new developments in cognitive retraining programming & reimbursement

New Developments in

Cognitive Retraining

Programming

Richard Louis, III, Senior Associate, OPEN MINDS

The 2011 Planning & Innovation Institute

June 16, 2011

OPEN MINDS © 2011. All Rights Reserved.

Learning Objectives

Update on the developments in cognitive

retraining programs

Overview of the current applications of

cognitive retraining tools

Discuss the implications for behavioral health

care providers

2


An Overview Of The

Latest Developments

For Cognitive

Retraining

3


Cognitive Testing: “We‟ve Come Along Way

Baby”

Memory Check Cognitive Testing &

Assessment Program, operated by College

Health Enterprises

Launched in 2004

In partnership with Dr. Karen Miller, Ph.D,

UCLA Center for Aging

4



Assessment Program

Service: Provides cognitive testing and

assessment of adults 40 years and older who

are experiencing initial signs of memory loss

Assessment: 3 hour, battery of clinically

proven tests conducted in person by a licensed

Neuropsychologist

Where: Assessment conducted at the office of

the referring psychiatrist, primary care

physician, gerontologist, or neurologist

5



Assessment Program (cont.)

Report: Comprehensive 10-page written report

reviewed by the neuropsychologist with

referring physician

Physician meets with patient to present the

findings of report and prescribe treatment or

course of action

Reimbursement: Medicare

6


Scientific Discoveries Fueling Commercial

Neuroscience Offerings

Ability to monitor brain functionality using scanning

technologies and new biologic tests

Changing theory of brain development and maturity –

longer and later

Discovery of brain cell regeneration – role of physical

exercise, cognitive exercise, etc.

Better understanding of brain chemistry

Identification of genetic and epigenetic factors in

behavioral and cognitive disability

7


Recent Commercial Developments

Better diagnostics – brain scans, biomarkers, and

more – for mental, addictive, and cognitive

disorders

Innovative drug delivery systems – patches,

injectables, and genetically-designed drugs – for

mental illness, addictions, dementias, intellectual

disabilities

Virtual reality and alternative reality treatment

applications

Neurotech treatments

8


Neurotherapy Market Has Two Sectors

Stimulation-based or neuromodulation therapies Invasive

• Vagus nerve stimulation

• Deep brain stimulation

Non-invasive • Transcranial magnetic stimulation

• Light therapy

• Frequency-based light & sound neurotherapy

Exercise-based therapies Neurofeedback (EEG, HEG, & rt-FMRI)

Cognitive retraining

Mindfulness meditation

9


Definitions

Neurotechnology – Tools that analyze and influence the

human nervous system, especially the brain

Neuroplasticity - The brain's ability to reorganize itself by

forming new neural connections and allows the nerve cells in

the brain to compensate for injury and disease and to adjust

their activities in response to new situations or to changes in

their environment

Cognitive retraining – A therapeutic method of restoring or

improving cognitive skills

Brain fitness - Hypothesis that cognitive abilities can be

maintained or improved by exercising the brain, in analogy to

the way physical fitness is improved by exercising the body.

10


Randomized, Double-Blind Study Shows Computer-

Based Cognitive Training Improves Memory &

Attention

Older adults in a randomized, double-blind study, who

received computer-based cognitive training, improved their

memory and attention scores and doubled their cognitive

processing speed, with an average increase of 131%.

The training used The Brain Fitness Program™ software from

Posit Science. Compared to their performance before starting

training, the people improved their memory and attention so

much that their average scores matched age-expected memory

and attention function of adults ten years younger.

Participants reported significant improvements in daily

activities such as remembering names or participating in

conversations.

11


ADHD

Study assessed the impact of computerized attention

training and computerized instruction on measures of student

attention, academic achievement, academic productivity, and

student behavior.

Results showed that 6 out of 10 children with 6 or more

ADHD symptoms were asymptomatic after completing 6

months of Captain's Log training, when rated independently.

Only 2 out of 10 of these children who did not receive the

cognitive training became asymptomatic.

