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Autism Care Demonstration (ACD) Program


PURPOSE: To describe impacts to military readiness due to TRICARE policies decreasing access to applied behavior analysis (ABA) for beneficiaries diagnosed with autism spectrum disorder (ASD).

BACKGROUND: Congress enacted the Autism Care Demonstration (ACD) program in 2014 to analyze and evaluate the validity of ABA under TRICARE. ABA services include assessment and intervention pursuant to a treatment plan developed by a Board Certified Behavior Analyst (BCBA) together with the beneficiary and their family. The services are delivered by the professional behavior analyst and/or a registered behavior technician (RBT) who is trained and overseen by the behavior analyst. As of October 2021, there are 50,749 BCBAs and 109,088 RBTs in the United States.

All states mandate health insurance coverage of ABA as a basic medical benefit. The Federal Employee Health Benefits Program and Civilian Health and Medical Program of the Department of Veterans Affairs also provide ABA as a basic medical benefit for Federal employees and families of veterans with service-related disabilities. Only TRICARE does not provide ABA as a basic medical benefit. The Defense Health Agency (DHA) currently uses the Pervasive Developmental Disorder Behavior Inventory (PDDBI) to evaluate the validity of the ABA tiered-delivery model.

DISCUSSION: In March 2021, the DHA made significant changes to the TRICARE Operations Manual (TOM) concerning ABA policies. These changes include, but are not limited to: Requiring parents/guardians to take stress assessments to receive ABA services and restricting ABA therapy by eliminating use of RBTs in the school and community settings.

Only families utilizing ABA are required to take the parent stress assessments. Receiving services are contingent upon their completion. This comes as the DoD fights to destigmatize mental health issues and perceptions of negative career impacts. DHA’s withholding of medically-necessary services until completion of these assessments every 6 months is perceived by affected families as discriminatory and invasive.

The removal of RBTs in school and community settings greatly reduces the dosage and efficacy of ABA interventions. This contradicts professional standards of care as well as scientific evidence. Research shows that ABA interventions must be delivered consistently across multiple settings for 10 - 40 hours per week, depending on the needs and preferences of the beneficiary and their family. Intensity levels of 30-40 hours per week are common and necessary to achieve meaningful improvements in a large number of treatment targets.

A technical report written by Dr. Ira Cohen (the creator of the PDDBI), states the assessment has not been used appropriately. Three main issues were noted: the inappropriate elimination of over 90% of the sample due to a lack of understanding on scoring the PDDBI, examining only one composite score as the outcome measure when use of the other fourteen composite scores provide a holistic measure of ABA efficacy, and setting an unrealistically high bar for improvement over a six-month period. Use of the PDDBI to support changes to the TOM or to justify future cuts to ACD funding is not justified based on incorrect use of the assessment.

DHA’s position of not providing ABA as a basic medical benefit is out of alignment with the rest of the country and medical community. The American Academy of Pediatrics has endorsed ABA interventions as proven effective and medically necessary for individuals with ASD. According to TRICARE’s 2020 report to Congress, there were a total of 15,928 beneficiaries participating in the ACD. The policy changes to the ACD are contributing to ABA providers no longer accepting TRICARE as a medical insurance. This is driving families to seek secondary insurance, go without services, or terminate their careers early, therefore losing talent represented by families who are seeking effective ABA services for their loved ones.

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