July 17, 2013

Dr. Jonathan WoodsonAssistant Secretary of Defense for Health Affairs1200 Defense Pentagon Room 3E1070Washington, DC 20301-1200

Mr. Richard H. Breen, Jr., APRDirector of Strategic CommunicationsOffice of the Assistant Secretary of Defense for Health Affairsand the TRICARE Management Activity7700 Arlington Blvd., Room 3M709Falls Church, VA 22042

Re: Policies issued June 25, 2013 as described in the following: Basic – TRICARE Policy Manual 6010.57-M, Chapter 7, Section 3.18 – Applied Behavioral [sic] Analysis (ABA); Pilot – TRICARE Operations Manual 6010.56-M, Chapter 18, Section 15 – Department of Defense (DoD) Applied Behavior Analysis (ABA) Pilot for Non-Active Duty Family Members (NADFMs); Demo – TRICARE Operations Manual 6010.56-M, Chapter 18, Section 8 – Department of Defense (DoD) Enhanced Access to ASD Services Demonstration; (4) ABA Pilot QAs posted June 27 at http://www.tricare.mil/customerservicecommunity/source.aspx

Dear Dr. Woodson and Mr. Breen:

We are writing to respectfully convey concerns about the above-referenced policies regarding TRICARE coverage of applied behavior analysis (ABA) services for military dependents with autism spectrum disorders (ASD). By way of background, the Association of Professional Behavior Analysts (APBA) is a nonprofit membership

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organization whose mission is to promote and advance the science and practice of ABA. One of APBA’s principal activities is promoting public policies to support the practice of ABA. That has included working on laws requiring certain health plans to cover ABA services for people with ASD as well as laws and regulations governing who can practice ABA professionally and how they practice. Among APBA’s members are many professional behavior analysts who have been credentialed as ABA providers for the TRICARE ECHO ASD demonstration that was first established in 2008. Dr. Gina Green, Executive Director of APBA and an ASD researcher and practitioner, provided input to the Department of Defense on development of the provider standards for that demonstration program.

APBA appreciates the DoD’s designation of ABA as a medical benefit to be covered under TRICARE Basic, and its stated intention to increase access to TRICARE-covered ABA services by both active-duty and non-active duty military beneficiaries with ASD. We applaud TRICARE’s continued recognition of the credentials for practicing ABA professionally that are issued by the nationally accredited Behavior Analyst Certification Board (BACB), and the incorporation of some BACB standards and guidelines in the new policies. We also concur with other efforts to establish quality control standards for TRICARE ABA providers. Several provisions in the new policies, however, contradict best practices in ABA services for people with ASD as well as some state laws and regulations, and will create significant obstacles for military families, ABA providers, and TRICARE contractors unless they are modified prior to implementation. Some of the most problematic provisions are highlighted in blue text here, followed by analyses of their likely effects and some suggested remedies. These comments reflect input APBA has received from numerous TRICARE ABA providers and military parents of children with ASD, as well as our own analyses.

Differentiating ABA services under TRICARE Basic and Demo/Pilot programsWe understand there may be administrative rationales for bifurcating ABA treatment covered under TRICARE Basic and what TRICARE calls “ABA reinforcement” (a misnomer, in our view) to be covered under the Demo and Pilot programs. But that bifurcation and the associated policies are inconsistent with the nature of ASD, evidence-based ABA practices, BACB standards and guidelines, and cost effectiveness.

1. The principal concerns lie with

Requirements that (a) only Board Certified Behavior Analysts (BCBAs)/Board Certified Behavior Analyst-Doctoral (BCBA-Ds) can be reimbursed for providing ABA services directly to clients in the Basic component; (b) Board Certified Assistant Behavior Analysts (BCaBAs) and paraprofessionals (ABA Tutors) can provide direct services only in the Demo and Pilot components; and (c) parent/caregiver training can only be reimbursed under the Basic component and only to the BCBA-BCBA-D, with no coverage of such training in the Demo or Pilot. Neither the needs of people with ASD and their families nor ABA treatment for such individuals can be compartmentalized into two distinct components. Treatment targets for people with ASD do not occur only in certain settings or at certain times,

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and changes in those target behaviors are not likely to generalize unless treatment is delivered in a cohesive, consistent, well-coordinated fashion across multiple settings, times, and people. Therefore, all those who deliver ABA services to a person with ASD must be trained to implement all of the treatment procedures for all of the treatment targets accurately and consistently. That is accomplished most effectively and efficiently when the direct interventionists, parents, and supervising BCBA/BCBA-D work together on initial treatment planning and treatment plan revision, and on delivering services across times and settings.

