Wednesday, January 19, 2011

Comments made at the NYS Medicaid Redesign Public Hearing

I was impressed with the good attendance at the public hearing and the attendees represented a Who's Who of Health Care and Human Service Providers in WNY. There were CEOs from most major hospitals, directors of community service programs, community activists, and consumers. Their interests ranged from emergency room care, medicaid transportation, primary care providers, hospital and nursing home care, residential programs for people who have developmental disabilities, mental health agencies, substance abuse agencies, and so many more.

I was deeply saddened that I was the only person there who talked about Medicaid in education and early intervention.

These comments were hashed together from old blog posts and other rantings:


My name is Christopher Alterio and I am a pediatric occupational therapist. Thank you for the opportunity to provide information from a street-level provider's perspective on the Medicaid program and funding for early intervention, preschool, and school special education services.

No one questions the need to reform Medicaid, but I am calling for a scientific and evidence based process to be used when reforms are being implemented.

Reform is hard but reform can be good when it is done correctly. The problem with recent efforts of cost control are that reforms are being driven by political expediency and to satisfy legal settlements. Recent cost controls have included a 10% pay cut to early intervention providers, removing minimum service requirements for some therapies, and allowing for higher student to teacher ratios in special education classes.


The problem with all these changes is that there is no evidence that indicates this is the best way to reform or modify the system. This is pure knee-jerk reaction to a budget shortfall and has nothing to do with best practices. So, as we all continue to pay for waste, fraud, and abuse throughout the system - our elected officials are making cuts to budget lines without any apparent regard for evidence. Also, these reforms are being made within the regulatory and rule making process that has some procedural safeguards for public participation but it does not seem that input into that process seems to make any difference.

Our special education system and its funding mechanism is broken and now we have a real chance to improve.

I believe that this particular situation provides an opportunity for districts to begin looking at their models of service provision and see how to provide services more efficiently. That includes setting appropriate entrance and exit criteria for related services, adopting evidence-based or RTI-type models for educational intervention, and improving team building to ensure that services are reinforced in a transdisciplinary way throughout the curriculum. All of these strategies would help improve the efficiency and also the quality of special education services. They would also by design promote cost savings and prevent Medicaid waste.

Professionals also have new opportunities to improve focus on school-home carryover. Parent involvement is critical for positive educational outcomes and may be the largest underutilized resource in the special education equation.

I am not speaking code for decreasing related services and abdicating responsibility to parents. I am talking about an open dialogue about educational best practices and establishing responsible and defensible criteria points for intervention. We have had too many years of poor oversight, lack of accountability, and variable interpretation of special education regulations. I am a practitioner who provides services across dozens of school districts and I can report that there is almost no consistency between districts in how the special education system is administered. This is shocking, particularly in consideration of the tremendous legal process and regulatory requirement that is already present in the system.

In all fairness, there is indeed a price for the fraud and abuse that has existed in this system for many years - but you do not solve the problem with fraud and abuse by failing to address the real problems. New York State has a long history of policy making on the periphery - we decrease service utilization and try to save money by layering complex rule and regulatory changes for Medicaid reimbursement - when what we need to do is establish criteria for the service utilization itself and standardize administration of the program across the State.

We cannot continue to make policy on the periphery of this problem by layering bureaucratic solutions for reimbursement at the feet of school districts or providers. When you present your report to Governor Cuomo, please include reforms that are targeted at the heart of the problem. That means that we need standard procedures, standard entrance and exit criteria, and evidence-based interventions.

Thank you very much for your consideration and for the opportunity to present this information.


If you were unable to attend the meeting you can provide online comment at http://www.health.ny.gov/health_care/medicaid/redesign/

I think it is important for this team to hear from more people about Medicaid reimbursement for services to children. They got an earful from every other constituency - and early intervention and education people need to show up for this conversation.

Tuesday, January 18, 2011

The roulette wheel of qualifying for preschool special education services.

I received a referral today for Trevon, who I initially evaluated eight months ago. His mother was concerned about his development and asked the school system for help when he turned three years old. The initial OT evaluation indicated that he had significant fine motor delays and a speech evaluation indicated that he had significant speech and language delays. The school approved speech therapy and a special education teacher but declined the occupational therapy.

Eight months later, I received an authorization to provide services because the motor concerns were impacting his participation in preschool. In the interim months when there was no OT intervention a second OT evaluation was completed which had essentially identical findings to the first evaluation. Apparently, the lobbying efforts of the preschool teacher and speech language pathologist helped convince the district that the OT services were required.

