Sunday, December 29, 2013

The architectural legacy of George Barton

n.b. ongoing series related to a study of George Barton, founder of the Occupational Therapy Profession. 

George Barton was diagnosed with tuberculosis in 1901 (Reed and Sanderson, 1999) and he traveled to Colorado some time after that.  I could not confirm the exact dates of his travel but an educated guess would be sometime around 1907, because his architecture practice with Sturgis was listed as  being active up until that approximate time (AIA, 1914).

It is difficult to know exactly what brought George Barton to Colorado - it could have been his own "chase" for a tuberculosis cure or it could have been that he had political connections with the Colorado governor, John Shafroth who was a member on the Committee on the Philippines in the 65th Congress and prior to that was a Colorado representative and frequently involved in US-Filipino relations. Reed and Sanderson document that the Governor commissioned Barton to investigate factors related to famine along the Kansas Border (p. 423).  It is possible that Barton was acquainted with Shafroth prior to his move to Colorado because in 1906 Barton's architectural firm in Boston designed the St. Mary and St. John Cathedral in Manila (Far Eastern Review, 1906).  Here are some pictures of the beautiful St. Mary and St. John Cathedral in Manila:













And here it is following the Battle of Manila in 1945:
















Barton had several health setbacks during his early working years.  Tuberculosis was a major public health concern at the turn of the century.  Antibiotics like streptomycin were still 50 years away from discovery - so people used a variety of other methods to find a cure for their condition.  'Climactic therapy' was a popular approach and reading scientific papers of that time period provides fascinating perspectives and insights on what drove the social behavior of 'chasing the cure' (Hinsdale, 1913).  During this time, a diagnosis of tuberculosis caused people to move themselves into sanatoriums where they could convalesce.  The high incidence of tuberculosis spurred travel to places like Saranac Lake, NY, and Colorado Springs, CO.  Below is a video that shows a treatment facility (in 1933) that was near Colorado Springs and gives a pretty good idea of how this treatment was conducted at that time.


At the turn of the century, tuberculosis treatment was a primary economic driver for the Colorado Springs community (Vail, 2012).  It is possible that George Barton went to Colorado Springs directly related to his 'chase' of a cure, just as many people at that time did.

At some time in 1912 he had convalesced sufficiently that he was again practicing as an architect.  He is listed in the Colorado State Business Directory listings as an architect from 1912-1914 (Architects of Colorado, 2006).

George Barton left a measurable impact on Colorado architecture.  Winfield Scott Stratton was a philanthropist who became rich in mining and prospecting.  When he died he made arrangements for his fortune to be used to establish and maintain a home for poor people. That home was named in memory of his father, Myron Stratton, and was designed by George Barton.  Below is a video that explains the founding and legacy of the Myron Stratton Home:


Framing Community, Exposing Identity: Myron Stratton Home from PPLD TV on Vimeo.

Here is an original print of the home as it was in 1916 near the time that it was opened:


http://c590298.r98.cf2.rackcdn.com/ILW2_406.JPG









And here is a closer view of the main building, although this picture was taken in 1930:















Following his work on the Myron Stratton Home, George Barton was asked to redesign Cragmor Sanitorium, a major tuberculosis treatment facility (UCCS, Cragmor, n.d.).  In January 1913 it was apparently determined that Barton's design was too costly, and so another famous architect, Thomas MacLaren, re-worked Barton's designs (UCCS, Building History, n.d.).  The Cragmor Sanitorium still stands, in some measure reflecting Barton's design, but is now the Main Hall of University of Colorado Colorado Springs. 













Barton's architectural work was notable and he contributed to important and beautiful buildings that were constructed in places including the Philippines, Colorado, and of course in his native Boston.  His designs were intricately related to his own illness, his own chase for a cure, and his own recovery.

 References:

American Institute of Architects (January, 1914). R. Clipston Sturgis, President of the Institute.  Journal of the American Institute of Architects, v.2, 5.

Architects of Colorado (2006). Database of State Business Directory Listings 1875-1950 compiled by J. Palmer and I. Bergsmann.  Retrieved online at http://www.historycolorado.org/sites/default/files/files/OAHP/Guides/Architects_Colorado_Database.pdf

Far Eastern Review (1906). Reinforced concrete in the cathedral church of St. Mary and St. John, Manila, V.3, No.6.  Retrieved from http://books.google.com/books?id=z-siAQAAMAAJ&pg=PA180&lpg=PA180&dq=sturgis+barton+philippines+design&source=bl&ots=TTofidie5m&sig=lDolVOAetLGAQOl8VCWh5DcNGkI&hl=en&sa=X&ei=dqbAUoCALc7hsATo44HoDA&ved=0CCoQ6AEwAA#v=onepage&q=sturgis%20barton%20philippines%20design&f=false

Hinsdale, G. (1913).  Atmospheric air in relation to tuberculosis. Smithsonian Miscellaneous Collections, 63(1).

Reed, K.L., Sanderson, S.N. (1999). Concepts of Occupational Therapy. (4th ed). Philadelphia: Lippincott, Williams and Wilkins.

University of Colorado, Colorado Springs (UCCS), Cragmor.  Building History of Cragmor, retrieved from http://www.uccs.edu/cragmor/main-hall-project/cragmor-construction-timeline.html

University of Colorado, Colorado Springs (UCCS) Cragmor.  Edwin Solly, retrieved from http://www.uccs.edu/cragmor/colorado-medical-history/cragmor-sanitorium-physicians/edwin-solly.html

Vail, N. (2012, July 15).  A healing past: Tuberculosis sanitoriums were Springs' 1st major economic drive.  Retrieved online at http://gazette.com/article/141701

Tuesday, December 03, 2013

On Pygmalion and sensory integration research

Occupational therapists have been attempting to improve research on sensory integration by adopting more strict fidelity standards and by using Goal Attainment Scaling as an outcome measure.  Three years ago I blogged about an SI effectiveness study and expressed some concerns on the research design - you can read about that at http://abctherapeutics.blogspot.com/2011/01/new-study-on-si-effectiveness-but.html.

A new study has been published by Schaaf et al (2013) and can be accessed online in full text at http://link.springer.com/article/10.1007%2Fs10803-013-1983-8/fulltext.html  However, one major difference is that in the new study the researchers used an intervention and a 'usual care' group.

Use of control groups in this manner can help to correct for potential Hawthorne effects - but only if the study is designed properly.  In the previous study there was an OT/SI group and a fine motor training group.  The fine motor group in the first study was probably not exactly a 'sham intervention' but at least offered a parallel point of comparison because it controlled for some Hawthorne effects.  Both groups made progress but the OT/SI group made more progress.  It was difficult to know if the progress was due to the intervention or the attention (since both groups made progress) or expectancy bias because there was inadequate blinding with measurements.

In the new study the researchers added a 'usual care' research design which actually is quite different from a sham design.  'Usual care' designs are valuable if you are using psychometrically sound measurements but you run into potential problems with Hawthorne effects again if you fail to adequately match the treatment experiences.  So, the new study substituted the sham intervention with a 'usual care' approach when the most appropriate design would have been to do a three-group study of sham and usual care and intervention groups.  That would have left the only potential point of weakness the nature of the 'usual care' group and what therapies they were receiving. 


I don't understand why this study had a usual care (non OT/SI)  group and used GAS as a primary measure. From a design perspective that is confusing.  The concept of GAS is that you are developing meaningful outcome measures based on parent input - so they developed goals for both groups but then only one group got the intervention and the other did not. Hawthorne effects would dictate that the parent's expectations for the intervention group could have influenced their GAS outcome reporting. After all, if you take a group of families who have children with autism, ask them to develop goals, and then do nothing it is not likely they will connect a 'no treatment' condition to any kind of goal attainment! The fact that the evaluators are 'blinded' is a design canard and really does not address this important issue.  I am also not sure that 'usual care' mitigates the design flaw.

If you are asking the 'treatment' families to participate in a high intensity 3 day per week program - of course they will have a lot of sunk cost bias in reporting positive treatment outcomes. In order to equalize for this effect you have to have the non-treatment group equally investing in some other activity, and then you would more fully control for Hawthorne effect and see if the intervention itself accomplished the GAS objectives.

This is why a three group design would be most appropriate, particularly in the case where you can't possibly blind the families who are self-reporting on progress with GAS.