Ref: Rabiner D., Murray, D., Skinner, A., ―A Randomized

Trial of Two Promising Computer-Based Interventions for

Children with Attention Difficulties.‖ Journal of Abnormal

Child Psychology. 2010 38(1): 131-142.

12


Schizophrenia

After 8 hours of training using the Captain's Log system with

individuals with Schizophrenia, cognitive functioning for

verbal memory and attention were significantly improved and

the negative symptoms of schizophrenia were also reduced.

The importance of this finding is that negative symptoms

(lack of verbal output, lack of emotional responsiveness, lack

of social connectedness, and apathy) are not usually improved

via medication.

Ref: Bellucci, D.M., Glaberman, K., Haslam, N. (2003)

"Computer-assisted cognitive rehabilitation reduces negative

symptoms in the severely mentally ill." Schizophrenia

Research, 59, 225-232.

13


Traumatic Brain Injury

Study looked at TBI patients with working memory problems and used a

cognitive rehabilitation treatment program to specifically train them to

improve their working memory skills.

Treatment group was compared to other TBI patients who had processing

speed problems but did not have problems with their working memory

abilities.

The experimental group showed improvement in working memory and

executive function. The control group did not show any improvement in

memory skills after undergoing the cognitive remediation therapy.

Ref: Serino, A., Ciaramelli, E., Di Santantonio, A., Ladavas, E., ―A

Rehabilitative Program for Central Executive Deficits after Traumatic

Brain Injury.‖ Brain and Cognition. 2006 Mar; 60(2): 213-4.

14


Parkinson‟s Disease

This study found that specific cognitive rehabilitation

training is needed to improve executive, higher level mental

functioning in Parkinson's patients.

Half of the patients were randomly assigned to the cognitive

rehabilitation treatment group and the other half received the

standard medical treatment for Parkinson's disease.

The cognitive training group significantly improved on two

measures of executive functioning and no improvement was

found in the standard treatment group.

Ref: Sammer, G., Reuter, I., Hullmann, K., Kaps, M., Vaitl, D.

―Training of Executive Functions in Parkinson's Disease.‖

Journal of Neurological Sciences. 2006 Jun 8.

15


The State Of The Brain Fitness Market

In a report, titled ―Transforming Brain Health The

State of the Brain Fitness Market 2010,‖ by Sharp

Brains, an independent market research firm found:

The Internet is becoming a primary distribution

vehicle for brain fitness software

Few vendors have developed on-line mobile

platforms to deliver the software and services

16


The State Of The Brain Fitness Market (cont.)

Adults over the age of 50 appear to be

adopting brain fitness technology as a

mainstream aspirational and lifestyle choice

The development of education-focused

cognitive training programs received a boost in

2009 from federal funding and research linking

cognitive and self-regulation capacities to

academic performance over time

17


The State Of The Brain Fitness Market (cont.)

The largest customer segment deploying brain

fitness software includes provider

organizations such:

Insurers

Health plans

Senior living chains

Brain-based clinical decision support systems

are becoming available and integrated into

electronic health records

18


Brain Fitness Software Market Continues to

Grow

Between 2007 and 2008, the fledgling market

for brain fitness software increased from $225

million in 2007 to $265 million in 2008

Currently more than 700 residential senior

living facilities and communities have installed

computerized cognitive training programs

19


By 2015, Brain Fitness Software Market

Projected to Reach $2 Billion

The worldwide digital brain health and fitness

software market was valued at $295 million in 2009

By 2015, the market value has been projected to

increase nearly tenfold, reaching at least $2 billion,

with the possibility of reaching up to $8 billion

The 2009 market value was 35% higher than the 2008

value

Since 2005, the market has experienced an annualized

growth rate of 31%

20


Brain Fitness Software Market Segments

Health care provider organizations

Schools

Consumers

Employers

21


United States market leaders In 2009:

The Schools Market

The school market was valued at $90 million,

a 38% increase over the 2008 value of $65

million

The market leader was Scientific Learning

The market focus was on addressing

underlying learning problems

22



The Consumer Market

The consumer market was valued at $70 million, a

40% in crease over the 2008 value of $50 million

The market leaders were:

Lumos Labs

Posit Science

Market focus was maintaining or enhancing targeted

cognitive functions

23



Employer Market

The employer market was valued at $40

million, a 60% increase over the 2008 value of

$25 million

The market leader was Brain Resource

Market focus was on improving productivity

via enhanced brain health and wellness

24



The Health Care And Insurer Market

The health care and insurer market was valued at $95 million,

a 18% increase over the 2008 value of $80 million

Market focus was the delivery of scalable, cost effective,

evidence-based solutions for cognitive and emotional health.