There are many studies that have been completed that discuss the value of prevention and early intervention services for children - I linked a couple good RAND summaries below for primer reading. I wish that we had more sensible policy about child identification - specifically entrance and exit criteria for pediatric services. So much is left to the decision making of committees, and so often the reasoning behind what is or is not approved is impossible to decipher.

In preschool services, a school district has approximately 24 months (between the ages of three and five) to identify children and provide an intervention program. In Trevon's case, this particular district's whimsical decision making threw 8 of those 24 months away. Based on typical patterns within this school district, it is likely that he will be declassified at the end of his preschool career and an additional 1-2 years will pass before he is reconsidered for CSE participation. How much more opportunity will be lost?

There is no doubt that failure to identify needs and failure to provide services saves money in the short term, but in the above referenced studies it is reported that the returns to society for each dollar invested in early intervention services extend from $1.80 to $17.07. The large variability is due to the nature of individuals. For some, early intervention prevents the need for special education services in later grades. For others there are longer term benefits to society like crime prevention and decreased reliance on social safety nets. Short term savings are notoriously shortsighted.

None of this even touches on the subject of the cost to Trevon. In class he is frustrated and now he tantrums when someone places crayons or scissors in front of him. He has the functional skills of an eighteen month old - and now the world is demanding things of him that he can not do. He could have had support, and his family could have received training and education on how to help him, but we have tossed 30% of his available preschool years away.

If there was reasoning behind the school's decision it is not apparent. He didn't qualify before but now he does. We will improve our system tremendously by employing common sense guidelines for related service entry and exit. There will always be room for individual decision making on borderline cases - but real criteria would allow us to appropriately target children who have needs and who would benefit from timely help.

It shouldn't feel so much like a roulette wheel with the likelihood of a child getting the help they need being governed by chance or house rules.

References:

Karoly, L.A..; Greenwood,P.W., et.al. (1998) Investing in our children: What we know and don't know about the costs and benefits of early childhood interventions. Santa Monica: RAND Corporation.

Karoly, L.A., Kilburn, M.R., and Cannon, J.S. (2005). Early childhood interventions: Proven results, future promise. Santa Monica: RAND Corporation.

Sunday, January 16, 2011

A new study on SI effectiveness but measurement conundrums persist

Just a quick couple thoughts as I got a few emails asking me to comment on an article in the new AJOT. The study people are interested in is Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. (linked for those of you who have access). The study found that both intervention groups demonstrated significant improvements toward goals on the Goal Attainment Scale, but the SI group demonstrated more significant improvement than the FM group. Also, the SI group displayed significantly fewer autistic mannerisms than the FM group as measured by a sub test of the Social Responsiveness Scale.

One of the nicest features of this study is that the researchers completed a series of fidelity measures on the interventions. This is a big step forward because so many of our research studies state that the intervention reflects sensory integration but this particular effort describes a solid fidelity test for each of the interventions provided (fine motor and sensory integration).
The authors state that "one of the purposes of this pilot study was to provide information to guide the development of future RCTs..." I believe that they met this objective well, particularly in consideration of the fidelity measures.

The researchers report that heterogeneity in their intervention groups may have impacted their results. This is probably quite a profound issue. Although we don't know the actual differences between individuals in the study, the tremendous variability in functional levels in ASDs is something that probably should be addressed in study design. The researchers took some positive steps to exclude people who have Asperger Syndrome and to restrict participation to Autism or PDDNOS. This is a good step, but I am not sure that it is an adequate step given the variability in this population.

There are a few design issues that I think need additional discussion. It is difficult to judge the relevance of the outcomes because there is not a non-intervention group. This makes it very difficult to factor out any Hawthorne-type effects. Similarly, the authors conclude that the study supports use of Goal Attainment Scales (GAS) for this type of research but I am not so sure about this. The challenges of GAS include possibly relevant confirmation or expectancy biases if the measurements are being made by the intervening therapists or the parents of the children in the study. I think that GAS can be strengthened if there is a way to more objectively measure progress based on those GAS measures by having independent assessment of results.

Use of the QNST-2 and the SPM are also appropriately identified as limiting because neither is designed or has been confirmed to be a valid pre-test post-test measure. I think that this is good reason to further narrow subject selection and find accepted tools that measure change across time instead of using this as justification to use GAS. That is easier said than done - undoubtedly - but it is just a thought.

