NEWS - Huffington Post: "Will Schwarzenegger and Obama Require Insurers to Pay for Autism Care?"

The news is from California, but the questions, and the tactics being used, are ubiquitous, so this is a lawsuit worth paying attention to.

Will Schwarzenegger and Obama Require Insurers to Pay for Autism Care?
Jamie Court
Huffington Post, July 1, 2009

Parents of autistic children gathered this morning at Consumer Watchdog's Los Angeles headquarters to announce a lawsuit against Governor Schwarzenegger's administration for allowing health insurers to refuse to pay for Applied Behavioral [sic] Analysis ("ABA"), an essential treatment for autism, in plain violation of the California Mental Health Parity Act.

Independent panels of doctors paid by California had been ruling in every autistic child's case that the ABA treatment was medically necessary [my emphasis], so insurers changed the rules of the game with the help of the Schwarzenegger administration. The insurers simply claimed the treatment wasn't covered, because it was educational in nature, and therefore independent panels of medical reviewers no longer had the power to overrule the insurance bureaucrats. (...)

FULL STORY AT THE HUFFINGTON POST

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Don't forget to see the recent post on the CURRENT ACTION ITEM to contact our
Oregon Delegation to Congress and urge their support of the ATAA.
Thank you for your action and your support!

We can do it and we can get there.
Thanks for your help and your support!

Sidebar: A VERY Interesting Article on the BC/BS of Michigan Settlement

A Law.com article going into more and different detail than many of the currently circulating stories on the recent settlement by BC/BS in Johns v. Blue Cross Blue Shield of Michigan.

Well worth reading.

Michigan Class Action Settlement on Autism Treatment Hailed as Landmark Case
Tresa Baldas
The National Law Journal
June 23, 2009

---------------
Previous blog post

Friday, June 19, 2009
Sidebar: Blue Cross Blue Shield of Michigan Forced to Pay for Behavioral Therapy for Autism In Landmark Case

VIDEO: Autism Not Treatable? Sam Summers, MI 4th Grader Disagrees.

This was from the testimony for the Michigan autism bill--Sam Summers, Michigan 4th grader diagnosed with autism at 2, given intensive behavioral intervention...well, let Sam speak for himself.

Sam Summers Testimony for Autism Insurance

Sidebar: Blue Cross Blue Shield of Michigan Forced to Pay for Behavioral Therapy for Autism In Landmark Case

Release issued by Mantese and Rossman, P.C., on June 19, 2009

Detroit, Michigan. The family of an autistic child filed a motion in federal court today to confirm settlement of a class action against Blue Cross Blue Shield of Michigan. The family alleged in the suit that the insurer wrongfully refused to cover behavioral therapy for children with autism spectrum disorder (ASD), on the baseless ground that the care was"experimental. "

Under the terms of the settlement reached at a court-ordered conference on Wednesday, June 17, 2009, Blue Cross [of Michigan] has agreed to reimburse all families who paid for behavioral therapy for their children after May 1, 2003, and who were covered under a Blue Cross Blue Shield of Michigan insurance policy. Blue Cross had earlier filed a motion seeking dismissal of virtually the entire case on legal grounds, but the Honorable Stephen J. Murphy III permitted the case to go forward and scheduled the matter for further proceedings, including a settlement conference before Magistrate Michael Hluchaniuk.

The settlement was reached in the case of Christopher Johns v. Blue Cross Blue Shield of Michigan, 08-cv-12272, filed in Detroit. In the suit, the plaintiff alleged that Blue Cross' pattern and practice of characterizing the scientifically established Applied Behavioral Therapy as "experimental, " and thus as excluded under its insurance policies, was arbitrary, capricious, illegal and contradicted by many years of scientific validation.

Under the settlement, Blue Cross [of Michigan] will pay for behavioral therapy rendered to over 100 children in the last six years. Plaintiff's counsel, Gerard Mantese and John J. Conway, were pleased with the settlement.

Mr. Mantese and Mr. Conway issued a joint statement emphasizing:

"No insurer should ever take this approach to needed care for children. Applied Behavioral Analysis therapy is supported by science and is not 'experimental. ' Delays by insurers in authorizing this treatment, when it is covered by insurance policies, should not be tolerated. Research shows that children with autism spectrum disorder need this therapy early on in life and delaying treatment can irreversibly prevent them from achieving their full potential."

Mr. Mantese emphasized that the settlement includes even families who never submitted a claim to Blue Cross, but who obtained this care for their children and were covered by a Blue Cross policy. Mr. Conway believes that this is the first such settlement addressing Applied Behavioral Analysis (ABA) in the country.

ABA therapy is administered under the supervision of licensed psychologists and other professionals. ABA applies one hundred year old concepts of changing behavior through positive and negative reinforcements. The federal suit in which this settlement was achieved centered upon the ABA treatment provided by prestigious Beaumont Hospital and its HOPE Center, including Dr. Ruth Anan and Dr. Lori Warner.

