Sunday, November 28, 2010

Carving the Turkey and Medicaid

The Thanksgiving turkey wasn’t the only reason people have been sharpening their carving knives.  The national economic crisis has led the President’s Panel on the Economy chaired by Alan Simpson and Erskine Bowles to begin their own carving.  Among other steps, the Committee Chairs propose to reduce health care costs by paying doctors and other providers less for seeing patients under government programs like Medicare and Medicaid.  They also propose to expand cost-containment programs.  The Federal Medicaid program has already begun planning for cost containment. Several reports indicate that 10% of Medicaid recipients account for 72% of expenditures, mostly people with chronic health conditions (arthritis, high blood pressure, heart disease and asthma), mostly older (64+) and often receiving hospital or home health care. Other research indicates mental health disorders, including schizophrenia and addiction are among the most costly. It is likely autism service will also rank among high cost services in states mandating such services.  Among Medicaid cost containment proposals are increasing co-payments, reducing the scope of covered benefits and enhanced medical case management, which translates into close monitoring of adherence with services and their outcomes.

It’s possible the horse is already out of the barn, but it may not be too late to have some impact on how these proposed cuts play out.  As long as consumers and early intervention providers are unwilling to make distinctions among the types and intensity of services children and youth with autism spectrum disorders should receive, these changes will be made unilaterally by Medicaid and private insurers, and not necessarily based on the best available outcome evidence. It would be better if, as a field, we developed rational strategies for individualizing types and intensities of intervention.  

To contend, for example, that every four year old child with an ASD diagnosis requires 35-40 hours of Discrete Trial Intervention, whether he has Asperger disorder or Autistic disorder, whether her IQ is 55 or 115, whether he is non-verbal or speaks in short phrases, whether she is interested in other children or hides when another child is nearby, doesn’t make a great deal of sense.  Laura Schreibman and her colleagues have published several promising papers attempting to predict which children will profit most from a Pivotal Response Training strategy, a naturalistic intervention approach, which is an important step in the right direction.  

We need to develop more rational, evidence-based approaches to deciding how much and what kind of intervention strategy is most appropriate for each child with autism, which is the subject of my forthcoming book, Individualized Autism Intervention for Young Children: Blending Discrete Trial and Naturalistic Strategies (Paul H. Brookes).  You can receive an alert when the book is out by clicking on the "Keep Me Posted" link at Brookes website.     It would be wise for all of us to begin taking concrete steps to address this problem before the green eye-shaded bean counters do it for us and our kids.

Sherer, M.R., Schreibman, L., 2005. Individual behavioral profiles and predictors of treatment effectiveness for children with autism. J. Consult. Clin. Psychol. 73, 525–538.

Stahmer, AC, Schreibman, L. and Cunningham, AB (2010) Toward a technology of treatment individualization for young children with autism spectrum disorders. Brain Research. 2010 Sep 19. [Epub ahead of print]

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