Tuesday, March 10, 2009

Should insurers be required to pay for behavior therapy for autism

I was interested to read an article in the los angeles times today about the California state department of managed care declining to force insurers to pay for behavioral therapy for autistic children in spite of the fact that they are saying that insurers must pay for speech therapy, occupational therapy, and physical therapy. The article quotes behavioral therapy as being quite expensive, costing as much as $70,000/year. The legal argument for requiring insurers to pay for autism care is a law called the Mental Health Parity Act, which requires insurers to treat mental conditions the same as medical conditions. I do not believe that this law would cover behavioral therapy ,as the mental conditions that are treated under this law are quite different from behavioral therapy for reasons I will outline in this blog post.

The insurers argue that they are not required to pay for behavioral therapy because it is an educational service and not a medical condition. They also argue that this would drive up insurance premiums though studies from other states have found increases to be minimal. I suspect one problem with these studies is that the states which provide insurance for behavioral therapy have only recently done so and it is too early to measure effects that it would have on insurance costs.

The article quotes ABA advocate Gina Green as saying some studies show that 47% of children are able to enter school with no further interventions and few if any symptoms of the condition. The only study that I know of that fits that description is Lovaas (1987) in which aversives (now illegal in the state of California) where used and in which there are no adult outcomes published, though they have been given NIMH money to study these and publish the results which they have not done.

One of the differences between speech therapy/occupational therapy and behavior therapy is that speech therapists and occupational therapists are required to be licensed in California and are regulated by state agencies. Such is not true of ABA therapists. There are no licensing requirements for ABA therapists, no training requirements. Many behavioral therapists are college students, taking courses for credit in college in exchange for coming to people's homes and doing in home ABA, some of them are not even old enough to legally buy a six pack of beer. There is no state regulation of ABA therapists and they are accountable to no one. I presume the treatments covered by the mental health parity act, are done by physicians( mostly psychiatrists) who are licensed and regulated by the state. Therefore it is my belief that the mental health parity act may not be a legally valid argument for forcing insurers to cover behavioral therapy.

The precedent for no credentialing requirements for ABA therapists has its origin in special education case law. The Shannon Carter decision by the U.S. supreme court said that under IDEA parents could be reimbursed by the local education authority for private school education, even if the teachers in the private school are not credentialed. The Carter decision paved the way for the case of Malkentzos v. DeBuono which decided that uncredentialed Lovaas therapists could use behavioral therapy on autistic children. So under the IDEA there is a legal basis for the lack of credentialing and regulation of ABA therapists.

However, the IDEA is not the mental health parity act. I feel that under the latter law, the former law would not be applicable and insurers should not have to pay for uncredentialed, unlicensed and unregulated ABA therapists.

Parents have the legal right to pursue ABA therapy at taxpayer expense under IDEA. One of the problems with this is that the school districts will do what they can to avoid paying for the possible $70,000 a year treatment. Thus, parents will have to hire a lawyer and possibly pay a retainer of thousands of dollars, spend multiple time fighting the school district and even have the possibility of losing their case. If insurance covered this treatment this would not be a problem for the parents. This is why autism speaks unfortunately has successfully lobbied several states to enact legislation forcing insurance to pay for these treatments. This is why there is this movement in California.

Another problem that I have written about in another gadfly post is that once insurance starts covering multiple autism treatments, autism will be looked at as a pre-existing condition. This means that if an autistic child has leukemia, needs heart surgery, they may not be able to get insurers to insure them or their families if they change medical insurance and have had insurance pay for an autism treatment.

Hopefully, the effort for insurance to pay for these treatments, particularly behavioral therapy, will not come to fruition in California, but with the resources of autism speaks as well as other powerful lobbies behind the people pushing for these changes, I am not terribly optimistic.


Anonymous said...

We have been getting ABA paid for for about 3 years. It took making calling the insurance company a hobby for a couple of months and writing a complete medical plan signed off on by our doctor to keep them paying last year. This was a LOT of work and I can see a lot of parents not jumping thru all the hoops.

SM69 said...



I thought I should update you on my quests; no reply so far from Partington, but one from the Lovaas I. which I intend following up somewhat (but not for ever, because indeed I don't think this study has been done).

I paste the response I have received below- I have not read your post on ABA in great details as I've got your views on this issue. I can explain what is good and what is less good about ABA at some point if you want me too, but I am not ready for one more long argument on this, hope you don't mind.


On behalf of the Lovaas Institute, thank you for your inquiry. I have been trying to gather some more information concerning this research, but have not yet received any specifics. I do know that the study has not yet been published. I am not positive, but Dr. Jacqueline Wynn at Columbus Children's Hospital (614) 355-8315 may have been working on this with Dr. Lovaas at one time. I will let you know if I learn anything else.


Vincent J. LaMarca, BCBA
Human Resources
Lovaas Institute

jonathan said...

thanks for the post SM, but we have gone through this before. The curt response from the Lovaas institute indeed is not surprising. Clearly, there was funding offered to study and publish the adult outcomes of the children. Clearly they attempted to do this, since they have made some sort of informal presentations at conferences and there was a paragraph or two written by lovaas about it in a book published in 2000, though i don't recall the name of the book offhand and did not read it, but read about it. Again, the fact that this research was done and was not published in a peer reviewed journal means one of two things, either the results were less than stellar or for some reason when they tried to publish the findings they did not pass peer review, but we are once again going over old ground.

If you find any more info keep me updated.