This new study also measured adaptive behavior and autism behaviors; there were no differences between the intervention and usual care groups.  Actually, this is the most concerning finding in the whole study.  So, the only potentially interesting findings were in the parent-reported GAS measures.

For those who are more interested in statistics, there is also the issue of using parametric statistics on GAS measures - which may or may not be interval level data. It looks like the researchers took pains to use "equally spaced probability intervals" and they did this with indirect time measures (in the example they gave).  However, given the large number of goals we don't really know how they operationalized this overall.

I understand that they probably tried to address the issue about use of parametric statistics with the way they scaled the goals but there are some big questions about whether this is an appropriate measurement strategy for these kinds of goals that are notoriously difficult to scale.  As an example, just because you scale the amount of time to complete a toothbrushing task does that mean that the difference hypothesized to be caused by intervention is equivalently distributed across the scaling of time expectation to complete a task?  In order to validate the findings there would first need to be a validation of the scaling - and this is something that needs more description and scrutiny in order to understand the findings.

It appears that there are both research design and statistical questions about this study. Given the small sample sizes, the lack of difference on adaptive behavior scales and autism behaviors, and the questions listed above re: GAS designs and measurement concerns, this study will probably not be accepted as game changing. It is disappointing that this study substituted one limited design for another, and in addition to the lack of functional progress on true gold standard testing like the Vineland, this will be the basis for criticism regarding these findings.

I believe that we need to carefully reflect on GAS designs, because if I attempt to take an outside view it appears as though multiple research studies failed accepted measures of significance, and now we are like Pygmalion asking Venus (played by self report of parents) to breathe life into our sensory integration statue.

There are even larger issues, of course, and these were mentioned in my blog post three years ago.   Specifically, a three time per week intensity is often not feasible (either given insurance restrictions or school district authorizations). In many localities, the ship sailed on this kind of high intensity direct intervention model years ago.

Three years ago I thought that the Pfeiffer study was a good step forward and it gave us a lot of useful information on how to design future studies.  Some of those issues were addressed in this new study but many were not and in fact new problems were introduced.

If there are true differences to be measured because of sensory integration treatment we will find them after we design studies that are not so vulnerable to criticism.


References:

Kerckhofs, E. (2010). Letter to the editor: Ordinal goal attainment scores are not suited to arithmetic operations or parametric statistics.  Comment on GAS in rehabilitation: A practical guide.  Clinical Rehabilitation, 24, p. 479.

Pfeiffer, B.A., Koenig, K., et.al. (2011) Effectiveness of sensory integration interventions in children with autism spectrum disorders: A pilot study. American Journal of Occupational Therapy, 65, 76-85.

 Schaaf, R. et al (2013). An intervention for sensory difficulties in children with autism: A randomized trial. Journal of Autism and Developmental Disabilities, published online at http://link.springer.com/article/10.1007%2Fs10803-013-1983-8/fulltext.html

Tennant, A. (2007). Goal attainment scaling: Current methodological challenges. Disability Rehabilitation, 29, 1583-1588.




Monday, November 18, 2013

On beehives, planetary motion, and reasons for not writing reports sooner.


Autumn clings tightly to these late November days like the last remaining leaves on the trees.  Looking out into my front yard I see that bee hives and abandoned birds nests also populate the branches of trees.  I know that the leaves fall and they fertilize the earth and feed the trees for the Spring.  I have been wondering if the bees re-populate their hives, or if the birds recycle their nests.  I have to look into that.

Why is it that my immediate impulse was to remove these remnants of the Spring and Summer?  In my mind I was waiting for it to be cold enough so that the bees would be torpid.  I have been developing a plan for the last several weeks to knock the beehive out of the tree, recreating a childhood family tradition of smashing a pinata with a bat on New Years Day.  I didn't expect that candy would come out.  In fact, I was praying that angry bees would not possibly come out, which is why I was waiting until we were full into Winter.

Being a professional beehive tickler, I know the seasons for when you should and should not be messing with beehives.

Presented with data, my tendency for action orientation demands a measurable and vectored response.  It is a program that comes genetically embedded and socially reinforced:

1. See beehive or similar problem.
2. Poke with a stick.

I am kind of glad that the slow disrobing of leaves through Autumn made me notice the hive later rather than sooner.  I have had time to think about this, and it is best that I was not seduced to action sooner than was prudent.

The world spins at approximately 1000 miles per hour, relatively, but we don't notice it that much because of momentum and gravity and other complex forces.  Technically I guess it is around 1000 miles per hour at the equator, which is probably one reason why NASA shoots rockets into space from Florida and not Maine.  Anyway, the point is that our relative position on the planet, or in life, causes changes in real and perceived motion through space.

I guess I am in a place where I am trying to slow down the data stream and not make hasty decisions.

That is so important for us to do - but the counterbalancing stressor is that we operate in systems that create forces that demand action orientation in amounts that might not always be in sync with our relative location.

I have been thinking about all this because someone wanted my evaluation report last Thursday, and I am still stewing on the data.  The matters are weighty and I don't want to make a hasty decision.  The world is spinning and I am trying to slow it down.

The Mom does not want to hear me babble on about beehives and planetary motion, so I better get moving.

This is a very real problem.

Tuesday, October 29, 2013

Reasons to pause when discussing a "sensory processing disorder" construct.


The Sensory Profile is an assessment tool that purports to measure sensory processing abilities (Pearson Education Inc., 2008); there are versions for infant/toddlers, school aged children, and adolescent/adult populations.  The tool has been used to document the incidence of a "sensory processing disorder" construct (Ahn, et. al., 2004; Ben-Sasson, et. al., 2009).  To date, although many scientists recognize that children can have difficulties with processing sensory information, this diagnostic construct has been rejected and is not considered as a distinct clinical entity (AAP, 2012).   For more in depth reading, please reference previous blog posts here.

I was interested to see an article in a recent OT Practice magazine regarding sensory processing abilities of children involved in the justice system (Shea and Wu, 2013).  The article presents an interesting test case for use of the Sensory Profile to help understand the nature of some difficulties that these adolescents may have.

Face validity is a construct that relates to whether or not an assessment measures what it is supposed to measure.  The question we can ask about this study is: Does the Sensory Profile measure what it is supposed to measure?  A statement in the article that caught my attention was
The occupational therapists were particularly surprised by the low score in sensation seeking, because they had hypothesized that these youths would have higher sensation-seeking tendencies, and their need to seek sensory stimulation may have led them to delinquent behaviors...The combination of high-sensation-avoiding and low-sensation-seeking profiles implies that the youth participants would be less likely to seek sensory stimuli and more likely to avoid stimuli than we had expected.

I had a similar experience with the Adolescent Adult Sensory Profile as documented here.  In my doctoral study, I hypothesized that people with Complex Regional Pain Syndrome would have heightened scores on Sensory Sensitivity scales.  Just as the authors in the present study, I was surprised that Sensory Profile Scores were quite different from what I expected.

Still, in both instances, the scores were atypical - they were just atypical in directions other than what was hypothesized.  This leads to a concern that I have with face validity of the tool.  It is certainly measuring something, but is it measuring sensory processing?  Is it measuring it the way that we think it is measuring things?  When a tool ends up giving us information that is diametrically opposed to what we believe we are going to get out of it then I think we need to start asking some serious questions about what it is exactly that we are measuring, and whether or not our theoretical construct and understanding  is correct.

Other questions seem rather pertinent:

1. Do the high numbers of atypical scores really indicate that 40-45% of this juvenile justice population has a 'disorder.'  That level of identification, if sensory processing difficulties as measured really are a disorder, would be rather stunning.

2. Do people who have atypical scores on the Sensory Profile truly represent a subset of the population that could also be more prone to violence or asocial behavior?  The Sensory Processing Disorder Foundation was quick to jump on the Sandy Hook massacre and describe Adam Lanza's behavior as a sensory 'diagnosis,' much to the outrage of families who made their opinions on the matter quite clear on the SPD website.

3. A fact not mentioned in the article is that in the past a small study was done on sensory profiles of people who have mental illness, and the distribution of scores as described for people who have schizophrenia was identical to the pattern of scores reported in this study - low sensory seeking and high sensory avoiding (Brown, et.al., 2002).  Other scientists have more recently supported the notion that the population of people who have schizophrenia also have sensory processing difficulties (Javitt, 2009).  It has been widely quoted that the incidence of mental health diagnoses in the justice system is 16% (Ditton, 1999). Since so many people in the current study scored atypically, is the Sensory Profile just measuring a "sensory processing disorder" construct, or is it measuring something else?

