I have been consistently optimistic that our President and the Administration are trying to move us in the right direction as best they can.  I understand the need to control healthcare costs.  As a speech-language pathologist who has worked in Home Health, long term care, and now a for-profit hospital setting, I understand that there is a need to provide services in the most cost-effective way.  But I didn't think that controlling costs was supposed to mean eliminating services completely when I listened to the President speak of his plans for the future.  

My professional organization is called the American Speech-Language-Hearing Association (ASHA).  I received my ASHA Leader Magazine last week and on the front page was a headline:
Speech-Language Services:  Not "Optional"

It appears that HHS Secretary Kathleen Sebelius is advocating eliminating speech therapy to Medicaid recipients as a way of controlling costs.  For more information, join me below:

On February 3rd of this year, Sebelius sent a letter titled  "Medicaid Cost-Savings Opportunities"  to all 50 state governors stating:


" While some benefits, such as hospital and physician services, are required to be provided by state Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional."

In an attachment to the Sebelius letter there is a Medicaid benefits table.  Programs such as the EPSDT (Early and Periodic Screening, Diagnosis and Treatment) program for children up to age 21 are clearly listed under mandatory services, but the letter lists "speech, hearing and language disorder services" under the optional services category.  

My professional organization is helping state associations respond to this, because under the federally mandated EPSDT program,  speech-language therapy, hearing services, and speech-generating devices and hearing aids for children up to age 21 are required services.  

In addition, it is not cost-effective to eliminate speech-language therapy services for adults.  Swallowing therapy, which now makes up a huge portion of the services provided to adult patients with medical conditions is a cost-saver because it has been shown to demonstrably reduce pneumonia.  Furthermore, we treat the brain when it has been damaged or injured by stroke, illness, or trauma.  A huge part of a person's medical recovery can be influenced tremendously by their improvements in communication, memory, judgment, and problem-solving.  If Medicaid provides physical therapy but not speech therapy, someone who has had a stroke might regain walking but not talking.  I recently helped a Medicaid patient obtain a very expensive speech-generating device and I can't begin to tell you what it meant to see the tears in his eyes when he realized he could now express himself without everyone trying to guess and asking him yes/no questions.  He could go to the food page, click on desserts, click on pies, then click on lemon meringue pie in a matter of seconds.  He can now even use it to talk on the phone for the first time again.

Often, the speech-language pathologist is the only person on the team tuned into hearing loss and its impact on medical care.  I cannot count the times I've gotten a referral on a patient with undiagnosed hearing problems that others were trying to interact with unsuccessfully.  I bring a high-quality assistive listening device into the situation and all of a sudden nurses can explain medications, patients can answer questions, and someone everyone thought was showing confusion responds with clarity.  One woman with a history of brain tumors was showing speech and cognitive decline but no one realized she had gone almost completely deaf.  

Communication breakdowns are one of the leading causes of medical errors and the Joint Commission on Accreditation for Hospitals has a whole new set of standards requiring hospitals to address the communication needs of patients as a means of improving patient care.  Eliminating expert consultation for Medicaid patients with communication handicaps is not going to help make that happen.  

Speech-language services are a very small budget investment to make.  In all settings where I work, physical therapy staff are typically four to five times that of speech-language.  We are a small but important part of the rehab team of physical, occupational, and speech-language therapy.  

It's not as if Medicaid authorization is something easy to obtain that is being abused.  For children in EPSDT, therapists must write a letter supporting medical necessity along with physician authorization of medical necessity every six months.  There are nurse and physician reviewers who frequently deny authorization and families must appeal to get services reinstated.  On my regular adult Medicaid recipients this year, they are now only authorizing 12 or fewer visits at a time before reviewing and they read the reports in detail.  I have to document progress very carefully and show adequate measurable gains on functional skills.  I understand this kind of scrutiny, and while it is not always reasonable (patients get sick, they don't always show steady progress, they sometimes plateau then make leaps and bounds of gains) it is reasonably fair to ask for this kind of documentation.   And fortunately I'm a pretty good writer so I have not had difficulty getting authorization or winning an appeal.  

I want to add that private insurers often do not cover speech-language services, limit  visits to 30  per year (try that with a child with autism), cover speech therapy but not "swallowing therapy" or "cognitive treatment" (tell that to someone with a closed head injury),  and on and on.   I can't schedule an evaluation on a referral until we verify coverage--because we find that a woman with post-polio who is now choking on her foods doesn't have coverage for swallowing treatment under her particular Anthem BC/BS policy.   In the past we could always at least start a Medicaid patient and get an evaluation and 12 to 15 visits before any authorizations were required.    

If controlling costs means reducing government programs to the limitations of private insurance plans, we are not going in the right direction.   In conclusion, I want to urge everyone to watch very closely to what comes out of the recommendations for "controlling health care costs" debate.  

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