The requirement for the BCBA/BCBA-D to be supervised by the referring physician or psychologist (see further comments about this below).

Restriction of the BCaBA’s role to direct intervention, rather than assisting their supervising BCBA/BCBA-D with case management and other tasks, including training and supervision of ABA Tutors and parents. This contradicts BACB standards and guidelines. For instance, the BACB’s description of the role of BCaBAs makes it clear that they are assistant-level professionals, not paraprofessionals and not “surrogate parent interventionists” as they are characterized by TRICARE. BCaBAs are qualified to do much more than provide direct intervention:

The BCaBA conducts descriptive behavioral assessments and is able to interpret the results and design ethical and effective behavior analytic interventions for clients. The BCaBA designs and oversees interventions in familiar cases (e.g., similar to those encountered during their training) that are consistent with the dimensions of applied behavior analysis. The BCaBA obtains technical direction from a BCBA for unfamiliar situations. The BCaBA is able to teach others to carry out interventions and supervise behavioral technicians once the BCaBA has demonstrated competency with the procedures involved under the direct supervision of a BCBA. The BCaBA may assist a BCBA with the design and delivery of introductory level instruction in behavior analysis. It is mandatory that each BCaBA practice under the supervision of a BCBA.  Governmental entities, third-party insurance plans and others utilizing BCaBAs must require this supervision (http://www.bacb.com/index.php?page=4) [emphases added]

Further, the BACB Guidelines for Health Plan Coverage of Applied Behavior Analysis Treatment for ASD Spectrum Disorders describe the BCaBA’s role in the tiered service delivery model, which has been incorporated in the TRICARE policies, as “[providing] clinical case management support” under the supervision of a BCBA/BCBA-D (p. 25). The guidelines go on to say that clinical case management activities include “Meet and evaluate performance of Behavioral Technician staff” (ABA Tutors in TRICARE), “Supervise implementation of treatment,” “Train and consult with caregivers and other professionals,” “Ensure satisfactory implementation of treatment protocols,” and “Develop and oversee transition/discharge plan” (p. 29).

The restriction on BCaBAs also contradicts the statement in the policies for the TRICARE Demo and Pilot programs that “The BCaBA assists BCBAs or BCBA-Ds in

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various roles and responsibilities as determined appropriate by BCBAs or BCBA-Ds and delegated to the BCaBA” (emphasis added).

Reduction of the reimbursement rate for BCaBA services covered under the ECHO Demo from $125 per hour to $75 per hour (the latter rate also applies to the Pilot).

2. If these provisions are implemented as currently written, they are likely to have multiple deleterious effects, including but not limited to:

Making it difficult for beneficiaries to obtain effective ABA services under the Basic program because few BCBAs/BCBA-Ds will be able to provide adequate direct intervention and also fulfill their responsibilities for overall case management, parent training, supervision, etc. for the TRICARE beneficiaries they serve.

Forcing some current TRICARE ABA providers to pull out of TRICARE, and making it difficult for TRICARE contractors to find ABA providers because the staffing patterns and reimbursement rates make it impossible to operate a business that provides effective and ethical ABA services. That will in turn restrict rather than enhance access to ABA services by military dependents with ASD.