The case settled shortly after Plaintiff's counsel obtained a court order requiring Blue Cross to produce file documents which validated the effectiveness of ABA therapy for treating children with autism spectrum disorder.

Among the documents in the Blue Cross files obtained by Plaintiff's counsel was a draft of a Blue Cross Blue Shield Medical Policy for 2005, which acknowledged the following:

Applied behavioral analysis (ABA) is currently the most thoroughly researched treatment modality for early intervention approaches to autism spectrum disorders and is the standard of care recommended by the American Academy of Pediatrics, National Academy of Sciences Committee and the Association for Science in Autism Treatment, among others.

Blue Cross' own documents further acknowledged that:

The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions.

Mr. Mantese stated,

"After we compelled Blue Cross through motion practice to produce all materials supporting its position that this care was allegedly experimental, we received numerous file documents which actually established that ABA therapy works and is highly effective in increasing the functioning of these children."

Mr. Conway emphasized, "We are pleased that we were able to obtain a result which will require Blue Cross to pay for this important care and will alleviate some of the financial strain imposed on over a hundred families by having to pay for this care when it was covered under their insurance policies."

Contact information for the families' attorneys follows:
Gerard Mantese, Esq.
Mantese and Rossman, P.C.
1361 E. Big Beaver Road
Troy, Michigan 48083
248-457-9200 Office
248-515-6419 Cell

John J. Conway, Esq.
John J. Conway, P.C.
645 Griswold St, Ste 3600
Detroit, MI 48226
313-961-6525 Office
313-574-2148 Cell

--------------
Previous newsstories on the case:

Blue Cross Reverses Position on Autism After Federal Court Litigation Intensifies
Monday 11th of May 2009 13:19

Blue Cross ordered to defend stance on autism therapy coverage
Detroit News | March 9, 2009

COMMENT: Virginia does "poor job" providing autism services, and what that has to do with Oregon.

A couple of hours ago, a news alert from the Richmond Times-Dispatch (VA) came across my desk and definitely got my attention. Why is Virginia of so much interest? During the Oregon House Health Care Committee public hearing on HB 3000, this point was brought up by a consultant to one of the insurance companies,

"...but we will point out that in places like VA, where one of our leading developmental pediatricians comes from, the schools do much more on this [autism], and they feel that they have not even begun to reach the level of what their side of the bargain should do in this...".

And my reaction at the time was,

[Blog author note: Without the particular significance or special insight involved, the description of what was said by the colleague, "leading", or not is what is known as "anecdotal" or "testimonial". It may well be that VA schools are better, or not. If such was sufficient as evidence, the matter at hand, then we could dispense with experimental design altogether. The point is moot and irrelevant of the merits of this legislation. And if retaining it to the question of schools, if the anecdote that VA schools are doing much more but only scratching the surface, what does that say about the level of therapy in any venue available in Oregon?..."

So the headline from Virginia that caught my attention was,

VA. does poor job providing autism services, study says
by Tyler Whitley
Richmond Times-Dispatch

Published: June 8, 2009

"The state [VA] does a poor job of providing services to people with autism, the legislature's watchdog group said today...Parents seeking benefits for autistic children, and insurance lobbyists gearing up to oppose the possibility of mandated insurance benefits that might include autism treatments, filled a room at the General Assembly Building to hear the report...JLARC [Joint Legislative Audit and Review Commission] began the study last year. Its first report recommended that health insurance require that autism treatment be covered. Under heavy pressure from insurance interests and small-business owners, the General Assembly rejected the proposal..."

[Blog author: So that was what was really going on with insurance proposals in Virginia, and what does the JLARC report say (keeping in mind that the conditions in Virginia were presented as superior to that in Oregon)?]

Report of the Joint Legislative Audit and Review Commission To the Governor and The General Assembly of Virginia
Commission Draft: Assessment of Services for Individuals with Autism Spectrum Disorders
June 8, 2009, 256pp.

CHAPTER 2: ASDS CAN OFTEN BE EFFECTIVELY TREATED, RESULTING IN COST SAVING
"...Several treatment approaches have been scientifically shown to meaningfully improve the outcomes of individuals with ASDs, including the commonly referenced applied behavioral analysis (ABA) method. In particular, most young children with ASDs who participate in intensive early intervention programs based on ABA principles experience improvements, with almost half achieving normal levels of functioning and another 40 percent realizing moderate gains. According to cost-benefit analyses, providing intensive treatment to young children can significantly reduce public costs by decreasing the need for special education and other forms of public assistance, with savings likely to accrue over the lifetime of individuals with ASDs. While many approaches have been categorized as effective for treating ASDs, research indicates that packaged programs with a pre-determined curriculum, such as ABA, appear to have more promising results than programs that rely on a more informal mix of interventions..."