The market leaders were

Brain Resource

CogniFit

Posit Science

Ultrasis

United BioSource

25


An Update On Current

And Potential

Applications In

Behavioral Health

26


27

Companies In The Business

Product Company

Brain Fitness Program Posit Science

Brain Training Solutions Brain Resource

Cognitive Training CogniFit

My Brain Solutions Ultrasis

CDR System United BioSource Corp.

Adaptive Computerized Cognitive

Training New England Cognitive Center

Neurofeedback Training The Center for Cognitive Enhancement

Mobile Training Lumosity

BrainAge Games BrainAge

Brain Fitness Software Dakim

Brain Games Fitbrains


PositScience: Cognitive Enhancement

Programs

Auditory System

Visual System

DriveSharp

Compatible with Mac and Windows

Cost: $690 (Auditory and visual)

28


29


Technology-Based Cognitive

Enhancement Programs

Posit Science study shows

that brain fitness software

can improve memory and

attention in older adults

Increased processing speeds

averaging 131% in

participants


Auditory System

The Brain Fitness Program is Posit Science's clinically proven,

award-winning software for a sharper brain.

The Brain Fitness Program speeds up and sharpens auditory

processing—the listening system of the brain. By improving

the quantity and quality of what your brain takes in through

sound, it drives an overall improvement in thinking, focus, and

memory. Use the Brain Fitness Program to: Improve memory

by 10 years

Speed up auditory processing by 131%

Find words on the tip of your tongue

Participate in and remember conversations more fully

31


Visual System

The InSight brain fitness software targets visual processing—how

efficiently your brain takes in and reacts to what you see

The Benefits of InSight Brain Fitness Training

Clinical studies show that training with InSight: Speeds up visual

processing by up to 300%

Helps people take in more with each glance

Improves brain activation in areas related to attention and focus

These improvements lead to generalized gains, too. Studies also show that

InSight:

Enables people to drive more safely and confidently

Helps people to be more effective, efficient, and in control of everyday

tasks

Allows people to retain health-related quality of life and independence over

time

33


DriveSharp Brain Fitness Program

DriveSharp brain fitness software is clinically proven

to make people safer drivers.

Decades of research show the technology in

DriveSharp: Speeds up visual processing and

increases "useful field of view" so drivers see more of

the road with each glance

Decreases reaction time, so drivers can stop 22 feet

sooner at 55 mph

Cuts at-fault crash risk by 50%

35


Posit Science Launches Brain Odyssey—Free

On-Line Brain Games!

Posit Science has launched a free social networking web site

that offers team cognitive training exercises.

The site went live on October 4, 2010. Although the games are

free, the web site operates like a multiplayer platform by

offering virtual goods that can be purchased to further progress

through the game.

The game is targeted at older adults, and the move is geared at

expanding the availability of cognitive training, which has

been proposed as a way to delay onset of Alzheimer‘s disease.

The prevalence of dementia world wide has been projected to

triple by 2050.

37


Brain Fitness Program Studies And Research

1. Evaluation of Approaches to Auditory

Rehabilitation For Mild TBI

2. Brain Fitness in Parkinson's Disease

3. Cognitive Training for Post-Traumatic Stress

Disorder (PTSD)

4. The ACTIVE cognitive training interventions and

the onset of and recovery from suspected clinical

depression

5. Combined Cognitive Remediation and Vocational

Therapies for Schizophrenia

6. Improving Task Engagement in Schizophrenia

38


Evaluation Of Approaches To Auditory

Rehabilitation For Mild TBI

This in-progress study is testing the efficacy of

the Brain Fitness Program on improving

auditory performance in veterans with mild

traumatic brain injuries.

