range of symptoms that collect over time, and its disease course can be either progressive or relapsing/remitting, which can also impact the definition and assessment of value, Cameron said. Disease-modifying therapies change the trajectory and relapse frequency of the disease but do not reverse symptoms, whereas symptomatic therapies help patients feel better but do not change the course of the disease. The proliferation of treatment choices for MS means that there is no single go-to drug, but rather the choice of treatment depends on the individual patient’s presentation and goals.

Cameron highlighted a 2019 study that aimed to define value in MS care and concluded that although patient-reported outcomes have the greatest consensus as valuable, MS flares requiring health care utilization are most easily collected.4 These findings, according to Cameron, indicate the need to better integrate rehabilitation alongside disease-modifying therapies. “Rehabilitation [is defined as] interventions that help a person be as independent as possible,” she said. “That’s what patients care about.”

After value in MS care is defined, it can be optimized—the focus of the next speaker, Rebecca Spain, MD, MSPH, FAAN, associate professor of neurology at Oregon Health & Science University and codirector of the MS Center of Excellence-West within the Portland Veterans Affairs Medical Center. Like Cameron, Spain emphasized that the divergent disease courses of MS—relapsing/remitting vs progressive—determine which outcomes are appropriate for measuring value. For instance, the annualized relapse rate will not reflect improvements in progressive MS, where a disability status scale may yield more useful outcomes data.

These considerations extend to assessing the value of individual treatments, Spain explained. Monoclonal antibody therapies have shown superior annualized relapse rate as a class compared with oral drugs like fumarates and S1P inhibitors, but there do not seem to be major differences in these rates among the individual monoclonal antibodies.5 Other contributors to value are patient-reported outcomes, acceptability, and quality of life, Spain said.

“Hopefully soon, there’ll be value-based assessments of symptomatic and rehabilitative strategies, because they in fact lead to better function,” Spain concluded. “I wonder if we will shift from thinking of confirmed disability progression to thinking of improved functional outcomes as a frame shift, as a field.”

The panelists then came together on stage to discuss the overlaps between MS and Alzheimer disease. One key is to train primary care providers to recognize signs of the disease and initiate risk reduction strategies quickly before referring the patient to a neurologist. For dementia, Chapman said, providers should screen for reversible causes of cognitive decline before making a referral. For MS, primary care clinicians can advise patients on fall prevention and medication safety, Cameron added.

Risks can also come from unexpected sources, Humphreys shared, so it’s important to consider all possibilities. “One of the clinics reported more falls than any other clinic, and nobody knew why. Eventually, one of the building managers put in a request for fixing the parking lot. It turns out there’s an imbalance in the parking lot…that’s where people fall,” she said.

Thinking outside the box can also help patients engage in activities that stimulate cognition, which can help slow cognitive decline. Chapman advises patients to do what they enjoy, with the hope that forthcoming trials will show the efficacy of tools like crossword puzzles for brain training.6

Lastly, the panelists agreed that a team approach is essential for expanding access to novel therapies, whether for MS or Alzheimer disease. “Having a clinical pharmacist on your team is invaluable,” Spain said, to “raise that quality of care, do that coordination, keep track of the patients with lab monitoring, discontinue old drugs, and follow up on side effects.”

Author Information: Ms Mattina is an employee of MJH Life Sciences®, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

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2. Mintun MA, Lo AC, Duggan Evans C, et al. Donanemab in early Alzheimer’s disease. N Engl J Med. 2021;384(18):1691-1704. doi:10.1056/NEJMoa2100708

3. NCTRC Staff. The telehealth policy cliff: preparing for October 1, 2025. National Consortium of Telehealth Resource Centers. September 26, 2025. Accessed November 4, 2025. https://telehealthresourcecenter.org/resources/the-telehealth-policy-cliff-preparing-for-october-1-2025/

4. Swart ECS, Neilson LM, Good CB, et al. Determination of multiple sclerosis indicators for value-based contracting using the Delphi method. J Manag Care Spec Pharm. 2019;25(7):753-760. doi:10.18553/jmcp.2019.25.7.753

5. Lin GA, Whittington MD, Nikitin D, et al. Oral and Monoclonal Antibody Treatments for Relapsing Forms of Multiple Sclerosis: Effectiveness and Value—Final Evidence Report. Institute for Clinical and Economic Review. February 21, 2023. Accessed November 4, 2025. https://icer.org/wp-content/uploads/2024/05/ICER_MS_Final_Evidence_Report_05152024.pdf

6. Wang LA, Goldberg TE, Harvey PD, et al. Crossword puzzle training and neuroplasticity in mild cognitive impairment (COGIT-2): 78-week, multi-site, randomized controlled trial with cognitive, functional, imaging and biomarker outcomes. Int J Clin Trials. 2025;12(2):111-120. doi:10.18203/2349-3259.ijct20251032