Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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9/20/21  9:52 am
Commenter: Hannah Robicheau, Compass Behavioral Solutions

This is going to hit hardest for Virginians who are people of color and/or have ASD

The task of standardizing codes so that billing for necessary ABA services, and hopefully decreasing the amount of administrative time, while increasing clarity, is a big but important venture. I think that some of the proposed changes open up some great options for families, such as more structured group therapy and more oversight over center-based programming. While there is potential for many positives, some of these proposed changes will also lead to poorer quality treatment (or lack of treatment) for Medicaid ABA therapy recipients.

That said, individualized treatment planning and data review for ethical providers providing appropriate treatment, can be extensive. The time that goes into ensuring that each ISP and supporting document for each individual client is not only appropriate and updated in a timely fashion, but written in a way that is able to be utilized by caregivers so that they can implement the strategies and we can develop capacity, can (and should) vary between clients. This ultimately leads to better, more efficient treatment, and a lower cost, across the life of the individual. Insufficent or capped treatment planning, results in further services, escalated interfering behavior, lower communication ability, and may result in requiring inpatient hospitalizations for clients over the long term, or a poorer quality of life for that individual and increased family stress. 

The biggest stressors for families of individuals who have ASD diagnoses is fear of the future, child behavior, treatment setbacks, getting treatment, exhaustion, and treatment disappointment, per Coping and Growing with Autism, IAN Research Repot #8 -April 2009: Family Stress.  - Part 1. Clinical research indicates that increases in these stressors are directly proportional to decreases in appropriate, individualized, and early treatment.

While an increased rate for LBA/LaBA services may assist in offsetting some of the cost of treatment planning, it wont be sufficient for appropriate (sometimes daily) individualization of services in the home, especially considering the variables to consider in planning treatment in the natural setting, and the training for family members necessary to ensure interventions are carried over outside of sessions. In addition, the lowered tech rate and lack of indirect supervision further undermines treatment integrity. Over time, if treatment planning and supervision is not included as a billable service, then center-based services will become the standard of care, reflecting on paper as mastery of skills, but skills that never generalize or are usable for clients with Medicaid outside of highly controlled settings. This also would prevent services for individuals in rural areas who cannot access center-based or telehealth treatment. Bear in mind that per the Virginia Poverty Law Center, 66% of Medicaid recipients are people of color in Virginia. This doesn't account for those that fall into the coverage gap, so that percentage is likely higher. These proposed changes favor individuals who are white, middle class, have numerous community supports, and are already physically healthy living in stable environments. Haven't we learned over the past year that we cannot allow this discrepancy to continue to happen?

Many other states have recognized this and kept H codes to cover the time that is spent to individualized programming. Think of the additional treatment planning time and supervision for parent training, and care coordination, that goes into ensuring that the parent of an individual with ASD, who has 2 jobs, a developmental delay or mental illness, and unstable housing, would need. That is simply not covered with a standardized code. The same code that a stay-at-home mom, with two kids, a nice well-kept stable home, would be applied.

What has resulted in practice from changes that cap or eliminate indirect services in other states is more center-based treatment, higher turnover of staff, fewer ethical treatment providers, poorer quality of services, poorer treatment integrity, poorer buy-in to treatment from caregivers, "canned" treatment informed only by assessments and "filling in the gaps" in an individual's skill assessment battery rather than individualization of programming, which impacts treatment efficacy and leads to higher costs overall, and no room for caregiver input (which impacts not just family buy-in to services, but ultimate maintenance of skills), and other short cuts to treatment. Individuals with developmental delays end up with less communication, more interfering behavior, more residential stays, lower family involvement, more restrictive treatment, and much, much higher costs to the family and the state. 

Research and recommendations from CPT consultants, the BACB, ABA professional organizations, researchers, health care fund managers, and other non-profit organizations that have been looking at what is necessary to provide appropriate ABA services and have consistently come back to the following list as essential services for healthcare plans to cover: “If there is a question as to the appropriateness or effectiveness of ABA for a particular client, a review of treatment data may be conducted more frequently (e.g., after 3 months of treatment). 1. Assessment 2. Treatment Plan Development 3. Direct Treatment 4. Supervision (direct and indirect) 5. Parent and Community Caregiver Training 6. Consultation to Ensure Continuity of Care 7. Discharge Planning” per the BACB’s Health Plan Coverage Guidelines for ASD found here: This same source notes that proper assessment takes between 15-40 hours, solely for problem behavior assessment. Additionally, “On average, direct supervision activities comprise 50% or more of supervision; both direct and indirect supervision activities are critical to producing good treatment outcomes” (pg 28). The the Model Coverage Policy for Adaptive Behavior Services further supports this. This is not able to be accomplished with the proposed coding for DMAS behavioral therapy. It puts LBAs in a position in which instead of being able to plan appropriate treatment for a client, given the environment, family dynamics, location of the family, quality of the technician, and speed of the LBA in completing documents, we will have to make choices about which of these areas we attend to given a set amount of time, regardless of if the client regresses, progresses, or the environment changes.

Out of all of the states that I've worked in over the past 15 years, Virginia has been the most progressive in what we do to support individuals with ASD/ developmental diagnoses and his/her family through behavioral therapy/ABA, which overall increases the quality of life for individuals and families, and decreases the overall cost of treatment. Between the individualization of supports, the care coordination, and the focus of caregiver training and generalization of learned skills to help individuals with developmental diagnoses maintain skills, Virginia's Medicaid behavioral therapy program has been remarkable in that aspect. We as a state have an opportunity to keep this program remarkable.

For the sake of the community of families that only has access to proper and appropriate treatment because of Medicaid coverage, I urge you to consider the minimum of treatment planning, supervision (both direct and indirect) and care coordination being included in this proposal. Otherwise, these changes will result in a substantial hit to the quality of services for the population in our state that needs these services the most. Please make the decision to stand up for Virginians who do not have a voice to advocate for him/herself.


CommentID: 100038