In: N/A - Study in progress

Program: Brain Fitness Program

At: Portland VA Medical Center

Indication: Traumatic Brain Injury (TBI)

39


Brain Fitness In Parkinson's Disease

The goal of this in-progress study is to

determine whether the Brain Fitness Program

improves outcomes for people with

Parkinson's disease.



At: University of South Florida

Indication: Parkinson's

40


Cognitive Training For Post-Traumatic Stress

Disorder (PTSD)

The goal of this in-progress study is to determine

whether cognitive training improves outcomes for

veterans suffering from post-traumatic stress disorder

(PTSD.)



At: SF Veterans Administration Medical Center /

University of California, San Francisco

Indication: Post Traumatic Stress Disorder (PTSD)

41


The ACTIVE Cognitive Training Interventions And

Onset Of And Recovery From Suspected Clinical

Depression

This study examined the effects of cognitive training on 1606

people without suspected clinical depression at baseline. Only

the Posit Science program intervention group had a significant

effect on depression, with its participants being 38% less likely

to develop suspected clinical depression at a 1 year follow-up.

In: Journals of Gerontology

Program: DriveSharp

InSight

At: Iowa City Veterans Administration Medical Center,

University of Alabama Birmingham, Posit Science

Indication: Depression, Healthy Aging

42


Combined Cognitive Remediation And

Vocational Therapies For Schizophrenia

Study of individuals with schizophrenia

combines Posit Science programs and

vocational therapies to measure improvements

in cognitive tasks, task engagement, and

everyday function.

In: N/A - study is in progress


At: Yale New Haven Medical Center

43


Improving Task Engagement In

Schizophrenia

People with schizophrenia frequently have

impairments in attention which have been shown to

be related to overall functioning. Study goal is to test

whether the Brain Fitness Program improves task

engagement in individuals with schizophrenia.

In: N/A - study is in progress


At: Columbia University, Yale School of Medicine

44


Posit Science Announces Success in Reversing „Chemobrain,‟

the Debilitating Side Effect of Chemotherapy Experienced by

75% of Breast Cancer Survivors

Using the computer-based Posit Science Brain Fitness

Program™ may improve mental function in cancer patients

with symptoms of ―chemobrain,‖ a condition that affects three

of four breast cancer survivors who undergo chemotherapy.

―Chemobrain‖ impairs concentration, memory, and decision-

making skills, and can cause anxiety and depression.

About 94% of participants in a recent study of women

suffering from ―chemobrain‖ reported statistically significant

improvements in cognitive function, stress levels, and health-

related quality of life after using the Posit Science Brain

Fitness Program.

45


Brain Resource: Brain Training Solutions

www.MyBrainSolutions.com

Online brain Assessment to identify your brain

profile that is automatically matched to the

best brain training exercises to optimize your

wellness & brain function

Computer Games

Interactive Videos

Cost: $10-month, $24-quaterly, $72-annually

46

http://www.mybrainsolutions.com/


Research Solutions

Brain Resource proprietary platforms are used

to predict who will best respond to what drug

( iSPOT ) , develop new drugs

( PharmaceuticalTrials ) , and discover new

brain insights ( Discovery Science)

49


OptumHealth Behavioral Solutions Partners

With Brain Resource

OptumHealth Behavioral Solutions and Brain Resource have

entered into an agreement that provides for Brain Resource‘s

WebNeuro and MyBrainSolutions to be incorporated in

select OptumHealth offerings in the US Managed Care market.

Through the partnership we provide the standard for reliably

measuring brain health with goals to:

Engage Employees, Employers and Care Providers in

improving brain health, minimizing risk, maximizing

productivity Make best use of limited resources

Reduce overall health costs by early detection of

behavioral health issues and better management of brain

health to keep people well

51


OptumHealth Behavioral Solutions Partners

With Brain Resource (cont.)

