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Clinical Neuropsychology in Clinical Neuropsychology in North America:North America:
What the First Twenty Five Years Might Tell What the First Twenty Five Years Might Tell Us About the Future of the SpecialtyUs About the Future of the Specialty
Antonio E. PuenteAntonio E. PuenteDepartment of PsychologyDepartment of Psychology
University of North Carolina at WilmingtonUniversity of North Carolina at Wilmington
Wilmington, North Carolina 28403Wilmington, North Carolina 28403
www.uncw.edu/people/puentewww.uncw.edu/people/puente
www.clinicalneuropsychology.uswww.clinicalneuropsychology.us
[email protected]@uncw.edu
OutlineOutline
IntroductionIntroduction Brief Overview of Twenty Five YearsBrief Overview of Twenty Five Years Current StatusCurrent Status Projections for the FutureProjections for the Future Challenges, Pitfalls and OpportunitiesChallenges, Pitfalls and Opportunities
History: OrganizationalHistory: Organizational
American Psychological AssociationAmerican Psychological Association Division of Clinical Neuropsychology (40)Division of Clinical Neuropsychology (40) National Academy of NeuropsychologyNational Academy of Neuropsychology International Neuropsychological SocietyInternational Neuropsychological Society Other issues/groups;Other issues/groups;
APA’s First Specialty (1996)APA’s First Specialty (1996) Board Certification (e.g., ABPN)Board Certification (e.g., ABPN) Licensure (e.g., Louisiana)Licensure (e.g., Louisiana) Specialty Groups (e.g., Pediatrics)Specialty Groups (e.g., Pediatrics)
History: InformationalHistory: Informational
PublicationsPublications BooksBooks JournalsJournals OnlineOnline
TrendsTrends AssessmentAssessment RehabilitationRehabilitation ForensicForensic
History: PersonnelHistory: Personnel
Overall TrendsOverall Trends Growth PatternsGrowth Patterns Demographic PatternsDemographic Patterns Academic Vs. ClinicalAcademic Vs. Clinical
IndividualsIndividuals ReitanReitan GoldenGolden KaplanKaplan OthersOthers
History: Clinical ActivitiesHistory: Clinical Activities
AssessmentAssessment Fixed Battery (Halstead-Reitan Vs. Luria-Fixed Battery (Halstead-Reitan Vs. Luria-
Nebraska)Nebraska) Flexible ApproachFlexible Approach
RehabilitationRehabilitation Cognitive RehabilitationCognitive Rehabilitation
ForensicForensic DisabilityDisability Worker’s CompensationWorker’s Compensation
Current Status: Review of the Current Status: Review of the SurveysSurveys
Brief History of SurveysBrief History of Surveys HartlageHartlage DeLuca & PutnamDeLuca & Putnam
Current Survey MethodologyCurrent Survey Methodology Sweet & PeckSweet & Peck Division 40 and NANDivision 40 and NAN
APA MembershipAPA MembershipYear Doctorate Masters Bachelors
1970 1505 457 2975 218319077 14602
1980 1921 1333 4096 5812 15440 26653
1990 1566 2245 3377 7353 15336 38616
2000 1405 2905 3552 10913 17402 56600
APA Membership by DivisionAPA Membership by Division
Approximately 150,000 membersApproximately 150,000 members Approximately 50 different divisionsApproximately 50 different divisions Top three divisions are:Top three divisions are:
Clinical Psychology Clinical Psychology Clinical NeuropsychologyClinical Neuropsychology Independent PracticeIndependent Practice
What is Clinical What is Clinical Neuropsychology?Neuropsychology?
Study and practrice of the relationship Study and practrice of the relationship between brain and behavior, especially between brain and behavior, especially in neurological patientsin neurological patients
Approximately 4-5,000 (out of 150,000)Approximately 4-5,000 (out of 150,000) Doctorate with post-doctorate training is Doctorate with post-doctorate training is
minimum requirementminimum requirement Difficulties in agreement of definitionDifficulties in agreement of definition
Survey of Clinical Survey of Clinical NeuropsychologyNeuropsychology
National Academy of National Academy of NeuropsychologyNeuropsychology
Division of Clinical Neuropsychology Division of Clinical Neuropsychology of the APAof the APA
Surveyors: Jerry Sweet & Ted PeckSurveyors: Jerry Sweet & Ted Peck Date: 2001-2002Date: 2001-2002
Survey Return RatesSurvey Return Rates
ActualActual Return Rate Return Rate 1569 returns1569 returns 5791 mailed5791 mailed
1569/5791 = 1569/5791 = 27.127.1%%
AdjustedAdjusted Return Rate Return Rate Or returns, 1406 Or returns, 1406
U.S., Doctoral, U.S., Doctoral, Licensed, CliniciansLicensed, Clinicians
Of mailed, 1590 Of mailed, 1590 excluded excluded (duplicates, (duplicates, unintended, unintended, undelivered)undelivered)
1406/4201 = 1406/4201 = 33.533.5%%
Organizational Organizational MembershipMembership
(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
05
101520253035404550
NAN only(n=156)
D40 only(n=276)
Both(n=670)
Unknown(n=304)
Percent
Gender Gender (All Doctoral Licensed Clinicians vs. (All Doctoral Licensed Clinicians vs.
