Clinical Neuropsychology in North America: What the First ...
Transcript of Clinical Neuropsychology in North America: What the First ...
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Neuropsicologia Clinica:
Fundamentacion y Trayectoria en el Conjunto de la Psicologia
Antonio E. Puente
Avances en Neuropsicologia ClinicaFundacion Mapfre
MadridOctubre 26, 2006
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Vision General
• Parte I– La Construcion de Una Neuropsicolgia Global
de Una Perspectiva Personal• Parte II
– Fundamentacion y Trayectoria en el Conjuntode la Psicologia
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Revision: Parte I
• Temas Cientificos• Temas Clinicos• Temas Politicos
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Revision: Parte II
• La Neuropsicologia en el Contexto de la Psicologia
• Revision de 25 Anos de la Practica de Neuropsicologia
• Estatus Actual de la Practica de Neuropsicologia
• La Relacion a la Medicina• Amenazas y Oportunidades
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Asociados de APAYear Doctorate Masters Bachelors
1970 1505 457 2975 2183 19077 14602
1980 1921 1333 4096 5812 15440 26653
1990 1566 2245 3377 7353 15336 38616
2000 1405 2905 3552 10913 17402 56600
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APA Membership by Division
• Aproximadamente 150,000 Asociados• Aproximadamente 50 Diferente Divisiones• Las Tres Divisiones Mas Grandes:
– Clinical Psychology– Clinical Neuropsychology– Independent Practice
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Que es la NeuropsicologiaClinica?
• Estudio y practica de la relacion entre cerebro y conducta, especialmente aunque no exclusivamente en pacientes neurologicos
• Aproximadamente 4-5,000 neuropsicologos (de 150,000 psicologos)
• Doctorado con entranamiento de postgraduado
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Historia: Organizacional
• American Psychological Association- 1892• Division of Clinical Neuropsychology- 1980• National Academy of Neuropsychology-
1980• International Neuropsychological Society-
1975
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Historia: Informacional• Publicaciones
– Libros (Goldstein)– Revistas (International Journal of Clinical
Neuropsychology)• Tendencias
– Evaluacion– Rehabilitacion– No Relacionado a la Salud
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Historia: Neuropsicologos
• Tendencias Generales– Patrones de crecimiento– Patrones demograficos– Patrones clinicos
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Historia: Activades Profesionales
• Evaluacion– Fixed Battery (Halstead-Reitan Vs. Luria-Nebraska)– Flexible Approach
• Rehabilitacion– Cognitive Rehabilitation
• Forensic– Discapacidad– Compesacion– Dano Personal– Pena de Muerte
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La Practica de la Neuropsicologia Clinica
• Resumen de Actividades Profesionales• Relacion a la Medicina
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Estudio Sobre la Practica de la Neuropsicologia Clinica
• National Academy of Neuropsychology• Division of Clinical Neuropsychology of the
APA• Jerry Sweet & Ted Peck• Date: 2001-2002
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Asociados(Todos clinicos doctorados)
05
101520253035404550
NAN only(n=156)
D40 only(n=276)
Both(n=670)
Unknown(n=304)
Percent
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Sexo
62.3
37.7
0
10
20
30
40
50
60
70
Male (n=871) Female (n=528)
Percent Age: Males = 48.6 (n=866)Females = 45.5 (n=524)
Years Since Licensed: Males = 14.6 (n=855);Females = 10.1 (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%
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Tipo de Doctorado
0102030405060708090
PhD (n=1225) PsyD (n=143) EdD (n=24)
Percent
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Campo de el Doctorado
0
10
20
30
40
50
60
70
Clinical Couns. Neuro. School Ed. Psy. Comb.
Percent
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Lugar de Trabajo
05
101520253035
40
PrivatePractice
Institution Comb. Other
Percent
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Activades ProfesionalesSemaneles
por organizacion
01020304050607080
Clinical Pract.
Teach. Research($)
Res. (No $)
Non-ClinAdmin.
NAN D40 Both Unknown
Percent
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Activades ProfesionalesSemaneles
por organizacion
01020304050607080
Supervision Forensic
NAN D40 Both Unknown
Percent
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Reembolso por Fuentes (%)
0
5
10
15
20
25
30
Managed Care
Medi- care
IndemnityInsur
Self Pay
CHAMPUS Public Aid
Indigent Forensic
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Tiempo por Actividad
319260
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
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Uso de Asistentes
51.2 48.8
0
10
20
30
40
50
60
Yes (n=692)
No (n=660)
Percent
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Relaciones EntreNeuropsicologia Clinica y
Cuidados de la Salud
• Neuropsicologia Como Parte de Psicologia
• Psicologia Como Parte de la Salud• Current Procedural Terminology Como un
Modelo para la Comprension del CuidadoGlobal de la Salud
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Medicare
• El Estandar Universal para Cuidados de la Salud:– Codificacion (lo que se puede hacer)– Valor (lo que pagan)– Documentacion (que se necesita ser escrito)– Auditoria (determinacion si de hecho ocurrio)
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Que es un CPT?
