October 21, 2009

How Am I Going To Get Paid If It Isn't Autism?

But many children whose symptoms significantly differ from classic autism--who belong only on the milder end of the autism spectrum, if they belong anywhere on the spectrum at all--are inaccurately ending up with serious autism diagnoses.

Wait: it isn't what you think.

In The Atlantic, Behind The Autism Statistics:

So parents whose kids' challenges are less severe are often urged to accept a full-fledged autism diagnosis, as otherwise they would lose access to state-funded treatment, and might, down the line, end up ineligible for support services in public school.   The result is that the autism statistics grow and grow.

In diagnoses without obvious physical pathology (i.e. anything in the DSM), doctors often give a diagnosis to a person with the express purpose of getting them benefits, e.g. Medicaid, school  supports, etc.

The Atlantic hints at one side effect of this: the national statistics for psychiatric diagnoses may be inflated.  I'll editorialize: not maybe, but absolutely are; we can't get paid un;ess we bill a diagnosis.  In the chart we may write, "rule out MDD" and in the note indicate they were normal, but epidemiological studies don't read notes; they take billing diagnoses or look at the listed Axes.

This is compounded by "awareness"-- as more people hear about a diagnosis is, and they come in for an eval, their very presence contributes its prevalence even if they are told they don't have it.


The Atlantic spends the bulk of the space lamenting the inappropriateness of the diagnosis:

[Dr.] Greenspan told me on the phone, (and later on camera), "Basically we have to misdiagnose these kids to get them help."  It's the wrong help sometimes, but it's the only way to get state funding.
The concern isn't the state funding, but the odd way the government, e.g. Medicaid, covers treatments.  There are "approved treatments" for autism; any other treatments are out of pocket.  However, if you're not sure of the epidemiology, then you're not sure of anything else like treatment or  sequelae.  If the autism stats are skewed by the presence of kids with something else other than autism, then how can anyone say with any usefulness that "studies have shown that treatment X is effective"?   How can any government tell you what the best practices" are?

The article talks about Sensory Processing Disorder-- if the kid has it, he has to get an autism diagnosis to be eligible for services, except

...while [the child] was making some progress, the therapy didn't seem to be addressing his biggest problems, which involved motor challenges and sensory issues, rather than the kinds of social impairments typical of autism.
I know very little about this diagnosis or its treatment.  However, it's logical and obvious that its inclusion in autism will make a) autism treatment seem less effective; b) SPD treatments untestable.


The article, and the supporters of "autistic-like" disorders, take (IMHO) the wrong tack: they want "Sensory Processing Disorder" to be included in the DSM, "which would turn it into an official diagnosis that would come with much-needed help."

That's the wrong approach, because it legitimizes the government's use of the DSM, and so every new treatment will have to wait for their blessing.   The better approach would be to provide coverage for treatments based on the recommendation of a treatment team, within the limit of a budget.  Instead of saying, "we'll cover this treatment at $120 a session but not this other", simply provide $120/session for any kind of treatment suggested by the team.


Here's the most important secret about Medicaid and Medicare: it isn't about improving health, it is about paying people off.

While the kid described above can only get the "approved" treatments for autism, he can get the approved treatments for every other condition as well:  surgery, eye evals, antibiotics for infections.  In other words, his "autism" got him full health insurance. 

Medicaid requires a "disability" and a very low income.  The income of the child's parents is irrelevant.  All kids with a "disability" (e.g. ADHD, depression, etc) are eligible for Medicaid and its services.  A child can get physical therapy, occupational therapy, speech therapy,  not to mention a prescription plan, doctor visits, etc -- all for free; never mind that the "child" goes to Eaton.  Certainly the parents' private insurance might cover these things but it might not.  Maybe the Dad owns a restaurant and doesn't want to pay for insurance.

If you have a 25 year old unemployed actor for a son who lives rent-free in your house and  spends your money on chest waxing and self-tanning cream, and he can get a doctor to believe this depresses him, he can get Medicaid.

Because a disability has to be verified by a doctor and updated over time, the patient's only  way of maintaining the coverage is to use it.  This happens all the time.  Patients will come once a month for visits, fill the Zyprexa prescription and then throw them out-- all to maintain their benefits.

Before you get angry, understand that this isn't a loophole, it is the point of Medicaid.  For a myriad of reasons we do not have universal (not single payer, but universal) coverage, which would have the (seemingly) paradoxical result of reducing healthcare costs.  But, surprisingly, we have a lot of poor people in the country.  The government has found a way to transfer to them just enough money and services to keep them from rioting, without calling it a transfer, without calling it socialism.  Simultaneously, it manages to pay doctors, hospitals, employers (through tax breaks), etc.  Where is all the money coming from?



A Boy With SPD?