Friday, March 30, 2012

Field report: Fidelity problems persist with 'sensory integration'

Consider this as Part II of Sensory integration: More evidence that OTs have lost control of the narrative. A major HMO in my region just published a clinical practice guideline update on sensory integration, which I will re-publish in full below. However, if you want to understand the fidelity problem, I think the graphic to the left says it all.

Sensory Integration Therapy

Implemented By: Chief Medical Officer, Health Care Services

Policy No.: M110207082

Effective Date: May 1, 2011

Location/Type: MRM/EXT

Revised Date: May 1, 2012

Signature: (Signed copy on file)

Reviewed Date:

To provide clinical coverage guidelines for sensory integration therapy for Independent Health plan members.

Responsible Departments: Medical Resource Management

Applicable Vendor: N/A

Sensory integration therapy: sensory integrative techniques are performed to enhance sensory processing and promote adaptive responses to environmental demands. These treatments are performed when a deficit in processing input from one of the sensory systems (e.g., vestibular, proprioceptive, tactile, visual or auditory) decreases an individual’s ability to make adaptive sensory, motor and behavioral responses to environmental demands. Individuals in need of sensory integrative treatments demonstrate a variety of problems, including sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems.

Corporate Medical Guideline:
Sensory integration therapy is a covered benefit only for Medicare Advantage members. Insufficient evidence exists in the form of a well-designed, large-population, prospective, randomized, controlled trials to draw definitive conclusions regarding the accuracy of sensory integration therapy and the impact of sensory integration therapy testing to determine if such tests result in improved health outcomes.

Medicare Advantage Medical Guideline:
Sensory integration may be considered medically necessary for acquired sensory defects resulting from:

¨ Head trauma;

¨ Illness; or

¨ Acute neurological events including cerebrovascular accidents.

Sensory integration is not appropriate for Medicare members with progressive neurological conditions without potential for functional adaptation.

Therapy is not considered a cure for sensory integrative impairments, but is used to facilitate the development of the nervous system’s ability to process sensory input differently.


NGS LCD for Sensory Integration Therapy, L26884,01/01/10

Sensory Based Treatments for Autism Spectrum Disorders, Hayes Inc. Medical Directory 5/9/2011

Sensory Stimulation for Patients in a Persistent Vegetative State (PVS), Hayes Inc. Medical Directory 1/13/2012

Evidence based review of interventions for autism used in or of relevance to occupational therapy, Case-Smith J. Arbesman, 2008

This policy applies to:

X All Products*

FlexFit Select
Child Health Plus
Healthy New York
Easy Access
Healthy New York Select
Independent Health’s Medicare Family Choice (HMO-SNP)
Encompass Plus
Medicare Encompass (HMO)
Encompass I2
Medicare Encompass (HMO-POS)
Encompass Plus I2
Medicare Passport (PPO)
Encompass 65 (HMO)
Encompass 65 (HMO-POS)
Family Health Plus
Passport Plan Select
Self-Funded (See Grids)*

*In the event of any conflict between this policy and the summary plan description (SPD) of a self-funded plan, the SPD shall supersede the policy.

Reviewed/Revised Dates:


Revised: 05/01/2012

Caution:Independent Health updates its corporate policies frequently. Please reference the Internet for the most current version.

Wednesday, March 21, 2012

More regulatory changes to impact NYS occupational therapists very soon.

This is a follow-up to my entry on 2/16/12: In NYS a single OT can still supervise a million OTAs, for a while at least.

Something will happen on June 13th...

Unless there are some unanticipated changes, new regulations regarding supervision of OTAs will go into effect in NY. Perhaps the largest issue that will impact jobs is the new restriction that reads as follows:

In no event shall the occupational therapist or licensed physician supervise more than five occupational therapy assistants, or its full time equivalent, provided that the total number of occupational therapy assistants being supervised by a single occupational therapist or licensed physician shall not exceed ten.