Unnecessarily high costs for ABA services covered under TRICARE Basic because all direct services will have to be provided by BCBAs/BCBA-Ds and supervised by referring physicians or psychologists, making it unlikely that most eligible beneficiaries with ASD will receive more than a few hours of ABA treatment under this component if they can meet eligibility requirements and find qualified evaluators and ABA providers in their area (see comments below)

Poor generalization and maintenance of treatment gains by military dependents with ASD who are able to get some ABA services, creating a Catch 22 because that is likely to result in their being discharged from ABA treatment per these policies

Suboptimal, fragmented ABA service delivery, resulting in suboptimal benefits for military dependents with ASD and suboptimal returns on TRICARE’s investments

3. All of the risks listed above can be avoided by (a) allowing reimbursement for the services of BCaBAs and ABA Tutors and parent/caregiver training under TRICARE Basic as well as the Pilot and Demo programs; AND (b) allowing BCaBAs to train and supervise parents/caregivers and ABA Tutors in all three programs; AND (c) increasing the reimbursement rate for BCaBAs to at least $100 per hour; AND (d) eliminating the requirement for ABA services to be supervised by a referring physician or clinical psychologist.

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Requirement for BCBAs/BCBA-Ds to be supervised by referring physicians or licensed clinical psychologists 1. This provision in the policy regarding the TRICARE Basic ABA benefit contradicts

Physician and clinical psychologist licensure laws and ethics codes prohibiting those professionals from practicing outside of the boundaries of their education, practical training, and competence. Evidence-based medical and psychological services for people with ASD should certainly be covered by TRICARE. As noted in the above-referenced TRICARE policy, however, “ABA has established standards for practice and distinct methods of service by providers with recognized experience and educational requirements for practice” [citing the BACB’s requirements and standards] (p. 1) and “ABA is a specialized intervention administered by an authorized provider…who is a professional with advanced formal training in behavioral [sic] analysis, to include at least a master’s degree and several hundred hours of graduate level instruction or [should be AND] mentored or supervised experience with another BCBA” (p. 4). A small proportion of licensed clinical psychologists who are not BCBAs may have the level of education and experiential training in ABA that is endorsed by TRICARE, but most programs that prepare and license clinical psychologists and physicians do not include the specialized training in ABA and passage of a professional examination in ABA that is required for certification as a BCBA or BCBA-D.

State laws regulating the practice of ABA. To date, twelve states have adopted laws to license or certify behavior analysts (AZ, KY, LA, MA, MO, ND, NV, OH, OK, RI, VA, WI). All of those laws have BCBA certification as an eligibility requirement; none require licensed or state-certified BCBAs or BCBA-Ds to be supervised by members of other professions, such as clinical psychology or medicine.

BACB requirements and standards. The BACB’s standards, which are incorporated in the TRICARE ABA policies, specify that BCBAs and BCBA-Ds can practice independently, without supervision from other behavior analysts or members of other professions.

Other TRICARE policies on ABA. In addition to the sections of the policies regarding the Basic ABA benefit excerpted above, the supervision requirement contradicts the statement in the new policy governing the Demo program that “The BCBA or BCBA-D is ultimately responsible for all aspects of case management and clinical direction” (p. 2), and an identical statement in the new policy governing the Pilot program (p. 3).

2. If this provision is implemented as currently written, it is likely to have multiple deleterious effects, including but not limited to:

Putting referring physicians and clinical psychologists at risk of violating their professions’ licensure laws and codes of ethics

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Putting TRICARE contractors at risk of violating state laws regulating the practice of ABA as well as the practice of clinical psychology and medicine

Creating confusion as to whether the BCBA/BCBA-D or the referring physician or psychologist has primary responsibility and accountability for the ABA services covered by TRICARE

Causing disagreements between BCBAs/BCBA-Ds and referring professionals who are not behavior analysts regarding the general treatment approach, selection of treatment targets, measurement of progress, and specific aspects of specialized ABA intervention procedures. That will in turn put military dependents with ASD at risk of receiving services that are not consistent with the best available research evidence and best practice standards regarding ABA services.

Significantly decreasing military dependents’ access to ABA services in the many locations where it will be very difficult to find physicians or clinical psychologists who are trained to oversee ABA services and can devote the time required to provide that oversight ethically and effectively

Increasing the cost of ABA services by the amounts required to secure supervision by referring physicians or clinical psychologists

3. All of the risks listed above can be avoided by eliminating the requirement for ABA services to be supervised by a referring physician or clinical psychologist.