This analysis should help us to more deeply understand that our current assessment tools, which are apparently measuring something, may not just be measuring a sensory processing construct.  In my opinion, the assessment tool also includes many questions that are broad and general and could represent a number of behavioral phenomenon, primarily dependent on the interpretation or labeling of the examiner.

I believe that we should consider pausing when we use tools like the Sensory Profile to report an incidence of "sensory processing disorder."   It is apparent that atypical scores on this assessment may indicate co-morbid issues that are interwoven with a number of other behavioral and social and psychiatric diagnostic constructs.




References:


Ahn, R. R., Miller, L. J., Milberger, S., and McIntosh, D. N. (2004). Prevalence of parents’ perceptions of sensory processing disorders among kindergarten children. American Journal of Occupational Therapy, 58, 287–293

American Academy of Pediatrics (2012). Policy Statement: Sensory Integration Therapies for Children With Developmental and Behavioral Disorders. Pediatrics, 129(6), 1186-1189.

Ben-Sasson, A., Carter, A.S., and Briggs Gowan, M.J. (2009). Sensory over-responsivity in elementary school: prevalence and social-emotional correlates. Journal of Abnormal Child Psychology, 37, 705-716.

Brown, C., Cromwell, R., Filion, D., Dunn, W., and Tollefson, N. (2002). Sensory processing in schizophrenia: missing and avoiding information. Schizophrenia Research, 55(1-2):187-95.

Ditton, P.M. (1999). Mental Health Treatment of Inmates and Probationers, Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Javitt, D.C. (2009). Sensory processing in schizophrenia: Neither simple nor intact. Schizophrenia Bulletin, 35(6), 1059-1064.

Pearson Education, Inc. (2008).  The Sensory Profile Technical Report.  Retrieved 10/29/13 from http://www.pearsonassessments.com/NR/rdonlyres/6AB47882-1271-4D6A-BB3D-1AF8692D67B9/0/SP_TR_Web.pdf

Shea, C. and Wu, R. (2013). Finding the Key: Sensory Profiles of Youths Involved in the Justice System. OT Practice 18(18),  9–13.

Friday, October 18, 2013

Written testimony for public hearing on EI fiscal agent implementation

Although I was initially planning to present oral testimony for the upcoming public hearing on EI fiscal agent implementation I have decided to present written testimony.  My ideas on this differ a little from other providers who very understandably are stressed by the notion of billing because of how difficult this process has been.  I think that a correctly implemented plan as outlined here would be the best solution. Here is what I have submitted:

+++++++++++++++++++++++++++++++

My name is Christopher Alterio and I am an occupational therapist and private practice (small business) owner in Western New York. Thank you for the opportunity to submit this written testimony. In my practice I see children through the early intervention program and I also see children whose families choose to be seen privately outside of that system. I have been involved with the early intervention system since its inception in the early 1990s and have been working as a pediatric occupational therapist since I was initially licensed in 1987.

Children who have developmental delays or disabilities represent a problem and the early intervention program was designed to represent a solution. In very simple terms, alignment between problems and solutions is an objective for a municipality that provides services based on the shared cultural values of the populace. That is why it was easy for New York State to create a robust early intervention program, because people know that when we provide therapies and other help to children and families that it is a known investment with a very measurable and positive outcome in the future.

We know that early intervention outcomes are not always immediately evident because we have to wait many years in order to realize savings from decreased special education enrollment or decreased engagement in other social support programs. As we live in an environment and culture that is clearly oriented toward immediate gratification there are risks to any programs and policies that promote this kind of long term investment.

The New York State Early Intervention Program is at risk.

For many years there has been a 'chipping away' of our early intervention program investment. It is politically painful and perhaps culturally inappropriate for a politician to announce opposition to programs that are designed to support babies so our elected representatives find alternate strategies for controlling our spending. I call this 'peripheral policy making' because it is easier to control costs through administrative hurdle creation than it is to have a real policy debate on what the parameters and structure of a program should be. In recent years the State has created administrative hurdles by introducing regulations that change documentation requirements, decreasing payments made to providers, and introducing revised billing and payment mechanisms. All of these actions reduce the 'attraction' for providers working within the system and in the more recent examples with billing changes it actually drives providers directly out of business.  This is an indirect and inappropriate method of cost control.

The population's desire for what is popularly referred to as mandate relief, as expressed through the Counties, is absolutely appropriate. Similarly, the State's intentions of cost sharing by asking providers to interact with the private insurance system are appropriate. The problem is that there is a disconnect between intention and result when the municipality takes action. Counties were only collecting pennies on the dollar from private insurance companies for early intervention services, and in fact they were only moderately successful in reaching into their own proverbial Medicaid pockets. Imagine that our municipalities could not even competently bill our own Medicaid program and get reimbursed!

The municipalities' inability to collect revenues should be held in sharp contrast to what private practice small business owners must do on a daily basis. People come into my private clinic daily and I bill private insurance and Medicaid regularly. I am able to collect 95% of my claims within 60 days of service delivery. Why can a very small business private practice be able to do what a multimillion dollar early intervention system cannot do?

The answer is rather simple and has everything to do with competence and appropriate planning. My small business private practice holds no special level of competence; this competence of medical billing is shared by thousands of other health care entities around the State. Unfortunately, rather than harnessing the power of this competence the State has simply created more administrative hurdles by using a State Fiscal Agent - and the very predictable result has been a rapid decline in the Early Intervention Program. Payments have been very slow, providers have limited their participation in the program, and in some cases businesses have been shuttered because they no longer have the cash flow support to make their payrolls and continue to function.

The ultimate cost is not to providers, of course - even though jobs are lost and businesses are closed. The ultimate cost falls to the children and families who have their services interrupted or even discontinued.

So how can a system with good intentions carry over those intentions into results? The most common sense answer to that would be to create a mechanism that harnesses a system that is already known to work. Current evidence indicates that providers all over NY State regularly submit claims to private insurance and Medicaid and are able to get paid. We need to re-create and re-apply that successful model.

Up until this point in time providers were able to effectively ignore the insurance payment system and simply submit vouchers to their Counties. Billing happened unsuccessfully and behind the scenes as the municipalities struggled with medical billing functions that they had no competence in. Having providers interact with the insurance industry is not an ill-conceived intention. The problem is that the implementation of this system has been absolutely incompetent.

I hold a perspective that is very different from other providers, but that is because of my own successful experience with billing as a private practice. I know that the intention of direct provider-insurance interaction is correct. I also know that there would need to be a planned and piloted transition to a new system in order for us to achieve a result that was correctly aligned with our intentions.

These providers who previously have not interacted with the insurance industry directly will now require training and support so that they can take over billing functions and do so effectively. Providers also need to have a system in place whereby they could submit residual bills to a State or County escrow system after attempts were made to bill the private insurance. I estimate that it would take twelve months of planned effort and training to prepare providers to take over these functions directly.

The current system has the State Fiscal Agent performing this billing function, and it is akin to inserting an ill-fitting cog between two gears that could perform more effectively if they interacted directly. No one will care more about having claims adjudicated efficiently than the providers themselves who are awaiting payments. There is no need to have a proverbial third wheel, the State Fiscal Agent, in this system.

The need for provider training in order to support such a process cannot be underestimated. Training in interacting with the private insurance industry would be required. Additionally, it must be noted that the State previously afforded compensation to Counties for assuming the billing duties. As billing duties represent a significant administrative burden, provider rates would need to be accordingly adjusted. Even with a rate that included compensation for taking on the additional administrative burden, the likely cost savings and improved revenue collection would more than make up for expenses that are currently being paid to support the very broken State Fiscal Agent system and its record of abysmal municipal collections.

At this point in time providers will likely fear taking on this billing burden, but that is mostly because of the very poor experience that the State has just dragged them all through. If the State were to operate in good faith by providing training support and revenue enhancement to take on this billing function, providers would be well positioned to not only participate in the program but also help insure its longer term fiscal viability through improved interaction and improved revenue collection from the insurance industry. Again, this will all constitute a 'hard sell' to a provider group that already has legitimate feelings of distrust - but had such a plan been instituted from the outset most if not all of these difficulties could have been easily averted.

