1 - Prigatano (2010) Advancing the profession of CN with appropriate outcome studies…
Introduction
• A major issue facing clinical neuropsychologists is getting financially reimbursed for the services they provide. For clinical
neuropsychology to flourish as a profession, two types of “data” or “evidence” are needed.
1. One type comes from well-designed, “evidence-based” outcome studies that demonstrate the efficacy and the
cost-effectiveness of our procedures and interventions.
2. Another type is needed for individual practicing clinicians to demonstrate clearly to the referring physicians the value
of their clinical judgment in patient care.
• If we don’t take this seriously, the end result will be two-fold:
1. Patients will be seen only on a “fee for service” basis, which only some families can afford. This means that some
patients will not get neuropsychological services, which could lead to postponement of proper diagnosis, lack of proper
treatment interventions, or other negative outcomes.
2. An expanding trend of neuropsychologists to do more “medical-legal” work to survive economically.
Professional identity of neuropsychologists
• Our goal is not only to demonstrate the efficacy and cost-effectiveness of our work, but also to develop and train
neuropsychologists to be scientist-practitioners who are able to blend our science with patient and family needs and concerns.
Patient satisfaction is often directly related to the perception that the clinical neuropsychologist took adequate time to
carefully listen to his or her concerns and then acted on those concerns in a way that helped the patient.
Scope of practice of clinical neuropsychologists
• Neuropsychologists are interested in the successful management of neuropsychological disturbances in different patient
populations and trying to remediate or reverse the effects of neuropsychological disturbances. When the disturbances can’t be
remediated, helping the person and family adjust to the permanent neuropsychological disturbances and return to a
productive lifestyle when possible becomes a major focus of clinical neuropsychologists.
• Clinical neuropsychologists must demonstrate to physicians the logic behind what they say concerning a patient, and how
their knowledge contributes to patient care. To do this, they must share a similar language and terminology as physicians, but
never lose their identity as psychologists or their insight as to the underlying nature of the psychological disturbance of a
patient. They must articulate in a clear and concise way what is “wrong” with the patient, but at the same time indicate what
are the next practical steps in caring for that patient.
Previous and continuing efforts
• Advancing the profession of clinical neuropsychology requires carefully designed outcome studies, which unequivocally
demonstrate the ‘‘objective’’ (i.e., economic and scientific) value of our work, as well as its ‘‘subjective’’ value to the patient,
family, and physician (i.e., the degree to which they are personally satisfied with our work and are willing to pay for it).
• Outcome research refers to research that produces some measurable change in a functional system as a direct (or indirect)
effect of a planned intervention or service. RCTs are often considered the “gold standard” for documenting evidence of a
treatment of intervention effect.
● When considering an economic effect, one typically refers to “cost-outcome” studies.
● There are four basic types of cost analysis used in outcome research: cost-efficiency or minimization, cost-benefit,
cost-effectiveness, and cost-utilization.
• Healthcare economic studies often deal with cost-effectiveness issues. These studies measure the relative healthcare benefit
of at least two different treatments, and relate the degree of benefit relative to the costs involved.
• Intrinsic to cost-outcome research is the concept of value. Value refers to the ‘‘worth’’ of the service, and this can be
measured both objectively and subjectively.
● Economic value is one objective marker. If the service is worth more than what is paid for it, then healthcare
economists would consider it to have ‘‘good value,’’ and vice versa. The goal of neuropsychologists is to obtain ‘‘fair
value’’ for their services.
● Value can also be measured in non-economic terms, such as the quality of life of the person. This implies a relative
state of good health and reduction of symptoms, including psychiatric symptoms.
,Future efforts
Outcome studies
• Neuropsychologists should conduct outcome studies that demonstrate neuropsychological testing/evaluations lead to
practical decisions for patients (and their families).
● Clinical neuropsychologists are frequently asked to help neurologists determine if a patient’s subjective complaints
correlate with objective measures of brain functioning. The differential diagnostic question of neurological versus
psychiatric disorders persists.
● Identifying patients who have epileptic vs nonepileptic seizures could potentially save the healthcare system millions of
dollars yearly.
● Neuropsychologists sometimes conduct presurgical evaluations to determine their cognitive level.
● Another area where neuropsychologists impact medical decision making includes when neurosurgeons request
objective information about change and neuropsychological functioning after surgery. They may ask if abnormal
findings observed on neuroimaging are paralleled by neuropsychological impairments.