Requirements for (a) the ASD Diagnostic Observation Survey-2 (ADOS-2) and Vineland [Adaptive] Behavior Scales II (VABS II) to be included in initial ABA assessments; (b) VABS II assessments to be repeated every 6 months; and (c) results of the repeated VABS to concur with behavior analytic progress data in order for ABA services to be re-authorized 1. Serious concerns about the requirements for using results of the specified psychometric tests to determine initial and continuing eligibility for ABA services include

Relatively few TRICARE ABA providers are trained to administer these instruments. They are not ABA assessments. Diagnosing disorders and administering psychological/psychoeducational tests are not in the scope of practice of behavior analysts certified by the BACB, unless those individuals hold certain other professional credentials. Only a small proportion of them do. For those who do not, state laws may prohibit them from conducting diagnostic and psychological/psychoeducational testing.

Even if they were legally authorized to conduct diagnostic evaluations, obtaining the specialized training required to administer, score, and interpret the ADOS-2 would be

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expensive for many ABA providers. It does not appear that TRICARE would cover the cost of that training.

Many ABA providers and military families report that there are very few, if any, professionals near them who are qualified to administer the ADOS-2 (clinical psychologists, pediatricians), and there are long waiting lists for appointments with those professionals where they do exist.

The ADOS-2 involves an evaluator sampling a circumscribed set of skills and behaviors in a short time, often in a setting with which the person with ASD is not familiar (e.g., the evaluator’s office or a clinic). That sample may not be representative of the person’s functioning in their everyday environments. That is, ADOS-2 results often do not match data from baseline ABA assessments, which involve directly and repeatedly observing and measuring specific skills and problem behaviors and associated environmental events in the individual’s everyday environments.

The VABS II, which relies on the impressions of teachers or caregivers, can provide a global estimate of an individual’s adaptive skills and maladaptive behaviors in comparison to same-age peers, but does not yield precise enough information for individualized ABA treatment planning and is not sensitive enough to detect improvements made by many people with ASD over the course of 6 or 12 months of comprehensive or focused ABA interventions. That is, the results of VABS II teacher or parent interviews or ratings often do not correspond perfectly with data from ABA assessments, which involve directly and repeatedly observing and measuring specific skills, problem behaviors, and associated environmental events in the individual’s everyday environments.

Both the ADOS-2 and the VABS II yield multiple scores. For instance, the VABS II has a checklist form and an interview form. The latter yields raw, standard, and age equivalent scores for several domains and an overall adaptive skills composite. Due to the way they are calculated, the standard and age-equivalent scores for many people with ASD may not increase over a 6-12-month span even when they have made clinically important improvements. The TRICARE policies do not specify which of the ADOS-2 and VABS II scores are to be used to determine initial eligibility for ABA services, reauthorization for those services after the first year, or eligibility for waivers.

2. If these provisions are implemented as currently written, they are likely to have multiple deleterious effects, including but not limited to:

Delaying or precluding access to ABA services by military dependents with ASD because they cannot get timely – or any -- access to professionals who are qualified to administer the ADOS-2 and the VABS II

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Increasing the cost of ABA services by the fees charged by evaluators to conduct, score, and report on the ADOS-2 and VABS II and in many cases, costs incurred by families who have to travel to obtain those evaluations

Inappropriate and damaging decisions to deny ABA services to military dependents with ASD, and to prematurely terminate ABA services for individuals whose repeated VABS II evaluations are construed to reflect insufficient progress. Young children with ASD who receive intensive, comprehensive ABA treatment will be at particular risk because the first 1-2 years of that treatment often does not focus heavily on many of the skills and behaviors that are sampled in the VABS II, though substantial research shows that such children make other clinically important improvements during that time. Similarly, many children and youths with ASD who receive focused (rather than comprehensive) ABA interventions will have clinically important improvements in the specific, usually small number of skills/behaviors targeted by those interventions that will not be reflected in VABS II scores. That is particularly true for many military dependents with ASD for whom delays, disruptions, and reductions in ABA treatment due to deployments and relocations as well as TRICARE policies often result in slow progress at best, loss of prior treatment gains and regression at worst.