That means that a couple things might happen on 6/13/12:
  1. A bunch of OTAs will get their walking papers and agencies/schools will hire OTRs instead to avoid being out of compliance with the regs.
  2. A bunch of job postings will appear for OTRs so that agencies around the state will be in compliance with the new regs and OTAs will maintain their employment.

I have some OTR colleagues around the state who I know are supervising more OTAs than the proposed regs will allow. In this economic climate I will not be holding my breath to see agencies bite the bullet and just hire more OTRs.

My advice to OTAs who believe they will be out of compliance with the new regs is to start having conversations now with your supervisors. You don't want to be blindsided in June.

Other significant issues that will occur with these new regs are stricter supervision requirements that will decrease OTR productivity and have an associated impact on the cost of delivering OT services. It is impossible to predict the exact cost impact because of the varied experience of OTAs and the flexibility allowed in the new regs with regard to developing plans. Still, there will be some cost impact. Too bad that NYS is doing their time and motion studies BEFORE the regs go into effect and BEFORE there is any increase in indirect costs associated with stricter supervision requirements.

In NY State when regulations are proposed there needs to be a statement of potential costs associated with regs and a potential job impact statement. This is the best that NY State will offer:

Entities that employ occupational therapy assistants and holders of limited permits might believe that the additional cost associated with compliance will result in the loss of jobs or job opportunities.

If you are an OTA and if you lose your job, you will probably think that is the whitewash of the century. If you are an agency who contracts for OT services and you suddenly find that costs are increasing because of these requirements you also aren't likely to be very happy. Provide your comments here (presumably for 45 days from publication):

Office of the Professions,
Office of the Deputy Commissioner
State Education Department
89 Washington Avenue, 2M
Albany, NY 12234
(518) 474-1941

Monday, March 19, 2012

Going the extra mile.

I recall being a newbie occupational therapist and having a keen sense of "having to put my time in." It is probably a broad cultural value passed to me first from my family. My Dad was a hard working person who I saw go to work every day and sometimes even every night when he was assigned an evening shift.

When I graduated from college I gravitated toward home care and consultative occupational therapy; the freedom and responsibility of these settings matched my interests and work style. Since I was a newbie and trying to work for home care agencies all of the preferred geographic areas were taken by more seasoned occupational therapists. That left me with assignments in far-flung areas where I had to drive up to an hour to get the the patient's home. I figured that I would accept these cases and then after some time I would be offered cases that were not as far away.

So, during this time in my career when I was driving from Buffalo to Farnham and North Collins, dreaming of closer assignments, I met Peter Talty.

Peter was one of those 'more seasoned' OTs who I imagined I was competing against for favorable home care referrals. He called on the recommendation of Kent Tigges who was a mutual friend and said to me, "So I hear you are interested in some work and Kent tells me that I should call you!"

I already knew who Peter was although I never met him - and I was nervous and excited that he would call and offer me a job! Now being a newbie and most certainly not being in a position to turn away work and being flattered to have Peter Talty call me and definitely wanting to show my best for my mentor Kent I listened to myself reply, "Sure... definitely!" even before asking for any other details.

I'll never forget meeting Peter in person for the first time and I will never forget the first question I asked: "So... where did I agree to work and what kind of work will I be doing???"

Peter didn't hesitate a second in his response - he delivered the news to me in the straightest of terms. He deadpanned, "You know when you are driving along a major road like the Thruway and there is an exit for a town you never heard of? Then you look over and all you see is trees and maybe a gas station sign? You might wonder what is over there if you took that Thruway exit. That is where we are going to go!!!"

I noticed that he said "we" and that surprised me a little - after all, most "seasoned" occupational therapists only worked in places that were geographically close to their homes. I quickly learned that although Peter was very experienced he was definitely not like "most" therapists.

Although Peter lived near the Buffalo area he went with me to set up and deliver occupational therapy services in very distant places all over Western NY. We went to nursing homes in Salamanca and Machias. We went to community rehabilitation programs in Olean. We went to a residential program for children who had developmental disabilities in Bradford, PA. I will also never forget how Peter gave me directions to find these places: "Keep driving down this road and you will see a place called 'The Cow Palace' on your right. Keep on going and take the right fork in the road after that - but it won't have a street sign." Peter's directions were legendary.

