CE hospital service utilization is reduced following neuropsychological evaluation in a sample of U.S. veterans

Relatively undervalued: Comparing the work relative value units of neuropsychological evaluation to other services

Objective: We examined work relative value units (wRVUs) and associated revenue of current procedural terminology (CPT) codes for evaluation and management (E&M) services, neuropsychological evaluation (NPE), psychological evaluation (PE), and psychotherapy. Method: CPT code wRVUs were aggregated for E&M (99202-99215), NPE (96116, 96132, 96133, 96136, and 96137), PE (90791, 96130, 96131, 96136, and 96137), and psychotherapy (90791 and 90832-90837 with and without the complexity modifier, 90785). Per minute wRVUs were calculated for each CPT code. The Centers for Medicare and Medicaid Services 2023 conversion factor ($33.8872) was multiplied by wRVUs to examine reimbursement per hour and per prototypical four-hour clinic slot. Results: The wRVUs per minute showed the following ranges: 0.032-0.07 for E&M services, 0.015-0.063 for NPE, 0.015-0.124 for PE, and 0.043-0.135 for psychotherapy. Average hourly revenue ranged from $72 for NPE to $132 for psychotherapy with the complexity modifier. Revenue for prototypical four-hour clinics ranged from $283 for NPE to $493 for psychotherapy with the complexity modifier. PE and psychotherapy services were valued at 124-184% of NPE. Conclusions: E&M code wRVUs increase with case complexity reflecting greater work intensity, and a modifier to PE and psychotherapy captures additional effort needed in complex cases. In contrast, NPE codes lack a complexity modifier, and NPE wRVUs are lower than those of PE and psychotherapy, the latter of which can be billed by master's level providers. NPE is undervalued compared to PE and psychotherapy based on wRVUs currently assigned to the CPT codes used for the respective services.

Tele-Neuropsychology: From Science to Policy to Practice

OBJECTIVE

The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t).

METHOD

We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access.

RESULTS

The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology.

CONCLUSIONS

More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

Comparison shopping: Is neuropsychological evaluation more expensive than neuroimaging?

OBJECTIVE

This study empirically examined if neuropsychological evaluation (NPE) is expensive compared to other diagnostic procedures such as neuroimaging.

METHOD

We aggregated data on charges for NPE and common neuroimaging procedures (e.g., head CT and brain MRI) from hospitals in the U.S. Charges for five-hour NPE and eight-hour NPE were compared to charges for head CT and brain MRI, respectively. Difference scores were calculated between five-hour NPE and head CT and between eight-hour NPE and brain MRI. A charge difference of $250 or less was considered minimal. NPE and neuroimaging charges were compared across U.S. regions.

RESULTS

Median head CT charges were $1942 to $2699. Median brain MRI charges were $3103 to $4487. Median five-hour NPE charges were $1855 to $1977. Median eight-hour NPE charges were $2757 to $2917. Head CT and five-hour NPE charges were not significantly different. Eight-hour NPE and brain MRI charges were not significantly different. Charge differences between five-hour NPE and head CT were minimal in 32.3% of hospitals. Charge differences between eight-hour NPE and brain MRI were minimal in 21.2% of hospitals. U.S. regions were not significantly different in charges for NPE or neuroimaging.

CONCLUSIONS

Findings provide preliminary data on charges for NPE in relation to charges for common imaging procedures. NPE does not appear to be more expensive than neuroimaging and, in fact, appears comparable. Future research might expand the information on NPE charges to include additional settings.

Integrating Neuropsychology into Interprofessional Geriatrics Clinics

Interprofessional healthcare teams are increasingly viewed as a clinical approach to meet the complex medical, psychological, and psychosocial needs of older adult patients. Despite the fact that older adults are at risk for cognitive difficulties, neuropsychologists are not routinely included on Geriatrics consult teams. The primary aim of this paper is to highlight the utility of neuropsychology within an interprofessional Geriatrics consult clinic. To address this aim, we describe specific benefits to patient care that may be associated with the inclusion of neuropsychologists on Geriatrics consult teams, including differential diagnosis, enhanced patient care, and reduced barriers to care. We provide a description of the integration of neuropsychology within a Veterans Health Administration (VA) interprofessional Geriatrics consult clinic team in order to illustrate the implementation of this model.