3. All of the risks and costs listed above can be avoided by (a) replacing the requirement for the ADOS-2 to be part of the initial ABA assessment with a requirement for a diagnosis by a professional who is qualified by training and authorized legally to make that diagnosis; AND (b) eliminating the requirement for the VABS II to be re-administered every 180 days; AND (c) changing the main criterion for reauthorizing ABA services from progress documented on the VABS II and concurrence of VABS II results and ABA data to a determination by the ABA treatment team that continuing ABA services are medically necessary for the individual, as evidenced by persisting needs and clinically important progress on treatment targets over time documented in graphed data representing objective, repeated direct observation and measurement of those targets in everyday environments.

Requirements for (a) assessments of parents’ ability to implement ABA interventions at initial treatment planning, and (b) documentation of parents full engagement and ability to consistently implement the treatment plan in order for limits on ABA services to be waived Research shows that many parents of people with ASD can effectively implement certain ABA assessment and intervention procedures with competency-based training and ongoing supervision and feedback from a professional behavior analyst. We know of no objective, validated procedures for assessing parents’ ability to acquire the necessary skills before they have had any training, and assert that requiring BCBAs/BCBA-Ds to make such a subjective judgment at the initial treatment planning stage puts them at risk of violating the BACB Guidelines for Responsible Conduct. It is appropriate and ethical for ABA providers to specify training targets and procedures for parents at the treatment planning stage, and to report data from objective, direct measurements of parents’

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performances on those targets at baseline and periodically during treatment. Such data should not, however, be given inordinate weight in decisions to authorize or re-authorize ABA services for TRICARE beneficiaries. Proper ABA treatment planning and implementation requires careful consideration of many factors, including the family’s situation (e.g., parents’ marital status, employment, and health; children and other family members living in the home; available supports and resources; etc.). That is especially important with military families whose circumstances may make it very difficult for one or both parents to function optimally as co-therapists for their children with ASD. It would be inappropriate and damaging to deny those children ABA services. We strongly recommend dropping the requirements for the ABA provider to predict parents’ ability to implement ABA interventions at initial treatment planning, and for parents to fully and consistently implement the ABA treatment plan to be eligible for waivers.

No authorization of ABA services beyond two years or age 16 without special waiversWe are not aware of any compelling logical, clinical, or empirical rationale for these cutoffs; quite the contrary. Like people with other neurological conditions, for many people with ASD the symptoms and associated difficulties do not disappear after a limited period of time or at a certain age, even when they receive sustained excellent treatment. For instance, the best available research and clinical experience shows that with high-quality comprehensive and intensive ABA treatment provided without significant interruptions, some young children with ASD need more than two years to improve functioning and avoid regressing. Children and youths with ASD who did not receive that kind of treatment when they were young, who have significant needs, or who receive ABA treatment that is focused on only a small number of target behaviors often need continued ABA treatment to manage symptoms and prevent deterioration. Again, that is particularly true for military dependents with ASD for whom family circumstances and other factors make it difficult for them to obtain appropriate levels of ABA treatment even for short periods of time. Although the new TRICARE policies indicate that families can apply for waivers to extend ABA services beyond two years or age 16, it is not clear how eligibility for those waivers will be determined or how likely it is that such waivers will be approved. We strongly recommend eliminating the arbitrary cutoffs.

APBA will welcome opportunities to clarify any of the above comments and to work with TRICARE to assure that military dependents with ASD receive timely, effective, and cost-effective ABA services.

Sincerely,

Gina Green, PhD, BCBA-DExecutive Directorggreen3@cox.net, ggreen@apbahome.net

cc: Kevin Dwyer, TRICARE Management Activity

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Karen Driscoll, Autism Speaks Stuart Spielman, Autism Speaks James E. Carr, PhD, BCBA-D, Behavior Analyst Certification Board Margaret Bloom, Esq., Behavior Analyst Certification Board APBA Board of Directors

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