● Rehabilitation is another area where neuropsychology plays an important role and our impact could be measured and
quantified. Neuropsychologists predict the time that is needed for patients to achieve rehabilitation goals and they
play a role in educating family members in order to manage a person with known neurological disturbances.
● Attorneys request neuropsychological evaluations in a variety of medical-legal cases. Questions range from whether or
not a patient is legally competent to make economic decisions to whether or not the individual in fact has suffered a
brain disorder and can return to previous life activities.
• Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological testing/evaluations lead to the
development of new knowledge relevant to patient diagnosis and care.
• Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological knowledge/tests can be
combined with neuroimaging to improve patient care.
• Neuropsychologists need to conduct outcome studies to demonstrate that intervention programs, based on
neuropsychological and psychological principles, result in important cognitive and behavioural changes for the patient, and
these changes are mirrored in brain structure and activation pattern changes.
• Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological interventions with patients
not only reduce disability and improve the quality of life of the patient, but also improve the quality of life of caregivers.
• Neuropsychologists need to conduct outcome studies to demonstrate the economic impact of not receiving
neuropsychological assessment and interventions in a timely fashion.
Developing the clinical and professional skills of neuropsychologists
Primary clinical skills
• Clinical skills that make a difference for the viability of the profession of neuropsychology in the healthcare marketplace:
1. Capacity to review the medical and psychosocial history of a patient and identify key variables that bear on the
neuropsychological interview and the examination procedures.
2. Capacity to carefully interview the patient and family and briefly reveal the complexity of the problem.
3. Capacity to establish a therapeutic alliance with the patient and family member.
4. Capacity to examine (via various neuropsychological tests or procedures) a broad range of abilities that are necessary
to refine the diagnosis, clarify the patient’s strengths and weaknesses, and develop possible interventions.
5. Capacity to give verbal feedback regarding the test findings to the patient and family that is understandable and
acceptable. The patient and family should have a clear understanding of what was found and the rationale for the
interpretations that were arrived at.
6. Capacity to write reports that are concise (not necessarily short) and clear, which identify the next step in the patient’s
care and provide practical suggestions.
7. Capacity to perform cognitive rehabilitation as a method of either compensation or restoration of function.
8. Capacity to conduct psychotherapeutic interventions to help the patient struggle with his or her personal losses.
9. Capacity to educate the patient, family, and physician regarding how the underlying brain disorder impacts
neuropsychological functioning.
10.Capacity to elucidate the next step in the patient’s care.
,Professional skills
• Professional skills that make a difference for the viability of the profession of neuropsychology with other professions and the
public at large.
● Demonstrated acknowledgement of the limits of our knowledge with the capacity to advocate for the patient given the
knowledge that is available.
● Demonstrated capacity to negotiate conflicts within and between professions.
● Demonstrated steadfastness in learning one’s profession over several years.
● Seeking out fair reimbursement for our services, but never putting economic gain over patient needs.
● Self-monitoring of our personal and professional behavior (including our appearance, our office space, and how we
talk to and relate to other healthcare providers).
● Demonstrated capacity to conduct ongoing clinical research to check on the validity of our clinical assumptions, even
though the time needed to do this may not be financially reimbursed by an employer or a granting agency.
, 1 - Glen et al. (2020) Return on investment and value research in neuropsychology: A call to arms
Introduction
• In the climate of growing healthcare utilization and budgetary limitations, all medical specialties need to demonstrate the
tangible benefits of their services. The “return on investment” (ROI) is essential when advocating for the need for services
within the context of a larger system of care and when advocating for change at a policy level.
Clinical value of neuropsychological evaluation
• Clinical value in neuropsychology refers to the effectiveness of neuropsychological assessment in patient diagnosis and
prognosis and contributions to outcomes and patient satisfaction.
• 3 areas of existing research that document the benefit and “clinical value” of neuropsychological services:
1. Neuropsychological assessment has been shown to improve diagnostic decision-making and predict outcomes in
various conditions.
2. Neuropsychological assessment assists planning and predicting clinical outcomes following surgical procedures.
3. Neuropsychological assessment is useful in the prediction of treatment response and functional outcome.
• Neuropsychologists may be tempted to define their value to payers or institutions as “value-added,” which refers to the
enhancement of value of a good or service due to some element of its delivery or production; for instance, patients may
choose to visit the neurology clinic that has its own neuropsychologist in-house. Whereas this should not be the sole method
of demonstrating value, the concept of added value is important because it may increase revenue for an organization and/or
enhance the perceived value of the service with consumers.
