Clinical Neuropsychology and Cost Outcome Research

A Beginning

George Prigatano, Neil Pliskin

• Publisher: Psychology Press
• Year: 2020
• ISBN:
  9781317722298
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Neuropsychologists are being increasingly called upon to demonstrate the value of their services. This edited book introduces clinical neuropsychologists to the concepts and challenges involved in conducting cost outcome research. It provides examples of how such research can be conducted within clinical neuropsychology and therefore is a "beginning" step in what must become an interdisciplinary effort. The text suggests that more than cost effectiveness studies should be considered when demonstrating the clinical utility of neuropsychological services. The concept of "objective" and "subjective" markers of value is emphasized, particularly as it relates to measuring the impact of a neuropsychological examination. Chapters review the economic burdens associated with different neurological conditions commonly seen by neuropsychologists. They also provide examples of how clinical neuropsychological services to different patient populations may reduce "costs" and increase "benefits" and suggest directions for beginning cost outcome research. Furthermore, the book summarizes the utility of various neuropsychological services that may be helpful to readers concerned with healthcare economies. The book is intended as a resource for clinical neuropsychologists who wish to explain to healthcare providers the value of their work. It is the first book of the National Academy of Neuropsychology book series entitled: Neuropsychology: Scientific Bases and Clinical Application.

1
CHAPTER

George P. Prigatano

Health-Care Economics and Clinical Neuropsychology

Introduction

America’s ideals and its economy are interrelated. The pursuit of life, liberty, and happiness implies the enjoyment of good health. Numerous studies have documented the obvious point that impaired health is readily associated with unhappiness (see Csikszentmihalyi, 1999). But what is the cost of “good health,” and who is to pay for it? Kaplan (1999) noted that for the last 30 years economists have expressed concern about the rising costs associated with health care in America. He noted that almost 15% of the U.S. gross domestic product (GDP) is spent on health care, “while no other country in the world spends more than 10%” (p. 160). Moreover, economists question whether the rising health-care costs are actually associated with better health status (Gold, Siegel, Russell, & Weinstein, 1996).

Certain statistics raise the suspicion that the increased cost of medical care is, at least in part, related to poor business practices. For example, Stein and Foss (1995) compared the annual rate of change in “output, prices, and employment” between health-care delivery services and all private industry in the United States between 1977 and 1992. During that time the domestic output of all private industries grew at a rate of 2.6%, compared to 2.4% in the health industry. Yet prices for health industry services and products increased more than 8%, whereas “all domestic private industries grew at a 5% rate” (p. 236). Employment-compensation costs also increased dramatically compared to the private sector. Were Americans paying more but getting less compared to other services they were receiving?

Part of the problem in answering this question is that the health-care service arena had insufficient data to counter attacks on its business practices and to demonstrate that the health-care services provided to Americans were needed and valued by the public. The rapid changes in reimbursement schedules, difficulties encountered in receiving “good” hospital care, and restrictions on seeing doctors that patients knew and trusted have resulted in America’s dissatisfaction with changes imposed by policy makers interested in lowering the costs of health care but not in understanding what healthcare consumers actually experience as a result of those changes.

Although the percentage of “other professional services” (including psychological services) accounted for 10% to 12% of health expenditures in 1993 (Stein & Foss, 1995), psychologists are being asked to justify their services and their associated fees. This book is the first major effort by clinical neuropsychologists to state the utility of their clinical services and to provide consolidated information regarding studying cost outcomes. Like many areas within the health-care delivery system, few systematic data are available on this important topic. Consequently, this text attempts to help clinical neuropsychologists learn how to demonstrate the economic value of their work. The book was conceptualized as a first major effort to help clinical neuropsychologists meet the challenges imposed by contemporary health-care economic policies and procedures.

Economics and Health Care

Economics is “the science that deals with the production, distribution, and consumption of wealth” (Webster’s, 1983, p. 574). It attempts to apply statistics, mathematical models, research designs, and, to the degree possible, controlled observations to understand how money is used and saved; how expenditures flow from certain principles of supply and demand; and how various business practices influence the distribution of wealth.

In their discussion of the American economy, Stein and Foss (1995) noted that the GDP for the United States has grown dramatically since the late 1890s. Consumer spending has fueled much of the growth. They compared the distribution of consumption expenditures during 1963 and 1993, noting that the proportion spent on food decreased dramatically during this period. Apparently, this is a well-recognized economic principle. The more wealthy a nation is, the less it spends proportionately on food. During the same time, however, a greater proportion of the GDP was spent on medical care and transportation. Regarding the increase in medical expenditures, they commented as follows: “The rising share of medical care reflects higher incomes, more new but costly medical procedures and drugs, an aging population, and the increasing prevalence of medical insurance that weakens patients’ incentives to economize on medical care” (Stein & Foss, 1995, p. 22). The notion that the mere presence of health insurance may result in overutilization of a given health-care service is referred to as the “problem of demand response” (see Frank & McGuire, 1999).

