SchaferAutismReport: Coverage for Autism Therapy Prompts State Mandates and Lawsuits

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Thursday, August 28, 2008

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Vol. 12 No. 127p

In This Issue:

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ADVOCACY

Coverage for Autism Therapy Prompts State Mandates and Lawsuits Against

Blues Plans

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•

•

PEOPLE

Disabled Palestinian Siblings Hidden Away For Decades

Attack on Autistic Indiana Teen Posted to YouTube

UK Hacker McKinnon Plays the Asperger's Card

•

•

•

•

•

•

PUBLIC HEALTH

Mumps Outbreak In Christian Group Raises Ethical Alarms in Canada

RESEARCH

Oral Tolerability of Cysteine-Rich Protein Isolate (Immunocal) in Autism

- A Pilot Study

Researchers Report Advances in Cell Conversion Technique

EVENTS

Latest Therapies on Autism at Austin Conference, Sept. 4

LETTERS

The Vaccinated 'Herd'

Did You Ever See An Elephant Fly Therapy

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ADVOCACY

Coverage for Autism Therapy Prompts State Mandates and Lawsuits

Against Blues Plans

tinyurl.com/633wek

Reprinted from The AIS Report on Blue

Cross and Blue Shield Plans, a hard-hitting independent monthly newsletter

on business strategies, products and markets, mergers and alliances, and

financing of BC/BS plans.

An explosion in the number of children

diagnosed with autism has led to lawsuits against Blue Cross and Blue

Shield plans and other carriers over health insurance coverage for

controversial therapies. Concerns over autism therapy also have prompted

several states, such as Arizona, Florida and Pennsylvania, to enact new

autism benefit mandates, forcing Blues plans to revise coverage policies.

On July 1, the father of a 7-year-old with

autism filed a lawsuit against Blue Cross Blue Shield of Michigan to force

the insurer to reimburse about $8,000 paid for therapy, according to one of

the family's attorneys, J. Conway of Detroit. Another suit over autism

therapy coverage was filed in April against WellPoint, Inc. subsidiary

Anthem Blue Cross and Kaiser Permanente in California.

Autism is a baffling and costly

developmental disability that affects about 1.5 million Americans,

according to the Autism Society of America (ASA). The disorder is marked by

impaired social interaction and communication, and engagement in repetitive

behaviors. The condition is on a continuum of " autism spectrum

disorders " that includes Asperger syndrome. Autism has become a

hot-button issue as its prevalence has increased dramatically in recent

years and as some critics have linked childhood vaccines to the condition.

According to the federal Centers for Disease Control and Prevention (CDC)

in Atlanta, the incidence of autism has almost doubled since 2000, now

affecting about 1 in 150 American children. Autism cases in Michigan have

skyrocketed from 4,700 in 2002 to 11,000 in 2006, according to CDC.

Treatment of autism can be expensive. The

ASA estimates that the lifetime cost of caring for a child with autism

ranges from $3 to $5 million.

During a hearing scheduled for Oct. 22 in

the U.S. District Court for the Eastern Division of Michigan, Southern

Division, the court will consider a motion to certify the Michigan Blues

suit for class-action status. Certification as a class would broaden the

suit " to represent other potential claimants in the same

situation " as his client, explains Conway.

At issue in the lawsuits against the Blues

plans is an intensive one-on-one therapy called applied behavioral analysis

(ABA). A full course of ABA therapy costs upwards of $90,000, according to

Conway.

Conway says the Michigan Blues plan sent

hisclient's family " a pretty bare-bones, perfunctory denial that says,

'Our in-house people think [ABA] is experimental.' "

Michigan Blues spokesperson Helen Stojic

declines to comment on the specifics of the lawsuit filed against the plan.

But, she says, " Blue Cross Blue Shield of Michigan understands the

concern and is very sympathetic to the challenges of families dealing with

autism. However, the push to expand employer insurance coverage — through

the courts or legislation — comes at a time when many employers are

seriously struggling to pay for their existing coverage. "

Conway says that ABA is endorsed by the

American Academy of Pediatrics, the U.S. Surgeon General, the Association

for the Science of Autism Treatment and the New York State Department of

Health, among other authorities, and notes that ABA therapy is covered by

Blue Cross and Blue Shield of Minnesota.

" Applied behavioral analysis isn't

experimental to Blue Cross and Blue Shield of Minnesota, " he says.

" They pay for the treatment in Minnesota, so we don't know why kids

covered in Michigan don't get it, even though they're both covered by Blue

Cross entities — same therapy, same medical cases. "

Ginny Calega, M.D., vice president of

medical management and policy at Pittsburgh-based Highmark Inc., says that

the evidence on ABA is not all that clear-cut.

" When you look at the clinical

literature around applied behavioral analysis, it's very difficult to

compare one study to another, " she tells The AIS Report. " They

tend to be small populations and have highly individualized needs. When you

look at effectiveness and outcomes, it's really difficult to compare study

to study because the parameters are different.

+ Read more: tinyurl.com/633wek

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