Chapter 2: Autism Spectrum Disorders Can Be Effectively Treated, Producing Cost Savings
p.11, "... The largest body of research exists for interventions based on applied behavior analysis (ABA). ABA-based interventions are supported by approximately 30 years of research pointing to their effectiveness and have been accepted by much of the medical community as effective techniques for treating ASDs, along with several other interventions. Further, research indicates that treatment is beneficial for many and could result in long-term savings of public resources over these individuals’ lifetimes...

See Figure 2: Interventions Have Been Categorized Based on Category: Scientifically Based Practices

"Significant and convincing empirical efficacy and support:
Applied Behavior Analysis, Discrete Trial Training. Pivotal Response Training, LEAP"

p.16, "...By applying the methodology used in the Pennsylvania and Texas studies to Virginia-related data, JLARC staff estimate that the Commonwealth could save approximately $137,400 in special education costs per student with an ASD if EIBI was consistently provided. In fact, the analysis indicates that Virginia could realize savings as long as at least 42 percent of students with ASDs who received EIBI make moderate improvements (require less intensive services and fewer supports), which is a substantially more conservative outcome than the outcomes reported in the research literature..."

p.33 -34, Table 8: Common Arguments Concerning Health Insurance Coverage for ASD-Related Therapies

[yin:] Many treatments are experimental, investigational, or unproven for ASDs. No treatment is known to be effective for all individuals.
[yang] Many in the medical community (including the U.S. Surgeon General, the Institute of Medicine’s National Research Council, and the American Academy of Pediatrics (AAP)), recognize certain therapies as research-based, including speech, occupational, physical, and behavioral therapies such as those based on the principles of applied behavioral analysis (ABA). Medical treatments are generally not effective for everyone who suffers from a given medical condition

Chapter 7: Improving the Delivery of Services to School-Age Virginians With ASDs
p.114, Specific “Packaged” Interventions Appear More Promising, but Many Schools Use the Mixed-Methods Approach

"...Because individualized educational programming often necessitates the use of multiple instructional strategies, Virginia schools commonly rely on a variety of approaches to serve students with ASDs. However, only a minority of schools report using comprehensive packages such as applied behavior analysis (ABA). Further, fewer than ten percent of schools use these packages as their preferred intervention, relying instead on a “mixed methods” approach to meeting the needs of students with ASDs, despite evidence that packages tend to yield better results (Chapter 2). The literature does note that a mixed methods approach could be just as effective as a package, in theory, but that it requires a degree of expertise, planning, and coordination that is often not present in Virginia schools..."

Read the report.

NEWS: U.S. Senate Bill 1169 introduced to expand autism treatment coverage under TRICARE

"On June 3, 2009 S. 1169 was introduced by Senator Kirsten E. Gillibrand (NY), as the Senate-side companion resolution to the previously introduced H.R. 1600. Both bills would "amend title 10, United States Code, to provide for the treatment of autism under TRICARE..."

Full article:
Monday, June 8, 2009 Practitioner Issues in Behavior Analysis SIG Blog

NEWS: Federal S. 1169 joins H.R. 1600 to provide for the treatment of autism under TRICARE

SIDEBAR: "CLEARING THE AIR ABOUT ABA… And having fun as we do it!"

Friday, June 19^th, 2009, from 9:00a – 12:00p at

The Jean Baton Swindells Resource Center for Children and Families

830 NE 47^th Avenue, Portland, 97213

Downloadable flyer

CLEARING THE AIR ABOUT

ABA…

And having fun as we do it!

Presenters: Sarah L. Schaefer, LPC, BCBA, www.advbehavioralconcepts.com

Mark Vogl, BS, Program Coordinator, CCI Enterprises

plus a special parent testimonial

Parents, professionals, and all “Anti-ABAers” are invited to join us while we present the truth and dispel the myths about

Applied Behavior Analysis

Families and professionals are often faced with various approaches to teach children with special needs. While there is a vast array of approaches, families encounter confusion and doubt about which approach will effectively teach children a new skill or reduce behaviors that interfere with learning. This presentation will present the science of applied behavior analysis while dispelling common misperceptions. It will clarify the basic principles of behavior analysis and how they may be applied to people with a wide variety of needs both in an intensive teaching and natural learning environment.

Friday, June 19^th, 2009, from
9:00a – 12:00p at

The Jean Baton Swindells Resource Center for Children and Families

830 NE 47^th Avenue, Portland, 97213

NEWSFLASH: Texas Legislature Passes Expansion of Insurance Coverage for Children with Autism!

F O R I M M E D I A T E R E L E A S E

Texas Legislature Passes Expansion Of Insurance Coverage for Texas Children with Autism
Effective Date: May 31, 2009
Contact: Mike Bernoski, Executive Director
512-402-5842 Phone;
media@texasautismadvocacy.org

Austin, Texas – The Texas legislature showed their support today for families by passing a measure to expand the age of mandatory insurance coverage for children with autism from the time of diagnosis to the 10th birthday. HB 451 expands on the existing law passed in 2007 which requires coverage for generally recognized autism services, including Applied Behavior Analysis. Parents of children with autism spectrum disorder celebrated today and are urging the Governor [Perry] to sign this bill into law.