OptumHealth Beahvioral Solutions will work with

Brain Resource to provide clinicians with a Web-

based assessment that measures general cognition

(how people process information) and social

cognition (how people manage their emotions).

This 40-minute assessment is based on well-known

and validated tests of memory, attention, executive

function, and response speed, and mood, social skills

and emotional resilience.

52


CogniFit: Personalized Brain Fitness

Online technology developed and patented by

CogniFit that provides an automated

assessment of one‘s cognitive profile

Builds a matching brain training program that

is optimized to fit that profile

Provides an assessment cognitive abilities

Memory

Attention

Perception

Focus

53


CogniFit: Personalized Brain Fitness (cont.)

Cognitive abilities ranking

One hour a week

Cost: Free

54


CogniFit Studies And Research

CogniFit Personal Coach for Patients with Multiple

Sclerosis

Cognitive training with CogniFit Personal Coach

boosts reading skills in dyslexic students

Improving Cognitive Performance in Elderly

Subjects Using Computerized Cognitive Training

CogniFit Personal Coach Program Improves

Cognitive Abilities Among Older Adults

57


CogniFit Personal Coach For Patients With

Multiple Sclerosis

The findings are evidence that cognitive

training can significantly improve a wide range

of memory skills in MS patients.

Article published in NeuroRehabilitation 26

(2010) 143–153.

58


Cognitive Training With CogniFit Personal

Coach Boosts Reading Skills In Dyslexic

Students

When dyslexic college students trained with

CogniFit Personal Coach®, their brain

activity, working memory and reading

performance were shown to increase

significantly, and results lasted up to six

months after training.

59


Improving Cognitive Performance In Elderly

Subjects Using Computerized Cognitive

Training

The results show that systematic, individually

tailored training can improve several important

functions. Abstract published in Alzheimer's &

Dementia: The Journal of the Alzheimer's

Association, July 2008 (Vol. 4, Issue 4, Page

T492)

60


CogniFit Personal Coach Program Improves

Cognitive Abilities Among Older Adults

People who played computer games showed an

improvement in performance, but for people

who used CogniFit Personal Coach, the

improvement was significantly greater.

61


Ultrasis: My Brain Solutions

Ultrasis is the market leader of computer

delivered, interactive healthcare products;

providing user friendly and cost effective

solutions for:

Healthcare professionals

Corporate market

Individual consumers

62


Ultrasis: My Brain Solutions

BrainSolutions delivers employers with

affordable, scalable and completely confidential well

being and performance solutions to their employees.

MyBrainSolutions is an interactive brain training site

which brings together a brief objective brain

assessment, games, videos and trackers designed to:

Reduce your stress

Boost your memory and attention

Maximize your positivity

Cost: $10-month, $24-quarter, $72-annually

63


Beating The Blues:

Cognitive Behavioral Therapy

Beating the Blues has been proven to help people suffering

with mild and moderate depression to get better and stay better

and is based on Cognitive Behavioral Therapy (CBT)

It is a way of helping people to learn to cope with anxiety and

depression and has been recommended for use in the NHS by

the National Institute for Health and Clinical Excellence

(NICE).

Beating the Blues brings all the benefits of CBT directly to

your patients by the use of computer and multi-media

technology which means that you can access the treatment

when and where you want. This type of therapy is referred to

as Computerized CBT.

67


United BioSource Corporation: CDR System

UBC offers the computerized CDR System to assess

the major aspects of cognitive function known to be

influenced by medicines and disease, including

attention/ concentration, short- term working memory

and long-term episodic secondary memory.

The CDR System can be utilized in any clinical

setting and with any population, throughout the drug

development process, from first-in-man trials to

global trials during phase III and IV.

Cost: Not available

68


Scientific Learning: FastForWord Program

The Scientific Learning family of software

products strengthens brain processing and

literacy skills to increase reading proficiency

in students of all ages.

The Fast ForWord program is a reading

intervention program designed for K-12

education institutions and clinical specialists,

whose students are struggling and reading

below grade level.

70


Scientific Learning: FastForWord Program

(cont.)