While thousands and thousands of miles ticked off my odometer I never minded it at all. Peter was an amazing role model and I quickly dropped my preconceived notions of how far experienced OTs should have to travel for work. Peter Talty went the extra mile.

He didn't just go the extra mile in physical distance - he did the same for me, for the COTAs we supervised, and for all those patients including every child who had an IEP along the old Route 17 between Randolph and Belmont. In places where there was no occupational therapy, in places where occupational therapy needed to be, Peter Talty made occupational therapy happen.

I also recall Peter's phone call to me asking if I was interested in teaching some lab sections at a college. By that time I knew enough to ask "where is this college where we will be going??" Of course he was referring to Keuka College - a two hour drive for us both - but it was another tremendous opportunity to watch Peter 'go the extra mile' in so many ways for hundreds of occupational therapy students over the years.

A year or so ago Peter called me and wanted to spend some time in my private practice. Watching him work again was another amazing reminder of what he brought to patients, how he listened to their stories, and most importantly how he helped them move forward with their own recovery.

Peter Talty is retiring from Keuka College this year and I can think of no better way of honoring him than telling this story of how much good you can create when you are willing to 'go the extra mile' as an occupational therapist.

Whenever I drive along a road and wonder what is over the treeline I think of how important it is to care. I also remember that Peter showed me that you also have to care enough to actually put yourself into action. Sometimes the people who need us the most will be in places where we haven't been before and where we never imagined ourselves being. His example is one I will always aspire to.

Thursday, March 15, 2012

Will my child be eligible for services this year?

This is a common question that parents ask this time of year - many children are having their annual reviews and determinations are being made for eligibility. In an interest of making sure that all families are aware of their rights, New York State does things like releasing the new translation of revised procedural safeguards into multiple languages.

Families might want to look elsewhere for information about how eligibility determinations will be influenced in the future in NY State. In addition to focusing on translation of procedural safeguards maybe the Department of Education and Department of Health and the Governor's office should be more clear about new funding methodologies that are being considered.

I will attempt to demystify what is going on because I don't see that they are informing the public in a particularly clear way.

Last year Governor Cuomo held meetings around the state discussing plans for redesigning Medicaid. I was really hoping we would see some opportunity for impacting service delivery concerns like entrance and exit criteria, consistency in eligibility standards, and promotion of evidence-based interventions. Instead we are getting another year of smoke and mirrors widget counting in a hope and prayer to eke more money from the federal Medicaid till.

Currently, the SSHSP (Preschool/School Supportive Health Services Program) rates for services in schools are set at 75 percent of the mid-Hudson Medicare rates. The government allows several methods for coming up with reimbursement rates - either as a percentage of the Medicare rate or based on commercial rates or based on actual costs of providing the services. Apparently someone is of the opinion that there will be more money available if we start doing time and motion studies and ask for reimbursement based on actual costs incurred.

Proposal 13 was discussed last year as one possible way to realize more Medicaid revenues and was introduced as part of a larger plan to control the Medicaid budget. This proposal led to a a Request for Proposals that was announced last summer to bid on the project entitled "Cost Study and Implementation of Revised Reimbursement Methodology for the Preschool/School Supportive Health Services Program (SSHSP)." The RFP asked for a vendor who could deliver a cost study to determine whether current reimbursement for preschool and school supportive health services furnished in school districts, certain schools, and counties in New York reflects the actual cost of service delivery. The vendor also has to implement a Certified Public Expenditure (CPE) reimbursement model to enhance Medicaid reimbursement. At some point in time that contract was awarded to Public Consulting Group.