This brings me to my final point. The citizens of this State make substantial contributions to these systems through their taxes and when the State is entrusted with this kind of investment there is a concomitant expectation that there will be appropriate stewardship of these programs. The citizens of this State, which in fact also includes all of the providers and service recipients in this program, have a reasonable expectation for forward planning, efficiency, and effectiveness. In this regard the system has measurably failed. We should not be spending this kind of money to achieve such a pitiful result. There should be some accountability for the damage caused to this program.

In addition to the fiduciary responsibility that we reasonably expect we also have a moral responsibility to fulfill. Culturally, our State has valued reasonable social safety nets. Our shared sense of responsibility for our vulnerable citizenry was borne out of Willowbrook and translated into our special education and early intervention programs. New York has a storied history about its sense of responsibility for these programs. Good intentions are not adequate, and we need to measure our success by actual outcomes. The current administration of our Early Intervention Program is an embarrassment. We are not meeting our responsibilities with our current systems - and meaningful adjustments and reforms like those that I have outlined must be started immediately.

Saturday, September 28, 2013

Evidence update: Pediatric fecal incontinence and best practices for intervention


Almost seven years ago I wrote a blog entry on pediatric fecal incontinence which is archived here.  In that review I briefly discussed psychological and physiological and regulatory factors that might contribute to the problem.  The evidence at that time indicated that dietary, activity, and cognitive behavioral interventions were most likely to be successful in helping families.

I also discussed a common occupational therapy mythology that sensory processing factors such as preference for deep pressure stimulation might contribute to fecal retention.  There has never been any evidence to indicate that this is a relevant factor.

In the current issue of the American Journal of Occupational Therapy there is an article by Bellefeuille, Schaaf, and Polo (2013) that describes OT intervention for a child with retentive fecal incontinence.  The authors hypothesize that a 3 year old child's difficulty with passing stool is related to overresponsivity to sensory stimulation.  By report, toilet training started at 2.8 years of age when he had to attend a preschool.  The parents were concerned after 4 months of unsuccessful training and according to the article they felt 'pressured' because he needed to be toilet trained for preschool participation.

An assessment included the Sensory Profile which indicated overresponsivity to sensory stimulation.  Occupational therapy intervention began at 3.7 years using an Ayres Sensory Integration Approach.  The authors report that the Ayres Sensory Integration was a useful framework that contributed to the child's improvement.

I have several questions about this article because I believe it represents a rather serious departure from conventional evidence and knowledge on the topic.

To begin with, fecal incontinence is not generally diagnosed in three year old children. At a minimum this diagnosis is not applied until the age of four, at which time a child may be reasonably expected to have completed toilet training and have the ability to exercise bowel control (Mayo Clinic, 2011; American Academy of Pediatrics, 2013). Additionally, at least 20% of developmentally normal children 18 to 30 months of age may refuse stool toilet training at some point (Taubman, 1997). Therefore the core premise of the article that the child had any actual diagnosable condition as would be identified under conventional medical standards is dubious.

A second concern is that the 'objective' data collected as reported in the article is a parent questionnaire about sensory processing difficulties.  Parent reports may be important to help obtain narrative understanding of a clinical problem but they do not represent any direct measure of a child's actual capability in an objective sense.  Additionally, Dickie, Baranek, et.al., (2009) indicated quite clearly that parents don't automatically frame children's activities in sensory terms. Specifically, they state

 "that sensory aspects of experiences are often not noted unless they are unusual (as in having a child who is hyperresponsive to certain sensory situations), or attention has been drawn to them (e.g., through education about characteristics of autism, or by an occupational therapist reframing a child’s behavior in sensory terms)."

Certainly, and as indicated above, childhood fecal retention is hardly an unusual phenomenon and it  does not automatically link to sensory overresponsivity.  It seems reasonable to wonder if the interpretation of the problem was reinforced by the frame of reference of the occupational therapist.

Of additional note is that there was no report of direct assessment of the child that would support the hypothesis that the child had any sensory processing difficulty.  Additionally, no other developmental atypicalities were reported.  If a child had a sensory overresponsivity, wouldn't we expect to see other developmental consequences of the problem?

I am concerned about the concept of providing skilled occupational therapy intervention to three year olds simply on the basis of slow toilet training.   There is no questions that fecal incontinence and struggles to develop toileting skills are a significant point of stress for families, particularly in relation to enrollment in institutionalized day care.  However, individual child readiness has to be assessed across a multitude of factors including child developmental factors, contextual demands, and cultural norms (Brazelton, Christophersen, Frauman, et al (1999).  There is simply no evidence that a sensory overresponsivity construct is an important factor to consider for this problem, particularly in otherwise typically developing children.

It seems irresponsible to suggest that application of a treatment program to an otherwise typically developing child is responsible for progress that one would expect under any circumstance within that developmental period.

Families should always consult with their pediatricians about these concerns to rule out medical difficulties.  The recommendations I made from seven years ago still stand.  Occupational therapists might help families with these difficulties through basic education about healthy activity and nutrition, providing support and information about normal development, and implementing simple cognitive behavioral plans that can be applied across care contexts. This intervention can be provided in time-limited consultation models.


References:

American Academy of Pediatrics (2013, July 9). Soiling (Encopresis). Retrieved at http://www.healthychildren.org/English/health-issues/conditions/emotional-problems/pages/Soiling-Encopresis.aspx

Bellefeuille, IB; Schaaf, RC; and Polo, ER. (2013). Occupational therapy based on Ayres Sensory Integration in the treatment of retentive fecal incontinence in a 3-year-old boy.  American Journal of Occupational Therapy, 67(5), 601-606.

Brazelton, T.B., Christophersen, E.R., Frauman, A.C., et al (1999).  Instruction, timeliness and medical influences affecting toilet training. Pediatrics, 103, 1353-1358.

Dickie, V. A., Baranek, G. T. Schultz, B. Watson, L.R., and McComish, C.S. (2009). Parent reports of sensory experiences of preschool children with and without autism: A qualitative study. American Journal of Occupational Therapy, 63, 172-181.

Mayo Clinic (2011, Jan 4). Encopresis.  Retrieved at http://www.mayoclinic.com/health/encopresis/DS00885

Taubman, B. (1997). Toilet training and toileting refusal for stool only: A prospective study. Pediatrics, 99, 54–58.

Thursday, September 26, 2013

Are NYS Medicaid audits improperly destroying care systems?


Follow up to earlier post: http://abctherapeutics.blogspot.com/2013/03/how-citizen-participation-impacts.html

++++++

New York State Medicaid regulations are a dizzying and complex ruleset that most providers in good faith attempt to follow in their care of people who are Medicaid recipients.

There is an appropriately strict set of rules that most people don't disagree with because naturally we want our State monies to be distributed appropriately and we certainly don't want people fraudulently gaming a reimbursement system.

Undoubtedly, there are examples of fraud and abuse that require strong auditing response and hopefully even referral to the criminal justice system.  We have all heard of stories of providers submitting documentation for services that were never provided, or providers claiming all kinds of illegitimate program costs, and even providers creating no-show Medicaid funded administrative jobs for friends and relatives.  These are the kinds of cases that everyone agrees should demand the attention of the NY State Comptroller's Office or the Office of the Medicaid Inspector General (OMIG).  Every right thinking person wants this kind of real fraud ended.

However, NY State does something much more insidious with its Medicaid auditing that often gets lost or misconstrued when these audits come to public knowledge in the press.

In a recent OMIG audit of preschool services I witnessed overzealous auditing practices that threatened community agencies and a County with several hundred thousand dollars of alleged 'fraud' and 'overpayment.'  The issue had to do with complex supervision requirements of therapists and what constituted evidence of said supervision.  OMIG was not satisfied with co-signature of treatment notes and quarterly review; they were demanding a level of face to face supervision that was not actually required by regulation.  Wanting to be a compliant Medicaid provider, I asked them to please indicate exactly where in the regulations this kind of supervision that they wanted was required, and they referenced the NYS Education Law that describes the legal practice of occupational therapy in NYS.  Thankfully I know that law rather well, and was able to point out that what they were claiming was nowhere to be found in the law or the regulations.

Flustered by the evidence, I recall the auditor stating, 'Well, if I was a parent I would want more supervision' to which I was able to reply, 'Although I highly respect what you would want if you were a parent, what you want is not in the regulations and therapists are required to follow the regulations when they participate in the Medicaid program.'