“It is hard to appreciate how much effort on the part of so many goes into passing a bill of this nature,” said Mike Bernoski, Executive Director of Texas Autism Advocacy. “The broad bipartisan support shows that Republicans and Democrats alike understand this is a family issue, and it moves Texas a significant step forward in its response to the growing crisis of autism.”

This is Texas Autism Advocacy’s second successful push to secure better insurance coverage for children with autism.

This legislation, authored by representatives Dr. Alma Allen (D-Houston), Eddie Lucio III (D-Brownsville) , and Senfronia Thompson (D-Houston), and carried in the Senate by Sen. Eddie Lucio Jr (D-Brownsville) , author of the existing law which has been in effect since January 1, 2008, was a welcome relief to parents whose children were excluded by the first law because they were either too old or too young or the child of a teacher.

Taxpayers have something to cheer about as well. By expanding the number of children covered, the bill will triple the existing law’s $1.35 billion in lifetime savings to a projected $4.06 billion over the next 50 years.

“One in 150 children is diagnosed with autism. If we do not take care of our children now, we as Texans will suffer later,” Rep. Allen explained. “This bill will help the hardest working in Texas - those that deal with the challenges of raising a child with autism.”

“Early intervention has proven to be able to turn a child’s life completely around,” commented Senator Eddie Lucio Jr., “Now that we have a better understanding of the associated costs and benefits it is time to take the next step".

The Texas bill remains the only state insurance reform that has no dollar caps on the stipulated coverage which includes diagnostic testing, speech, OT, PT, as well as medical and behavior therapies.

Parents and teachers are eager for Governor Perry to sign the bill into law. This bill does not affect ERISA, Medicaid, or CHIP plans, however efforts are underway to address these plans as well.

To learn more about legislation and other initiatives, please visit www.texasautismadvocacy.org.

Texas Autism Advocacy’s mission: To seek to create systemic change by identifying practical solutions that will positively affect the lives of people affected by Autism Spectrum Disorders.

------

--"Don't mess with Texas". Congratulations.--

SIDEBAR: States with insurance coverage or bills in progress

States with insurance coverage for autism treatment, including ABA

2001: Indiana, Minnesota
2007: South Carolina
2008: Texas, Florida, Louisiana, Pennsylvania, Arizona
2009: New Mexico, Colorado, Nevada, Connecticut.


View States with insurance coverage of ABA in a larger map

Key:
Status of insurance coverage of behavior analysis for children with autism.
Green = passed bill/law
Red = bill in progress or previously introduced
Purple = bill waiting for endorsement by autism votes or introduction
Yellow = bill in progress
Blue = little activity at this time.

For more information, see Autismvotes

NEWSFLASH: Connecticut passes autism reform bill

CT Substitute Bill No. 301 passed in the House by roll call vote, has been approved by both legislative houses and now goes to enrollment and the CT governor for signature.

Vote for SB-301 Roll Call Number 307
Taken on 05/27/09 AS AMENDED
The Speaker ordered the vote be taken by roll call at 10:12 p.m.
Yes 140, Nay 2. Number required for passage: 72

Substitute Bill No. 301
January Session, 2009 *_____SB00301APP___041609____*

AN ACT CONCERNING HEALTH INSURANCE COVERAGE FOR
AUTISM SPECTRUM DISORDERS.

12 (3) "Behavioral therapy" means interactive therapies derived from
13 evidence-based research that are provided to children less than
14 thirteen years of age, including, but not limited to, applied behavior
15 analysis that is provided or supervised by a behavior analyst who is
16 certified by the Behavior Analyst Certification Board.

FULL TEXT OF THE SUBSTITUTE BILL
http://www.cga.ct.gov/2009/TOB/s/pdf/2009SB-00301-R03-SB.pdf

Status and all info,
http://www.cga.ct.gov/asp/cgabillstatus/cgabillstatus.asp?selBillType=Bill&bill_num=301&which_year=2009&SUBMIT1.x=0&SUBMIT1.y=0&SUBMIT1=Normal

NEWSFLASH: Nevada Passes Autism Insurance Reform Bill

5/29/09: AB 162 Signed into law.
Autism Coalition of Nevada
Legislative Actions
Governor Gibbons Signs AB 162!
-----------------------

Nevada just passed an autism insurance reform bill, AB 162. Besides allowing families to access reimbursible treatment of autism, the amended bill (amendment 699) also specified competencies and licensing of those providing behavioral treatment. The bill has been sent to the Nevada Governor to await his signature.

Bill text and status is accessible after the newsblurb.