The Fast ForWord program develops and strengthens:

Memory

Attention

Processing rate

Sequencing

The strengthening of these skills results in improved

critical language and reading skills

User qualifications: Professional or State Board of

Education Certification, e.g., Audiologist, Speech-

Language Pathologist, Psychologist, Educator, etc.

Cost: Not available

71


New England Cognitive Center: Adaptive

Computerized Cognitive Training

ACCT is designed to maintain or enhance cognitive

fitness utilizing computer-based activities and offers a

complete mental fitness workout on the computer.

ACCT offers a wide range of challenge levels,

making it a highly flexible program which may be

adapted to each client‘s functional and personal

needs.

Client and caregiver feedback indicate improvement

in areas such as concentration, decision making, self-

esteem, socialization, self-confidence and quality of

life.

74


State of Connecticut Support For NECC

Since 2004, NECC has received ongoing financial

support from the Aging Services Division of the State

of Connecticut Department of Social Services.

An three-year research grant was followed by the

establishment of a dedicated line item in the State

budget.

The funds have been used to underwrite research

efforts, contribute to the development of programs,

and serve individuals with Alzheimer‘s disease and

dementia.

Cost: Not available

75


Center For Cognitive Enhancement :

Neurofeedback

EEG biofeedback, or neurofeedback, has been

used successfully for over two decades at the

clinical level on the effects of stress, epilepsy,

ADHD, anxiety disorders, depression,

fibromyalgia, chronic fatigue syndrome,

addictions, post traumatic stress disorder,

obsessive compulsive disorder, TMJ, and pain

management

78


Center For Cognitive Enhancement :

Neurofeedback (cont.)

Neurofeedback is best provided by experienced EEG

biofeedback specialist or neurotherapist

Treatments range from 10 to 50 sessions

Treatments usually involve one hour of training two

to three times per week

Cost: Affordable financing is available on their

website

Brain mapping and EMDR also available

79


Lumosity: Personalized Brain Training

Lumosity.com provides users with constant

access to an ever-growing library of brain

games, training courses and assessments.

Training courses typically consist of 20 to 40

daily sessions. During these daily sessions,

users complete 3 to 5 different exercises over

the course of 10 to 15 minutes.

Lumosity selects these exercises based on your

specific training goals and priorities.

81


Lumosity Automatically Tracks Your

Progress

Your Brain Profile Index, gives you an instant

snapshot of your improvement across five core

cognitive areas: speed, flexibility, memory, attention

and problem-solving.

Calculate BPI using not just your results, but also

those of other users within five years of your age.

BPI gives you a sense of how you compare to others

in your age bracket.

Cost: Registration free (fee for some services)

82


The Nintendo DS

The Brain Age games feature activities

designed to help stimulate the brain and give

by solving simple math problems, counting

currency, drawing pictures on the Nintendo DS

touch screen

Cost: $19.00 (purchase at online retailers:

Amazon, Target, Best Buy, WalMart)

85


The Benefits of Dakim BrainFitness

Dakim BrainFitness Software provides rigorous cognitive

exercise, cross-training the brain in six cognitive domains

Long-term memory

Short-term memory

Language

Computation

Visuospatial orientation

Dakim‘s exercises are presented at five levels of challenge to

meet the needs of patients with a broad spectrum of cognitive

functionality—at the highest level, appropriate for patients

with the highest brain function, and at the lowest level,

Appropriate for patients with cognitive impairment or

dementia.

87


Dakim BrainFitness Program Raises Memory

Improvement Scores

Elderly adults who played Dakim BrainFitness program over a

six-month period of time increased their memory scores by

almost two points, from 10.4 to 12.1.

The results indicated that longer use of the BrainFitness

program was likely to produce ongoing improvement in visual

and verbal memory over time.

A pilot study was also done before launching the clinical trials.

In the pilot study, 22 elderly adults were assigned to the

Dakim BrainFitness computerized game or to an active control

group. Participants used the game five times a week for half an

hour each time for two months. After the two months, a

modest effect size was seen on one memory test.

