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Autism Treatment for Oregon Health Plan Faces Hurdles, But Approval for Some Kids Likely

Applied behavior analysis has been rejected for coverage by a state evidence-based medicine panel once before, but the Legislature has passed a law requiring private insurance companies to cover the therapy, forcing the state to reconsider its decision.
September 16, 2013


September 16, 2013 -- Autism advocates presented their case for applied behavior analysis last week to an Oregon evidence-based medicine review panel, whose recommendation can make or break the ability of autistic Oregonians to receive the therapy under the Oregon Health Plan.

The approval faces a high hurdle: a staff member for the Center for Evidence-Based Policy at Oregon Health & Science University, Dr. Alison Little, has testified nationally against the psychotherapy for autistic children, including a Florida case in March 2012.

She testified on behalf of Florida’s Medicaid program, which had denied coverage for ABA. But in a sharp ruling, U.S. District Court Judge Joan Lenard in Miami immediately ordered the state to begin coverage for people up to 21, calling the state’s opposition to ABA “unreasonable and arbitrary and capricious.”

Little advises the subcommittee for Oregon’s Health Evidence Review Commission, which will recommend whether the state will cover applied behavior analysis for the nearly 400,000 children on the Oregon Health Plan.

A previous panel rejected applied behavior analysis coverage for the Oregon Health Plan in 2008, but this time, a strong appeal from the Legislature, led by osteopathic physician and Sen. Alan Bates, D-Medford, has forced the panel and its parent body, the Health Evidence Review Commission to reconsider.

The Legislature unanimously passed SB 365 into law, requiring all private health insurance companies to cover ABA for kids up to 9 by 2016, as well as health plans for public employees and teachers by 2015. The law keeps the door open for older children if a specialist approves the therapy.

But for the 44 percent of Oregon children on the Oregon Health Plan, the decision rests with the evidence commission, which will decide whether to recommend the therapy for its prioritized list of health services.

Lack of Controlled Trials

At the hearing in Tualatin on Thursday, Little again labeled the evidence behind ABA as “low quality.” The panel’s preliminary findings offered only a weak recommendation to approve it for children under 13. The opinion opposed treatment for teenagers and adults.

Little based her rationale on the lack of double-blind randomized controlled studies of applied behavior analysis. Many studies were based on just one patient, and there were almost no controlled studies for older kids.

“Not all children benefit and a great many remain impaired,” Little said.

But experts from around the country refuted the lack of evidence, noting that the strongest case came from comprehensive meta-analyses that aggregate and quantify data from hundreds of cases where applied behavior analysis has been tried and recorded. According to such studies, the treatment shows a decrease in destructive behavior in 80 percent of cases.

Gov. John Kitzhaber, a medical doctor who worked at the OHSU policy center before returning to office, signed SB 365 into law in August.

Randomized controlled studies are difficult because autistic behavior manifests itself differently in each individual, and the therapy is tailored to meet the child’s needs, according to Gina Green, a San Diego psychologist and the executive director of the Association of Professional Behavioral Analysts. “If behavior change is unsatisfactory, the practice can be changed,” Green said.

The therapy has also been a standard of care in many states for years, and finding parents willing to subject their children to a 50-50 chance of receiving a placebo for three years would not be practical or ethical.

Without the therapy, children with autism can injure themselves or others, jeopardize their health and impair their functioning. Children may scream, spit, throw objects, or eat non-food items like rocks, dirt and feces, as well as do dangerous things such as inserting objects into electrical outlets. They can face a life of intensive special education and institutional living situations.

But proponents of ABA believe many children can lead mainstream lives if they receive effective treatment, particularly if done before they start school.

Advocates are Optimistic

Eric Larsson, a psychologist from Minneapolis who specializes in ABA, told The Lund Report that he was more optimistic the therapy would get approved this time. Larsson testified as an expert in 2008, and now serves as an advisor to the evidence subcommittee. The committee, which meets again in November, might make a recommendation on ABA at that time. However, any change in policy could not take effect until at least October 2014.

“This time the order for them is to be much more broad,” said Larsson, adding that the evidence panel was more used to approving drug treatments, where the more clear-cut double-blind studies are more practical. Behavioral treatments are by their nature much messier.

“People are so different when it comes to mental health disorders. The results are very individualized.” Larsson said. “It doesn’t cure everybody, but what does?”

Louis Hagopian, a psychologist at Johns Hopkins University in Baltimore, noted that the meta-analyses found applied behavior analysis was most effective when a functional behavioral assessment was conducted before therapy was done.

This would presumably determine whether ABA is appropriate for a child as well as the appropriate areas for focus.

Hagopian said children with autism often suffer from an inability to communicate their needs and wants and act out to receive attention. The bad behavior is reinforced when the children receive attention. Applied behavior analysis works by improving the children’s communication skills, helping them to recognize the needs and body language of other people. The therapy is incredibly intensive, often requiring many hours each week for the patient to show progress.

Larsson, who has testified across the country in support of ABA, said autism advocates often face obstacles from insurance companies that don’t want to pay for the treatment, even if it costs less for society down the road.

But in the case of Oregon, an upfront cost to the state Medicaid plan could save money for schools and the Department of Human Services, if ABA is effective.

“The state does stand to gain in savings on special education costs,” Larsson said.

Christopher David Gray can be reached at [email protected].


Submitted by Christie Riehl on Tue, 09/17/2013 - 18:30 Permalink

I would be interested to see the Lund Report interview Dr. Alison Little. It is a travesty that she would be testifying against ABA. No wonder Oregon is so behind the times in the effective treatment of autism and its related problem behaviors. My daughter was treated by the program run by Dr. Louis Hagopian recently. After 5 years of trying to find effective treatment for her severe self-injury (hitting herself over 1000 times per day) throughout the west coast she finally has her life back after a 5 month admission. The scientific methodology used by Dr. Hagopian and his world-renowned program results in an 80% reduction of problem behaviors in 80% of their patients. Our daughter experienced an over 90% reduction in her self-injury. Oregon is over 30 years behind the times with its DHS and Medicaid advocated use of trial and error treatment of problem behaviors in the DD population. We need Dr. Little to be held accountable for thorough understanding of research designs used with low-incidence populations. The ABA-based methods used by Dr. Hagopian are highly scientific and proven to identify the function of problem behaviors and develop treatment targeted to those functions. Trial and error methods used in Oregon are akin to treating a medical condition without diagnosing it first. We need to move forward with effective treatments here in Oregon and we need the help of respected institutions like OHSU, not its hindrance.
Submitted by K Harris on Mon, 09/23/2013 - 09:24 Permalink

Another person that is single handedly stopping ABA from entering Oregon is Kathryn Weit of DD Services. She has testified against bringing ABA into Oregon under various reasons.
Submitted by Douglas Fettke on Mon, 09/23/2013 - 21:00 Permalink

Dr. Little, are you requiring cancer treatments to be validated by double-blind, placebo controlled studies? Is it ethical for a person with cancer to get a placebo? Early intervention is our children's only shot at having an improved quality of life and possibly avoiding institutionalization later in life. Do you think I want my child to be in the placebo group? No, thanks. Maybe you prefer to bankrupt the state in 15 years when a tidal wave of autistic adults needing full-time residential care hits the system.