So it wasn't that the therapists were not being supervised - the issue was how that supervision was documented and how frequently it occurred.  Supervision is never a bad issue to visit or even re-visit, but it is beyond the scope of OMIG to put itself in the position of dictating professional practice on whims of what individual auditors THINK should be happening.  Based on all of this information, the agencies and County did not have to make any 'repayments'

Unfortunately, OMIG has made this claim regarding supervision all over NY State, and who knows how many agencies and Counties rolled over and paid the improper OMIG tribute.  THAT is something that requires some investigation.

I revisit all of this because there is another story in the news today about Medicaid 'overpayments.'  I know enough to understand that you can't take the OMIG report at face value as I have some understanding of the OPWDD adult day treatment population.  I have some concerns about these 'overpayments.'

I want to focus on the largest issue, which as reported is lack of physician signature on an overall treatment plan for day treatment participants.  According to the article (linked) it seems that this is the largest issue uncovered in the audit.

This lack of signature could mean several things.  It could mean that there is absolutely no physician oversight and that the UCP of Ulster County is taking random people off of the streets and billing Medicaid for the services that are being provided.  In this possibility, the UCP of Ulster County is intentionally bypassing the requirement for MD authorization because they were hoping that no one would notice their nefarious scheme to defraud NYS of its Medicaid money.

Someone reading the article might come to that kind of conclusion because they know nothing about the structure of UCP agencies, they know nothing about OPWDD, and they know nothing about adults who have developmental disabilities and how services are provided.  I actually know nothing about this particular UCP agency but I would practically bet my life that this couldn't possibly be occurring.

It is more probable that there is sloppy documentation or perhaps systemic barriers to obtaining the authorization in the way that the regulation requires.  Perhaps there was a period of time when the agency did not have a 'medical director' willing to sign off on all of the care plans for these people.   That would have left the UCP in the position of having to ask the community doctors to sign a mountain of paperwork.  As many of these Medicaid participants receive multiple medically related services (OT, PT, Speech, etc.) it is likely that there is a lot of physician oversight of their participation, but maybe it was not documented on the correct form.  Or maybe they could not get the signature within the specified time period but in fact it is there, or many other possibilities.

Based on my own experience, it could just be that the OMIG auditor didn't like the way that the agency was getting physician signatures or did not like that the signature was present on a face sheet instead of an actual document.  OMIG has a history of being overzealous.

Here is the reality that the OMIG auditors and the general public are not considering.  People who attend OPWDD day treatment facilities are extraordinarily disabled.  They have significant intellectual disabilities and there is NO CHANCE that if you met one of these people that you would not be able to IMMEDIATELY figure out that they were disabled.

In NY State we have made a public covenant to provide meaningful active treatment for people who have developmental disabilities.  We made this covenant in response to NYS malfeasance in its care.  That is so we don't allow people to remain locked away in developmental centers in the so-named SNAKE PITS of Willowbrook and other institutions.

Now we have community agencies like UCPs that provide (hopefully) meaningful active treatment that respects the dignity of human beings, despite their developmental disabilities.  How ironic is it that we have NY State through its OMIG enforcement arm acting as some arbiter of justice regarding care of these people?  Why is UCP being threatened with severe financial losses and perhaps shutdown if they have to pay back all of this Medicaid money?  Was that money REALLY ill-gotten - or is this indicative of administrative and technical difficulty with complying with complex Medicaid rule sets?

Listen, maybe a head needs to roll at a UCP if there is a dereliction, or maybe they need to get smacked with a fine or an oversight process, and DEFINITELY there needs to be some more correct understanding of what exactly the problem with the physician signatures is.  However, there DOES NOT need to be a confiscatory removal of funds that jeopardizes the program for these people - who undoubtedly NEED IT - whether the physician signature was on the correct form or not.

Here is the solution to the problem: I propose that for every day treatment program that OMIG shuts down on technicalities and NOT on actual malfeasance, that those individuals in the programs be bussed to the OMIG offices so THEY can provide a day treatment program and comply with all of the technical rulesets.

Does NY State really want to shut down community agencies that provide care to people who have developmental disabilities?  If there is actual fraud and abuse then I have no quarrel - but based on my experience I am very concerned that this has more to do with an ill-conceived revenue generating scheme that is being perpetrated upon the most vulnerable people in our State and on those providers who are attempting to provide care.

People with developmental disabilities need your voice.  Ask your representatives if OMIG is shutting down agencies for real fraud - or if they are just beating upon vulnerable and politically weak groups that can't fight back.

We want OMIG focusing on the real fraud, and we want a legitimate process that ensures regulatory compliance without threatening the care systems of vulnerable populations unnecessarily.

Wednesday, September 18, 2013

The influence of William Morris and the Arts and Crafts Movement on Occupational Therapy


n.b. ongoing series related to a study of George Barton, founder of the Occupational Therapy Profession.

By my reckoning, it is probably impossible to conduct a study of an event without studying the context in which that event occurred.  Here I suspect that occupational therapy colleagues reading this will understand the bias of the author as he attempts to become a historian.  As clinicians we have well established practice frameworks like the P-E-O model (Law, Cooper, Strong, Stewart, Rigby, & Letts, 1996) that explicitly state that the behavior can’t be separated from its contextual influences. Additionally, this model re-introduced the importance of history-taking for establishing personal contextual relevance for clinical reasoning. Similarly, the Lifestyle Performance Model (Velde & Fidler, 2002) takes a congruent approach by completely embracing phenomenology as being the only possible method for understanding the personal contextual relationships between an individual and the occupations that they engage in.

So it is with this bias that I approached this task of re-constructing fragments of information so that I could better understand why George Barton was the man that he was.

As indicated in the last entry, we know that Barton was born in 1871.  We know that his father was a banker and that his family had some connection to other famous Boston families.  He studied in the Boston public schools and at that time architectural education was accomplished primarily through apprenticeship as formal training programs in Universities were just beginning to be formed.  At that time it was common for parents to secure an apprenticeship for their children and that model of pupillage, in combination with emerging organized architectural education, was a primary means for entry into the field (Crinson & Lubbock, 1994).

Several sources document that Barton was sent to London, England where he was apprenticed to William Morris and other notable Victorians including Sir Hiram Maxim and Henry James (Gifford, 1989; Licht, 1967).  At that time, the effects of industrialization on local artisans was profound in that machinery was replacing the handiwork of craftsmen and textile workers.  William Morris was a leading figure in the Arts and Crafts Movement which was a response against industrialization and its impact on Victorian interior design.  A classic Morris quote that captures the spirit of the movement and is oft-repeated is

If you want a golden rule that will fit everybody, this is it: Have nothing in your houses that you do not know to be useful, or believe to be beautiful.

When considered within the context of classic Victorian interior design, it is easy to understand the simple messages embodied within this statement.

William Morris was passionate about Illumination Manuscript and apparently introduced Barton to this art form.  This is a sample of original Illumination artwork created by Barton that was found amongst some of his possessions:






On the back of this artwork are some notes written by his wife, Isabel (Newton) Barton:





I was unable to find any evidence of Barton artwork or design that has ever been previously published.


George Barton was strongly influenced by Morris, and when he returned to America he became the first secretary of the Boston Society of Arts and Crafts.  The purpose of this Society as reported by Eaton (1949) was as follows:

The Society of Arts and Crafts is incorporated for the purpose of promoting artistic work in all branches of handi­craft. It hopes to bring designers and workmen into mutually helpful relations, and to encourage workmen to execute designs of their own. It endeavors to stimulate in workmen an appreciation of the dignity and value of good design; to counteract the popular impatience of Law and Form, and the desire for over-ornamentation and specious originality. It will insist upon the necessity of sobriety and restraint, of ordered arrangement, of due regard for the relation between the form of an object and its use, and of harmony and fitness in the decoration put upon it.

The Society was incorporated June 28, 1897. It is still in existence today.

Upon completion of his apprenticeship, George Barton worked in the architectural firm of Cram, Wentworth, & Goodhue, of Boston.  Around 1895 he went on a tour of England and France, with the special purpose of studying the domestic and church architecture of the smaller cities and towns (Brochure Series, 1895).

Early in his career he won the Shattuck Prize for Industrial Homes (Barton, 1947).  In 1902 Barton partnered with R. Clipston Sturgis and together they formed the architectural firm of Sturgis and Barton which continued until 1907 (AIA, 1914). 

