Two FDA-approved anti-amyloid therapies are now available. The clinical evidence is real. The patient need is urgent. And yet, adoption remains staggeringly low.
The easy narrative is that neurologists are skeptical. That the clinical data isn't convincing enough, or that the risk profile gives physicians pause. And while healthy clinical debate is warranted with any new therapy class, skepticism alone doesn't explain a sub-2% adoption rate.
The real barrier is far more mundane -- and far more solvable.
It's an Operations Problem
Anti-amyloid therapies like lecanemab (Leqembi) and donanemab (Kisunla) aren't simple prescriptions. They're operationally intensive treatment programs that require a level of care coordination most neurology practices were never designed to handle.
Consider what's required to put a single patient on therapy:
The Staffing Math Doesn't Work
Most neurology practices run lean. The typical clinic has one or two neurologists, a small nursing staff, and limited administrative support. Now layer on the operational requirements of anti-amyloid therapy -- for even 10 patients -- and the staffing math breaks down quickly.
A single patient on lecanemab can require 15+ coordinated touchpoints in the first 6 months: screening visits, PET or CSF confirmation, genetic testing, pre-treatment MRI, infusion appointments, ARIA monitoring MRIs, lab work, and follow-up assessments. Multiply that by a modest patient panel, and you've overwhelmed your existing workflow.
This isn't a knowledge gap. Neurologists understand the clinical protocols. The problem is that executing those protocols at any meaningful scale requires infrastructure that the typical practice simply doesn't have.
Why This Matters Now
The Alzheimer's treatment landscape has changed more in the last three years than in the previous three decades. For the first time, disease-modifying therapies are available -- not just symptom management. This is a generational shift.
But a therapy that can't be delivered is a therapy that doesn't exist for the patients who need it. And right now, the gap between FDA approval and real-world delivery is enormous.
The practices that figure out the operational layer -- how to screen efficiently, coordinate infusions reliably, monitor ARIA systematically, and manage prior authorizations without drowning their staff -- will be the ones that actually get these therapies to patients.
What Needs to Change
Closing the adoption gap requires rethinking the operational model for complex neurology therapies:
- Protocol enforcement, not just protocol awareness. Clinicians know the steps. What's missing is a system that ensures every step happens in the right order, at the right time, for every patient -- without relying on memory or manual tracking.
- Prior authorization that doesn't consume the entire back office. The PA burden for anti-amyloid therapies is among the highest in specialty care. Automating documentation, tracking payer-specific requirements, and managing appeals systematically is essential.
- MRI and infusion scheduling that coordinates itself. ARIA monitoring timelines are non-negotiable. The infrastructure to schedule, track, and enforce those timelines needs to be embedded in the care workflow, not bolted on as an afterthought.
- Caregiver engagement as a first-class workflow. Alzheimer's care is inherently a team effort. Caregivers need visibility into the treatment schedule, the ability to report symptoms between visits, and clear guidance on what to watch for -- especially around ARIA symptoms.
- Scalability from the start. A workflow that works for 5 patients but collapses at 25 isn't a solution. The operational model needs to be designed for growth, not patched together as volume increases.
The Opportunity
Here's the counterpoint to all of this: the practices that solve the operational challenge aren't just doing the right thing for patients -- they're positioning themselves at the center of a rapidly growing therapy area. Anti-amyloid treatments represent a significant new revenue stream for neurology, and payer coverage is expanding.
The bottleneck isn't demand. It isn't clinical willingness. It's operational readiness.
The practices that invest in the infrastructure to deliver these therapies reliably -- at scale, without burning out their staff -- will be the ones that define the standard of care for the next decade of Alzheimer's treatment.
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