The intervention provided in the study was quite intensive (three times per week for a six week period). In actual practice this kind of intensity is often not feasible (either given insurance restrictions or school district authorizations). This makes it a little difficult to know how this could or would generalize in a real-world setting.

Finally, the study is a little unclear about who was providing the SI intervention. The study explicitly states that a graduate student provided the FM intervention under supervision. It is unclear if the graduate students are certified or not, but given that they were being supervised it seems to indicate that they might not be certified. Given the relative lack of experience of an uncertified graduate student and the particular challenges of providing effective intervention to children who have ASDs, it might be important to control for the experience of the therapist between the two groups. It is not clear if graduate students also provided intervention to the SI group. This is a critical distinction and could have an important impact on progress made by the different groups.

I encourage everyone to read and discuss this study. It is a good step forward in our research regarding sensory integration and gives a lot of important information on how future studies might be designed.


References:

Pfeiffer, B.A., Koenig, K., et.al. (2011) Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65, 76-85.

Wednesday, January 12, 2011

Occupational therapists are beginning to ask questions about Interactive Metronome

The questions about Interactive Metronome have been coming fast and furious the last few months, perhaps associated with their increased marketing - although that is my own speculation. I am also aware of some franchised 'brain therapy' centers that are using the intervention protocol so that might also be driving some of the questions.

Anyway, I recently received this email, which reflects the typical question:
Thank you for your candid thoughts. I loved reading your blog and stayed up until 3 in the morning doing so. I am an OT who has been practicing in pediatrics for 12 years and have never really bought into the whole SI thing; I thought maybe I did not really get it. I have always felt like sensory issues are part of the big picture but have never observed them to be an isolated concern that is fixed by swinging or brushing. I have had some parents ask me about interactive metronome and some therapists I know swear by it. What are your thoughts? Does it have the research to back it up? Thanks for your work to improve our profession and help kids. Happy New Year!
First of all, I don't recommend that anyone stay up that late reading my blog, although I really do appreciate the kind words! :)

Interactive Metronome was introduced several years ago and marketed in perfect timing with an AJOT article that provided some initial evidence about its effectiveness. The basis of the method seems to have some sound science behind it.

In subsequent years, very little research has been done on the method. Most of the more recent 'research' that the IM people refer to is unpublished white papers and conference presentations. Rather than produce research, now all they put out are a bunch of anecdotal case studies - to the point where they now claim that IM helps every condition from soup to nuts. There is a particular case study on Alzheimer's on their website that states "To date there is no published research that clearly shows a link between the use of IM and clinical outcomes in patients diagnosed with Alzheimer’s. But sometimes patients are running out of hope. And sometimes their care providers take chances." What is that supposed to mean? If a desperate family is willing to shell out the dough, am I supposed to do ANYTHING? I just don't like it.

I don't know that IM training is any more or less effective than any other exercise-based therapy approach that focuses on motor planning, timing, and sequencing. At its basic core the concepts seem sound, but I don't think there is enough evidence to state that it is a superior or preferred method in any way - especially since people are charging exorbitant prices for the intervention.

As for their 'certification' process - I am doubtful about anything that 'certifies' anyone after a single day of training. Like many other therapy approaches out there - I think that the 'certification' is more marketing ploy than anything else. It allows someone to say that they are 'IM Certified" and then of course what follows is that people offer "IM Therapy" and of course they charge people a lot of money to receive this "special intervention." For these reasons I tend to dislike the whole premise of one-day crash-course certification so you can hawk someone else's product.

This type of marketing/research conundrum is common in the OT world. Sad to say, but the whole push to have Sensory Processing Disorder included in the DSM-V suffers from the same ill-fate - the people making the argument for inclusion talk about science on one side of their website and they also sell sensory processing disorder t-shirts and offer 'exclusive' sensory processing training on the other side of their website. They don't seem to understand that when they financially benefit it makes the so-called 'research' that they offer somewhat hard to swallow. They don't seem to understand the concept of 'conflict of interest.'

Someday, I am hopeful that people will realize how important it is to separate research and clinical interventions from product sales. For what might have been a program with some merit - the IM people have simply driven themselves down the road of lower credibility, at least from the perspective of people who actually think about these things and don't just drink the marketing Kool-Aid that they put out there for public consumption.