This is the known history of the beginning architectural and design work of George Barton.  His interest was nurtured through apprenticeship in England and he was significantly influenced by Morris and the Arts and Crafts Movement that he brought back to the United States, where it still persists today in both the occupational therapy profession as well as in the Boston artisan community.



References:

American Institute of Architects (January, 1914). R. Clipston Sturgis, President of the Institute.  Journal of the American Institute of Architects, v.2, 5.

Barton, I.G. (1947, May 16). "Talk Given Before the Western New York Occupational Therapy Association at the Clifton Springs Sanitarium."

Crinson, M. & Lubbock, J. (1994). Architecture: Art or Profession - 300 years of Architectural Education in Britain. Manchester, UK: Manchester University Press.

Eaton, A.H. (1949). Handicrafts of New England. New York: Harper and Brothers Publishers.

Gifford, F. (1989, May 23). Historian's Corner: George Barton - The Man Who Wouldn't Give Up. The Community Trader, p.7.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996).  The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9-23.

Licht, S. (1967). The founding and founders of the American Occupational Therapy Association. American Journal of Occupational Therapy, 21 (5), 269-277.

Morris, W. (1880, February 19). "The Beauty of Life," a lecture before the Birmingham Society of Arts and School of Design.

The Brochure Series of Architectural Illustration (1895), Personal, p. 109, Boston: Bates and Guild. 

Velde, B., & Fidler, G. (2002). Lifestyle Performance:  A model for engaging the power of occupation.  Thorofare, NJ: SLACK, Inc.

Saturday, September 07, 2013

When the fishing is good but the catching is bad.

I personally always fished with worms, or occasionally newts - but I am no fisherman and my knowledge of this occupation is restricted to the things a young boy would gain by spending summers casting into the Hudson River more for a way to commune with friends than for the sport.  Back then it never really mattered what we caught or even if we caught because the occupation was directed toward the social experience.  Besides, there is nothing worse than having to get a river eel off of your line.  Gross.

Anyway, I was preparing a lecture and the concept of 'emerging practice area' ran across my radar screen.  This is certainly nothing new in OT.  The word 'emerging' seems to be an interesting buzzword in occupational therapy right now and it is applied across many contexts.  There are 'emerging leaders' and there are 'emerging practice areas' and there are 'emerging fieldwork sites' just to name a few.  It must be important because there are even ACOTE standards that demand that accredited educational programs promote 'emerging' practice areas.

Sometimes words are used so frequently that there is a risk of just accepting the word without really doing much diligent investigation into why we are using the word.  I think that might be true with the concept of 'emerging' things.

'Emerging' sounds good, mostly, and generally evokes images of forward thinking or being innovative.  In the OT literature the word is often accompanied by 'niche' which makes me think of ideas that are small but valid.  So the concept of emerging niche actually seems kind of appealing, at least from the perspective that it might be kind of nice to find some things that are not easily noted but might be growing in significance.  Being 'cutting edge' is generally a positive attribute, so these words evoke some connections to other words that might seem to be good things.

If you try to trace back the use of the word 'emerging' as it relates to OT I think it is mostly fair to state that the AOTA Centennial Vision process really kicked off the use in its present context.  That is not to say that OT hasn't talked about future-thinking before - but just that the use of the word 'emerging' in so many contexts was spurred largely by that visioning process.

I have indicated previously that I am a pragmatist in my heart.  I spend time looking at the 'emerging practice' information because I am always wondering how we wed the intention of future planning to the realities of what we are demanded to do on a daily basis in our work.  It interests me that the Centennial Vision document specifically identifies misalignment between priorities and the external environment as a point of barrier.

As an example, under the Children and Youth heading of the AOTA website there is a tab for 'Emerging Niche.'  That tab has topics under it like childhood obesity, use of RTI models, bullying, and other topics.  All of these are interesting topics and they impact the occupational performance of children, but they really don't represent the efforts of what most practitioners are doing in their daily jobs.

So who determined that these areas were 'emerging' and others were not?  Are we using evidence to determine what is emerging?  Are we using evidence to determine if practicing OTs are really that involved in these areas? 

I recall an interesting conversation on the OT Connections site where the notion of strategic planning and the Centennial Vision was being discussed.  The issues discussed were whether or not it was correct to strategic plan on needs or to strategic plan solely on where you want to go.  It is a legitimate debate, but I believe that the best strategic planning has an important element of pragmatism.

You see, without that element of pragmatism, we run headfirst into misalignment between priorities and the external environment.  This creates a large problem, in my opinion.  Specifically, while we cast our line out and fish around for issues related to obesity and bullying we are actually catching severe problems with reimbursements and service delivery structures.  So the fishing is good but the catching is bad.

I have been trying for about two years to get the river eel of New York State's failed early intervention program off of my fishing line.  It is slimy and gross.  When I look over to my AOTA buddy's efforts all I see are 'emerging niches' of bullying prevention.  Are some folks catching bullies and doing great work???  They sure are!  But what are we doing about the slimy river eels on our lines?

It is not just AOTA though.  For months I would look over to see what NYSOTA is doing about the early intervention problems I have documented for a couple years now and although there are some johnny-come-lately efforts you were more likely to see tons of pictures about some marketing effort of taking pictures of some branded multicolor hand thingie as you were to see even a single picture and a story of some sad therapist turning the sign on the front of her early intervention business to where it reads "CLOSED."  That has changed recently, and that is good, but now it is too late.

This is misalignment between priorities and the external environment.

We all have responsibilities for this.  Outcomes are not measured by the integrity of our intentions.  Outcomes are measured by what actually happens.  I am acutely aware that banging the drum on a blog is not solving the problem either, so I am taking other steps to try to solve problems.  I have been meeting with my legislators myself.  I am educating parents about these issues even more directly.  I am trying to collaborate and team with others in my community that are facing the same issues.  I am even changing my lecture topic content.

We can walk and chew gum at the same time.  So, I can talk about 'emerging' practice but I can also talk straight about what is real and happening in the field now.  If educators fail to talk about what is real then all we will accomplish is promoting a bunch of disconnected graduate and doctoral projects on childhood obesity or bullying that have no traction beyond the demonstration project level.

The point is to serve the needs of people, not to endlessly prop up our own good intentions with non-viable ideas.  Honestly, how many AOTA poster sessions and student projects will we actually see about the role of OT with homelessness or domestic violence shelters before we realize that virtually no one is actually working in those areas?

Again, I want to point out that this kind of visioning about emerging areas is not bad in itself, but it really does increase the risk of distracting us from really important everyday concerns that are right in front of our faces.

I think there is great risk in this posting because I don't know if the notion of how fishing is good but catching is bad will resonate.  I was thinking instead of writing this around the Aesop's parable of the milkmaid and her pail.  She daydreamed endlessly and spilled her milk before she ever got to market - the moral being the same as my fishing analogy.  It is a little simplistic so I hope the fishing analogy is more apt.  You can legitimately think about it either way.

We just need to have some pragmatism.  Or at least a little more than what we are currently employing.


Thursday, August 29, 2013

NYS Early Intervention Program makes up more rule changes as they trip along


Here is an illustration for providers in the NYS Early Intervention Program that clearly illustrates the selfish orientation of thinking that is driving decision making on a central level at the Bureau of Early Intervention.

Exactly two months and two days ago, the Bureau of Early Intervention instructed providers to "accept claim amounts proposed by the insurer as payment in full from the insurer for the claim which are lower than the State-established EIP rate."  Although they explained that this would not impact payments from escrow in the short term, we explained that accepting these payments in this way would be problematic because of the long term intent of having providers accept payments directly from insurers.

TODAY we received a DIFFERENT set of instructions from the Bureau of Early Intervention that states:

Dear Colleague:

The Department is aware that insurers or insurer clearinghouses (Multiplan, Omni Plan) have sent expedited agreements to EI providers in response to claims submitted for EI services. The expedited agreements asked providers to accept claim amounts proposed by the insurer as payment in full from the insurer for the claim, which is lower than the State-established EIP rate.

DFS has recently informed the Department that commercial insurance plans that are regulated by New York State should not be sending these agreements to providers who submit claims for EI services. The New York State Prompt Payment Law requires that claims be processed within 45 days or the insurer could incur a violation and payment of additional interest.

