Musings on the Funding of Stuttering Treatment

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Editor’s Note: This post is another viewpoint on Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Volunteer firefighters are not presently supported by government funding; instead they rely on local fundraising and private donations. Everyone values their work, and all agree that firefighters should be compensated.

The professional association for volunteer firefighters proposes to the government that payment be provided for their services. Due to demands on legislators’ time and attention, the association selects one method for putting out fires – water – and suggests that firefighters should be compensated when they use water to put out fires.

Many firefighters ask, “What do we do when water is not the best way to fight a particular fire?” They point out that other methods for fighting fires have been shown to work just as well as water. They are told that water has more data, and they don’t want to confuse the legislators with multiple options.

Some firefighters express concern that their input was not solicited before the proposal was submitted. They further worry that their options will be limited by such legislation. The association says, “You will not be limited in what you do—only in what you get paid for.” The firefighters ask, “Will we get paid if we use another method?” The answer: “You don’t get paid for anything now, so this will definitely be better.”

The firefighters persist, “Why not seek payment for the service of putting out fires, rather than a particular method?” The association says, “When other methods have as much data as water, we can consider approaching the legislators again, telling them that the issue was not as straightforward as we first suggested. We can ask then them to consider other methods…That would be simpler.”

The firefighters collect numerous comments from specialty firefighters and support organizations in opposition to the proposal. Despite the grass-roots opposition, the proposal proceeds as originally written and is accepted. Volunteer firefighters start to receive government payment for one approach to fighting fires. Those who favor that approach are delighted. Others weren’t being paid before anyway, so nothing changes for them, at least not at first.

Soon, homeowners start to call the fire department to ask, “Does your department use water? I heard that you get paid for water. I want you to get paid, but I don’t want to pay myself. Plus, I read on a professional association’s website that water is ‘best!’” Thus, market forces drive firefighters to use water exclusively, although many know that there are other helpful approaches.

One day, a water-using firefighter finds himself working a fire against which water does not appear to help. He wonders if he should use some other approach in conjunction with—or instead of—water. Other firefighters have long used the method of changing the draft pattern in the house, but that method is not approved for payment. If he does it, his services will no longer be covered. He hesitates.

What is better for the homeowner? For the firefighter? Should he do what he knows is right for the house or what he gets paid for?

Ultimately, he decides that he should only respond to fires that can be put out with water. Other firefighters can deal with more complicated fires. It’s up to them if they don’t want to get paid?

Why has the firefighter been put in this ethical dilemma?

It all could have been avoided if only the professional association had pursued coverage for the service of fighting fires, not the specific treatment that they favored.

But that would evidently have been too complicated…

 

J. Scott Yaruss, PhD, CCC-SLP, is an affiliate of ASHA Special Interest Group 4, Fluency and Fluency Disorders. He is also associate professor and director of graduate programs in speech-language pathology at the University of Pittsburgh, coordinator of clinical research in audiology and speech-language pathology at Children’s Hospital of Pittsburgh, and director of the Stuttering Center of Western Pennsylvania. He can be reached at jsyaruss@pitt.edu.

Call for Advocacy to Garner Government Support for Evidence-Based Treatments

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Editor’s Note: This post is another viewpoint on the Speech Pathology Australia’s recent proposal and does not necessarily reflect the views or position of ASHA. 

Evidence-based practice encompasses evidence from high-level research, expert opinion, patient needs and values, along with the context within which the treatment is conducted. In the field of stuttering, we are fortunate to have strong evidence that the Lidcombe Program is effective. If we have clear evidence that a treatment approach works, it should be made available to the people who need it.

Speech Pathology Australia has made a submission to our [Australia’s] federal government to fund stuttering treatment. I’m sure it will be the first of many submissions, which aim to bridge the evidence-practice gap. However, there appears to have been a misunderstanding about the announcement, so SPA published a clarification on its website stating that “SPA’s submission relates only to the formation of the 2015-2016 federal budget. SPA is not supporting legislation or a policy change to promote one program, service or form of treatment over any other.”

As a founder of the speechBITE evidence-based practice website, I thought long and hard about the effect EBP has on clinical practice, funding sources and, most importantly, the clinical outcomes of the people we serve. There are three key aspects to making EBP a central component of clinical decision-making:

  • Firstly, clinicians need to know about the latest treatment advances.
  • Secondly, patients and clients need to be informed about current best practice options, and be satisfied with their treatment decision.
  • Thirdly, funding agencies need to be confident that they are funding treatments that are based on strong evidence.

