#behavioranalysis @TRICARE #ABAinsurance #autism #military #stickwithscience --a review of #ABACoverage My Take on TRICARE Policy Changes for ABA therapy Mon Jul 15, 2013 10:10 am (PDT). Posted by: "Scott Campbell" campbellsservices Please CALL me at home at 703 241-2640, if you have any questions. Good luck! Scott ---------------------- Why TRICARE continues to not understand Applied Behavior Analysis therapy? Since 2005, TRICARE has displayed an extraordinary unwillingness to understand Applied Behavior Analysis (ABA) therapy. Their most recent policy change on ABA therapy continues to demonstrate that unwillingness and an enormous lack of appreciation of its significant impact on affected military families. Even before the current Extended Care Health Option (ECHO) Program policy went into effect, there were indications that TRICARE policymakers did truly not understand ABA therapy. There were three criteria for eligibility. One was a diagnosis of moderate or severe mental retardation. The second one was any physiological disorder or condition or anatomical loss affecting one or more body systems which has lasted, or with reasonable certainty is expected to last, for a minimum period of 12 contiguous months, and which precludes the person with the disorder, condition or anatomical loss from unaided performance of at least one of a number of specified difficulties with an activity of daily living (ADL). The last one was a little used „Other‰ eligibility criteria. When the TRICARE program manager was asked at that time how someone with an autism spectrum disorder (ASD) would likely qualify, his response was that since everyone with autism is also retarded they would be eligible using that criteria. When he was repeatedly and strenuously informed that many individuals with autism have on IQ of well over 70, TRICARE changed their interpretation of the eligibility so that the second one was the most often used. At no time until last year was there ever a restriction that ABA therapy was only available to individuals with an ASD diagnosis, since it has repeatedly been shown to be of great value to many children with ADL difficulties regardless of their developmental delay medical diagnosis. This was the start of the evidence that TRICARE policymakers did remarkably not understand the value or benefits of ABA therapy. When the ECHO program was put into effect in September 2005, concerned active duty families pointed out that the new requirement for all hands-on therapy to be performed by a certified ABA therapist was not in keeping with the best practices of that therapy. Due to a shortage of certified therapists at that time, most hands-on therapy was appropriately performed by properly trained and supervised tutors, not the certified ABA therapist themselves. That is the standard best practice to this day. TRICARE‚s response to this concern was an insistence on following their rules in spite of the fact that those rules had no basis in sound and practical therapeutic standards. Thousands of children who could have benefited from ABA therapy in better and safer development of their ADL skills or reduction in their maladaptive behaviors were denied access to this most beneficial therapy. After years of complaints about these policy shortcomings, TRICARE introduced the ABA Demonstration in March 2008. This made great strides in the application of ABA therapy by providing for the use of ABA tutors, which is the way the business had persistently been operating for many decades. Unfortunately, this demo was only made available to children with an ASD diagnosis and excluded those without that diagnosis, but who would also greatly benefit from this therapy. Those without an ASD diagnosis were able to still possibly get ABA therapy through the ECHO Program. The tenets of the demo were the basis of decent policy that were subsequently whittled away into yet another empty benefit. However, TRICARE policy restrictions and a continued shortage of TRICARE-authorized ABA providers resulted in less than ten percent of children who could have benefited from these two programs from being enrolled in them in the first place. Of that incredibly low percentage, only about half were actually able to receive some amount of ABA therapy on a consistent basis. I ask you. When is a 95% failure to provide the only proven medical intervention for these children considered to be a success? Would failing to provide medically recommended chemotherapy to children with any form of cancer 95% of the time be acceptable to anyone in the health care professions? Yet, that was the accepted measure of success for ABA therapy by TRICARE in 2008. Why has TRICARE gotten it so wrong when it comes to ABA therapy? It appears to be their continued insistence that this therapy is an educational one and not a valid medical one. This has been routinely stated position in TRICARE policy and in testimony by TRICARE policymakers to this day. This is in spite of the fact that 34 states currently have some sort of ABA therapy mandate based on the medical necessity and proven clinical value of ABA therapy. Over 200 valid medical studies demonstrate the efficacy and value of ABA therapy. Someday, it would nice if a TRICARE policymaker would bother to read and comprehend any one of these studies. So, TRICARE set a very low bar on permitting affected children access to ABA therapy in 2008 with the ABA demo. Less than 5% actually got it, but at least some were getting the appropriate medical treatment they validly needed and deserved. However, children of retired families were restricted from access to this therapy at all. Since federal legislative efforts had failed for a number of years to address this disparity, TRICARE was sued over this policy denial in 2010. Their defense of denial was incredible. They started with the it‚s educational and not medical argument. When that did not work, they moved on to another leap in logic. ABA therapy was stated to not be a proven medical treatment