Providers should no longer be receiving expedited agreements from insurers that are regulated by New York State. In the event that a provider does receive an expedited agreement from an insurer that is regulated by New York State in the future, the provider should not sign the agreement. Providers can determine whether or not the insurance plan for a child is regulated by New York State by accessing the child’s home page in NYEIS and by selecting the insurance coverage option, and select view for the insurance company and policy information. If this information is not available in NYEIS, the provider should work with the child’s service coordinator to obtain this information. The service coordinator and/or the municipality are responsible to ensure that current insurance information for each child is updated in NYEIS or in KIDS.

So in other words, because the BEI crammed this system in at the 11th hour and never did any of the proper planning to enroll providers into networks, insurance companies are doing what they do by trying to get providers to sign expedited agreements which essentially helps the insurance control costs by clearing the claim and processing it as an 'out of network' situation.  That gets them off the hook for making a payment at the contracted rate.

The evil part is that when we see the insurance companies asking providers to accept negotiated rates the BEI is all over it and telling providers to go ahead and sign up - never telling providers what the long term impacts of those actions will be.

But when BEI figured out that signing the paperwork means that the BEI will get less than what they are entitled to, look how quick they are to issue guidance telling providers NOT to sign the paperwork!

 I understand that the complexity of this runs so deep that only medical billers might understand the full nuances of PPOs, negotiated payments for out of contract work, and similar posturing in insurance-provider relations.  What providers need to walk away with is the knowledge that if it serves the BEI they will take care of themselves.  If it is an issue that at the moment they don't think will matter to the BEI then providers are on their own.

This issue is prima facie evidence that they have no idea what they are doing over there.  Any provider that places trust for something as important as billing in the hands of this system is foolish - and we are all forced into a foolish situation because of the heavy handed way that the contracting came down and the absolute lack of meaningful stakeholder participation in making these transitions.

We would have all been better off billing the insurance companies ourselves and having the balances waterfall down to the escrow account as the payer of last resort.  That would have been a tough potato for the provider community to swallow, but I absolutely promise that it would have left this system in a much more favorable position than where it is today.

In the meantime expect more guidance from the early intervention program as they "learn" about medical billing. It is all happening on your backs, but they understand that you are not organized and you have no powerful voices so they can get away with just about anything.

Friday, August 23, 2013

New York State Early Intervention: Roadmap through the end of 2013


My email box is flooded from colleagues asking about the NYS Early Intervention program - so I thought I would lay out the likely path toward the end of 2013 so people can plan appropriately for what lies ahead.

I also have a roadmap through 2014 and 2015 which will be published as a part of this series.  Stay tuned.

Fall, 2013: The already stressed EIP will continue to come apart at the seams.  Payments to providers will continue to be excruciatingly slow and complex.  Even more providers will leave the system creating even longer waiting lists for children and families.

There will be no immediate 'fix' because the legislature is out of session until January.

Governor Cuomo and his administrative team will continue to blame the insurance industry for the problem and will refuse to acknowledge their own roles in creating the mess.  This will lay the groundwork for insurance reforms that will be introduced next year in the Governor's Budget.  The State will stick to the party line of offering 'safety net payments' and as providers go out of business they will claim that they could have taken advantage of the  safety net payments that may or may not be a loan depending on what day of the week it is at the DOH.

In mid-Fall, with much fanfare, the NYS DOH will say goodbye to their interim fiscal agent.  However, workers at James McGuiness and Associates will not have to fear for the immediate loss of their jobs because it will take months to get all of the payments processed through their systems.  Additionally, they will fade back into obscurity and will revert back to their roles as billers for County preschool payments.

Sometime in the Fall the new State Fiscal Agent, Public Consulting Group, Inc., will introduce new early intervention billing systems that will tie the provider community up in knots.  With all the negative press, they might consider removing the smirking dude on their website with the caption that reads "Our team has extensive experience with the full range of payment models and techniques that drive performance and reduce net state/municipal costs for health care services."  They might not have to remove it though because most early intervention providers spend their time appropriately attending to the needs of children and have not yet noticed the smirking dude on their website and what he is really saying.  If enough people read and think about what Public Consulting Group, Inc.'s expertise really is they might link it to the smirking dude on their website and that could be an image problem they want to avoid so we will see if that gets changed.

Since people might not notice the smirking dude on their website they might not also notice that NYS tax dollars are going to be paid to the Public Consulting Group, Inc. so they can increase jobs in.... TENNESSEE?  Yes, that's right - the call center support for the NY Early Intervention Program is hiring people in Nashville, TN.  Someone might want to make a call to Governor Cuomo about that because it is unfortunate that NYS would contract with someone who takes our tax dollars and then promptly applies them to the unemployment problem in Nashville.  Of course that link will be dead as soon as they hire the folks for the Nashville office - so go check it out now please.

Late in the year the provider community will receive tax guidance on how to process the loan money that is not really loan money.  Then it will become crystal clear that it is really not loan money because loan money is not taxed in NYS but your safety net payments sure will be.  Providers will gnash their teeth and regret ever taking the loan money that is really not loan money because they will find themselves in a very unfortunate tax situation.

As things continue to boil over the next couple months it is extraordinarily unlikely that there will be legislative action because that would take Governor Cuomo calling for an emergency session.  He can't take the risk of having legislators talking about the Early Intervention meltdown (reference the next post on Roadmap through 2014 - coming soon - hint: it has to do with elections) so unless he can find a way to control the spin or link it to some other heroic action on Upstate flooding or maybe the Women's Equality Act that the Senate did not pass it is much more likely that he will put on a SuperMan suit sometime in the Fall and announce yet another form of administrative financial support to prop up the program 'while we give the State Fiscal Agent time to get on its feet' or something like that.  He will make some speeches and people who know better will make statements like 'You can't put band aids on bullet wounds' but he will find enough sycophantic reporters to print that he has saved the day that he will remain unscathed if not heroic.  Then people will go into winter hibernation mode with visions of sugarplums and possible legislative proposals in their heads for the 2014 session.  Like I said - more on that soon.

Bottom line: good things are not on the horizon.  You heard it hear first.

Monday, August 19, 2013

Thursday, August 15, 2013

Early intervention providers: Look the 'Gift Horse' in the mouth please.

I received this in email today:

Dear Colleague:

The NYS Department of Health (Department) is offering a one-time State safety net payment to Early Intervention providers, and will not proceed to implement the Preliminary Escrow Payment (PEP) proposal due to insufficient county participation.  

State safety net payments will be calculated as seventy-five percent of the value of claims submitted to insurers, with the exception of the medical assistance program, in the period April 1, 2013 through July 29, 2013 for which no known payment or denial has been received.  The State safety net payments will be reconciled commencing on October 1, 2013 by assigning to the Department twenty-five percent of each early intervention payment payable from the escrow account until such time as the State safety net payment is fully recovered.  The safety-net payment is a one-time payment made by the State.  All claims submitted by the provider, including those submitted to insurers in the period April 1, 2013 through July 29, 2013, will continue to be processed and paid in the normal course.  

Providers who wish to participate in the State safety net payment must execute an amendment to the Provider Agreement held with the Department.  If you are interested in participating in the safety net payment and would like a Provider Agreement Amendment sent to you, please e-mail the Bureau of Early Intervention at Provider@health.state.ny.us 

We request that you included in the body of the e-mail

“I request that the Department send to me the Provider Agreement Amendment in relation to the State safety-net payment and I authorize the Department to send the Provider Agreement Amendment by UPS overnight mail/signature required.”

Please include in the e-mail your full name, mailing address, and phone number.

The Provider Agreement Amendment must be signed, notarized, and returned before the State safety net payment can be issued.  Provider Agreement Amendments should be returned to the following address:

Bureau of Early Intervention
ESP Corning Tower, Room 287
Albany, NY  12237-0660
Attention: Provider Unit

The Department is requesting that you return the Provider Agreement Amendment as soon as possible after receipt to ensure timely safety net payment.  The Department will not accept requests for Provider Agreement Amendments after August 31, 2013.
Please contact the Bureau of Early Intervention at 518-473-7016 if you have any questions. 

Just so everyone is clear - THIS IS NOT A PAYMENT.  This is a loan for the money that is already owed to you.  You will have to pay it back - and there is no accompanying fix for the mess that they have made of the billing and claiming system.

How many people are in a work agreement where they have to take a loan from the other party as payment for services rendered?

