Senators Question Proposal to Cut Tricare Autism Reimbursement Rates

Sen. Kirsten Gillibrand, D-N.Y.

Pentagon plans to reduce Tricare rates for autism therapy specialists came under fire this week from two U.S. senators who say they're concerned that the pay cut will result in few providers willing to accept Tricare patients.

Tricare officials announced late last year that they plan to reduce reimbursement rates for providers for "applied behavior analysis" autism therapy by as much as 35 percent for providers in certain locations.

Currently providers are paid a fixed rate based on education and certification level, regardless of location. Under the new plan, the national hourly rate will be set, for example, at $114 for providers with a doctorate -- more than $10 less than the current rate -- and then further adjusted either up or down based on a geographic rate calculation used by Medicare. Each education level will also receive a different rate based on location.

"The ABA treatment for persons with autism and the proposed rate cut is something that I'm concerned with the timing of," Sen. Thom Tillis, a Republican from North Carolina, told a panel of experts a Senate Armed Services subcommittee hearing this week.

"I think we may be making a mistake cutting treatment options below the national average and produce a bad outcome for something, I think, that has been proven to be highly effective and highly beneficial to those that take advantage of the treatment," he added.

Providing ABA therapy has long been a source of contention between military families and Tricare.

In 2013, for example, Tricare officials first sought to limit ABA coverage for active duty families, then abruptly changed course after public outcry. Then, in 2014, officials announced plans to slash reimbursement rates for day-to-day therapy by 46 percent, causing further outrage and a delay in the rate reduction plan. Instead, Tricare officials at that time commissioned a study from the RAND Corp. to examine reimbursement rates among private insurers.

That study has raised serious concern among autism therapy advocates lobbyists, including officials at Autism Speaks. Those experts said they worry that the reduction will cause a provider shortage near military bases, particularly ones in rural locations.

"Autism Speaks is concerned that the rate cuts will reduce access to ABA services. Shortages of Board Certified Behavioral Analysts already exist near Fort Campbell, Fort Sill, Wright-Patterson Air Force Base and other locations around the country," Autism Speaks officials said in a statement. "If adopted, the rate cuts might lead providers to leave Tricare's networks or give priority to children with other types of health insurance."

Dr. Jonathan Woodson, the Pentagon's assistant secretary for health affairs, told the committee that Tricare is keeping a close watch on whether or not there are enough providers.

"Certainly we'll be monitoring the situation very closely, and should we find in any locality that it's been adversely affected, we will make rapid changes," he said.

Sill Sen. Kristen Gillibrand, a Democrat from New York, worried that the Tricare-ordered RAND study is "misleading."

"I have some specific concerns in regards to the studies and the methodologies, because I don't think they are reflective of the cost, so I'd like to request some follow-up information specifically on that, and further consideration, because I think it's inadequate," she told Woodson during the hearing. "I think your study is misleading in its outcomes … I'm very concerned that there will be negative consequences for patients."

--Amy Bushatz can be reached at Follow her on Twitter at @amybushatz.

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