88


Dakim BrainFitness Software, Professional

1. Speech pathologists

2. Occupational therapists

3. Recreational therapists

4. Neurologists

5. Neuropsychologists

6. Gerontologists

7. Geriatric psychiatrists

8. Geriatric care managers

9. Nurse practitioners

10. Audiologists

11. Licensed clinical social workers

12. Rehab companies

13. All other healthcare professionals who provide therapy for cognitive impairment

Cost: $249.00 (software)

89


Fit Brains Games

Fit Brains provides scientifically developed

brain games targeting the five major brain

areas:

Memory

Problem solving

Concentration

Visual spatial

Language

91


Fit Brains Games (cont.)

Online service provides access to:

Brain circuit training

Tracks progress

Brain assessment

Earn awards

Cost: Free registration (fee for some services)

92


The Implications For

Behavioral Health

Care Providers

100


Implications Of These Tools For Consumers

Easy access and convenience

Can be used at home or work

Consumers may experience immediate

progress

Can be used in adjunct to traditional treatment

and therapy

Improved treatment compliance

101


Implications Of These Tools For The

Behavioral Health Market: Service Providers

Relatively low cost to incorporate

Does not require licensed staff

Tools can be provided in conjunction with

existing treatment programs and services in a

variety of settings:

Outpatient

Residential

Home based

School based

102


Tools As Service Line Expanders

The addition of cognitive retraining programs

to existing service lines may:

Expand your current patient base

Lead to new referral sources

Add a new billable service

Expand current continuum of care

103


Potential Market Advantages

Adding these tools to your service lines may

improve your competitive edge in the market

Creates an opportunity to repackage and

promote existing programs

Demonstrates organizational vision by

providing innovative programs to better meet

consumers, payer and the community needs

Enhanced focus on community-based services

Great PR

104


Potential Market Advantages (cont.)

Opportunity to revisit current and / or contact new

payers

Out-of-site, out-of-mind

Review with payers current and / or establish new

rates of reimbursement for existing and new services

Promote outcomes with payers and referral sources

for new contracts or to obtain reimbursement

Reduced consumer length of stay

Improved medication compliance

Reduced no show rate

Improved grades for youth

105


Reimbursement

Aetna considers cognitive rehabilitation as adjunctive

treatment of cognitive deficits (e.g., attention, language,

memory, reasoning, executive functions, problem solving, and

visual processing) medically necessary when all of the

following are met:

The cognitive deficits have been acquired as a result of neurological

impairment due to trauma, stroke, or encephalopathy, and

The member has been seen and evaluated by a neuropsychiatrist or

neuropsychologist, and

Neuropsychological testing has been performed and

neuropsychological results will be used in treatment-planning and

directing rehabilitation strategies, and

The member is expected to make significant cognitive improvement,

e.g.,is not in a vegetative or custodial state.


HealthNow New York Medicare Advantage:

Cognitive Rehabilitation

Cognitive rehabilitation is a therapeutic approach designed to

improve cognitive functioning after central nervous system

insult.

Therapy methods that retrain or alleviate problems caused by

deficits in attention, visual processing, language, memory,

reasoning, problem solving, and executive functions.

Cognitive rehabilitation consists of tasks designed to reinforce

or re-establish previously learned patterns of behavior or to

establish new compensatory mechanisms for impaired

neurological systems.

Cognitive rehabilitation may be performed by a physician,

psychologist, or a physical, occupational, or speech therapist.

108



Cognitive Rehabilitation (cont.)

Cognitive Rehabilitation may be medically necessary

for persons with acquired cognitive defects resulting

from head trauma, or acute neurologic events

including cerebrovascular accidents.

It is not medically necessary for patients with chronic

progressive brain conditions with no potential

restoration.

Be provided by a qualified licensed professional and

must be prescribed by the attending physician as part

of the written care plan.