Also, just like the original Provider Agreements, these are being crammed down the throats of providers with a demand for less than a two week turnaround.  That means that providers who are currently owed tens of thousands of dollars (and in some cases even more) will have to somehow make the legal determination that the agreement is legitimate and will have to make the accounting determination that it makes sense for their businesses - all with very little opportunity to study the issue fully.

As this is a "one time payment," how will this address the problem moving forward?  This 'solution' is another nail in the coffin of the Early Intervention Program because it does not solve any of the problems with the current system.  Will we see another LOAN to cover the period from August through November???  I can guarantee that there is no fix in the works that will make payments suddenly start flowing through this system.

Providers should be given adequate time to study the legal and accounting implications on our businesses before accepting such an agreement - and our State government should stop trying to throw band-aids on a gaping wound that they created.

Wednesday, August 14, 2013

Note to politicians: Grandstanding on important policy issues does not win votes.

All press is not good press.  Especially when people get distracted from what the primary issues are.

In tonight's Capitol Confidential post there is a report that is headlined: "Therapists want to get paid, Tedisco sees 'War on Women.'"

The headline I would like to see is: "Children go without important therapy as NYS decimates Early Intervention Program."

A parallel example recently was the announced closure of O.D.Heck.  This announcement generated conversation about the plight of union jobs.  What got lost in the shuffle was the important human rights policy of de-institutionalization and the very real fact that there are problems with maintaining appropriate standards of care when we warehouse people who have disabilities.

How do concerns with the early intervention program degrade into a headline about the 'war on women"  and grandstanding on some cause du jour???  The cheapening and coarsening of our policy discourse in this way moves us farther away from being able to solve real problems.

It is true that most of the early intervention providers are small woman-owned businesses.  However, conflating the early intervention program as an opportunity for some political haymaking with 'war on women' statements is farcical.  Similarly, showboating your position on restoring OPWDD funding does not have anything to do with the early intervention program.

In many ways this kind of coverage makes me glad that I missed the rally today.  I would have been there trying to raise awareness about the malfeasance that destroyed the program and suddenly I would have been in front of a couple politicians who make statements that sound like raw opportunism.

I will give the politicians a chance for a pass - because it is always possible that they were appropriately on-message about the real concern and a reporter simply focuses on some bizarre aspect of the message that doesn't quite fit.  Maybe writing about the 'war on women' generates blog hits?  If this reporter accurately reflected the tone and content of political participation today then we clearly have a problem.

Here is what we need to stay on message about and this is what we need to see reported:  As a society we make decisions and choices about what degree of social safety netting we will provide with vulnerable populations.  It is reasonable to have debates about how much netting we put down.  A question that we need to answer is - 'how robust of an early intervention program do we need and how robust of an early intervention program can we afford?'

Specifically, we should have debates about who should be in the program.  We may come to decide that we can't have the largest program because we just can't or don't want to afford it.  Maybe only children with certain levels of developmental delay or only those with severe diagnoses should be seen in the program.  Then we can refer other families to private providers or other resources.  That is a reasonable debate to have.

It is also reasonable to look for ways to distribute the costs fairly.  It is absolutely reasonable to enact cost sharing and to put some of those costs into the private insurance market where they rightly belong.

What is incorrect is to leave the program as-is and pretend that we can have unending and balooning entitlements.  It is also incorrect to be afraid to have that conversation and then control the cost and size of the program by back-door manipulation of insurance payments to providers.  Then the bureaucrats hide in their offices in Albany and release statements that 'it is the insurance company's fault for not paying.'  That is the most disingenuous set of statements I have heard lately.  The government was fully informed and advised of the municipal inability with medical billing - and they took it on anyway and the result was absolutely predictable.

Then as people scream about the end of the program, we have opportunistic pols talking about the 'war on women.'

This is how we are failing.  We need to elect better representatives, and then we have to encourage and enable them to have the correct conversations.  We have to eliminate their culture of pandering and grandstanding.  Then we can try to learn how to have real policy debates and make some real progress on our challenges.

Based on the reporting about politician's statements that I am seeing coming out of the 'rally' today - it seems that we still have a long way to go.


Saturday, August 10, 2013

George Barton: Birth and early influences.

George Edward Barton was born on March 7, 1871.  That is a rather dry fact about one of the important founders of the occupational therapy profession - so what can be done to help give it context?

Context provides dimension - and if we want to learn a little about George Barton it might be helpful to know a little about his history.  His parents lived in Boston, Massachusetts.   His father was Edward H. Barton, the Secretary and Treasurer of the South Boston Savings Bank.  His mother was Rebecca Duncan (Boynton) Barton.

It was difficult to find other information about George Barton's parents, but a rather unexpected pair of portrait photographs were contained in some of his possessions that led me through this investigation.  Here is the first picture:


I recognized this photograph; it is an original portrait of Louisa May Alcott - but why would it be in the possession of George Barton?  Louisa May Alcott was born November 29, 1832 and she died on March 6, 1888.  That would have made George Barton only 17 years old when she died, so they certainly were not contemporaries.

This is a second (smaller) original portrait photograph that identifies the photographer as Augustus Marshall.  A quick search led me to the fact that this was taken in 1870 and perhaps she was not happy with this photographer, writing "His pictures are vile."   (Shealy, D. [ed.], 2008).





















As I continued my search I learned that Louisa May Alcott was a prolific letter writer and I was able to find some letters that she had apparently written to a 'Barton' family (Shealy, D. [ed.], 2008).  I contacted Dr. Shealy about these photographs and he was extraordinarily helpful in providing some additional information:

Edward Henry Barton and his wife were neighbors of Louisa May Alcott and her sister May Alcott, when the two lived at a boarding house at No. 43 Pinckney Street in Boston in late 1869 and early 1870.  I know little of the the couple; however, they are mentioned a number of times in my edition Little Women Abroad: The Alcott Sisters' Letters from Europe, 1870-1871 (U of Georgia Press, 2008).  LMA, while in Europe, wrote to Mrs. Barton on 9 January 1871: "I shall come home as early as it is safe, & one of the first visits I make will be to my Bartons.  I hope I shall find a cradle in the house & a rosy little Edward Henry in it, ready to welcome his Aunt Weedy" (pg. 269).  From LMA's words, it appears the child is about to be born or was just born.  Since you indicate George Edward Barton was born in 1871, it appears likely he was the son of Edward Henry Barton.  That would be my first guess.  If not, he is clearly a relative.  I never located any information about the Bartons in my brief research into their lives.  However, I would suggest you use Ancestors.com or other similar websites to locate them.  You could do a search of births in Boston for 1871.

By the way, LMA's photographs, especially the Marshall one (a fairly common one), are mentioned several times in these letters in relation to the Bartons. You might find these references useful.  The index will guide you to them. (D. Shealy, personal communication, 7/31/13).

It seems that the 'rosy little Edward Henry' that Louisa May Alcott was thinking about two months before his birth was actually George Edward Barton!  I have been able to confirm dates, residences, and family members through genealogy databases and census records from that time period.

I was not able to find any other references or letters linking Louisa May Alcott to George Barton, but apparently she was important enough to him that he kept her photographs among his possessions.

Only speculation is left - but as I will show in future posts, George Barton was a Renaissance Man and had very broad intellectual interests.  It is possible that he was influenced in direct and indirect ways by Louisa May Alcott, who was obviously dear enough to him that he kept her photos.  We know that Louisa May Alcott was schooled by her father Bronson Alcott - one of the original Transcendentalists - and also spent time in the libraries of Ralph Waldo Emerson and Henry David Thoreau.

So these are the social circles of Edward Henry Barton and then his son George.  These social circles were the culture that he was immersed in and may have influenced his thinking.  It is likely that George Barton, through his family affiliation with the Alcotts, would have been very familiar with Emerson's (1837) thinking:

We will walk on our own feet; we will work with our own hands; we will speak our own minds.

This was a basic belief in American self-reliance.  It was a core philosophy of Transcendentalism.  It is just speculation, but it sounds like a foundational concept that might have been used to inform George Barton's thinking about occupational therapy.

References:

Alcott, L.M. and Alcott, M. (2008). Little Women Abroad: The Alcott Sisters Letters from Europe (1870-1871) D. Shealy, (Ed.).  Athens, GA: University of Georgia Press.

Emerson, R.W. (1837, August 31). The American Scholar.  Speech presented at the Phi Beta Kappa Society, Cambridge, MA.