Neurocognitive risk in sickle cell disease: Utilizing neuropsychology services to manage cognitive symptoms and functional limitations

Sickle cell disease (SCD) is an inherited blood disorder that is associated with developmental delays and neurocognitive deficits. This review details key findings related to neurocognitive outcomes for children and adults with emphasis on the impact of neurological correlates and disease severity. Associations between neurocognition, demographic factors and social determinants of health are also reviewed. Emerging literature has reported on the neurocognitive impact of SCD in children and adolescents in Africa and Europe, including children from immigrant communities. Neurocognitive deficits are linked to poor functional outcomes, including transition from paediatric to adult care, medication adherence and unemployment. Integrating neuropsychology into multidisciplinary care for individuals with SCD can assist with identification and management of neurocognitive concerns, intervention development, individualized care plan development and continued multidisciplinary research.

Gender Differences in Veterans Referred for Neuropsychological Evaluation in an Outpatient Neuropsychology Consultation Service

OBJECTIVE

The number of women veterans seeking Veterans Health Administration services has substantially increased over the past decade. Neuropsychology remains an understudied area in the examination of gender differences. The present study sought to delineate similarities and differences in men and women veterans presenting for neuropsychological evaluation in terms of demographics, referral, medical conditions, effort, and outcome diagnosis.

METHOD

A database collected from an outpatient VA neuropsychology clinic from 2013 to 2019 was analyzed (n = 232 women, 2642 men). Additional analyses examined younger (n = 836 men, 155 women) and older (n = 1805 men, 77 women) age cohorts.

RESULTS

Women veterans were younger and more educated than men, whereas men had higher prevalence of vascular risk factors. Both groups were most often referred from mental health clinics and memory was the most common referral question. Although men performed worse on performance validity measures, clinicians rated women as evidencing poorer effort on a cumulative rating based on formal and embedded performance validity measures, behavioral observations, and inconsistent test patterns. Older women reported more depressive symptoms than older men and were more commonly diagnosed with depression.

CONCLUSIONS

This exploratory study fills a gap in the understanding of gender differences in veterans presenting for neuropsychological evaluations. Findings emphasize consideration for the intersection of gender with demographics, medical factors, effort, and psychological symptoms by VA neuropsychologists. A better understanding of relationships between gender and these factors may inform neuropsychologists' test selection, interpretation of behavioral observations, and diagnostic considerations to best treat women veterans.

Return on Investment and Value Research in Neuropsychology: A Call to Arms†

There is substantial empirical evidence to support the clinical value of neuropsychological evaluation and the incremental value of neuropsychological assessment, suggesting such evaluation is beneficial in the prediction and management of clinical outcomes. However, in the cost-conscious and evolving era of healthcare reform, neuropsychologists must also establish the economic value, or return on investment, of their services. There is already a modest body of literature that demonstrates the economic benefits of neuropsychological evaluation, which is reviewed in the current paper. Neuropsychologists will need to be able to communicate, and develop evidence of, economic value of their services; thus, this paper also discusses common concepts, terms, and models used in healthcare valuation studies. Finally, neuropsychologists are urged to incorporate these financial concepts in their clinical practice and research.

The incremental value of neuropsychological assessment: A critical review

Objective: The purpose of this critical review was to evaluate the current state of research regarding the incremental value of neuropsychological assessment in clinical practice, above and beyond what can be accounted for on the basis of demographic, medical, and other diagnostic variables. The focus was on neurological and other medical conditions across the lifespan where there is known risk for presence or future development of cognitive impairment.Method: Eligible investigations were group studies that had been published after 01/01/2000 in English in peer-reviewed journals and that had used standardized neuropsychological measures and reported on objective outcome criterion variables. They were identified through PubMed and PsychInfo electronic databases on the basis of predefined specific selection criteria. Reference lists of identified articles were also reviewed to identify potential additional sources. The Grades of Recommendation, Assessment, Development and Evaluation Working Group's (GRADE) criteria were used to evaluate quality of studies.Results: Fifty-six studies met the final selection criteria, including 2 randomized-controlled trials, 9 prospective cohort studies, 12 retrospective cohort studies, 21 inception cohort studies, 2 case control studies, and 10 case series studies. The preponderance of the evidence was strongly supportive with regard to the incremental value of neuropsychological assessment in the care of persons with mild cognitive impairment/dementia and traumatic brain injury. Evidence was moderately supportive with regard to stroke, epilepsy, multiple sclerosis, and attention-deficit/hyperactivity disorder. Participation in neuropsychological evaluations was also associated with cost savings.Conclusions: Neuropsychological assessment can improve both diagnostic classification and prediction of long-term daily-life outcomes in patients across the lifespan. Future high-quality prospective cohort studies and randomized-controlled trials are necessary to demonstrate more definitively the incremental value of neuropsychological assessment in the management of patients with various neurological and other medical conditions.

