Thursday, March 31, 2011

Early Intervention Update - 3/31/11

I want to encourage people who are interested in updates on EI and other issues to follow our Facebook page at http://www.facebook.com/ABC.Therapeutics

I'll be posting brief updates there more often than I update the blog - which I generally reserve for longer rants or conversations. Blog traffic has spiked the last couple days so I know there are a lot of people out there looking for information.

The best information that I have available currently is that Senator Ranzenhofer's office confirmed to me that the EI rates have been cut 5%. In brief Facebook exchanges with NYSOTA they are also reporting the same information. A digital news service that covers NYC news is also reporting similar information. I spoke with people in the NYSDOH and EI programs specifically and they are keeping their lips sealed for now.

A 5% cut is better than the originally proposed 10% cut, but it will still create additional challenges for providers who are still accommodating to the 10% cut that occurred last year.

Right on the heels of all this news breaking I received an email from Public Consulting Group, Inc. (PCG) has been contracted by the NYS Department of Health to coordinate and implement a provider cost reporting system for the NYS Early Intervention Program. It involves filling out cost reporting forms and attending webinars on how to fill out their cost reporting forms - real exciting stuff that providers generally get excited over - right?

I called them up and asked what they want cost data on and they told me that it was to help provide data to stakeholders (I suppose that would include the legislature) about what the actual costs of providing EI services are. I fully understand the importance of cost reporting but to be quite frank it is rather ironic that they are gathering information on cost reporting AFTER cuts have already been made that are crippling ability to hire, train, and retain qualified professionals for the EI Program.

The consultant that I spoke to from this group was very pleasant but I gave her a 15 minute speech on the silliness of ex post facto cost reporting. I suggested that a better way to spend time would be to do a deep dive into the recently published early intervention report to the legislature. This report has shocking information about the absolute ineptitude of NYS in collecting money from third party insurers in their already-existing cost sharing allowances.

The report outlines an 85% denial rate that exists because our state government can't figure out how to cost share with commercial insurance - and the shocking 22% denial rate from our own Medicaid program! The primary reason for denials is not even because of exclusionary coverage rules or timely filing problems - but because providers do not 'participate' as credentialed professionals in the insurer's networks. That is a pretty lame reason to not get paid - and is so easily fixed by simply requiring that providers to EIP already be credentialed with Medicaid and whatever private/commercial entities serve their geographic area.

A tremendous amount of revenue is lost because of this - and rather than fix the problem I suppose it is faster to take an axe and lop off 5% of the reimbursement to providers. This has to be the laziest fix to a budget problem that I have ever seen before.

NY State doesn't know how to get paid for the services that are provided. Any private practitioner knows that you can't function if you don't get paid and now that lesson is about to be learned on a much larger scale across the state. You can't deficit fund forever.

One big part of the solution to all this is for everyone to learn how they can engage their own representatives and start talking about cost sharing through private insurance as a more reasonable model to support the costs of the program - unless you all know how to dodge the next clumsy swing of the budget cutting axe.


I guess that the state doesn't like Medicare rate cost reporting and the long-established formula that is already in place that has previously served as the basis of the EI rate. Maybe someone's friend owns this consulting group - I really don't know. I can't imagine why NOW is the time to do cost reporting - now that we are all about to experience another cut to reimbursement. Usually you might expect that they would make everyone do some little song and dance about cost reporting BEFORE they slash rates. That gives people the illusion that their input actually made a difference, a la the much exalted Medicaid Redesign Team. How funny is it that they slash rates first and then ask people to do cost reporting second?

Don't wait for NYS to figure it out - they are off on this new tangent that is best summed up with the phrase 'Ill-Timed.' Only government could be this dysfunctional.

Friday, March 25, 2011

Thoughts about use of seat cushions to promote attending behaviors in children

I encourage everyone to open up the current American Journal of Occupational Therapy and read 'Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder.' This is a fantastic article that looks at the issue of whether or not seat cushions were effective at promoting 'in seat' and 'on task' behavior.

I think this is a fantastic study because it take a very common OT intervention and puts it to the test. For many years OTs have been dispensing seat cushions to children in classrooms based on the thought that the seats provided sensory stimulation that busy children were 'seeking' or that the seats would demand a postural reaction that would promote attention and erect sitting. This has been done for so many years in so many settings that it becomes a common request from teachers who don't know what to do with fidgety children. How many OTs hear the request "Can we try to see if sitting on a seat cushion will help?"

We have precious little evidence that seat cushions do anything at all for children - and the lack of evidence is reflected in the fact that this intervention is barely mentioned in some common pediatric occupational therapy texts. However, given the formulaic and mythical popularity of the intervention you might think there would be more research!! This is good reason to celebrate this article - because it provides a great first step in researching issues like this.