Younger Samples)Younger Samples)62.3
37.7
0
10
20
30
40
50
60
70
Male (n=871) Female (n=528)
Age: Age: Males = 48.6 Males = 48.6 (n=866)(n=866)
Females = 45.5 Females = 45.5 (n=524)(n=524)
Years Since Licensed: Years Since Licensed: Males = 14.6 Males = 14.6 (n=855);(n=855); Females = 10.1 Females = 10.1 (n=508)(n=508)
--------------------------------------------------------------------
Among licensed <10 years: (n=525) Males = 48.6% Females = 51.4%
Among licensed <5 years: (n=216) Males = 36.6% Females = 63.4%
Percent
Type of Doctoral DegreeType of Doctoral Degree (All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
80
90
PhD (n=1225) PsyD (n=143) EdD (n=24)
Percent
Field of Doctoral DegreeField of Doctoral Degree(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
Clinical Couns. Neuro. School Ed. Psy. Comb.
Percent
Work StatusWork Status(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
80
Full Time Part Time Full + Part NotWorking
Percent
Work SettingWork Setting(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
0
5
10
15
20
25
30
35
40
PrivatePractice
Institution Comb. Other
Percent
Gender Within Work Gender Within Work SettingSetting
(Doctoral Licensed Clinicians)(Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
Private Institution Comb. Other
Male Female
Percent
Board Certification StatusBoard Certification Status(Doctoral Licensed Clinicians)(Doctoral Licensed Clinicians)
0
10
20
30
40
50
60
70
80
Board Certified(n=271)
Not Board Certified(n=1053)
Percent
Weekly Professional Activities Weekly Professional Activities by Organizationby Organization
01020304050607080
Clinical Pract.
Teach. Research($)
Res. (No $)
Non-ClinAdmin.
NAN D40 Both Unknown
Percent
Weekly Professional Activities Weekly Professional Activities by Organizationby Organization
01020304050607080
Supervision Forensic
NAN D40 Both Unknown
Percent
Percentages of Percentages of Reimbursement SourcesReimbursement Sources
(For All Doctoral Licensed Clinicians)(For All Doctoral Licensed Clinicians)
0
5
10
15
20
25
30
Managed Care
Medi- care
IndemnityInsur
Self Pay
CHAMPUS Public Aid
Indigent Forensic
Incomes by OrganizationIncomes by Organization(Doctoral Licensed Clinicians Working (Doctoral Licensed Clinicians Working
Full Time or Full Time+)Full Time or Full Time+)
78,228
99,296 107,856 108,794 103,336
0
20,000
40,000
60,000
80,000
100,000
120,000
NAN n=125
D40n=223
Bothn=581
Unkn.n=259
Overalln=1188
Mean Median
$
Correlates of IncomeCorrelates of Income
Years licensed .27**Years licensed .27** Work Setting Work Setting -.25-.25**** % Forensic .24**% Forensic .24** Gender Gender -.21-.21**** % Self Pay .19**% Self Pay .19** Age .18**Age .18**
Hrs Hrs billed/Eval .13**billed/Eval .13**
% Public Aid % Public Aid -.12-.12**** % Medicare % Medicare -.09-.09** % Man. Care % Man. Care -.09-.09** % Indemnity .07% Indemnity .07 % Indigent % Indigent -.04-.04
*=.05 **=.01 *=.05 **=.01 Negative correlations in red.Negative correlations in red.““Work Setting” above limited to Private and InstitutionWork Setting” above limited to Private and Institution
All All nns between 775 and 1185s between 775 and 1185
Income by Years of Income by Years of LicensureLicensure
0 Yrs $44,763 (47K)
1-5 73,567 (63K)
6-10 93,172 (77K)
11-15 109,457 (88K)
16-20 118,776 (93K)
21-25 126,979 (102K)
26-30 152,359 (120K)
0 Yrs $44,763
1 66,810 (56K)
2 61,512 (61K)
3 69,061 (60K)
4 94,800
4 (minus outlier)
78,641 (70K)
5 73,596 (65K)
Stratification - Mean (Median) ‘Starting’ Salaries - Mean (Median)
Income by Work SettingIncome by Work Setting(Doctoral Licensed Clinicians Working Full (Doctoral Licensed Clinicians Working Full
Time or Full Time+)Time or Full Time+)127318
105000
7646370000
105149
87750
$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
Private (n=424)
Institution(n=378)
Comb. (n=358)
Mean Median
HOURS/Week Clinical ActivityHOURS/Week Clinical Activity
3.32.1
13.73.7
2.12.5
4.90.6
2.22.1
0 5 10 15
DX Interv Nbeh Ex Npsy Test Psy TestF/ Up Ass. TX (BD) TX (No BD) CogRehTx plan Superv
Evaluation Time by Evaluation Evaluation Time by Evaluation GoalGoal
6.3
4.4
4.2
4.8
9.3
0 2 4 6 8 10
Determ DX (n=1022) (1-16)
TX Plan (n=914) (.5-12)
Pre/ Post (n=566) (1-10)
Baseline (n=784) (1-10)
Forensic (n=790) (1-20)
(Except forensic, those using assistants test more hours (e.g., for determination of diagnosis, 6.6 hrs vs. 5.8 hrs, p=.017.) However, hours billed are similar.