109




Must be a potential for improvement (based on

pre-injury function) and patients must be able

to actively participate in the program

Duration and intensity of cognitive

rehabilitation therapy programs vary

110




One approach for comprehensive cognitive

rehabilitation is:

16-week outpatient program

Five hours of therapy a day

Four days a week

Cognitive group treatment occurs for three two-

hour sessions each week

Three one-hour individual sessions (total of nine

hours per week)

111


The Association for Applied Psychophysiology &

Biofeedback: Guidelines for Third Party

Reimbursement for Biofeedback

To determine if you will be paid for biofeedback

services, you should call the insurance company and

verify coverage

Note the basic details of coverage may be available

on-line

Payment may be restricted to participating providers

or there may be higher deductibles and increased co-

pays if you are not a network provider

112




Reimbursement for Biofeedback (cont.)

Some services may require preauthorization

Many insurance companies have (long) lists of

excluded services, and the biofeedback codes are

often on these lists

In other cases, the procedure codes will only be paid

if the diagnosis code is from a list of covered

conditions.

Example: The basic mental health procedural codes, like

90806, used by psychologists and counselors are only

covered when the diagnosis is for a psychiatric or

developmental disorder.

113





There is a relatively small set of procedural codes for

biofeedback.

There are two pure biofeedback codes

90901 any modality of biofeedback

90911 pelvic floor training for treatment of incontinence

There are also two codes for mental health providers

90875 and 90876.

These refer to sessions that combine biofeedback with

some kind of talk therapy or counseling—90875 for a

25 minute session and 90876 for a 50 minute session

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The 90806 code is for psychotherapy, not

biofeedback, and providers combining

biofeedback and psychotherapy are advised to

use 90876 or 90875

The 97532 code refers to cognitive retraining

typically been used by speech and language

pathologists working to improve cognitive

function of patients with cognitive deficits

115





All Medicare carriers are now paying for the health

and behavior intervention codes.

In Florida, the allowance is $97 for the evaluation

(96150—1 hour or 4 units) and $89 for individual

treatment (96152—1 hour or 4 units)

The federal workers‘ compensation program

(http://owcp.dol.acs-inc.com/portal/main.do) will pay

for biofeedback training

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The best advice is to:

Be persistent and prepared

Verify coverage for all possible biofeedback codes

for all of your patients

Coverage often varies widely based upon the

specifics of a given contract and may include

restrictions based upon type of licensure

If you get a rejection initially, contact a

supervisor, case manager or provider relations

117





Many providers have reported success in

getting reimbursement for biofeedback

services, but it often requires getting

authorization on a case-by-case basis.

118


Are These Diagnostic Tools?

In an interview with a Brain Resource

representative they answered:

Brain Resource applications look at the person,

not the disease. Applications are evidenced-

based decision support tools that can assist

providers in clinical assessment, evaluation,

and decision making process.

119


Do Some Of These Applications Constitute

Treatment?

In a July 2008 press release Greg Bayer, CEO

of OptumHealth Behavioral Solutions,

positioned the applications as ―aiding

treatment‖.

120


Are These Technologies Cost Effective?

In a Market Watch interview in 2009, Dr. Eugene

Baker, Vice President of EAPs for OptumHealth

Behavioral Solutions responded:

―Improving brain health can result in less

‗presenteeism‘, the tendency to be at work but

distracted and not able to focus. If you look at the

disability costs, absenteeism and presenteeism

account for most of the medical costs, and that‘s a

good reason for employers to be focused on brain

health.‖

121


What Are The Outcomes?

In a March 2009 issue of Biomedicine, Mary

Furlong, Ed.D, a leading authority of aging

and consumer technology, stated, ―Consumers

should look for products with published

studies showing the product worked.‖

122


Computer Assisted Cognitive Retraining

Program: Clinical Considerations

1. Does the accompanying literature clearly define the objectives

of the program?

2. Does the program address what it claims to address?

3. Is the reinforcement and feedback immediate, friendly and

appropriate?

4. Is the program interesting?

5. Are the instructions easy to follow?

6. Are appropriate and useful data collected and analyzed?

7. Where would the program fit within your treatment model?

8. How much supervision is needed?


“The purpose of business is to create and keep

a customer.” Peter F. Drucker

124


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