"Nevada passes autism bill
By CATHY BUSSEWITZ Associated Press Writer
Posted: 05/23/2009 03:13:14 PM PDT
Updated: 05/23/2009 04:38:11 PM PDT

CARSON CITY, Nev.—Nevada lawmakers gave final approval Saturday to help children with autism by requiring health insurers to cover screening and treatment of the disorder..."

FULL POST San Jose [CA] Mercury News
http://www.mercurynews.com/breakingnews/ci_12437455

The text of the bill passed,

AB162	Requires certain policies of health insurance and health care plans to provide coverage for screening for and treatment of autism. (BDR 57-44)
	Introduced On: Feb 12, 2009
	By: Ohrenschall Buckley Leslie Woodbury Conklin Aizley Anderson Arberry Atkinson Bobzien Carpenter Christensen Claborn Denis Dondero Loop Goicoechea Grady Hambrick Hardy Hogan Horne Kihuen Kirkpatrick Koivisto Manendo Mastroluca McClain Mortenson Munford Oceguera Parnell Pierce Segerblom Smith Stewart Horsford Schneider Lee Wiener Townsend Amodei Breeden Care Carlton Coffin Copening Nolan Parks Rhoads Woodhouse
	Most Recent History Action: May 23, 2009 - Enrolled and delivered to Governor.

NEWSFLASH: Colorado passes Insurance Coverage for Autism Treatment!

Colorado becomes the 11th State to pass an autism treatment mandate
including Applied Behavior Analysis! Bill goes to the Governor for signature.

See the press release below

---------------------------------

<Autism Society.doc>>
FOR IMMEDIATE RELEASE

CONTACT:
Betty Lehman
Autism Society of Colorado
Cell: 303.898.7656
Betty@autismcolorado.org
www.autismcolorado.org

Colorado Legislature Passes Insurance Coverage for Treatment of Autism
Denver, Colorado, 5/5/09 – A landmark, bi-partisan bill expanding the treatment of autism was given final approval by the Senate and is on its way to the Governor. Senate Bill 244, sponsored by Senate Majority Leader Brandon Shaffer (D-Longmont) and State Representative Dianne Primavera (D-Broomfield) will require health insurance providers to cover assessment, diagnosis and treatment of autism, including Applied Behavioral Analysis (ABA), a substantially researched and favored behavioral treatment for autism spectrum disorders. This bill will require health insurance plans to include autism as a covered benefit.

Autism is extremely expensive to treat; the estimated lifetime cost of caring for a person with autism ranges from $3.5 to $5 million. However, if the appropriate early intervention treatments are applied, up to two-thirds of the cost for treatment can be avoided.

“The passage of this bill is a triumph for the most vulnerable among us; those who we, as a society, have a responsibility to protect,” said Sen. Shaffer. “Autism is treatable, but these families should not face this alone. This bill will finally make healthcare manageable for those with autism disorders and their families.”

After the bill passed the Senate, Betty Lehman, Executive Director of the Autism Society of Colorado and a key architect of the bill, thanked individuals with autism in Colorado , their families and their providers, indicating their continued support ensured the bill’s passage. The Autism Society asked those affected by autism in Colorado to contact their legislators to encourage a yes vote on the bill, to great effect. Lehman also thanked the lawmakers that recognized the impact of the bill on Colorado families affected by autism.

“This bill will have a tremendous impact on the lives of people with autism and their families. It will also alleviate some of the financial burden on the public education, public health care programs, and social services systems in our state,” said Lehman.

Michael Zeitlin, Board President of the Autism Society of Colorado acknowledged the landmark bill would not have been possible without the hard work of the bill sponsors and Betty Lehman.

“Except for Senate Majority Leader Brandon Shaffer and State Representative Dianne Primavera, Betty Lehman was the single most important person involved in shepherding this bill through the entire legislative process, winning approval in both houses of the legislature and vetting about 50 amendments negotiated by various interest groups,” said Zeitlin.

The bill now awaits action by the Governor. If SB 244 is signed, Colorado will become only the 11^th state requiring insurance providers to cover treatments for autism. The Autism Society of Colorado is excited to have worked diligently for legislation that improves the quality of life for people with autism and their families.

###

Bridget Cessar
Communications Director
Autism Society of Colorado
Office: 720.214.0794, ext. 10
Fax: 720.274.2744
www.AutismColorado.org

From the Oregonian on ABA and HB 3000

Families of the autistic struggle with care and costs
by Bryan Denson, The Oregonian Tuesday April 28, 2009, 7:22 PM
Photos by Benjamin Brink/The Oregonian

Annotated excerpts with links to additional info; comments in red.

