HMO & ASD

On Laura Shumaker's blog at The San Francisco Chronicle, Feda Almaliti writes of her struggle with Kaiser Permanente:

Over two years ago, I received my first set of denials associated with basic treatment for my son's disorder. They denied Applied Behavior Analysis (ABA), Speech therapy, and Occupational therapy.

To deny these treatments to children with autism is the equivalent of denying insulin to a diabetic or chemotherapy to a cancer patient. These all fall into what the health plans refer to as "best practices" in medicine.

Eventually, after months of stress, difficulty, and wrangling that made me far from "happy," I was successful. But most families are not. I now take my experience and use it to help families fight through the layers of the appeals process and bureaucratic red tape.

Kaiser Permanente's stance on autism treatments, specifically speech, occupational therapy and ABA, do not align with the vast preponderance of written policy guidelines on the subject. Among the most recognizable, The Journal of the American Academy of Pediatrics: The Management of [Children with] Autism Spectrum Disorders (10/2007) asserts that autism should be treated with a minimum of weekly speech and occupational therapies, and at least 25 hours a week of behavioral therapy.

I would like to encourage Kaiser Permanente to "increase your happiness quotient and do something nice for someone," and in doing so I urge them to think about their member families coping with autism.

Here are the APA principles and components of effective early intervention:

● entry into intervention as soon as an ASD diagnosis is seriously considered rather than deferring until a de finitive diagnosis is made;

● provision of intensive intervention, with active engagement of the child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities designed to address identified objectives;

● low student-to-teacher ratio to allow sufficient amounts of 1-on-1 time and small-group instruction to meet specific individualized goals;

● inclusion of a family component (including parent training as indicated);

● promotion of opportunities for interaction with typically developing peers to the extent that these opportunities are helpful in addressing specified educational goals;

● ongoing measurement and documentation of the individual child’s progress toward educational objectives, resulting in adjustments in programming when indicated;

● incorporation of a high degree of structure through elements such as predictable routine, visual activity schedules, and clear physical boundaries to minimize distractions;

● implementation of strategies to apply learned skills to new environments and situations (generalization) and to maintain functional use of these skills; and use of assessment-based curricula that address:

• functional, spontaneous communication;
• social skills, including joint attention, imitation, reciprocal interaction, initiation, and self-management;
• functional adaptive skills that prepare the child for increased responsibility and independence;
• reduction of disruptive or maladaptive behavior by using empirically supported strategies, including functional assessment;
• cognitive skills, such as symbolic play and perspective taking; and traditional readiness skills and academic skills as developmentally indicated.