for families of retirees, even though they had been paying for active-duty children to receive it since the late 1990‚s in some form or another. TRICARE lost that case in July 2012. The day after the legal decision was announced; TRICARE introduced a new policy on ABA therapy. It was now suddenly a valid medical intervention in policy, even though top TRICARE officials kept publically stating the opposite position about only its educational applicability. It was officially part of the basic medical policy of TRICARE. Families of retirees could now get access to ABA therapy. Not really. More restrictions were added. Your child had to be at least three years old. So much for the proven efficacy of early intervention. Your child would also not be eligible without an ASD diagnosis, and this standard was suddenly applied to active-duty families who had been receiving ABA therapy for their kids for years. A 2007 policy memo from TRICARE to Healthnet berating them over this exact same misapplication of the ECHO Program policy was ignored in the latest application of their own new policy of gradually diminishing eligibility of an appropriate, medically necessary therapy in 2012. A new restriction was that Board-Certified Assistant Behavior Analysts (BCaBAs) could no longer run an ABA program even though they had specifically been permitted to do just that since the ABA Demo started in 2008. So, it was okay and appropriate for the past four-plus years, but now it was suddenly not acceptable. Only Board-Certified Behavior Analysts (BCBAs) could perform the hand-on ABA therapy, which was the original concern by military families back in 2005. So in July 2012, TRICARE took a tiny tiptoe forward by begrudgingly agreeing to the medical necessity of ABA therapy for families of retirees, and then a huge leap backward by new and more restrictions, including the insistence that it can suddenly only again be done by BCBAs. 2,292 individuals were enrolled in either the TRICARE ECHO Program or the ABA Demo in 2008. By 2012, the figure had grown to 6,560 enrollees. Notice that I state the number enrolled and not the number receiving some (usually insufficient) amount of ABA therapy. Only 1,283 (53% of 2,292) of those enrolled were actually receiving some amount of ABA therapy in 2008. We have no idea of what that figure is today, since TRICARE refuses to provide it. However, 53% of 6,560 is about 3,500 individuals possibly getting some of their appropriate medical intervention in 2012. Using my educated guesses, I would imagine that the continued percentage of policy failure for ABA therapy has probably peaked at about 90% in 2012 and is now rising back up again due to these new policy restrictions. Autism rates usually grow at about 10% or more a year. Add in all of the few other children with development delays that were helped by ABA therapy who cannot now access that benefit, and growing failure of TRICARE‚s current ABA policy is evident. Once more, I ask for what other proven and valid medical intervention would denial to 9 out of 10 children be found to be acceptable? Sorry your kid has cancer ma‚am, but we only approve chemotherapy for children if their last name starts with the letters T through Z. Since July 2012, TRICARE has forced all active-duty families into the ABA therapy provisions of the new TRICARE Basic program, unless they were enrolled in the ABA demo. All active duty families enrolled in just the ECHO Program were required to switch to the new TRICARE Basic program with all of its new restrictions, which caused many families to be disenrolled. This shell game allows TRICARE to claim credit for success of a policy that continues to fail an increasing amount of children. The original reason for the move to the Basic program was to allow families of retirees to get access to ABA therapy. However, I do not know of a single retired family out of an estimated ten thousand that has subsequently been able to make that happen from scratch. And now, we turn to the latest TRICARE policy changes for ABA therapy. New policy guidance is due to go into effect on 25 July 2013. It maintains the same ineligibility for children if they do not have an ASD diagnosis. It also maintains the requirement for all hands-on therapy to only be performed by BCBAs, which again was original concern by military families back in 2005 and is still not in accordance with the best practices of this therapy. To increase in decline of the use of this therapy, three new sets of restrictions were added. There is a new requirement for initial and ongoing psychometric testing to get an authorization and then maintain eligibility. The Autism Diagnostic Observations Scale (ADOS) and the Vineland Behavioral Scale are the only acceptable TRICARE assessment measures. This causes significant problems and very likely further reductions in affected children getting appropriate access to ABA therapy. The biggest one is finding someone qualified by TRICARE to do these assessments, since families will likely have to pay out of pocket if the tester chooses not become an authorized TRICARE provider or if they have a long wait time. If a child can get initially authorized, these assessments must be repeated every six months to demonstrate adequate „progress‰. The second big problem with this process is that these are not the tools used by anyone in the ABA therapy field to measure progress, which is exactly the requirement by TRICARE. They are only initial assessment screening tools; nothing more. The two standard tools used for this therapy to determine progress (or regression) are the Assessment of Basic Language and Learning Skills- Revised (ABLLS-R) and the *Verbal Behavior Milestones Assessment and Placement Program* (VB-MAPP). As usual, TRICARE has again not done their homework to determine the appropriate and best practice tools to measure progress. There is a high likelihood that the ADOS and Vineland will not show adequate arbitrary progress since they were never designed