“Functional outcomes are those communicative behaviors acquired during the treatment process that increase a childs level of independence in real-life communicative situations” (Campbell, 1998). For young children, communicative independence ranges from the ability to express basic physical needs and emotions to their family members to the ability to socially interact appropriately with their peers in pre-school or play groups. For a child with a severe speech-sound production disorder, achieving basic communication independence typically requires intensive and lengthy speech therapy (Hall, Jordan & Robin, 1993). As health care costs continue to rise, it will become even more important to justify insurance payment for frequent speech therapy sessions over a long period of time. Therefore, speech-language pathologists need to collect and provide data that shows that positive changes in the childs communication skills are occurring while the child is in therapy (Zeit & Johnson, 2002).
Data that proves the effectiveness of speech-language pathology services (efficacy research) as well as data that documents positive functional change among individuals receiving treatment (functional outcomes) is lacking (Jacoby, Lee, Kummer, Levin & Creaghead, 2002; Campbell, 1999). Likewise, few studies have been pursued to attempt to define how much treatment is typically needed to manifest progress (Jacoby et. al, 2002). Within the field of communication sciences and disorders, outcomes research on children with motor speech disorders is particularly scarce (Campbell, 1999; Hall et al., 1993). This may be attributable to the lack of published outcome scales for documenting and measuring change in young children with motor speech disorders (Campbell, 1999). Moreover, there are substantially fewer efficacy studies for the pediatric population than the adult population for all types of communication disorders. This is likely due to the difficulty of determining that progress resulted from intervention alone rather than from a combination of factors including treatment, maturation/development and various environmental influences.
Despite these research challenges, the American Speech-Language Hearing Association (ASHA) realizes that functional outcomes data and treatment efficacy research supporting the value of speech and hearing treatment is critical to the survival of the profession. As a result, ASHA developed the National Outcomes Measurement System (NOMS) for the purpose of tracking functional gains in individuals receiving therapy. A recent study of children receiving speech therapy at Cincinnati Childrens Hospital Medical Center, using data collected within the NOMS framework, helps support that speech and language treatment results in positive changes. Specifically, the study examined 234 children between the ages of three and six years. Seventy-six and one half percent (76.5%) of subjects improved at least one Functional Communication Measure (FCM) level following 20 hours or more of treatment. The Jacoby et al study found that the FCM level improved for all subject groups as the number of treatment sessions increased, suggesting that positive functional change is one factor that is related to length of time in treatment (2002). These findings include children with mild to severe speech disorders in the areas of articulation, speech production and language comprehension.
For children with apraxia, the more important finding from the Cincinnati Childrens Hospital study may be the relationship of severity on progress and treatment time. Results of the study indicated that children with lower initial FCM levels (at the start of therapy) required more treatment sessions to demonstrate positive functional change than children with higher initial FCM levels (2002). In other words, children with more severe communication disorders took longer in treatment to achieve the same functional communication level for their age group than children with less severe disorders. These findings are similar to those reported by Campbell (1999).
In the area of articulation, ASHA NOMS data have reported similar findings, further supporting the link between treatment time and amount of progress in children with severe disorders. NOMS data reveal that after 17 hours of treatment, only 16.4% of children with a severe articulation disorder moved to a functional level at discharge. However the large majority of children studied (83.6%), did NOT move to a functional level and, therefore, required additional treatment. This information shows that short-term intervention can benefit a small percentage of children, but that most children with severe speech and language disorders require more treatment time to achieve a functional communication level that enables them to participate in age-appropriate activities (Zeit & Johnson, 2002).
A recent Medline and National Library of Medicine (Pubmed) search on published functional outcome data specific to children with severe motor speech disorders only resulted in one reference, “Functional Treatment Outcomes in Young Children with Motor Speech Disorders” found in Caruso and Strands text, Clinical Management of Motor Speech Disorders in Children (Campbell, 1999). Campbells study was performed at the Department of Audiology and Communication Disorders at Childrens Hospital of Pittsburgh (Campbell, 1998). In this study, individual speech therapy was provided to 11 preschool children with the diagnosis of apraxia of speech over a 12-14 month period.
A pre- and post-parental questionnaire was administered to measure parental views of their childs speech intelligibility when talking to unfamiliar listeners. All eleven parents responded that less than half of their childs speech could be understood by an unfamiliar listener when questioned at the beginning of treatment. When questioned again on the day of the last treatment session, only three of eleven parents (27%) responded with this same answer. In contrast, eight of eleven parents (73%) responded that three-fourths of their childs speech could be understood (Campbell, 1999). Campbell’s finding suggests that the majority of children with severe production disorders will demonstrate positive communication change with treatment.
Campbell also compared outcomes in relation to the amount of treatment provided for phonologically-disordered children with children with apraxia. The parents of 49 children with moderate to severe phonologic deficits receiving individual speech therapy were administered the same survey. For these children, an average of 29 individual treatment sessions (45 minutes in length) were required for parents to report that about three-fourths of their childs speech could be understood by an unfamiliar listener. To achieve the same intelligibility level among the parents of children with apraxia, an average of 151 individual treatment sessions were required. “In other words, the children with apraxia of speech required 81% more individual treatment sessions that the children with severe phonological disorders in order to achieve a similar functional outcome” (Campbell, 1999). These data are critical when advocating with health plans for an increased number of treatment visits for children with severe speech production disorders.