"Joe Joe McHenry, 4, uses toys to learn pronouns during a recent morning session with autism behavioral therapist Emily Hoyt. Joe Joe's mom, Lisa McHenry, says the intensive therapy has been vital to his development.
...But McHenry was astonished to learn that her health insurance didn't cover a penny of the expensive treatment...
Autism is also on center stage in Salem, and for good reason. U.S. prevalence of the brain disorder is about 1 in 150, according to the Centers for Disease Control and Prevention [1], but some estimates based on school data put Oregon's rate as high as 1 in 87 [2]. Policymakers warn of an approaching "autism tsunami" that will wash over the state's already troubled educational systems...
autism advocates and insurers are squared off over House Bill 3000. The proposed law would require insurance companies to pay up to $36,000 a year for Oregonians younger than 21 enrolled in the kind of intensive behavioral therapy Joe Joe McHenry undergoes....
[Blog Author note: The key phrase being "up to". While the most challenged children may require the entire amount specified under the cap, many children will probably require less and the cost should decrease with improvement through treatment, since the goal is to intervene early, and enable as many children to enter elementary school with no, or minimal aids. Some students will require more support and intervention. Cost analyses done by the actuarial firm of Oliver Wyman Actuarial Accounting, Inc., cites figures of a 0.1% increase in per policy cost in Texas since the passage of their mandate in 2007, with estimated per-policy costs for other states well under 1% (range 0.36- 0.75%)[3][4][5][6]. This corroborates with data from the states of Indiana and Minnesota which have had this coverage for several years [7]. In South Carolina, since passage of their autism insurance reform mandate, some insurers who were not required to provide the coverage under the law are choosing to do so voluntarily [8]. Canada's fiscal study of current cost vs. future savings assessed that current investment in intensive behavioral therapy will represent a future fiscal savings. [9] ]

Insurance companies generally pay for drugs that improve symptoms of autism. But they have been slow to embrace the concept of paying for the kind of behavioral therapy Joe Joe undergoes, describing it as not medically necessary [10] or experimental in nature [11].

This bewilders Laura Schreibman, Ph.D., a veteran autism researcher at the University of California at San Diego [12]...Though scientists are far from agreeing on the origins of autism, Schreibman believes it is a neurodevelopmental disorder present from birth that appears to be genetic. It is clearly a medical issue, she said...

"There's no other form of treatment for children with autism that's been demonstrated -- I mean empirically demonstrated [13] -- to be effective with these kids," Schreibman said. "I just don't know how much research and how much literature has to amass [14] before insurance companies are going to say, 'Yeah, OK.'"

FULL ARTICLE

-------------------------------

1. Prevalence of the Autism Spectrum Disorders in Multiple Areas of the United States, Surveillance Years 2000 and 2002. Centers for Disease Control and Prevention, Department of Health and Human Services. Date March 11, 2009 Content source: National Center on Birth Defects and Developmental Disabilities. Accessed April 28, 2009.
   http://www.cdc.gov/ncbddd/dd/addmprevalence.htm
   
   
2. "Services Aren't Keeping Up With Autism". Oregon Public Broadcasting (OPB) News. August 20, 2008.
   Accessed April 28, 2009.
   http://news.opb.org/article/2871-services-arent-keeping-autism/
   
   
3. A ctuarial Cost Estimate: Connecticut Senate Bill 301 An Act Concerning Health Insurance Coverage for Autism Spectrum Disorders
   

   Oliver Wyman Actuarial Consulting, Inc., Marc lambright, FSA, MAAA
   From Autism Votes
   
   
4. Actuarial Cost Estimate: Georgia Senate Bill 161 An Act Relating to Insurance Coverage for Autism Oliver Wyman Actuarial Consulting, Inc., Marc Lambright, FSA, MAAA, March 2, 2009
   From Autism Votes
   
   
5. Actuarial Cost Estimate: Kansas Senate Bill 12 An Act Relating to Insurance Coverage for Autism Oliver Wyman Actuarial Consulting, Inc., Marc Lambright, FSA, MAAA, March 2, 2009
   Addendum
   From Autism Votes
   
   
6. Actuarial Cost Estimate: Missouri Senate Bill 167 – An Act Relating to Coverage for the Diagnosis and Treatment of Autism Spectrum DisordersOliver Wyman Actuarial Consulting, Inc., Marc lambright, FSA, MAAA.
   From Autism Votes
7. Presentation by Lorri Unumb, Esq., Senior Policy Analyst, Autism Speaks, in public testimony to the Oregon House Health Care Committee, April 8, 2009.
   

8. Lorri Unumb, Esq., Senior Policy Analyst, Autism Speaks. (Personal communication)
   
   
9. Motiwala, S. S., Gupta, S., & Lilly, M. B. (2006). The cost-effectiveness of expanding intensive behavioural intervention to all autistic children in Ontario [Canada]. Healthcare Policy, 1(2), 135-151.
   
   
10. One definition: MEDICALLY NECESSARY – means any care, treatment, intervention, service or item which will or is reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, disease or disability; (ii) reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, disease or disability; or (iii) assist to achieve or maintain maximum functional activity in performing daily activities."
    
