|Considerations in Medical Necessity Determinations: Past, Present, and Future|
|Monday, May 29, 2023|
|8:00 AM–8:50 AM |
|Convention Center Mile High Ballroom 3C|
|Area: AUT; Domain: Service Delivery|
|Chair: Jesse Logue (LittleStar ABA Therapy)|
|Discussant: Allyson Moore (Center for Applied Behavior Analysis)|
|CE Instructor: Allyson Moore, Ph.D.|
Many experts consider Applied Behavior Analysis (ABA) to be the gold-standard treatment for children with autism spectrum disorder (ASD). Treatment intensity (sometimes referred to as dosage) typically comprises both the number of hours of direct ABA treatment per week and the total duration of treatment. Recommendations regarding the specific intensity of treatment should be based on the?medical necessity?of the treatment for each individual patient (BACB 2019), and it is the professional behavior analyst that determines the treatment intensity or dosage that is medically necessary. However, there is currently no standard method for making medical necessity determinations for ABA services and there is no data available on how behavior analysts individualize dosage for children who present with varied skills, needs, ages, and family contexts (Pellecchia et al., 2019). Indeed, researchers can only speculate as to the reasoning that each clinician uses in making treatment intensity recommendations, given that there is a high degree of variability reported in the number of treatment hours patients receive in clinical practice—an important limitation in large-scale outcomes research (Linstead et al., 2017). Medical necessity determinations are part of the careful construction and individualization of behavior analytic treatment and are an essential element of ABA practice that is not well understood. In this symposium, we will discuss considerations for determining medical necessity and calibrating recommendations based on the best available information, and the potential for greater standardization.
|Instruction Level: Intermediate|
|Keyword(s): Clinical judgement, Dosage, Medical necessity, Treatment intensity|
|Target Audience: |
Behavior analysts within their first 5 years of practice, practitioners, supervisors, and senior leaders.
|Learning Objectives: At the conclusion of the presentation, participants will be able to: (1) provide a working definition of medical necessity as it relates to ABA treatment; (2) identify at least 5 factors that BCBAs may consider when calibrating treatment intensity recommendations; (3) describe the most common modalities of training on medical necessity determinations currently in the field.|
Variation in Factors That Impact Behavior Analysts’ Treatment Intensity Recommendations
|KRISTIN M. HUSTYI (LittleStar ABA), Marissa Ellen Yingling (University of Louisville)|
Most published outcome research on Applied Behavior Analysis (ABA) treatment seems to suggest that high intensity yields the best outcomes for patients with autism spectrum disorder (ASD). Yet little is known about what impacts the medical necessity determinations made by behavior analysts to inform treatment intensity recommendations. We conducted a cross-sectional survey of behavior analysts with experience developing and overseeing behavior analytic programming for individuals with ASD (N = 559). We asked participants to report how 36 patient, familial, and logistical factors impact their recommendations using a 7-point Likert Scale (Significantly Decrease, Moderately Decrease, Somewhat Decrease, No Impact, Somewhat Increase, Moderately Increase, Significantly Increase). Results indicated variation in the factors that impact recommendations as well as the direction of impact. A majority agreed on the direction of impact among 9 of 10 factors related to patient diagnosis and skills (e.g., Level 3 DSM-5 Classification), 4 of 10 factors related to patient medical history (e.g., presence of seizure disorder), 3 of 5 additional patient-specific factors (e.g., age at treatment onset), and 3 of 11 familial and logistical factors (e.g., limited family availability). Implications will be discussed specifically as they relate to clinical practice when working with managed care organizations.
|Development and Preliminary Validation of a Tool for Determining Applied Behavior Analysis Treatment Dosage|
|LAURYN TOBY (LittleStar ABA Therap), Kristin M. Hustyi (LittleStar ABA), Breanne K. Hartley (LittleStar ABA Therapy )|
|Abstract: Board Certified Behavior Analysts (BCBA) are responsible for determining the medically necessary treatment dosage (i.e., the number of hours of therapy a patient should receive per week to optimize progress) during Applied Behavior Analysis (ABA) therapy. However, because there is currently no standard method for making these determinations, BCBAs often rely on their own clinical judgement. Given that clinical judgement is a subjective variable that may be underdeveloped in some BCBAs, particularly those who are newly certified, more formal strategies are needed to better guide decision-making as it relates to medically necessary treatment. In this paper we describe the development of a standardized decision-making tool for determining the medically necessary dosage of ABA treatment hours per week and appropriate treatment setting for individuals with Autism Spectrum Disorder (ASD). We present preliminary reliability data as well as construct validity data indicating statistically significant correlations between the tool and several norm-referenced and criterion-referenced assessments often used to estimate skill level within the ASD population to inform the ABA treatment model and goals.|