This issue was a large enough concern in our practice that we recruited some local OT students to help us do an in-house study on effectiveness of HowdaHug chairs in promoting attention for preschoolers. Our study found that the chairs were most effective for promoting visual attending and facing the teacher. This was most likely attributed to the physical design of the seats that provided a measure of physical confinement as opposed to any sensory benefits that were offered by the chairs.

The study in the current AJOT used a different measuring approach with interval recording. They had similar difficulties with the fact that issues in the natural context could not be easily controlled, but they did an excellent job of operationally defining their parameters. Overall their design was very clear and well-explained.

The study did not indicate that there were any substantial changes in sitting or task-related behavior when seated on cushions. The authors contrast this to a previous study where children demonstrated improved attention while seated on a therapy ball and suggest that the ball is more effective because it demands a more complex postural reaction from the child.

My takeaway from all this is that the objective of 'meeting sensory seeking need' may not be supported by research. In our own study we found that actual physical constraint was the primary reason for improving attending. This study does not support the hypothesis that attending will improve by allowing for sensory seeking behaviors/needs to be met in the chair. What seems to be evident is that seating that either controls extraneous movement or that demands controlled postural reactions may be most effective in promoting on task and in seat behavior.

The best part of this is that these conclusions have the best face validity. It is logical that attending would improve under control and demand contexts. It is not logical that attending would improve by allowing children to move more on an unstable seating surface. In anticipation of the comment "aren't therapy balls also an unstable surface" I offer this for thought: despite the ball being an extremely unstable surface, it makes the greatest postural demand on control. If you fail to activate a postural response on a ball you will likely fall right off. The seat cushion provides for movement that is supported by a stable surface - and thus there is less postural demand, decreased likelihood of falling off, and only the opportunity to increase fidgeting!

Congratulations and thanks to Caroline Umeda and Jean Deitz for excellent work that has real clinical application!


Reference:

Umeda, C., & Deitz, J. (2011). Effects of therapy cushions on classroom behaviors of children with autism spectrum disorder. American Journal of Occupational Therapy, 65, 152–159.

Saturday, March 19, 2011

NYS Budget Update - Impact for Early Intervention

If the number of hits to this blog regarding early intervention and the NYS budget are any indication - this is a MAJOR point of concern for therapists. Our traffic has been influenced heavily by this issue in the last month. Also, it is not just NY traffic - people around the country have been watching the proposed budget cuts to the NYS Early Intervention Program.

This week the Senate and the Assembly each put forward their own modifications to the budget and the budget reconciliation process begins. Click on the links to get to the respective budget proposals.

These documents don't always contain all the actual legislative language so it is sometimes difficult to precisely understand where specific budget lines are reflected. It appears that in the Senate version they are 'concerned' about the EI cuts and they are waiting on information about fund availability to see how they can 'minimize the impact of the Executive Proposal.' The Assembly version is more clear in that it 'rejects provisions to reduce the EI rate 10% and require providers to bill Medicaid directly.'

Insurance companies can rest easily, however, because in both the Senate and Assembly proposals they reject the requirements for expanding the mandate for commercial insurance companies to cover the Early Intervention Program. It is unfortunate that legislators didn't recommend a more reasonable cost-shifting plan that respected issues like network status of the provider, place of service, and prior authorization. Instead, they apparently over-reached by requiring a blanket mandate - and I can't really say I would support a blanket mandate either. It is reasonable for the insurance companies to have some typical process of utilization management but all or none thinking in this case will skew to the side of nothing happening. Big win for the insurance companies - big loss for the taxpayers. Blame the politicians for this one by being lazy and thinking a heavy governmental hand would be an effective strategy.

I am aware of several efforts to write in to legislators opposing the reimbursement changes. I am also aware of what appears to be a proto-union group that was able to get an Assembly bill introduced that would prohibit additional reductions to early intervention rates. I have corresponded with this group's leader and expressed some concerns about groups or professionals banding together (formally and informally) to set rates or to have the appearance of colluding about rates. I also have some personal philosophical concerns about the concept of collective bargaining against government entities. I was told that this was not a proto-union effort but this is one of those situations where if it looks like a duck and quacks like a duck it is probably not a rabbit.

Actually I admire this group's intent, and the group is comprised of parents and not only professionals, but I still think that this is like Little League playing at Yankee Stadium.

The lesson in all of this is that the way to effect change is to take the two following approaches:

1. Spend more money on lobbyists and become more active in the political process as it stands.

2. Instead of trying to be a break wall against the need for reform, try instead to ride the wave into another direction. In this case, it might mean helping families find the help they need from sources OUTSIDE of government mandated programs. That's a big mindset change against what many people perceive as an entitlement culture that exists in this state.