NYS released a Medicaid in Education Alert on March 1st regarding implementation of random moment time studies for the new CPE reimbursement strategy. That means that your OTs and PTs and STs will be documenting what they are doing on a daily basis and there will be more reporting requirements heaped upon providers. More concerning, there will have to be data sharing regarding salaries, fringe benefits, contract costs, equipment costs and more bureaucrats hired to track all the data. Then there will have to be some kind of formula for making sense of the very wide variety of ways that costs are incurred (direct through district salaries, billed out to BOCES, billed out to private contractors on all kinds of methods (per pupil, per service, etc.)). Given the inconsistency in cost outlays it will be very challenging to come up with a sensible cost per unit figure.

What will all this mean? The state hopes to get more money out of the federal till - and they are banking on the fact that their cost per unit will exceed the current 75% rate based on the mid-Hudson Medicare reimbursement. There will be more bureaucrats hired and there will be more number crunching to make sure that our costs will allow us to get the most possible money from the Feds. However, costs won't be allowed to go too high because that would mean that the State would have to send excess reimbursements back to the federal government.

In sum, systemic decisions about breadth of special education services will be made in accordance with maximizing federal reimbursement. Your districts will grumble about hiring more bureaucrats. Therapists will grumble about completing time studies. Agencies will grumble about having NY State stand on their necks until they release confidential or proprietary employee data on salaries and benefits.

You will go to your CSE meetings - but now you are armed with information on what is driving all of the 'reforms.'

Saturday, March 10, 2012

Why I support DSM-V criteria to make autism diagnosis more difficult.

Be patient as you read, please - and in advance I ask forbearance from autism advocates for use of this issue to make a point.

The Diagnostic and Statistical Manual is undergoing another revision and there are changes suggested that would effectively make the diagnosis of autism a little more specific. There has been a lot of popular reporting about the unintended consequences of 'tightening up' the diagnostic criteria. Specifically, many people are legitimately concerned that it will make fewer people who really need help eligible to receive services because they no longer meet the criteria for the diagnosis.

I have had concerns about this problem because I know people who would probably be negatively impacted by no longer meeting diagnostic criteria. However, after some additional thought, I decided that this was the correct time to take a different stand and support the DSM-V changes.

What prompted my change of heart? Let me walk you through the process.

Kent Tigges was my mentor and he introduced me to the concept of 'cardinal principles' in occupational therapy. I am not entirely sure where he first came up with the idea to explore 'cardinal principles;' I recall that we were furiously studying occupational behavior models and we thoroughly enjoyed Kitty Reed's book that laid out assumptions and concepts of different models. Perhaps he was driven by Dunton's idea of 'cardinal rules.' In any event we explored the concept in depth and in years following those initial discussions I adopted a 'cardinal principle' of my own after I heard a colleague make a value judgement about whether or not we should expend resources on people who (at that time) were living in developmental centers. My personal first cardinal principle can be summarized as:

Above all else, human life is valuable in all of its forms, and under every circumstance must be held in the highest regard.

Occupational therapists work with people who are in all different kinds of situations, and I found that this cardinal principle laid down a moral premise that supported all the efforts of people who were finding, developing, and cultivating meaning in their own lives. Sometimes that extended to parents and caregivers as well. It was a potent philosophical position that served many purposes to me as a professional. It provided me with justification when I was advocating for services. It also reminded me of the awesome responsibility I committed myself to when I accepted my role as an occupational therapist.

What is a life and what needs to be valued? How do we balance our value with pragmatism? Or is there no such issue of pragmatism if we are valuing life 'in all of its forms and under every circumstance.' This is a difficult question.

The case of Nancy Cruzan was being argued early in my professional career. It was a tragic situation and I don't know what the correct answer to this situation was - but in the end the US Supreme Court found that the State had to have the highest levels of evidence before they could sanction withdrawal of life-sustaining treatments for someone who was in a 'persistent vegetative state.' That led to a large social and cultural awareness of the concept of advance directives. I have no idea if the court was correct or incorrect with this individual case, but what caught my attention at the time was the opinion of Justice Stevens who wrote

"Nancy Cruzan is obviously "alive" in a physiological sense. But for patients like Nancy Cruzan, who have no consciousness and no chance of recovery, there is a serious question as to whether the mere persistence of their bodies is "life" as that word is commonly understood, or as it is used in both the Constitution and the Declaration of Independence. "

This is a chilling opinion that has bothered me for years. Stevens argued that the state had no compelling interest in preserving life - and went so far as to make value judgements about the worth of a life.

