Monday, June 19, 2017

How Did Early Intervention for Infants and Toddlers Get to Be Such a Mess, in Some States?

In a New York Times editorial this morning (June 19, 2017), Christy Ford Chapin, a historian at the University of Maryland, Baltimore County, blames the insurance company model on our messed-up health care system. She points out it’s not the care that’s messed up; it’s the cost structure. When the American Medical Association went to bed with insurance companies, health care moved to a fee-for-service payment approach. 

In early intervention for children 0-3 and their families, we have a similar history but it most definitely has hurt the quality of services or “care.” State administrators of Part C programs and some consultants realized that insurance would pay for the therapies—occupational, physical, and speech-language. Furthermore, Medicaid would pay for these and “targeted case management.” Some states have even persuaded their Medicaid programs to pay for “developmental therapy,” or whatever term is used in that state for special instruction or family counseling. A side note is that states are all over the place with the service provided by the nontherapy generalist—from states that rigidly insist on hiring only early childhood special educators to those that hire a myriad of professionals in that role: early childhood educators, psychologists, counselors, and so on.

Back to the insurance company model, the fee-for-service method, in which people are paid only for the time they spend in direct service with the child, is the main method in states using a vendor model. Here, the service coordinator, a technically defined position, finds services, theoretically to address the outcomes/goals on the individualized family service plan. These “dedicated” service coordinators are not service providers in vendor-model states; they help the family arrange for resources including services and they are not necessarily trained in child development or family functioning. They are therefore in a difficult position to make decisions about what services are needed. So they often resort to mindless assignment of services matching any deficits the child has. For example, if the child is behind in language development, a speech-language “pathologist” is put on the plan; if behind in gross motor development, a physical therapist; if behind in fine motor, an occupational therapist; if behind in cognitive or social, a special instructor. This idea that you have a different specialist for each area of development is the multidisciplinary approach, in which each person does his or her own thing and they don’t talk to each other. In fact, in the vendor model, they might all come from different agencies or be independent vendors.

They often resort to mindless assignment of services matching any deficits the child has

Not only do we have the mindless piling on of services, but the incentives are in place to have a high frequency of services. The first incentive is that, in the fee-for-service model, the more you see the child the more money you get. The second incentive is that, when you operate in a multidisciplinary approach, you think only of your interventions; you might not even know about the other professionals’ interventions. So your demands on the family might not be appropriate for their daily life. 

One of the worst outcomes of the insurance company model is that families get the wrong idea about how children learn and how services work. They see what’s recommended and what professionals do (seeing the child every week for a 1-hour session) and they come to the logical conclusion that these sessions are effective. Yet everyone understands that children don’t learn in single sessions in a week. I hope everyone understands that! Furthermore, any one so-called intervention in that session lasts probably no more than 15 minutes, because of the child’s attention span and tolerance level. So, really, 15 minutes a week—for an infant or toddler….

In the past 10 years or so, a number of states have realized the error of their ways, but breaking out of the golden handcuffs of insurance and Medicaid payment isn’t easy. States organizing services in geographic teams under contracts with the state have provided better services—more coordinated, generally addressing the whole child and family instead of a blinkered discipline focus. And this nonvendor or “program” approach doesn’t preclude using third-party payments. That’s the important part that state administrators need to realize. Insurance companies often won’t pay for special instruction, which is the most common service in Part C. Some states have, as I mentioned earlier, worked with their Medicaid office to get developmental intervention paid for, but they have to be careful that the tail doesn’t wag the dog: If Medicaid uses a fee-for-service method of payment, quality can suffer.
 What exactly is wrong with fee for service? First, it encourages a more-is-better mentality, and we have emerging evidence that more is worse, in some situations, such as more services and more frequent visits by multiple providers. Second, much early intervention happens when not in direct contact with the child, which fee for service usually doesn’t cover. For example, meeting with the family without the child or when the child’s asleep. Or meeting with other people working with the family. Or looking for a resource for the family. 

When we know how messed up the health care system is, why would we replicate it in early intervention?