Neuropsychology is thriving but gender salary gap exists
By Paula Hartman-Stein, Ph.D.
Gone are the days of 10 to 15 hour neuropsychological test batteries to diagnose dementia or other neurological conditions. Pressure from managed healthcare and Medicare have reshaped the national norm toward brief, cost-effective test batteries, and surprisingly the majority of neuropsychologists are thriving.
According to a national survey funded by APA division 40 and the National Academy of Neuropsychology, nearly 60% of the 1406 neuropsychologists in the sample report greater income in the last five years while 30% experienced a cut in their pay, and 10% had no change.
Jerry Sweet, Ph.D. from Evanston, IL and Edward Peck, Ph.D. of Richmond, VA. presented the survey data at the recent APA convention in San Francisco. The median income level for neuropsychologists for both genders in full time private practice is $105,000, with an average income of approximately $127,000.
However, the report clearly disclosed a gender gap pay. The median income reported by full time male psychologists who work in either private practice or institutional settings is $95,000 while for full time female clinicians the median income level is $68,500. No reasons were cited in the survey for the disparity.
However, a reason for the difference may be that women tend to be hired by institutions rather than entering independent practice. Also, many women are new in the field, having entered neuropsychology during the past five years. The record for men in this specialty can be traced over a longer period. Another factor may be that women have caregiver responsibilities, and spend less time in paid professional activities than men.
The survey showed that over a quarter of the sample of neuropsychologists were reimbursed by managed care sources. The next top three sources of payment included forensic cases (19%), Medicare (17%), and self-pay (16%). Psychologists accepting Medicare cases had lower incomes overall.
About half of the respondents (51%) use testing assistants but this varied by work setting, with a third of neuropsychologists in private practice employing assistants. Those using assistants reported significantly higher incomes.
Addressing the ways that managed healthcare trends have impacted neuropsychology practice patterns, Gordon Chelune, Ph.D., past president of the National Academy of Neuropsychology and of APA Division 40, explained, There is a growing impetus to look for more bang for the buck. Third party payors expect greater documentation about what it is done during an evaluation, and it must be linked to some beneficial impact on the client, according to Chelune.
Alfred Kaszniak, Ph.D., professor at the University of Arizona, acknowledged that in the past there has been little emphasis on incremental validity of test instruments. He explained, If including more tests does not add to the answer of the referral question, then the use of the instrument is not justified.
Amy Monicatti Leyva, Psy.D. from Michigan, who was trained as a neuropsychologist and now specialized in geriatrics, exemplifies the trend toward briefer test batteries. I find there is not a need for complete neuropsychological testing for most patients. I typically see patients for only neurobehavioral assessments (typically at 2 hours) no more days of big memory scales and category tests, etc. Chelune believes that brief batteries may be useful in 80% of cases, but in complex cases curtailed testing may prove to be a disservice to the patient.
The national survey data illustrated that the time to complete a neuropsychological evaluation varied according to the type of referral. Diagnostic determinations were billed an average of 6.5 hours, with forensic cases billed the greatest time on average, 9.5 hours. The maximum number of hours per evaluation that Medicare allows for an evaluation varies according to geographic region, with 7 billable hours allowed on average.
Direct patient contact time comprised about half (48%) of the actual time billed by the psychologist. Across the board in all practice settings, the survey found that a substantial portion of time spent on clinical activities cannot be billed such as time spent before the evaluation begins and time consulting to the referral source.
Advances in radiologic imaging techniques appear to have limited impact on frequency of requests for neuropsychological evaluations. Common referral questions include differential diagnoses of neurogenic versus psychogenic conditions and to monitor recovery for patients with newly diagnosed medical conditions such as strokes. In University hospitals with specialty centers for dementia patients, neuropsychologists get involved with differential diagnosis of the type of dementia in order to guide the medication treatment regimen. Practitioners who work closely with primary care physicians help to diagnose and follow patients with mild cognitive impairment and recommend when the cholinesterase inhibitors, drugs used in early dementia, are appropriate to use.
Brief neuropsychological evaluations are a growing part of geropsychology practices and are valuable in recommending resources and care plans with family caregivers.
Innovative neuropsychologists are finding new niches for business. Paul Domitor, Ph.D. from Spokane, WA conducts neuropsychological evaluations as a pre-surgical screening to rule out dementing disorders and/or depressive disorders in very advanced Parkinsons patients. The neuropsychological evaluations are useful for rehab/treatment planning as well as to assess candidacy for deep brain stimulation techniques. According to Domitor, we have not had a problem with third parties covering some portion of those services.
The next hurdle in the reimbursement wars involving psychological testing is the Health Care Financing Administrations (HCFA) potential study of the work value of testing codes. In a controversial move, HCFA has considered splitting the codes into two parts, a professional and a technical component. HCFA has asked APA for its recommendations before a survey is planned. So stay tuned.
Paula E. Hartman-Stein, Ph.D. is a clinical psychologist and consultant who specializes in assessment and therapy with older adults at the Center for Healthy Aging in Kent, Ohio. She teaches on-line courses in geropsychology for the Fielding Institute in Santa Barbara. She can be reached through her website, www.centerforhealthyaging.com.
Hartman-Stein, P.E. (2001) Neuropsychology is thriving but gender salary gap exists. The National Psychologist, Vol. 10, No. 5, p 18, 19.