Insurance Advocacy The Growth of a Grassroots Initiative Grassroots 101
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Grassroots 101  |   October 01, 2002
Insurance Advocacy
Author Notes
  • Katrina Zeit, is an SLP and project manager for the speech pathology department of Cincinnati Children’s Hospital Medical Center in Cincinnati, OH, and is a founder of NIAI. For more information on NIAI, contact her at katrina.zeit@chmcc.org
    Katrina Zeit, is an SLP and project manager for the speech pathology department of Cincinnati Children’s Hospital Medical Center in Cincinnati, OH, and is a founder of NIAI. For more information on NIAI, contact her at katrina.zeit@chmcc.org×
  • Pete Johnson, is a Florida SLP and a speech mentor with Select Medical Rehabilitation Services in Clearwater, FL. He is vice president of public relations and resource development for the Florida Association of Speech-Language Pathologists and Audiologists and can be reached at pjrnjojo@gte.net
    Pete Johnson, is a Florida SLP and a speech mentor with Select Medical Rehabilitation Services in Clearwater, FL. He is vice president of public relations and resource development for the Florida Association of Speech-Language Pathologists and Audiologists and can be reached at pjrnjojo@gte.net×
Article Information
Speech, Voice & Prosodic Disorders / Regulatory, Legislative & Advocacy / ASHA News & Member Stories / Language Disorders / Grassroots 101
Grassroots 101   |   October 01, 2002
Insurance Advocacy
The ASHA Leader, October 2002, Vol. 7, 1-13. doi:10.1044/leader.GR.07182002.1
The ASHA Leader, October 2002, Vol. 7, 1-13. doi:10.1044/leader.GR.07182002.1
Access to care for individuals with speech-language and hearing disorders is diminishing due to the decreased coverage by governmental and third-party health plans, posing a threat to the professions of audiology and speech-language pathology. In response, professionals in the field have launched an advocacy initiative, working with health plans and within ASHA, to improve health plan coverage for speech and language services.
The National Insurance Advocacy Initiative for Communication Disorders (NIAI) is a growing grassroots network that advocates with private health plans—as well as with Medicare and Medicaid—on behalf of patients of all ages. The NIAI’s mission is to educate employers, collaborate with health plans, advocate with national nonprofit organizations, and lobby state and national legislators.
Current NIAI members include representatives from Florida, Maryland, Ohio, Pennsylvania, and Virginia, and the organization has been collaborating with ASHA on a number of reimbursement issues, including health plan coverage, advocacy efforts, model benefits, and the delineation of medical versus educational services.
The national initiative was born in Cincinnati, OH, where a group of private practice speech-language pathologists decided to challenge insurers’ denials of claims for services to children. Staff from the speech pathology department at Cincinnati Children’s Hospital Medical Center joined forces with the SLPs in private practice to form a committee of the Ohio Speech-Language-Hearing Association, “The Ohio Insurance Advocacy Initiative,” in 1999. Through presentations at the 2000 and 2001 ASHA Conventions, as well as through various publications, professionals in other states expanded the effort into a national initiative. States continue to join NIAI—among the latest are California, Illinois, and Texas.
This spring, the NIAI met with members of ASHA’s Health Care Economics Committee to provide an overview of current and future activities. Two representatives of the NIAI also spoke at the Membership Forum during the Legislative Council’s (LC) spring meeting to stress the importance of reimbursement to the economic health of the professions. It was during that LC meeting that a resolution was passed identifying health care reimbursement as an ASHA focused initiative for 2003.
The Health Plans’ Perspective
Private health plans determine benefits from a cost-benefit perspective. The plans are interested in costs, outcomes, and customer satisfaction. Private health plans also require evidence that benefits maximize the patient’s functional improvement, which is similar to Medicare regulations. Cost-benefit analysis is an essential tool for clinicians entering into contracts with private health plans.
Health plans also require consistency among treatment plans, which often equates to better documentation and the use of more appropriate CPT (procedure) and ICD-9-CM (diagnostic) codes. In response to these demands, the Florida Association of Speech-Language Pathologists and Audiologists developed a documentation and coding course that is being offered statewide at universities that grant graduate degrees in speech-language pathology. Plans are underway to offer the course in other states (for more information, contact Pete Johnson at pjrnjojo@gte.net).
Collecting Data
Discussions with health plans emphasize the need for outcomes data that demonstrate the effectiveness of treatment for speech, language, and hearing disorders. In 1998, ASHA became the first professional association to develop an outcomes measurement tool for its members—the National Outcomes Measurement System (NOMS). Through NOMS, ASHA has partnered with its members to illustrate the value and benefits of speech-language pathology services provided to children and adults with communication and swallowing disorders.
The key to NOMS is ASHA’s Functional Communication Measures (FCMs), a series of disorder-specific, seven-point rating scales designed to describe the change in an individual’s functional communication and swallowing ability over time. By examining the patient’s scores at admission and discharge, clinicians are able to assess the amount of functional change in an individual’s performance and thus the benefits of speech-language pathology treatment.
By taking part in NOMS, participants receive periodic reports profiling their organization in areas such as functional outcome levels, amount of treatment time, funding, length of stay, and consumer satisfaction. Participants also receive comparative national data from similar treatment settings for benchmarking purposes.