    
11. Petitioner File No. 85641-001.STATE OF MICHIGAN DEPARTMENT OF LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE SERVICES Before the Commissioner of Financial and Insurance Services. Issued and entered 11/27/2007.
    In the matter of XXXXX v Blue Cross Blue Shield of Michigan, Respondent
    http://www.michigan.gov/documents/dleg/85641_BCBSM_11-27-07.pdf_222301_7.pdf
    Accessed April 28, 2009.
    Determined that ABA was an appropriate covered benefit, not educational and not experimental.
    
    
12. UCSD Autism Research Program, University of California, San Diego
    Accessed April 28, 2009.
    
    
13. Applied Behavior Analysis and Neurodevelopmental Disorders: Overview and Summary of Scientific Support. Louis P. Hagopian & Eric W. Boelter. The Kennedy Krieger Institute and Johns Hopkins University School of Medicine. Accessed April 28, 2009.
    http://www.kennedykrieger.org/kki_misc.jsp?pid=4761
    
    
14. Summaries of Research Evidence EIBI Comprehensive Interventions. p. 9-11, 13-16, from The Science and Art of Behavioural Autism Interventions: Designing Programs with Evidence and Compassion. Shahla Alai-Rosales, Ph.D., BCBA. February, 2009.
    ,
    

ABA and Neurodevelopmental Disorders - Scientific Support

Applied Behavior Analysis and Neurodevelopmental Disorders:
Overview and Summary of Scientific Support

Authors: Louis P. Hagopian & Eric W. Boelter
The Kennedy Krieger Institute and Johns Hopkins University School of Medicine

"Applied Behavior Analysis Defined.

Behavior analysis is the systematic study of variables that influence behavior (Sulzer-Azaroff & Mayer, 1991). Applied behavior analysis (ABA) is a discipline concerned with the application of behavioral science in real-world settings such as clinics or schools with the aim of addressing socially important issues such as behavior problems and learning (Baer, Wolf, & Risley, 1968). Procedures derived from the discipline of ABA have been implemented to assess and treat a broad range of behaviors with individuals diagnosed with intellectual and developmental disabilities. However, despite more than 40 years of applied behavior analytic research there continues to be misperceptions about ABA. One misperception is that ABA is a standardized treatment program that is used for a specific type of problem and with specific types of individuals. For example, some incorrectly believe that ABA is a type of therapy or a specific procedure for teaching children with autism, and that it is synonymous with “Lovaas Therapy” or “discrete trial training.” Although discrete trial training represents one type of ABA-based approach, the field of ABA is much broader and includes a range of tactics, methods, and procedures that have been shown to be effective for many different types of problems. Features common to all ABA-based approaches are the objective measurement of behavior, precise control of the environment, and use of procedures based on scientifically established principles of behavior. Any clinical procedure or research investigation adhering to these basic criteria can be considered to be an ABA-based procedure. This includes “functional behavioral assessment,” and approaches such as “Positive Behavioral Support,” and forms of “Behavior Therapy” that rely on direct observation of behavior and analysis of behavior-environment relations..."

FULL ARTICLE

• Applied Behavior Analysis Defined
• Scientific Support for Applied Behavior Analysis
• Application of ABA-based procedures across settings and populations
• Scientific, Professional, and Government Organizations’ Position on Applied Behavior Analysis.
• Empirically Supported Treatments for Problems Associated with Mental Retardation, Autism and Related Disorders.
• Legislative Rulings in Support of Funding and Access to ABA-Based Services.
• Link to list of references

How ABA/EIBI Can Change Autism Trajectory

"...Early intensive intervention offers considerable benefit.

This concept became clear in the 1980s and has wide support today,[3],[4],[5] based on the success of early training compared with treatment that starts after children begin school...there is evidence that every year intervention is delayed progressively reduces outcome,...Brain plasticity refers to this ability of the brain to change under genetic and environmental forces, and this plasticity is at the heart of why earlier intervention works so much better than later intervention...So what does this have to do with autism? Plasticity explains why autism...can be helped by intervention in the form of intensive teaching, and why the younger the intervention is started, the better it works...The concept that early intervention is about brain plasticity is growing. [3],[8]..."

ARTICLE
Special Commentary: How Can Early, Intensive Training Help a Genetic Disorder?
William A. Altemeier, MD; and Leah E. Altemeier, PhD
Pediatric Annals 38(4), 167-172. March 2008,

SELECTED REFERENCES
3. Dawson G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Development and Psychopathology, 20(3), 775-804.
doi:10.1017/S0954579408000370

4. Lovaas I.O. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.

5. Johnson CP, Meyers SM (2007). Council on Children with disabilities. Identification and evaluation of children with autism spectrum disorder. Pediatrics, 120(5), 1183-1215.
doi:10.1542/peds.2007-2361

8. Oberman L. M., & Pascual-Leone, A. (2008). Cortical plasticity: A proposed mechanism by which genomic factors lead to the behavioral and neurological phenotype of autism spectrum and psychotic-spectrum disorders. Behavioral and Brain Science, 31(3), 276-277.
doi:10.1017/S0140525X08004378

Excellent WA Article Covering the Issues of Treatment & Coverage

REMINDER: GET YOUR CALLS, EMAILS AND TESTIMONY
IN SUPPORT OF HB 3000 : Requires health insurers and state medical assistance program to reimburse for diagnosis and treatment of autism spectrum disorder.
IN TODAY!