Time-Related Case ActivitiesTime-Related Case Activities(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
319
260
050
100150200250300350
IntakeInterview
Rec Rev
Test Admin
Scoring *
Interp/ Rep
Feedback
Cons Ref So
Private Institution
Hours billed: Private=11.1 (SD=5.0); Institution=8.2 (SD=3.3)* Only scoring is not significant between groups; covarying amount of forensic practice did not eradicate group differences
Minutes
Use of Testing AssistantsUse of Testing Assistants(All Doctoral Licensed Clinicians)(All Doctoral Licensed Clinicians)
51.2 48.8
0
10
20
30
40
50
60
Yes (n=692)
No (n=660)
Percent
Use Of Testing Assistants By Use Of Testing Assistants By Work SettingWork Setting
72
48
46
51
39
0 20 40 60 80
Private Practice
Institution
Combination
Other
Total
Percent Using Assistants(n=1349)
CPT Code for Activities Frequency Percent
Intake Interview 90801 96117 96115 Other (16 codes)
2311064021
16.57.62.91.5
Clinical interview/history 90801 96117 96115 Other (20 codes)
2501805934
17.912.94.22.4
Test administration 96117 96100 96115 Other (12 codes)
498379
21
35.72.70.61.5
CPT Codes Used For Neuropsych Assessment Activities(Doctoral Level Clinicians)
CPT: Applicable CodesCPT: Applicable Codes
Total Possible Codes = 7,500Total Possible Codes = 7,500 Possible Codes for Psychology = Approximately Possible Codes for Psychology = Approximately
40 to 6040 to 60 Three ParadigmsThree Paradigms
Psychiatry/Mental HealthPsychiatry/Mental Health NeurologyNeurology MedicineMedicine
Sections = Five Separate SectionsSections = Five Separate Sections PsychiatryPsychiatry BiofeedbackBiofeedback Central Nervous AssessmentCentral Nervous Assessment Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation Health & Behavior Assessment & ManagementHealth & Behavior Assessment & Management
CPT: BackgroundCPT: BackgroundAmerican Medical Association
–Developed by Surgeons (& Physicians) in 1966 for Billing Purposes
–7,500 Discrete Codes
HCFA/CMS
–AMA Under License with CMS
–CMS Now Provides Active Input into CPT
Congress
–Trent Lott (2001)
Time for the FutureTime for the Future
Is History the Best Predictor for Our Is History the Best Predictor for Our Future?Future?
What are APA Members Worried What are APA Members Worried About?About?
My Own Personal Glimpse Into What My Own Personal Glimpse Into What Awaits Clinical NeuropsychologyAwaits Clinical Neuropsychology
Initial Results of APA Policy Initial Results of APA Policy & Planning Survey& Planning Survey
ProcedureProcedure Five Year Review of Status of APA & PsychologyFive Year Review of Status of APA & Psychology Random Survey of APA Membership, Staff, & Random Survey of APA Membership, Staff, &
GovernanceGovernance ResultsResults
Public Image of PsychologyPublic Image of Psychology Protecting & Expanding Sources of IncomeProtecting & Expanding Sources of Income Membership ConcernsMembership Concerns
What Trends Are DevelopingWhat Trends Are Developing
OrganizationalOrganizational InformationalInformational Professional (versus Clinical)Professional (versus Clinical) FinancialFinancial Public PolicyPublic Policy
Immediate Predictions Immediate Predictions Income (depends on activity; if clinical)
–Steadier (if economy does not further erode)
–Probable incremental declines, up to 10-20%
–“Final” stabilization by 2005
Recognition
–Physician Level
–Mental vs. Physical Health
Paradigms
–Industrial vs. Boutique
–Health vs. Non-Health
Potential Overall TrendsPotential Overall Trends
Catching up to PsychiatryCatching up to Psychiatry Leaving PsychiatryLeaving Psychiatry Joining MedicineJoining Medicine Leaving MedicineLeaving Medicine
LegalLegal SportsSports GovernmentalGovernmental IndustrialIndustrial
Future ProblemsFuture ProblemsEmpirical Data Base
Limited Understanding of Culture
Continued Professional Infighting
Personnel Issues
Value to Society (face vs criterion validity)
SummarySummary
Continued GrowthContinued Growth Especially in the Professional Especially in the Professional
DomainsDomains Expansion Beyond Mental Health, to Expansion Beyond Mental Health, to
Health, to Other AreasHealth, to Other Areas Vibrant and Unpredictable yet Vibrant and Unpredictable yet
ExcitingExciting
Defining the Defining the Future…Future…
New Paradigm = Change
