Managed Care - August 2008 - (Page 35) States Increasingly Mandate Special Autism Services Insurers are being handed some treatment responsibility for this complex disorder, but some say that it is an educational, not medical, task tensively. “There is clear evidence, from many studies, that applied behavior analysis improves behavior and allows kids to lead more normal lives,” dvocacy organizations are making headsays Andrew Zimmerman, MD, pediatric neuroloway in state legislatures to expand mangist and director of medical autism research at the dated private health insurance coverage Kennedy Krieger Institute in Baltimore. “The benfor autism services. In July, Louisiana efit is greatest when ABA is started as young as posand Pennsylvania passed legislation that guarantees sible. There has been a paper that showed that 60 specific services for children with autism. percent of higher functioning children can lose Mandatory coverage is being sought in many their diagnosis by age 8. The recovery rate is instates, driven by coalitions of autism groups strivcreasing; we’re seeing it here all the time.” ing to secure treatment for the growing number of Some children require intensive ABA services, up people with this condition. The number of children to 40 hours per week, and this may go on for with autism being treated under the federal years. The cost may reach $50,000 per year. Individuals with Disabilities Education Act Louisiana cuts off ABA at age 16 and caps increased 428 percent, from 42,517 in 1997 to lifetime expenditures at $144,000. Pennsyl224,594 in 2006, according to the Departvania’s law requires coverage until age 21 ment of Education. without a lifetime expenditure cap. Both laws were passed with modest oppoExtreme behavioral episodes sition. In Pennsylvania, several health insurAutism, a complex neurological disorder ers submitted comments for an impact analythat inhibits a person’s ability to communisis that was prepared by Abt Associates for the cate and develop social relationships, is often More and more accompanied by extreme behavioral episodes. children shed the Pennsylvania Health Care Cost Containment Council. The Centers for Disease Control & Preven- autism diagnosis The report said objections from health intion (CDC) says autism now affects 1 in 150 by age 8, says Andrew Zimmersurers and purchasers focused on two points: children. The increase may be partially atthat a mandate is not justified because covtributable to improved early identification man, MD, of the Kennedy Krieger erage is already available through the state’s in children ages 1–3. Institute. “We’re Medicaid program, and that a mandate for The two new laws mimic model legisla- seeing it here all private coverage would shift costs from the tion from Autism Speaks, one of the largest the time.” public sector to the private sector. advocacy organizations. The key service mandated in both states is applied behavior analysis (ABA). ABA uses educational techniques to modCosts shift ify dysfunctional behaviors. William Schlenger, PhD, of Abt Associates, says Both states require $36,000 in annual coverage that although health insurers commented that the for ABA, but it is a controversial service. Some bill would increase costs and administrative exhealth plans consider it experimental or say it is not pense, the health plans themselves submitted very medically necessary. few figures to substantiate this point. Even so, the efficacy of ABA has been studied exHighmark, the western Pennsylvania Blue Cross By Tom Reinke A AUGUST 2008 / MANAGED CARE 35
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