Tuesday, February 06, 2007

Sensory integration: warning to parents and insurance companies

In a recent entry I talked about the issues of pseudoscience and the problems with sensory integration theory from an academic and theory-based perspective. Today I got an email from a parent that illustrates the problem from the street:

QUESTION:

My child has just been diagnosed with sensory integration difficulties. I must admit the evaluation results are scary and seem overwhelming. I can only imagine what my child is feeling.

I am very anxious to get my child help. We had my child tested at A PROMINENT AND WELL KNOWN SENSORY INTEGRATION CLINIC (name redacted). They are excellent - but the treatment is very expensive and not covered by insurance.

Do you have any experience with how to get the insurance company to make an exception?

It has been recommended that we get 1 hour of weekly therapy for about 18 months and if possible a 3 week summer camp. The hourly sessions cost $165.00

Your response would be appreciated.

Thank you
NAME REDACTED

++++++++++++++++++++++++++

Insurance companies see the term 'SENSORY INTEGRATION' and they almost immediately deny the claim - and I DO NOT BLAME THEM! This is why:

First of all, we are occupational therapists, not sensory integration therapists. Most therapists use an eclectic grouping of intervention strategies in order to improve the functional performance of a child. If the accepted purpose of occupational therapy is to improve the functional performance of a child, and if there are CPT codes that correspond to this type of activity, why would OTs feel any need to try to bill using esoteric sensory integration codes that are marginally accepted - even at best??

Second, on what basis can any therapist tell a parent UP FRONT that a child will require 18 months of therapy??? Every child is unique and progress should be measured at regular intervals - I recommend every three months for children with developmental disabilities. If a child is not making adequate progress toward goals then either the goals should be modified or the methods should be changed.

I don't have evidence to support that 3 months is the 'correct' amount of time - it is simply based on common sense and a hope to measure progress at a more reasonable interval.

Some children benefit from long term supportive or maintenance-types of interventions. Insurances are not keen on paying for maintenance - and that is ok. These kinds of costs should be reasonably shared with families or school districts. Generally, for those children who require long term intervention, a good deal of the intervention should be directed toward the family in educating them about extracurricular activity configuration and educational planning.

To firmly state that a child will require 18 months of intervention plus a summer camp is not consistent with what I consider to be appropriate or ethical practice.

In summary, here is my warning to parents and insurance companies:

1. If someone tries to tell you that a child's problem with motor planning, attention, or learning will require a prescribed amount of therapy they are probably making it up. There is no evidence that states that a prescribed amount of therapy is required for fixing any particular problem.

2. It is reasonable to expect that you and your OT will set goals that you agree to. It is reasonable to expect that progress will be measured toward those goals at a prescribed interval that is reasonable.

3. It is reasonable to seek third party reimbursement for OT when problems are likely to remediate quickly. Some children's problems will remediate quickly, or therapy will 'set them on the path' toward changing their activity choices so that problems are not so disabling.

4. Some other children require long term intervention, beyond what can be achieved in short time frames. When therapy is long term, it is because problems are intractable and because there are constantly new issues that require skilled intervention to assist the family or school in developing strategies to work around. It is reasonable for third party insurers to restrict benefits so that therapy doesn't continue without any end in sight. Schools and families should help absorb costs for long term or maintenance types of interventions.

Insurance companies should run for the hills whenever an OT tells them up front that a child requires 18 months of therapy for a specified condition. I believe that is disingenuous. I also have some pretty significant concerns about charging a family $165 an hour. I suppose that there are demographic variations in rates for services but there would have to be some very specific and measurable progress and outcomes to suggest to a family that $165 an hour was worth the investment.

If we used Medicare as a national model of reasonably reimbursed occupational therapy - $165 an hour is FAR BEYOND any Medicare reimbursement for therapy services. WHY would an OT charge a family such a ridiculous rate when the insurance companies don't reimburse anywhere near that rate? Isn't that taking advantage of people who are willing (desperate enough) to private pay?

So here at the bottom of this entry I will post my secondary warning to OTs: if you ever expect to be taken seriously and if you want to insulate yourselves from this kind of criticism and if you want insurance to reimburse for services - please think very carefully about what I have written.