Monday, March 14, 2011

A critical look at goal writing in school-based occupational therapy

For those who are not aware, IEP Direct is a proprietary Internet-based software package that many school districts use for IEP writing. One value of this kind of tool is that there is more uniformity and subsequent adherence to regulation when IEPs are created in this format. However, a serious negative is that therapists often over-rely on the canned goals that are part of the drop down menus in the software.

I am not sure who writes/approves the canned goals in IEP Direct but some of them are rather silly.

Being a former full time educator myself I know that academic programs spend quite a bit of time teaching students how to write appropriate goals that are both functional and measurable. Something seems to happen between the classroom and practice because the quality of many goals that I see written for children in school settings is very poor.

This is not new but is a perennial rant because the situation does not ever change. Programs like IEP Direct have now compounded the problem because it perpetuates the thinking that "if the computer has it listed as a well-written goal then it must be ok."

The offending goal today is:
Joey will demonstrate a consistent hand preference and appropriate grasp on a crayon to trace basic shapes and letters using correct sequencing with 1/4" accuracy.
The problem with this goal is that it attempts to measure too many things with too little specificity. There are at least six goals in this single goal:
  1. Joey will demonstrate a consistent hand preference
  2. Joey will use an appropriate grasp on a crayon
  3. Joey will trace basic shapes
  4. Joey will trace basic letters
  5. Joey will trace with correct sequencing
  6. Joey will maintain accuracy within 1/4"
Also, what is an appropriate grasp? What shapes? What letters? What does 'correct sequencing' mean?

My favorite point of silliness about this goal is accuracy within 1/4". Here is a picture of the letter 'A' drawn correctly and also drawn within 1/4" accuracy. Obviously, the absurdity scales when the demand for writing within a more confined space increases - but this is a scaled size that a kindergarten student might attempt:

Would you feel as though your child had achieved this goal if they produced a letter that looks like the 'letter' on the left??

I would like to encourage school-based therapists to be a little more thoughtful when writing goals or when clicking the silly drop down menu options when writing IEPs.

I promise all practicing therapists that parents are getting very tired of trying to understand what the goals mean and how they are supposed to know if a child is really making appropriate progress.

Wednesday, March 02, 2011

Narrative analysis and meaning making in the face of vicious cycles.

Melissa is a happy three year old. She smiled brightly as she played with the 20 year old bead and wire toy in my waiting room. I am amazed at the durability of this toy that was originally a favorite of my oldest daughter. It has been played with by thousands of children over many years. Melissa talked quietly to herself as she slid the beads along their paths. Some of those paths are rather uniform and follow a predictable and simple geometric trajectory. Other paths twist, turn, climb and dip unexpectedly. All of them begin on one side of the toy and end on the other side of the toy.

Melissa's grandmother usually brings her to occupational therapy but her thirty-something year old father also began coming to therapy sessions. He was recently released from prison and a mandatory rehabilitation program. He has a long and repetitive history of substance abuse and criminal behavior. No one knows where the mother is.

Based on conversations we have had, Melissa's grandmother is heartbroken. That has nothing at all to do with her love for her granddaughter - but is more reflective of the love for her son who has disappointed her at every possible turn of his life.

At the end of the session cherubic Melissa hugged my leg goodbye and smiled as she grabbed her grandmother's hand and walked down the stairs toward their car. The father watched the scene as if it were a movie playing out in front of him. I saw pain and worry in his face as he told his mom that he would join them shortly.

After a moment we were alone in the waiting room. "Dr. Chris," he haltingly asked and worried, without much eye contact. "Is it too late for me to connect with my child?"

The question landed heavily on my shoulders and I felt the struggle in my knees as I shifted my efforts so I could find something meaningful to say.

"Of course its not too late" I answered automatically, not knowing exactly where the answer came from. I paused as I heard the reverberation of the assurance in the waiting room. I wondered if I was dispensing fact, or opinion, or maybe it was just hope.

I told him something about the importance of continuing to participate in his daughter's therapy and medical appointments. I told him that constancy is important to preschoolers and that everything he did on a daily basis with her was important. I said some other things.

It was hard to tell if my assurances had any chance of breaking through the curtain of fear and the sense of failure that surrounded him. He heard me, I think, because he shook his head in acknowledgment of what he already knew he had to do - and in some shame of how he had failed in his responsibilities up until recently.

I believe in redemption but I know it does not happen frequently. As he ran with an urgency out of the waiting room to his daughter I wondered if he would find it.

I turned to tidying up the waiting room and couldn't shake myself from the interaction. I looked at the toy, and some of the beads hung suspended in the middle of the wires along their paths. As I moved the toy to the table I pushed all of the beads so that they were neatly arranged at the termination of their paths, because that is where I willed them to be.

I moved those beads, even though I know it really isn't that easy. But I wish it were.