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.
States organizing services in geographic teams under contracts with the state have provided better services
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?