• Un Sistema de Codificacion de TrabajoProfesional
• Cada Codigo Tiene un Valor• El Servico esta Provisto Nacionalmente• Muchos Profesionales Desempenar los
Servicios• La Eficacia Clinica esta Establecida y
Documentada en la Literatura Cientifica
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Current Procedural Terminology (CPT)
• Background• Codigos• Sistema Modelo X Tipo de Problema• Necesidad Medica• Documentacion• Tiempo
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CPT: Background
• American Medical Association– Desarrollado por Cirujanos (& medicos) en
1966 – 7,500+ Codigos
• Center for Medicare & Medicaid Services– AMA bajo de licencia de CMS– CMS ahora provee input activo dentro de
CPT
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CPT: Composicion
• AMA House of Delegates– 109 Espacialidades Medicas– HCPAC– 11 Allied Health Societies (e.g., APA)
• CPT Panel Editorial– 17 Miembros Votantes
• 11 designado por AMA• 1 por cada uno para BC/BS, AHA, HIAA, CMS• 2 HCPAC
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CPT: Teoria
• Orden de Valor- Personal– De Cirujanos a Medicos a Otros
• Orden de Valor- Trabajo– Trabajo cognitivo, gastos, seguro
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Ciencia, Practica & Economia
• Desarollo de Codigos Especificos– 5-12 años de procesos– Representates de todo campos de salud
tienen apoyar el cambio– Cada codigo tiene un valor que esta
relacionado a el presupuuesto nacional parala salud
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CPT:Desarollo de Codigos
• Inicio– Health Care Advisory Committee (non-MDs)
• Primero– CPT Work Group (organizaciones
selecionadas)– CPT Panel (solo especialistas)
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Codigos Aplicables: CPT
• Total de codigos posibles = 7,500• Codigos posibles para psicologia = Approximadamente 40 to 60• Tres Paradigmas
– Psiquiatria/Salud Mental – Neurologia– Medicina
• Secciones = cinco secciones separadas– Psiquiatria– Biofeedback– Evaluacion Nerviosa Central– Medicina Fisica y Rehabilitacion– Salud & Conduucta Evaluacion & Manejo
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CPT: Desarrollo de un Codigo
• Inicio– Health Care Advisory Committee (non-MDs)
• Prioritario– Grupo de trabajo CPT (Organizaciones
seleccionadas)– CPT Panel (solo especialistas)
• Tiempo estimado– 3-5 años sobre una decada
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CPT: Psiquiatria
• Secciones– Entrevista (90801) vs. Intervencion (e.g., 908.06)– Oficina vs. Interno– Regular vs. Evaluacion & Manajo– Otro
• Tipos de Intervenciones– Insight, modificacion de conducta, y/o suporte vs.
Interaccion
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Examen de EstatusNeuroconductual
• 96116 – Examen de Estatus Neuroconductual– Evaluacion Clinica de Pensamiento, razonamiento y
Juicio ( e.g., conocimiento adquirido, atencion, lenguaje, memoria, planificacion y resolucion de problemas, y habilidades visuoespaciales) por horade tiempo de psicologo o medico, ambos cara a cara con el paciente y tiempo en la interpretacion de los resultados y preparacion de informe.
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Evaluacion Neuropsicologica porProfesional
• 96118 – Evaluacion Neuropsicologica– (e.g., Halstead-Reitan Neuropsychological,
WMS, Wisconsin Card Sorting) por hora de psicologo o medico, ambos cara a cara con el paciente y el tiempo en interpretar los resultados del test y preparar el informe.
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Evaluacion Neuropsicologica porun Tecnico
• 96119 – Evaluacion Neuropsicologica– (e.g., Halstead-Reitan Neuropsychological,
WMS, Wisconsin Card Sorting) por un profesional de la salud calificadointerpretacion e informe, administrado por un tecnico por hora de tiempo de tecnico, cara a cara
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Evaluacion Neuropsicologica porComputador
• 96120 – Evaluacion Neuropsicologica– (e.g., WCST) administrado por un
computador por un profesional de la saludcalificado interpretacion e informe
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CNS Ejemplos de Evaluacion
• Estatus Neuroconductual con evaluacionneuropsicologica– Entrevista por profesional– Evaluacion por
• Profesonal, y/o• Tecnico, y/o• Computador.