Economic value and ROI
• Despite the substantial evidence of clinical and incremental value of neuropsychological assessment, there is, as noted, a
relative dearth of literature on the economic value or ROI of neuropsychological services. A potential challenge for clinical
neuropsychologists seeking to understand and contribute to the ROI literature is a lack of familiarity with economic research
concepts and terms.
Cost-efficiency studies
• Cost-efficiency studies are those in which the goal is to minimize the cost of a stated outcome. Identifying the most
cost-efficient treatment is not synonymous with demonstrating equality of treatment outcomes, and a variety of patient and
clinician factors will affect outcome.
Cost-benefit studies
• Cost-benefit studies refer to research in which cost and outcome, or benefits, are expressed in purely economic terms: a
monetary value is assigned to each cost and benefit.
● This is very challenging because psychological outcomes may not be easily expressed in economic terms.
• Similar to cost-benefit analysis is the ROI calculation, which is net gain, divided by the costs of a program or intervention,
expressed as a percentage. Whereas a very useful basic gauge of profitability or feasibility, ROI examines costs and gains from
the perspective of the “investor” (e.g., the hospital or health system) and thus may not capture the subtleties of social and
psychological benefits of neuropsychological interventions.
Cost-effectiveness studies
• Cost-effectiveness studies measure outcome in units rather than dollars, which may be more appropriate for the
neuropsychological setting. The cost of neuropsychological evaluation may be compared with outcomes, such as point increase
in the MMSE score.
Cost-utility studies
• In cost-utility studies, which is similar to cost-effectiveness analysis, the primary outcome is the incremental
cost-effectiveness ratio (ICER). This refers to the cost of an intervention divided by the difference in quality-adjusted life years
(QALY), also called cost per QALYs. In theory, a service with a value below the named threshold would not be funded.
Cost-consequence analysis
• In cost-consequence analysis, costs of an intervention are compared with all outcomes described in natural rather than
economic or QALY terms.
● For example, the impact of a neuropsychological screening program on future resource use (including costs of services,
loss of productivity, etc.) and health outcomes such as quality of life (QoL) ratings, symptom ratings, need for caregiver
assistance, for example, may be examined in table format and compared to other approaches
Introduction
• A major issue facing clinical neuropsychologists is getting financially reimbursed for the services they provide. For clinical
neuropsychology to flourish as a profession, two types of “data” or “evidence” are needed.
1. One type comes from well-designed, “evidence-based” outcome studies that demonstrate the efficacy and the
cost-effectiveness of our procedures and interventions.
2. Another type is needed for individual practicing clinicians to demonstrate clearly to the referring physicians the value
of their clinical judgment in patient care.
• If we don’t take this seriously, the end result will be two-fold:
1. Patients will be seen only on a “fee for service” basis, which only some families can afford. This means that some
patients will not get neuropsychological services, which could lead to postponement of proper diagnosis, lack of proper
treatment interventions, or other negative outcomes.
2. An expanding trend of neuropsychologists to do more “medical-legal” work to survive economically.
Professional identity of neuropsychologists
• Our goal is not only to demonstrate the efficacy and cost-effectiveness of our work, but also to develop and train
neuropsychologists to be scientist-practitioners who are able to blend our science with patient and family needs and concerns.
Patient satisfaction is often directly related to the perception that the clinical neuropsychologist took adequate time to
carefully listen to his or her concerns and then acted on those concerns in a way that helped the patient.
Scope of practice of clinical neuropsychologists
• Neuropsychologists are interested in the successful management of neuropsychological disturbances in different patient
populations and trying to remediate or reverse the effects of neuropsychological disturbances. When the disturbances can’t be
remediated, helping the person and family adjust to the permanent neuropsychological disturbances and return to a
productive lifestyle when possible becomes a major focus of clinical neuropsychologists.
• Clinical neuropsychologists must demonstrate to physicians the logic behind what they say concerning a patient, and how
their knowledge contributes to patient care. To do this, they must share a similar language and terminology as physicians, but
never lose their identity as psychologists or their insight as to the underlying nature of the psychological disturbance of a
patient. They must articulate in a clear and concise way what is “wrong” with the patient, but at the same time indicate what
are the next practical steps in caring for that patient.
