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Our Point of View

November 6, 2008

Kaiser Permanente Comments on Autism

Kaiser Permanente plays an important role in providing compassionate care for autistic children and is a recognized leader in research into autism and its causes. Every week, our physicians and medical professionals provide medically needed health care services to thousands of patients with autism, including evaluation, diagnosis, and treatment.

In addition, we are helping to lead the nation's effort to understand autism and to find its cause or causes. We currently are involved in 15 different autism-related research studies.

When a child is diagnosed with autism, Kaiser Permanente has teams of experts that include developmental pediatricians, child psychiatrists, child neurologists, and speech therapists, and other professionals who all work together to provide and coordinate health care for the children and their families.

Health plan coverage is limited to the health care needs of members with autism. Once the medical diagnosis is made, it is likely to take support from the patient's family (parents, in many cases), schools, and social services agencies to help a child be as much a part of society as he or she can be. Much like a diagnosis of a learning disability, or being overweight, while the diagnosis is a medical condition, often the services involved go beyond health care services. In autism this is also true, where non-health care services may be required, as in these other conditions where private tutoring for learning disabilities or gym memberships for patients who are overweight are not part of the covered health care services. Services that teach these children social skills, or how to behave, including Applied Behavioral Analysis, were the subject of a July 6 Los Angeles Times article entitled "Who Pays for Autism Treatment?" These are services which have not been part of health plan benefits. As the Times points out, some people have begun demanding that these services, such as teaching children how to behave in a social setting, be covered by health insurance.

However, health plans in California, including Kaiser Permanente, are not licensed to provide non-health care services, which require different criteria, providers, monitoring, and evaluation than that of medical care.  Often, these services are provided by non-licensed non-health professionals, making it difficult for health plans to monitor the quality of services delivered.  And finally, health plans do not currently charge for these non-health care services in the premiums our members pay, because those services are not now covered by our plans.

Many parents are frustrated with the current state of services for autism, and looking for sources to pay for the services they expect, whether it is an appropriate source or not.  As a recent example, parents are also expressing many of the same health plan-related concerns in statements about school systems and state sponsored centers, whose job it is to provide these services to autistic children. On July 13 The San Francisco Chronicle reported, "Thousands of California families are caught in a chasm between what they believe their disabled child needs and what the schools are willing and able to provide."

A California Legislative Blue Ribbon Commission on Autism also found no comprehensive and cross-discipline approach to autism, after being formed in 2005 to figure out how public agencies could meet the growing needs of people with autism. The report also found that demand for services continues to rise.

If Kaiser Permanente, or the health care system as a whole, were to provide these additional non-health care services for autistic children, health premiums would have to be increased to cover the cost of those services – a move which would add hundreds of millions of dollars in new costs to the premiums already charged to the members of the health plans. It also would create a system in which health plans oversee and evaluate non-health care services. And, it would have health plans teaching children how to behave in social settings. While important steps, these are not improvements in the child's health. Employers, who purchase the majority of insurance coverage in California, would have to find a way to pay these additional costs – likely either by further limiting insurance availability, or by sharing these additional costs with their employees. People who buy their coverage directly will see their premiums increase to cover these new costs.

Rather than arbitrarily shifting costs to those Californians with health insurance, we believe the best approach is for all contributors of autism-related services (family members, educators, social services, philanthropic organizations, and medical professionals) to continue to work together to help children with autism. We need to figure out the best way of assuring that autistic children and their families get the support services that they need. Simply increasing premium costs to provide a particular service is not the best solution, especially when the costs are spread over a smaller and smaller group of people who are paying for health insurance. The field of available treatments for autism is constantly changing, and all providers of services must remain flexible. However, responsibility for these services must also be properly divided up, so that each area (health, education, developmental services) provides those services in the areas where they are most expert, to ensure the best benefit to the child.