– Interpretacion & Informe escrito por un Profesional de la salud Calificado
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CPT: Salud & ConductaEvaluacion & Manajo
(CPT Assistant, 03.04)(CPT Assistant, 08.05, 15, #6, 10)
• Proposito: diagnostico medico• Tiempo: 15 Minutos Incrementos• Evaluacion• Intervencion
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Salud & ConductaCodigos de Evaluacion• 96150
– Evaluacion de Salud y Conducta (e.g., Entrevista clinica focalizada en salud, observaciones conductuales, monitoreopsicofisiologico, cuestionarios orientados a la salud)
– Cada 15 minutos– Cra a ccara con el paciente– Evaluacion inicial
• 96151– Re-evaluacion
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Salud & ConductaCodigos de Intervencion
• 96152– Intervencion en salud y conducta– Cada 15 minutos– Cara a cara– individual
• 96153– grupal (2 o mas pacientes)
• 96154– familia (con el paciente presente)
• 96155 (aceptabilidad limittada)– familia (sin el paciente presente; no es reembolsado)
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CPT: Sistema Modelo
• Psiquiatrico• Neurologico• No-Neurologico Medico
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CPT: Diagnostico
• Psiquiatrico– DSM
• El problema con el DSM y la evaluacionneuropsicologica de problemas del desarrolloneurologicamente relacionados
• Lo medico Neurologico & No-Neurologico– ICD – 9 CM (codificacion de diagnostico
fisico)– www.cdc.gov/nchs/about/otheract/icd9
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Medicamente Rasonabley Necesario
Section 1862 (a)(1) 196342, C.F.R., 411.15 (k)
• “Servicios que son razonables y necesarios para el diagnostico y tratamiento de enfermedad o lesion o para el mejoramiento del funcionamiento de una parte malformada del cuerpo”
• Re-evaluacion deberia ocurrir solo cuando hay un cambio potencialen;– Diagnostico– Sintomas
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Documentacion: Informacion basica a traves de los codigos
• Fecha• Tiempo, si se aplica• Identificacion del Evaluador (tecnico ?)• Razon del servicio• Estatus• Procedimiento• Resultados/hallazgos• Impresion/Diagnostico• Disposicion
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Tiempo: Definicion
• AMA Definicion de tiempo
• Medico tambien ocupan tiempo durante el trabajo , despues, o antesde el tiempo cara a cara con el paciente, desempeñando tareastales como revisar codigos registros & tests, appuntando otros servicios & communicandosecon otros profesionales & el paciente a traves de informes escritos & contacto telefonico.
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Tiempo: Definido Minutos
(www.cms.hhs.gov/manuals/104_claims/clm104c05.pdf)
• Definidos 15 Minutos de Incremento– Unidades Monto de minutos
• 1 >08; <23• 2 >22; <38• 3 >38; <53• 4 >53; <68• 5 >68; <83• 6 >83; <98• 7 >98; <113• 8 >113;<128• Mas de 2 horas patron similar al de arriva
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RVU: Componentes
• Valor del Recurso Trabajo medico• Valor del recurso ocupado en la
practica• Malpractica• Geografico• Conversion Factor (approx. $37.8975
02.2005)
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Definiendo TrabajoMedico
• Trabajo Clinico– Juicio y esfuerzo mental– Esfuerzo tecnico fisico/habilidad– Estres psicologico
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Valores Nacionales RVU 2006 op=outpatient, ip=inpatient, est=estimado
Codigo # OP RVU IP RVU OP $ est IN $est96101 2.56 2.54 92.61 91.8996102 1.17 0.68 42.33 24.6096103 0.74 0.70 26.77 25.3296116 2.87 2.68 103.83 96.9596118 3.43 2.67 124.09 96.5996119 1.75 0.92 63.31 33.2896120 1.27 0.70 45.94 25.32
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Tiempo Para el Futuro
• Es la historia el mejor predictor de nuestro futuro?
• Una vision del futuro de la neuropsicologiaClinica
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Cuales Tendencias Estan en Desarrollo?
• Organizacional• Informacional• Profesonal (versus Clinica)• Financiera• Politicas Publicas
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Tendencias GeneralesPotenciales
• Interelacion & Dejando Psiquiatria• Interelacion & Dejando Medicina• Futuro
– Legal– Deportes– Gubernamental– Industrial
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Problemas de el Futuro
• Base de Datos Empirica• Limitado Entendimiento de la Cultura• Continua Disputa Profesional• Temas Personales• Valor para la Sociedad (aparente vs
velidez de criterio)
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Oportunidades Futuras
• Continuo Crecimiento• Especialmente en los Dominios
Profesionales• Inesperado e Inpredecible pero
Excitante