Our society revisited this debate in 2005 with Terri Schiavo. The slippery slope of Justice Steven's opinion was in full view and again there was a debate of what the State's compelling interest was. In this situation some argued that Terri Schiavo was not in a persistent vegetative state. Perhaps more importantly there was again conflicting information about her wishes and who would be responsible for making proxy care decisions.

I don't pretend to know what the correct course was in either of these cases. The point in referencing them is to highlight the cultural debate about life, and when it should be protected, and who is responsible for making decisions. In general I felt that my cardinal principle worked, because if nothing else the decision and action to hold life in the highest regard prevents the State from hasty decisions that can have disastrous and deadly consequences. Ultimately, all kinds of final decisions might be made - but at a core I believe that high regard for life is a preferable cultural value as opposed to a low regard for life.

The debate came home to occupational therapy in 2008 when Dr. Jane Sorenson wrote an opinion piece in an OT magazine where she argued for resource allocation decisions to be made upon the basis of what human potential was possible given 'the reality of a diagnosis.' To me this was a chilling reference to Justice Stevens' opinion and I wrote blog entries about it here and here. AOTA weighed into the conversation when Dr. Moyers wrote to the editor of the OT magazine; it was good to see AOTA take this kind of a stand.

Like all controversies do, all this died down but in the last couple months the debate about value of life seems to be coming up again in our culture. An article recently appeared in the British Journal of Medical Ethics that argued babies have no moral relevance because they can't make determinations about the value of their own lives. We also have the slickly marketed MaterniT21, which is little more than grease for the wheels of the Down Syndrome abortion industry. Fresh on the heels of the release of the MaterniT21 we have the case of Kalanit Levy, whose parents have openly stated they would have aborted her if they knew she had Down Syndrome. Perhaps they think that their $3 million dollar 'wrongful birth' lawsuit against the lab that did their prenatal testing will set their world aright. I am shocked at the concept of 'wrongful birth.' What will happen if Kalanit is provided the supports so that she is able to learn how to read about how her parents wanted her aborted and how she is compared against her oldest brother who "is a competitive chess player and has placed in the 99th percentile on standardized tests." Wow.

So we have some important cultural debates going on regarding life, the value of life, and who determines the value of life. We see doctors and ethicists advocating for the moral irrelevance of infants, we have slickly marketed Down Syndrome prenatal tests being covered as 'preventive care,' and we have parents suing for 'wrongful birth' of their children. All of this follows a slow cultural slide out of the confusion of cases like Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo. In OT we have even heard about witholding services from children who won't make progress based on the 'reality of their diagnosis.'

This is why I support the DSM-V criteria to make autism diagnosis more difficult. Now is NOT the time to want a diagnosis of a developmental disability. Watch out for ethicists, doctors, testing companies that are more interested in profits than moral debates, and a misguided populace that doesn't know which way to turn anymore. Our society is creating this disaster right in front of our eyes.

By my reasoning, at the rate of our current cultural delay, fewer diagnosed cases of autism might actually save lives. The community of people who have autism might go underground for a while and stay safe, at least until we can smack some collective sense into the skulls of this society that is not making sane value determinations.

As for me, I will hold onto my cardinal principle, because it provides a clarity that serves me everyday and gives me hope and reason to serve my purpose as an occupational therapist for all people - including the ones that some people are now considering inconvenient or a resource drain.

There is great risk in taking stands and writing opinions. There is even greater risk in case of being accused of reductio ad Hitlerum - but I take the risk and ask people to remember Martin Niemoller and his poem 'First they came...'