Previous and continuing efforts
• Advancing the profession of clinical neuropsychology requires carefully designed outcome studies, which unequivocally
demonstrate the ‘‘objective’’ (i.e., economic and scientific) value of our work, as well as its ‘‘subjective’’ value to the patient,
family, and physician (i.e., the degree to which they are personally satisfied with our work and are willing to pay for it).
• Outcome research refers to research that produces some measurable change in a functional system as a direct (or indirect)
effect of a planned intervention or service. RCTs are often considered the “gold standard” for documenting evidence of a
treatment of intervention effect.
● When considering an economic effect, one typically refers to “cost-outcome” studies.
● There are four basic types of cost analysis used in outcome research: cost-efficiency or minimization, cost-benefit,
cost-effectiveness, and cost-utilization.
• Healthcare economic studies often deal with cost-effectiveness issues. These studies measure the relative healthcare benefit
of at least two different treatments, and relate the degree of benefit relative to the costs involved.
• Intrinsic to cost-outcome research is the concept of value. Value refers to the ‘‘worth’’ of the service, and this can be
measured both objectively and subjectively.
● Economic value is one objective marker. If the service is worth more than what is paid for it, then healthcare
economists would consider it to have ‘‘good value,’’ and vice versa. The goal of neuropsychologists is to obtain ‘‘fair
value’’ for their services.
● Value can also be measured in non-economic terms, such as the quality of life of the person. This implies a relative
state of good health and reduction of symptoms, including psychiatric symptoms.
,Future efforts
Outcome studies
• Neuropsychologists should conduct outcome studies that demonstrate neuropsychological testing/evaluations lead to
practical decisions for patients (and their families).
● Clinical neuropsychologists are frequently asked to help neurologists determine if a patient’s subjective complaints
correlate with objective measures of brain functioning. The differential diagnostic question of neurological versus
psychiatric disorders persists.
● Identifying patients who have epileptic vs nonepileptic seizures could potentially save the healthcare system millions of
dollars yearly.
● Neuropsychologists sometimes conduct presurgical evaluations to determine their cognitive level.
● Another area where neuropsychologists impact medical decision making includes when neurosurgeons request
objective information about change and neuropsychological functioning after surgery. They may ask if abnormal
findings observed on neuroimaging are paralleled by neuropsychological impairments.
● Rehabilitation is another area where neuropsychology plays an important role and our impact could be measured and
quantified. Neuropsychologists predict the time that is needed for patients to achieve rehabilitation goals and they
play a role in educating family members in order to manage a person with known neurological disturbances.
● Attorneys request neuropsychological evaluations in a variety of medical-legal cases. Questions range from whether or
not a patient is legally competent to make economic decisions to whether or not the individual in fact has suffered a
brain disorder and can return to previous life activities.
• Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological testing/evaluations lead to the
development of new knowledge relevant to patient diagnosis and care.
• Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological knowledge/tests can be
combined with neuroimaging to improve patient care.
• Neuropsychologists need to conduct outcome studies to demonstrate that intervention programs, based on
neuropsychological and psychological principles, result in important cognitive and behavioural changes for the patient, and
these changes are mirrored in brain structure and activation pattern changes.
• Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological interventions with patients
not only reduce disability and improve the quality of life of the patient, but also improve the quality of life of caregivers.
• Neuropsychologists need to conduct outcome studies to demonstrate the economic impact of not receiving
neuropsychological assessment and interventions in a timely fashion.
Developing the clinical and professional skills of neuropsychologists
Primary clinical skills
• Clinical skills that make a difference for the viability of the profession of neuropsychology in the healthcare marketplace:
1. Capacity to review the medical and psychosocial history of a patient and identify key variables that bear on the
neuropsychological interview and the examination procedures.
2. Capacity to carefully interview the patient and family and briefly reveal the complexity of the problem.
3. Capacity to establish a therapeutic alliance with the patient and family member.
4. Capacity to examine (via various neuropsychological tests or procedures) a broad range of abilities that are necessary
to refine the diagnosis, clarify the patient’s strengths and weaknesses, and develop possible interventions.
5. Capacity to give verbal feedback regarding the test findings to the patient and family that is understandable and
acceptable. The patient and family should have a clear understanding of what was found and the rationale for the
interpretations that were arrived at.
6. Capacity to write reports that are concise (not necessarily short) and clear, which identify the next step in the patient’s
care and provide practical suggestions.
7. Capacity to perform cognitive rehabilitation as a method of either compensation or restoration of function.
8. Capacity to conduct psychotherapeutic interventions to help the patient struggle with his or her personal losses.
9. Capacity to educate the patient, family, and physician regarding how the underlying brain disorder impacts
neuropsychological functioning.