In addition to a greater proportion of the GDP being spent on medical care, an equally large portion is now spent on transportation. Americans are more mobile and use their health-care system perhaps to a greater degree than in the past. Although efforts have been made to reduce the cost of air travel and health-care services, the public seems unhappy with the imposed changes. The news is frequently filled with discussions of the problem of crowded airplanes, delays, the failure to provide meals on long flights, and the failure of the airline industry to consider consumer complaints seriously. Yet the airline industry continued to flourish until the attack on America on September 11, 2001.

Likewise, concerns about health-care costs have resulted in briefer hospitalization stays, less nursing coverage, less and restricted access to physicians, and long delays in getting authorization to see physicians for services. Americans have become more vocal and contentious about their dissatisfaction with health maintenance organizations (HMOs). Lawsuits filed and won against HMOs seem to be on the increase. The liability suits often include emotional distress as well as failure to provide adequate physical care. In fact, a journal has appeared that provides attorneys with information dealing solely with lawsuits filed against managed care organizations (i.e., Mealey’s Managed Care Liability Report).

Considerable inequity also is inherent in our present system. A case in point follows: The medical director of an HMO denied clinical neuropsychological evaluations for young adult traumatically brain-injured (TBI) patients covered under their organizational care. However, when that medical director suffered a mild head injury, he arranged for his corporation to authorize a clinical neuropsychological examination by a clinical neuropsychologist who was out of the network. These arrangements reflected his perception that a clinical neuropsychologist would provide the most expert evaluation of his cognitive difficulties.

Despite the absence of statistics justifying the service for a large number of enrollees under their insurance policy, the medical director’s “subjective” or personal perception revealed that, in fact, he considered the service important enough to get it for himself. This “subjective” side of health-care expenditures should also be monitored and not forgotten when the utility of our services, their costs, and the perceived and actual benefits of such services are studied. A growing literature has emerged around the topic of the impact managed care has had on the utilization of psychological testing in general and neuropsychological testing in particular. The reader is referred to several recent publications focusing on this topic including Groth-Marnat (1999); Kubiszyn, Finn, Kay, Dies, Meyer, Eyde, Moreland, and Eisman (2000); Maruish (2001); Norcross, Karg, and Prochaska (1997); Piotrowski (1999); Piotrowski, Belter, and Keller (1998); Stout (1997); Stout and Cook (1999); and Sweet, Moberg, and Suchy (2000).

Productivity and Standard of Living

Many practicing clinical psychologists and clinical neuropsychologists report that they must work several more hours each week than they once did to maintain their present income. As managed care policies have resulted in less financial reimbursement for health-care services in the United States, physicians report the same phenomenon. Managed care often is a misnomer for managed costs. How the quality and quantity of health-care services are related to their cost is the true question. Answering this question requires not only accounting and statistical skills but innovative ways of measuring the direct and indirect benefits (and costs) of neuropsychological services.

In the broad economic picture, of which health-care costs are only a portion, some basic economic ideas need to be considered. In a free enterprise economic system, three basic points are often made. First, “production is important because it determines income, and income determines consumption” (Junior Achievement, 1996, p. 82). Second, standard of living is measured in part by “the amount of goods and services available to citizens” (Junior Achievement, 1996, p. 82). Third, the average citizen’s “piece” of the GDP is an index of the funds available within a country to purchase goods and services to increase or maintain the standard of living.

In the present health-care environment, clinical neuropsychologists must be very productive to generate an adequate income to keep themselves and their profession alive and healthy. These services must provide a higher standard of living for the people whom they serve without substantially increasing that proportion of the GDP devoted to health-care costs in this country. Squarely stated, these are the hard facts confronting our profession.

In the early 1990s, the apparent perception of many business and government leaders was that the U.S. economy needed to reduce health care costs to remain competitive in various international markets. Thus, managed care began to influence health care delivery services in the early and mid-1990s.

Our institution (St. Joseph’s Hospital and Medical Center) was greatly affected by reimbursement patterns superimposed by managed care. By mid-1995, the Department of Clinical Neuropsychology within Barrow Neurological Institute (BNI), St. Joseph’s Ho...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Contributors
• Chapter 1 Health-Care Economics and Clinical Neuropsychology
• Chapter 2 The Clinical Neuropsychological Examination: Scope, Cost, and Health-Care Value
• PART I. TRAUMATIC BRAIN INJURY
• PART II. CEREBRAL VASCULAR DISORDERS
• PART III. NEOPLASMS
• PART IV. DEMENTIA
• PART V. EPILEPSY
• PART VI. LEARNING DISABILITIES
• PART VII. REHABILITATION, PSYCHOTHERAPY, AND PATIENT MANAGEMENT
• PART VIII. SPECIAL TOPICS
• Postscript: Reflections and Future Directions
• Chapter Learning Objectives
• CME Questions
• Author Index
• Subject Index
• About the Editors