References:

Shaffer, R. J., Jacokes, L. E., Cassily, J. F., Greenspan, S. I., Tuchman, Robert F., Stemmer, Jr., P. J. (2001). Effect of Interactive Metronome Training on Children with ADHD. The American Journal of Occupational Therapy 55 (2); 155-161.

Wednesday, January 05, 2011

Occupational Therapy Job Opportunity in DC!

In partial fulfillment of my ongoing public service mission, I wanted to bring a job opportunity to everyone's attention. There is an interesting article in The Washington Examiner today that talks about the DC area Department of Youth Rehabilitation Services wanting to find someone who can teach yoga or tai-chi to children in the program.

I am sure that educating at-risk children in stress management and situational coping strategies is probably a good idea. However, this isn't the only issue in the article that got my attention.

According to the article, the Interim Director got some people suggesting other programs including building a race car, involvement in music programs, and instruction in boxing.

As I read this I couldn't help but think that there were some needs in that program that were obviously not being met.

The article states that "Ward 1 Councilman Jim Graham questioned if turning to yoga was the best approach given the problems the youth face." This makes good political theater, because in a time of fiscal constraint and questions about mandated services it is easy to take pot shots at things that are not well explained. The value of engaging children in normalizing occupations and teaching them appropriate leisure time use is precisely what they need to help avoid recidivism when they get back to the pressures and stresses of their neighborhoods.

How well is the DC Department of Youth Rehabilitation Services meeting the need? Well they have had four Directors in the last year and their system seems to be under a great deal of stress given the severity of behavioral problems that exist in their programs.

I called the Department and spoke to their Human Resources Division. They don't employ occupational therapists, at least not in that job title. There is no Occupational Therapy Department. They have a Recreation Therapy Department, but there are no openings.

This seems like a prime opportunity for someone to go and help them understand a little more about occupational therapy and how it can help with their programs. With such close proximity to AOTA and OT educational programs in the area there are a lot of local resources to leverage.

In full disclosure, I want to state that I don't make these recommendations from an armchair. Locally, we have taken a deep dive into similar programs and transformed the OT services there. We still have some way to go and a lot of opportunity for developing the services further, but it is possible to enter these systems and begin to make a difference.

If any audacious therapist wants a road map to what we did, feel free to contact me. It sounds like this DC program needs some help.

Monday, January 03, 2011

What early intervention providers need to know about administrative rule changes, Part One

The NYS Early Intervention Program recently issues some FAQs on some regulation revisions that happened in June 2010. These changes are insidious and fly beneath the radar of most people because they constitute rules and regulations that can be administratively altered without a full deliberative process that is associated with actual changes to law/statute.

I figured I would post this today because it is a new year and I think that everyone needs to keep their ears to the ground for changes in rules and regulations that will have a significant impact on the way that health care is delivered on local, state, and federal levels.

This particular gem places additional stress on an already over-burdened New York State Budget. The regulation states that social security numbers and citizenship are required for participation in the early intervention program, BUT NOT REALLY.

June 2, 2010 - Webinar 1 - Overview of Revisions to the EI Regulations
Frequently Asked Questions

1. Question:
Are parent and child social security number required? What if a parent refuses to provide or does not have a social security number?

Answer:
The social security number of the parent and the child are required. However, not having a social security number does not preclude a child from participating in the EIP. If a parent refuses to provide their social security number, the refusal should be documented in the child’s record by the Early Intervention Official or designee (EIO/D), but the program continues to be available to the family. There is no citizenship requirement for eligibility in the EIP. The Department has developed a standard form that municipalities may use for this documentation.

The purpose of requiring SS# and citizenship is so that there can be some mechanism for the state to obtain reimbursement for the services provided (private insurance or perhaps federal Medicaid).

Rather than make effort to increase reimbursement for these services, the state - via their Enforcement Arm (OMIG) - places providers in the crosshairs with a tangled array of ever-evolving documentation and billing requirements that make payment to providers less likely.

Do the math: Allow anyone into the program, whether they can pay or not. Then pinch the providers and find as many reasons as possible not to reimburse for the care that you are mandating. Does anyone really think this will lead to a sustainable service?

The large question is: What is the end game? I predict a socialized system or a mandated unionization of the EIP workforce that will functionally accomplish the same end...

...unless the citizenry starts understanding the insidious world of administrative rule making manipulation in health care that we are now entering.