What can clinicians, facilities, and families do to help advocate for improved health benefit coverage for speech-language services?
- The most important step families can take is to inform their employer about the limitations in their health plan. Employers have the greatest influence in obtaining better insurance coverage as they negotiate the contracts with the insurance companies. Many large employers are self-insured and can more easily adapt the benefit plans to meet their needs. For mid-sized and small employers, insurance riders can be purchased and added to their existing policy to increase speech and language benefits. Typically, the Human Resources Manager at ones place of employment is in charge of health benefits and, therefore, is the appropriate person to address. For those families that have union representatives, these individuals should also be informed as they can advocate on their members behalf and often have some influence over benefit plans. Families should voice their concerns both verbally and in writing. The letter of concern should:
- State the reason therapy was denied.
- Comment if the plans handbook/brochure is misleading regarding the speech therapy benefit.
- Provide examples of common limitations in health coverage for pediatric speech therapy.
- Include the ideal benefit language for speech, language, and hearing services.
- Provide a cost estimate of expanding coverage. ASHA plans to update their cost data by the end of 2003.
- Cite examples of outcomes research supporting the benefit of speech therapy. Include the data above that shows that children with severe disorders, such as apraxia, require longer treatment periods to attain reasonable progress. Offer to help decrease the cost to the employer through co-payments and deductibles.
- Be proactive and not reactive: Families that are satisfied with their current levels of benefits should inform their employer in the form of a thank you letter. Request that the employer continue to purchase health benefits that cover pediatric speech, language, and hearing coverage.
- Formally document complaints with your state insurance department. Although state insurance departments cannot require an insurance plan to cover certain benefits, they do collect data regarding the number of complaints by insurance plan as well as per health area. Governmental officials and policy makers may use this data to aid them in making decisions regarding mandated coverage.
- Educate your state legislators about the limitations of health benefits for pediatric speech, language, and hearing services. A similar letter that you give to your employer can be emailed to your legislator.
- Collaborate with special interest and advocacy groups dedicated to children and communication disorders. Offer to unite other parents and send mass mailing to employers, legislators, and the media. Request a meeting with your state legislator as a group.
- Submit letters to the editor of your local newspaper about the need for better coverage of pediatric speech, language, and hearing services. Target the month of May for Better Speech and Hearing month.
- Enroll your children in functional outcomes research studies related to speech, language, and hearing services.
- Encourage and help families perform the steps listed above. Develop standard or model letters for families to personalize and send to their employers. Offer to contact the families employer to discuss the issue. Offer to attend a meeting along with the family and their employer, union representative, state legislator, or local media professionals.
- Join your state speech and hearing professional association and begin or continue insurance advocacy efforts. Represent your state in the new State Private Insurance Reimbursement Advocacy Leaders (SPIRAL) network, organized by ASHA for the 2003, focused initiative on health care reimbursement. Contact your state association President for more information.
- Collect functional outcomes research data that shows that treatment results in positive functional change. Learn how to enroll in the ASHA NOMS system by visiting www.professional.asha.org. An example of an outcomes questionnaire that uses multiple sources to document communication change in a variety of environments is provided in Campbells chapter in Caruso and Strands text (1999).
- Ensure that your own employer offers appropriate coverage for speech, language, and hearing services. If coverage is inadequate, lobby for better coverage using many of the strategies listed for families in #1.
- Submit articles, press releases, and letters to the editor about the limitations of pediatric coverage to local newspapers, televisions, and radio stations.
- Educate the association of health plans/insurance plans in your state. Share outcomes data, cost of insurance coverage, and model policy language for services.
In summary, I cannot emphasis enough the need to get involved in advocacy for improved insurance coverage! The Ohio Speech-Language-Hearing Associations Insurance Committee has been working on this issue for several years. The overwhelming advice the committee has received from insurance plans, employer health care alliances, and health care benefit consulting firms, is to encourage parents and family members to educate their own employers and convince them of the need to expand benefits. As I stated in an article for Advance, “Parents are the strongest voice in our grassroots effort. It is their children who are not receiving services that will impact their development and future success” (Palacio, 2001). Parents and families cannot do this alone, however. Professionals serving children with communication disorders should help parents in this endeavor, providing them with tools that they need, such as functional outcomes data and efficacy research. In a recent email conversation with me, Tom Campbell put it best, “The final outcome for improving reimbursement for children with communication deficits will ultimately lie with the joint efforts of professional and parent advocacy groups.”
[Katrina Zeit, M.H.A., M.A., CCC-SLP, is a Speech-Language Pathologist at Cincinnati Childrens Hospital and also serves as Project Manager, coordinating the departments focus on advocating to employers, legislators, and health professionals for improved access to health insurance for children. Ms. Zeit chairs the Ohio Speech-Language-Hearing Associations Insurance Committee, which is working with ASHA and other state associations (including Pennsylvania, Florida, Maryland, Virginia, and Texas) to form a national state network dedicated to insurance issues.]