Saturday, February 03, 2007

Is a doctoral degree necessary for entry level Occupational Therapy practice?

I entered my profession in 1987 and at that time a bachelor’s degree was required to practice as an occupational therapist. At the American Occupational Therapy Association's Annual Conference in 1999, the Representative Assembly passed Resolution J, mandating post-baccalaureate education for entry into the profession.

I still have not seen any study that indicates that baccalaureate-trained professionals are in any way less effective than people who enter the profession at the master’s level. The marketplace also never acknowledged the alleged benefit of the master’s degree, as people with advanced credentials did not make any more money than people with bachelor’s degrees.

I summarize from this set of facts that the move to post-baccalaureate education served the needs of educational institutions who were able to get more tuition from students who were trying to enter the profession. Students stay in school longer and educational institutions benefit by collecting more tuition. I do not see any other benefit to any other stakeholder (consumers, therapists, or others). I imagine that the possible intent of OT post-baccalaureate education was to ‘keep up with the Jones’ – that is the PTs and pharmacists who moved in that direction. Still, important decisions should be based on what is good and necessary for the occupational therapy profession, not based on what someone decided was a good idea for some other profession.

Following Resolution J, ACOTE (the educational credentialing agency for OT) began looking at doctoral level education and formed a committee to look into the issues. The ESRC (Educational Standards Review Committee) identified some significant concerns about any move toward accrediting doctoral level programs. It seems that someone didn’t care what ESRC had to say because a different committee was formed (the ACOTE OTD Standards Committee) to develop standards for doctoral degrees despite what ESRC reported. This represented a major switch for ACOTE, who traditionally was always in the business of credentialing PROGRAMS, but now would be granting different credentialing for different DEGREES.

Additionally, the AOTA Representative Assembly was supposed to be the body responsible for making recommendations about the doctoral level of education. They were supposed to finish this work in 2006 but had to extend their process until 2007. Now whatever the RA has to say is a moot point because ACOTE has already made unilateral decisions about doctoral level education.

At this point I imagine that the eyes of many street-level occupational therapists begin to glaze over… but this is an important issue to study. The question I have is this: why does it appear that ACOTE, with the tacit approval of AOTA, is trying to ramrod an entry level doctoral level of training on the profession?? Is there some unpublished study that has been done that identifies how this change will benefit consumers?

Just because other professions have moved to a doctoral level of training doesn’t mean that OT also has to. Just because some people have the IDEA that advanced training is needed for practice doesn’t mean that IN FACT advanced training is needed for practice.

As collective shepherds of our occupational therapy profession we can’t allow major decisions like this to occur without the input of the membership or without careful and thoughtful study of the impact.

What should street-level OTs be concerned about:

1. If it is true that practice is becoming so complex that doctoral training is required, what does this mean for people who are functioning as occupational therapy assistants and only have an associate’s degree?

2. Are there some glaring inadequacies in the skill sets and competencies of associate and baccalaureate and master degree level practitioners that need to be acutely addressed in order to ensure the safety of consumers?

3. If there will be two levels of entry into the profession (from the masters level and from the doctoral level) does this mean that people with degrees below the doctoral level will be restricted from certain areas of practice?

4. If it is true that doctorally trained professionals are practicing at a stratospheric level of competence do they even need to be credentialed for entry level practice? How would they be credentialed and what will state regulatory boards think of multiple levels of certification?

5. Since there was an RA process in place to look at the issue of doctoral level education, does this mean that the RA is irrelevant since ACOTE already acted on this issue?

6. If the RA is irrelevant and if constituent feedback to the ESRC was irrelevant, and since the ESRC report was summarily dismissed, do we even really have a representative membership organization?

So if you managed to read through all of this, contact your RA representative and ask them what they think.


References/background:

AOTA (11/12/06). Frequently asked questions about the Doctor of Occupational Therapy Degree (OTD). Downloaded 2/3/07 from http://www.aota.org/nonmembers/area13/links/link56.asp

AOTA (July 2006). Background on the development of ACOTE standards for OTD programs. Downloaded 2/3/07 from http://www.aota.org/nonmembers/area13/docs/otd-process-7-06.pdf