10.Capacity to elucidate the next step in the patient’s care.
,Professional skills
• Professional skills that make a difference for the viability of the profession of neuropsychology with other professions and the
public at large.
● Demonstrated acknowledgement of the limits of our knowledge with the capacity to advocate for the patient given the
knowledge that is available.
● Demonstrated capacity to negotiate conflicts within and between professions.
● Demonstrated steadfastness in learning one’s profession over several years.
● Seeking out fair reimbursement for our services, but never putting economic gain over patient needs.
● Self-monitoring of our personal and professional behavior (including our appearance, our office space, and how we
talk to and relate to other healthcare providers).
● Demonstrated capacity to conduct ongoing clinical research to check on the validity of our clinical assumptions, even
though the time needed to do this may not be financially reimbursed by an employer or a granting agency.
, 1 - Glen et al. (2020) Return on investment and value research in neuropsychology: A call to arms
Introduction
• In the climate of growing healthcare utilization and budgetary limitations, all medical specialties need to demonstrate the
tangible benefits of their services. The “return on investment” (ROI) is essential when advocating for the need for services
within the context of a larger system of care and when advocating for change at a policy level.
Clinical value of neuropsychological evaluation
• Clinical value in neuropsychology refers to the effectiveness of neuropsychological assessment in patient diagnosis and
prognosis and contributions to outcomes and patient satisfaction.
• 3 areas of existing research that document the benefit and “clinical value” of neuropsychological services:
1. Neuropsychological assessment has been shown to improve diagnostic decision-making and predict outcomes in
various conditions.
2. Neuropsychological assessment assists planning and predicting clinical outcomes following surgical procedures.
3. Neuropsychological assessment is useful in the prediction of treatment response and functional outcome.
• Neuropsychologists may be tempted to define their value to payers or institutions as “value-added,” which refers to the
enhancement of value of a good or service due to some element of its delivery or production; for instance, patients may
choose to visit the neurology clinic that has its own neuropsychologist in-house. Whereas this should not be the sole method
of demonstrating value, the concept of added value is important because it may increase revenue for an organization and/or
enhance the perceived value of the service with consumers.
Economic value and ROI
• Despite the substantial evidence of clinical and incremental value of neuropsychological assessment, there is, as noted, a
relative dearth of literature on the economic value or ROI of neuropsychological services. A potential challenge for clinical
neuropsychologists seeking to understand and contribute to the ROI literature is a lack of familiarity with economic research
concepts and terms.
Cost-efficiency studies
• Cost-efficiency studies are those in which the goal is to minimize the cost of a stated outcome. Identifying the most
cost-efficient treatment is not synonymous with demonstrating equality of treatment outcomes, and a variety of patient and
clinician factors will affect outcome.
Cost-benefit studies
• Cost-benefit studies refer to research in which cost and outcome, or benefits, are expressed in purely economic terms: a
monetary value is assigned to each cost and benefit.
● This is very challenging because psychological outcomes may not be easily expressed in economic terms.
• Similar to cost-benefit analysis is the ROI calculation, which is net gain, divided by the costs of a program or intervention,
expressed as a percentage. Whereas a very useful basic gauge of profitability or feasibility, ROI examines costs and gains from
the perspective of the “investor” (e.g., the hospital or health system) and thus may not capture the subtleties of social and
psychological benefits of neuropsychological interventions.
Cost-effectiveness studies
• Cost-effectiveness studies measure outcome in units rather than dollars, which may be more appropriate for the
neuropsychological setting. The cost of neuropsychological evaluation may be compared with outcomes, such as point increase
in the MMSE score.
Cost-utility studies
• In cost-utility studies, which is similar to cost-effectiveness analysis, the primary outcome is the incremental
cost-effectiveness ratio (ICER). This refers to the cost of an intervention divided by the difference in quality-adjusted life years
(QALY), also called cost per QALYs. In theory, a service with a value below the named threshold would not be funded.
Cost-consequence analysis
• In cost-consequence analysis, costs of an intervention are compared with all outcomes described in natural rather than
economic or QALY terms.
● For example, the impact of a neuropsychological screening program on future resource use (including costs of services,
loss of productivity, etc.) and health outcomes such as quality of life (QoL) ratings, symptom ratings, need for caregiver
assistance, for example, may be examined in table format and compared to other approaches