to perform that task. Even if the ABLLS-R and/or VB-MAPP are adopted and adequately used, they are difficult to use with children who do not speak (sometimes not at all) or who have an intellectual disability. For other children, a reduction in regression of their ADL skills or reduced self-injurious, aggressive, or destructive behaviors is considered „progress‰. Increased safety concerns may spike during service member deployments or duty station moves and cannot be addressed by any of these tools. While requiring a standardized test to determine progress is a desirable goal, TRICARE has chosen the completely incorrect tools to attempt to determine the authorization and continued eligibility for these children to get what may be a lifesaving therapy for them or their siblings. The next new restrictions are on age. ABA therapy cannot start until the child is 18 months old. Again, so much for the proven efficacy of early intervention. Also, it is likely limited to only two years and/or up to age 16. Waivers are supposedly possible for both of these limitations, but the effort to get those waivers is beyond the grasp of almost every affected families in my experience. Like the previous new requirement, this is an arbitrary one that has no basis in standard best practices for ABA therapy. Individuals can make measurable and adequate progress in their ADL skills or reductions in their maladaptive behaviors if that progress is meaningfully measured using the ABLLS-R and/or VB-MAPP. If a child is hitting himself or banging his head against a wall only ten times a day after two years of ABA therapy when he use to do it a hundred times a day, isn‚t that progress? However, if he turns 16 at the end of two years of therapy, the TRICARE policy says that he is no longer eligible. Some self-injurious, aggressive, or destructive behaviors do not even begin until some boys start puberty, which is often delayed for many of these children. Many individuals cannot even begin ABA therapy until they are nearly 16 due to late medical diagnoses or lack of authorized TRICARE providers at most duty stations. Implying that ABA therapy will not help someone if they are over 16 years of age is simple absurd. Repeated studies have shown efficacy of this therapy far past age 16. The third set of new restrictions are necessary for reauthorization and continued eligibility. The first is a requirement for developed ABA therapy gains to be „generalizable or durable over time‰ and be transferrable to the larger community setting (to include school)‰‚. Again, what if progress is defined as reduction in self-injurious, aggressive, or destructive behaviors. This seems to be a very loosely defined criteria that could easily be used to discontinue therapy due to the nature of disability. It is like asking a blind person to start seeing all the time everywhere they go or TRICARE will no longer pay for their replacement canes. Additionally, parents and caregivers must participate in the ABA therapy with their child or children, regardless if the service member is deployed, frequently TDY/TAD, is serving on a one year assignment overseas, or is a single parent on active duty. That is a lot to dump on a single parent for either marital or geographic reasons on top of whatever else they need to do from day to day, including caring for a significantly disabled child the vast majority of each and every day for their entire lives. This is also increasingly likely scenario given the reductions in respite care through TRICARE and the Services. TRICARE has stated that only a BCBA with a Masters degree in that therapy can adequately provide it for a beneficiary. However, the parents are on their own after two years or at age 16. That seems to be an enormously high standard for a parent or caregiver who may have barely graduated from high school or gotten their GED. That could be exacerbated if the parent or caregiver has a medical or mental health condition or other children that they may have to care for. We are asking quite a bit of these parents and caregivers after only limited ABA therapy, which may only be once a week or even a couple of times a month. Parents will become their child‚s therapist to implement and reinforce skills and behaviors, whether they are capable of doing that or not. If not, then the therapy is not continued. To put it in more perspective, what medical procedure becomes the sole responsibility of the parent after two years of inadequate training? If a therapy is medically-necessary, it must continue to be performed by someone specifically educated and skilled to do that therapy. If ABA therapy can be done by anyone, then TRICARE would not require a Masters degree and years of credentialed training to be able to perform it in the first place. In summation, TRICARE has not understood ABA therapy from the start of the current round of policy changes in 2005. They now place nearly impossible and increasing difficult eligibility requirements for active duty families. Again, I do know of a single retired family out of eligible thousands that has managed to navigate this incredible maze of nonsensical requirements to even start the medically-necessary and potentially life-saving ABA therapy for their child using this new round of policy restrictions. Even if ABA therapy has been begun, continuation of it for an adequate amount of time to ensure appropriate success seems to be outside the realm of the possible. My child and all children with developmental delays or intellectual disabilities deserve the adequate medical care that their service member parents have paid for and continue to pay for in blood, sweat, tears and worry for their future. Again, the most recent TRICARE policy change on ABA therapy continues to demonstrate an unwillingness to understand ABA therapy and an enormous lack of appreciation of its significant impact on affected military families.
Posted on: Tue, 16 Jul 2013 15:01:46 +0000
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