Integration of neuropsychology services in a sickle cell clinic and subsequent healthcare use for pain crises

Objective: Growing literature has documented the clinical utility of neuropsychological evaluations for predicting functional outcomes, including reduced healthcare service utilization, in a variety of clinical samples. The present study investigates the relationship between the integration of clinical neuropsychology services into an existing outpatient sickle cell clinic and frequency of emergency department (ED) visits and hospitalizations for pain crises. Method: Participants included 144 adults diagnosed with sickle cell disease (SCD) who either underwent neuropsychological evaluation (NP+), including interview, neuropsychological testing, and feedback, or treatment as usual (NP-). Medical records were reviewed for a two-year period, one year prior to study enrollment (pre-assessment) and one year post-study enrollment (post-assessment), to track the number of ED visits and hospitalizations related to sickle cell pain crises. Results: When examining pain crises ED visits prior to and following neuropsychological evaluation, there was a significant decrease in ED visits for the NP + group, but no change for the NP - group. No significant changes in pain crises hospitalizations were observed for the NP + and NP - groups. For the NP + group, the decreased incidence of pain crises ED visits and hospitalizations was associated with an estimated total cost savings of $994,821. Discussion: Results highlight that integration of neuropsychology services into an existing outpatient sickle cell clinic may reduce healthcare costs, particularly use of pain crises ED services, for adults with SCD.

The utility of neuropsychological consultation in identifying medical inpatients with suspected cognitive impairment at risk for greater hospital utilization

OBJECTIVE

This was a retrospective study designed to examine the relationship between inpatient neuropsychological status and future utilization costs.

METHODS

We completed a retrospective chart review of 280 patients admitted to a large academic medical center who were referred for bedside neuropsychological evaluation. Patients were grouped based on neuropsychological recommendation regarding level of supportive needs post-discharge (low, moderate, high). Level of support was used as a gross surrogate indicator of cognitive status in this heterogeneous sample. We also included patients who refused assessment. Outcome variables included time to readmission, number of emergency department visits, inpatient admissions, length of hospitalization, and total costs of hospitalizations, 30 days and 1 year following discharge.

RESULTS

Multivariate analysis indicated patients who refused assessment had higher inpatient service utilization (number of ED visits, number of admissions, and total cost of hospitalization) compared to those with moderate needs. Also, high needs patients had higher total cost of hospitalization at 1 year, and those with low needs used the ED more, compared to those with moderate needs.

CONCLUSIONS

Our findings replicate prior studies linking refusal of neuropsychological evaluation to higher service utilization costs, and suggest a nonlinear relationship between cognitive impairment severity and future costs for medical inpatients (different groups incur different types of costs). Results preliminarily highlight the potential utility of inpatient neuropsychological assessment in identifying patients at risk for greater hospital utilization, which may allow for the development of appropriate interventions for these patients.

Toward patient-centered outcomes for cognitive evaluations: the perspective of those affected by Parkinson's disease

OBJECTIVE

Patient-centered outcomes research is predicated on the idea that the opinions, attitudes, and preferences of patients should help inform study design and interpretation. To date, little is known about what defines patient-centered outcomes from cognitive evaluations. The current evaluation sought to explore this issue in persons with Parkinson's disease (PwPD) and their care partners (CP).

METHOD

Focus groups of 22 PwPD/CP dyads were conducted to identify potential consumer oriented endpoints from cognitive evaluations. These endpoints were utilized to create a Patient-Centered Cognitive Assessment Outcomes Scale, which was administered to a different group of 50 PwPD/CP dyads who rated the importance of each outcome and identified their top three priority outcomes.

RESULTS

Three themes emerged from the focus groups: improved knowledge, advice, and planning. Both PwPD and CP rated items in all three domains as being very important outcomes. Priorities for outcomes in both groups favored treatment planning information slightly above knowledge based outcomes.

CONCLUSIONS

The PwPD and CP identified improved knowledge, advice for daily activities, and knowledge they could use to plan for future eventualities as very important. This information can be used as a framework for future studies aimed at demonstrating patient-centered outcomes from neuropsychological evaluations. Implications for future research are discussed.

Retaining homeless veterans in outpatient care: a pilot study of mobile phone text message appointment reminders

OBJECTIVES

We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows.

METHODS

We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation.

RESULTS

Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI]  = 2.2, 17.8; P = .01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI = -0.4, 6.4; P = .08).

CONCLUSIONS

Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.