With ASHA’s NOMS database—which includes more than 40,000 cases—clinicians are armed with the essentials tools needed to answer key questions about treatment expectation. Recently, NOMS data have been used in testimony at both the federal and state level to showcase the necessity and importance of speech-language pathology services to improve the function and independence of individuals with communication and swallowing disorders. NOMS is vital to meaningful communication with all stakeholders as we advocate for better access to speech, language, and hearing services.
Adult Outcomes Data
ASHA’s Adult NOMS data reveal that nearly half (47.8%) of the patients treated for a swallowing disorder in a skilled nursing facility who required a feeding tube at admission were able to be removed from that tube subsequent to treatment by an SLP. The amount of treatment needed to show these gains depended upon the patient’s severity level at admission.
Pediatric Outcomes Data
Children often are excluded from coverage due to restrictive clauses in health plan policies. The NIAI intends to use ASHA’s NOMS data and data collected from Cincinnati Children’s Hospital Medical Center to eliminate such restrictive/exclusionary language in health plans.
The most common restriction affecting children is the “acquired disorders only” or “rehabilitative/restorative” policy, which requires that the patient/client once have been able to perform the function, then subsequently have lost the ability due to accident, injury, or illness. This restriction is unreasonable for children with speech, language, or hearing disorders. Speech-language pathology services are needed to promote function that has been disrupted and prevented from occurring.
ASHA NOMS data and outcomes data from Cincinnati Children’s Hospital reveal that both rehabilitative and habilitative speech and language treatment works. One recent study examined 234 children between the ages of 3–6 years who received speech and language treatment at Cincinnati Children’s Hospital Medical Center and whose progress was reported using ASHA’s FCMs [Jacoby, G., Lee, L., Kummer, A., Levin, L., Creaghead, N., (2002) AJSLP, in press]. In this study, Jacoby, Lee, Kummer, Levin, and Creaghead report that following 20 hours or more of treatment, 76.5% of subjects improved at least one FCM level.
The data also show that progress is related to treatment time. The Jacoby et al. study revealed that, as the number of treatment sessions increased, the FCM level improved for all subject groups. These data are critical when advocating with health plans.
ASHA NOMS data also have reported that additional treatment time results in improvement in functional communication ability and is associated with more children progressing through multiple FCM levels.
Another common health plan restriction is coverage only for children older than 3 years of age; the health plans’ rationale for this restriction is that speech and language development does not fully develop until this age. This rationale is contrary to the proven effectiveness of early intervention and to research on human language acquisition demonstrating that language development begins at birth (Gleason, J.B., The Development of Language, 1997).
Outcomes data demonstrating the effectiveness of early intervention need to be emphasized when advocating with health plans. Jacoby et al. found that “younger children received the greatest benefit per units of therapy provided … younger children in each group [articulation/intelligibility, spoken language production, and spoken language comprehension] generally required less treatment time to exhibit FCM improvement.” The study also found that, in the area of articulation disorders, the youngest age group (3-year-olds) made improvements at a faster rate than the older age groups (4 to 6-year-olds).
Another recent trend with health plans is to reimburse for a predetermined “maximum” number of sessions—often limited to 20—in lieu of approving an initial number of treatment sessions, with the possibility of additional sessions being reimbursed after the SLP completes a reauthorization process. The data linking more treatment time to additional progress can be used to address this restriction. It is also important to stress with health plan representatives that children with speech and language disorders are a diverse population and cannot be addressed with a “one-size-fits-all” approach.
NOMS data reveal that 16.4% of children with a severe articulation disorder (entering at FCM level 1 or 2) progressed to a functional level (FCM level 5 or greater) at discharge and required, on average, 17 hours of treatment. This information shows that short-term intervention can benefit a percentage of children with severe articulation disorders. However, the large majority (83.6%) of the children did not move to a functional level and would therefore require additional treatment.
The Jacoby et al. study also analyzed outcomes for children who received less than 20 treatment hours versus those who received more than 20 treatment hours. For the FCM categories of articulation/intelligibility, spoken language production, and spoken language comprehension, “a statistically significant increase of 70%–80% was found in the odds of more, versus less, improvement” following 20 hours or more of treatment.
Additionally, Jacoby et al. highlight the influence of severity on progress and treatment time. Results of the study indicate that children with lower initial functional communication ratings (FCM levels 1–3) required more treatment sessions to demonstrate improvement than children with higher initial FCMs (FCM levels 4–6). This study suggests that, for the majority of children with severe speech and language disorders, the 20-visit maximum policy for speech/language treatment is inadequate and more coverage would produce more progress in speech and language skills.
The bottom line is that outcomes data demonstrate that speech and language treatment is effective and improves the quality of life for children and adults when the appropriate amount of treatment is provided. To facilitate successful dialogues with health plans, quantifiable outcomes data for all ages and disorders are needed. As such, it is essential for facilities employing audiologists and SLPs to participate in ASHA’s NOMS project.
For more information or to become involved in NOMS, click here or contact Tobi Frymark through the Action Center at 800-498-2071, ext. 4330.
Call to Action
The NIAI’s initial goals are to target major national health plans to discuss the need for more comprehensive speech and hearing benefits. Long-term goals include developing a survey for state associations to identify their concerns, surveying nonprofit organizations and support groups to learn what coverage employers are offering, and building relationships with small business organizations and private health plans that might be likely to improve their coverage.
Successful insurance advocacy must be a collaborative effort. Let the NIAI hear from you, so that we can help you make appropriate recommendations to health plans. Your input can make a positive difference in the lives of your patients and clients with communication disorders.
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October 2002
Volume 7, Issue 18