The bill MUST BE approved in the House Health Care Committee to have a chance to go to the full Oregon House! See yesterday's post for who and how to contact.

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Excellent WA article summing up the situation and the points of view; while from our neighbors to the north, the issues are the same in Oregon.

Popular autism treatment often goes uncovered
By DEBBIE CAFAZZO, The News Tribune
October 12, 2008, updated Nov. 21, 2008

Talking points from the story:

INSURERS: Argue autism treatments aren't really medical, but are more educational and that education is the responsibility of the public schools. Can't cover teachers or paraprofessionals or parents who have training in ABA. Medical and rehabilitation services through licensed providers covered [pediatrician, psychologists, OT, PT, Speech].
[Comments: Autism is a medically defined and diagnosed disorder. The state can, and has in those states that have already passed such mandates, assist in determining competencies of service deliverers, and many of the mandate bills include such provisions, including those who are Board Certified Behavior Analysts , awarded certified status dependent on meeting conditions of required education, practical supervised experience, passage of an examination and ongoing education in applied behavior analysis, The licensed professionals cited by the insurance representatives, while competent in their own subject area, may not have appropriate or specific training in ABA. The services of OT, PT and Speech are necessary as part of a multidisciplinary treatment team, but to deliver behavior analytic treatment, the team must also include behavior analysts to supply competently delivered applied behavior analysis.]


SCHOOLS: Schools can't go it alone. The Federal government does not provide enough funding through IDEA, and local funds are insuffient as well. Children would be unlikely to get intensive 1:1 ABA. Not something one agency is responsible for and needs multiprong approach.
[Comments: IDEA is now and historically underfunded. Local funds have multiple demands, and are not always stable, as well as insufficient. Underproviding therapy by lack of intensity has been shown to undercut effectiveness of therapy, with threshholds where a "little" ABA is not that different from "no" ABA. The schools have a valid point that they are unreasonably expected to deliver behavioral health for a complex medical disorder requiring intensive treatment, without support of the usual medical entitities. ]


FAMILIES : Spending through IRAs, spending through savings, cutting back on personal expenditures, but seeing big benefits of ABA therapy. Sometimes have to stop because they no longer can afford. One spouse has to stop working to take care of the child because professional services not provided. The insurance covered services of OT, PT and speech through licensed providers have per year visit limits, so they have to cut back or suspend treatment when coverage ends until next eligibility period.
[Comments: Families purchase or count on health insurance as part of employment package in anticipation of avoiding financial disaster in the event of a catastrophic medical event. Current situation is that they can have health insurance and STILL have to suffer financial disaster because treatment excluded, or face the frustrating scenario of knowing they will receive less than the recommended hours of therapy because of limits in a quarter or year. Equivalent would be rationing medication for a chronic condition or giving partial treatment, or suspending treatment from time to time for an acute condition--expensive and less effective because insufficient].


SOME POLITICIANS: Schools already have multiple demands and kids can't be left to be cared for by the schools. Mandating coverage treatments and ABA treatment ultimately saves taxpayer dollars because early treatment reduces life risk of being permanently dependent [at higher cost] on the state as adults, and may allow mainstreaming in typical schools by 8 or 9. Saves money in the long run.
[Comments: These politicians are taking the long, and arguably, the correct view on social policy. Access to health care is a social question. From a financial and societal cost view, sufficient expenditure upfront for competent and necessary medical treatment can reduce lifelong cost per child/person by millions of dollars over the lifespan, and at current conservative prevalence of 1/150 this longterm cost will be a potentially frightful public expenditure. One might also argue that it keeps parents in the workforce, reducing their lost revenue, and with better outcomes, the children have higher probability as future taxpayers or at least require reduced public support as adults.]

CBS News On ABA and Who Covers It

CBS News Medical Correspondent Dr. Jennifer Ashton, discussing the Federal Autism Treatment Acceleration Act of 2009, S. 819, which, like Oregon's HB 3000, is also considering coverage of applied behavior analysis treatment for children with autism,

"...(ABA) is considered by many to be the "gold standard" in therapy and treatment for children and other disorders, but specifically for autism...[on whether autism should be addressed by schools or medicine] right now autism is diagnosed by physicians, not teachers, so that really puts the onus on the medical community, and therefore, the insurance companies to cover it. I think we're starting to see now people thinking not just with their bankbooks here, but with their hearts, soul--they need to invest in the future of these children, or the costs will be much higher."

What's at stake--Best Outcome From Autism

Breaking Barriers: "Can You Recover From Autism?"
MSNBC, 5:17min
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