Autism Coverage Doubtful for Older Kids on Oregon Health Plan

Applied behavior analysis has been used most prominently in younger children, but experts testify that less-intensive treatment could provide relief to older kids with autism as well.
The Lund Report
An evidence subpanel of the powerful Health Evidence Review Commission appeared poised last week to recommend applied behavior analysis for younger kids on the Oregon Health Plan, but at the same time stuck to denying treatment for children older than 12.
 
A state law passed this summer will require private insurance companies to cover applied behavior analysis, or ABA. But for the 44 percent of Oregon children covered by the state Medicaid plan, the Legislature’s unanimous opinion is less important than the opinion of the Health Evidence Review Commission and its panels, which rely on the evidence reviews of the Center for Evidence Based Policy at OHSU. 
 
The commission has already rejected the autism treatment once, in 2008, but the new law compelled the health evidence board to reconsider the evidence and come to a new decision about providing treatment, beginning next fall.
 
“If you don’t have good evidence, it could suck up resources,” Dr. Alison Little, a physician at the policy center, told The Lund Report. “If this doesn’t work, we really need to be putting resources into what does.”
 
Autism is one area that is particularly rife with pseudo-scientific treatments, including everything from wilderness camps and holding therapy to dolphin therapy.
 
But applied behavior analysis is a set of techniques rooted in evidence-based behavioral psychology that’s already covered in three dozen other states.
 
Another rejection would disproportionately affect racial minorities, particularly blacks and Latinos, whose representation on the Oregon Health Plan is roughly twice what it is in the statewide population.
 
Dr. Katharine Zuckerman, a pediatrician at OHSU, testified that denying treatment to older kids would further disproportionately affect children from these minority groups. 
 
The average autistic child is diagnosed at 5, but the age is 7 for black and Latino children. 
 
Half of these kids, of course, would be older than 7, meaning they would no sooner be properly diagnosed with autism than the clock would start running out on their ability to receive treatment.
 
Dr. John Sattenspiel, who sits on the evidence subcommittee, pointed out that the new coordinated care organizations are being monitored on the percentage of behavioral health exams they conduct for children, eliminating much of the racial and class disparity in diagnosis and catching these kids at the crucial younger ages.
 
The mention of CCOs brought up an ironic twist — the organizations have been championed for their flexibility to use cost-effective, common-sense solutions like employing community health workers and buying air conditioners to improve overall health.
 
But without the ability to provide proper psychological treatment for autism, the CCOs as well as the Department of Human Services will be on the hook for millions of dollars more to provide for their needs of disabled kids and adults in more intensive settings, such as special education, group homes, and 24-hour nursing care.
 
“If you intervene early, you won’t have to pay as much later,” said Dr. Keith Cheng, the medical director at Trillium Family Services, Oregon’s largest provider of juvenile mental health treatment.
 
Evidence Spotty on Older Kids
 
For some kids, going without treatment means special education for children who have a chance to attend regular school. In more severe cases, a full recovery from autism disorder is not possible, but experts testified that its methods could still be used to dampen behavior that is destructive to themselves and others.
 
The subcommittee still leaned toward denying care to older kids, because the Center for Evidence Based Medicine had only found one weak case study showing that ABA methods are effective with older kids. The center analyzed studies provided by the federal Agency for Healthcare Research & Quality.
 
The center didn’t find any evidence that ABA was ineffective for older kids, but the data was too sparse to give it a seal of approval.
 
But Dr. Eric Larsson, a Minneapolis psychologist, told The Lund Report that the policy center had ignored a lot of other evidence, and he intends to submit research studies that might end up allowing treatment for older kids on a focused basis.
 
Larsson did say that the kind of intensive, total behavior treatment used on younger kids that often gets associated with ABA would not be appropriate for older kids. But treatment that focuses squarely on problematic behaviors can greatly reduce the behavior, even if the autism disorder remains.
 
At last week’s hearing, Christie and Eric Riehl of Salem showed a video of their teenage daughter before and after applied behavior analysis treatment at the Kennedy Krieger Institute at Johns Hopkins University in Baltimore.
 
Before treatment, Elie needed to be straitjacketed in a blanket to keep from striking herself repeatedly and involuntarily — injuring herself hundreds of times a day. 
 
After treatment, she still has some of the handicaps of autism, but has been able to free her arms and enjoy many of her favorite pastimes — swinging, bicycling and walking leisurely on the sand along the Oregon coast.
 
Follow-up Critical
 
The subcommittee voted to make a strong recommendation for a periodic review of any child’s treatment, preferably at six months. Applied behavior analysis doesn’t work in every case. Sometimes certain methods show progress while others don’t. The relationship with the analyst can also be crucial.
 
If applied behavior analysis is approved for a child, periodic assessments were crucial to determine whether they were on the right track, according to the subcommittee.
 
“The children who aren’t responding deserve other treatment,” Larrson said. “The children who are responding deserve a chance to be integrated into regular school.”
 
TO LEARN MORE:
 
The draft Evaluation of Evidence for Applied Behavior Analysis has been posted for public comment from now until 8 a.m. December 16, 2013. Public comments will be reviewed at the EbGS meeting 2/6/2014. The draft evaluation of evidence is located here. ( http://www.oregon.gov/oha/herc/EvidenceEvaluation/Evaluation%20of%20Evidence%20Applied%20Behavior%20Analysis%20For%20Autism%20Spectrum%20Disorders%2011-14-13.pdf )
 

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Christopher can be reached at chris@thelundreport.org.
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