How can funding agencies be aware of current best practice and confident in their funding decisions? As a profession we need to be proactive by giving this information to funding agencies and lobbying the government. This is precisely what SPA is doing with its proposal. I applaud SPA for taking this step and promoting evidence-based speech pathology practice at the highest level.

 

Leanne Togher, PhD, SLP, is a professor of communication disorders following traumatic brain injury at The University of Sydney and is Senior National Health and Medical Research Council Fellow of Australia. Togher is the director of the speechBITE evidence-based practice website. She is also an international affiliate of ASHA and Fellow of Speech Pathology Australia. She can be reached at Leanne.togher@sydney.edu.au.

Another View on Speech Pathology Australia’s Stuttering Treatment Proposal

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Editor’s Note: This post is a follow-up to yesterday’s post from Craig Coleman regarding a controversial proposal on stuttering treatment and reimbursement from Speech Pathology Australia. We reached out for responses from Ann Packman and Mark Onlsow, two of the originators of the Lidcombe approach to stuttering treatment—on which the SPA proposal centers. We also reached out to SPA and include a statement here from SPA President Deborah Theodoros.

Response from Ann Packman and Mark Onslow:

During the past two decades the Australian government has invested millions of dollars in research funding to develop an evidence-based treatment for early stuttering. The Lidcombe Program is a result of this funding and is now supported by strong evidence from randomized controlled trials. Those randomized trials include evidence for face-to-face treatment, for treatment using webcam, and for group treatment. The Speech Pathology Australia proposal is for our government to further invest in the health of Australian children who stutter, but in a more direct way by contributing to the cost of their treatment.

We wish to clarify that the Speech Pathology Australia proposal is not for a mandate—a directive—that Australian speech pathologists must use the Lidcombe Program to treat preschool children who stutter. Nor is it a proposal to overturn customary evidence-based reasoning and standardize how Australian preschoolers who stutter in Australia are managed. Nor is there any suggestion that the Australian government would not in the future fund any other evidence-based intervention that is supported by randomized controlled trials. Indeed, if such evidence emerges for the efficacy of another treatment for early stuttering, we would encourage Speech Pathology Australia to approach the Australian government to consider it also for taxpayer-assisted support.

 

Message from Deborah Theodoros, president, SPA:

Speech Pathology Australia is advocating for public funding (Medicare) rebates for early stuttering intervention at a level which is demonstrated to be highly efficacious and supported by the strongest level of evidence. However, SPA is not suggesting any policy or legislation which would restrict interventions to one program over another or would require a speech pathologist to use a specific treatment, intervention or service. SPA continues to strongly support the principle of practice that speech pathologists remain free, and duty-bound, to exercise their clinical decision-making in relation to the interventions they provide to clients.

 

Ann Packman, PhD, SLP, is associate professor and senior research officer for the Australian Stuttering Research Centre, The University of Sydney. She has more than 30 years’ experience in the area of stuttering as a clinician, teacher and researcher and researches nature and treatment of stuttering. Packman recently served as associate editor for fluency for the American Journal of Speech-Language Pathology and is associate editor for fluency for Language, Speech, and Hearing Services in Schools. Packman is an international affiliate of ASHA. She can be reached at ann.packman@sydney.edu.au.

Mark Onslow, PhD, SLP, is the foundation director of the Australian Stuttering Research Centre, The University of Sydney. He was a principal research fellow of the National Health and Medical Research Council of Australia. Onslow’s research interests are the epidemiology of early stuttering in preschoolers, mental health of those who stutter, measurement of stuttering, and the nature and treatment of stuttering. He is a member of the international Lidcombe Program Trainers Consortium. Onslow is an international affiliate of ASHA. He can be reached at mark.onslow@sydney.edu.au.

Deborah Theodoros, PhD, SLP, national president of Speech Pathology Australia, is also professor and head of the division of speech pathology in the University of Queensland’s School of Health and Rehabilitation Sciences. She is a founder and co-director of the multidisciplinary Telerehabilitation Research Unit in the school and past chair of the Telerehabilitation Special Interest Group of the American Telemedicine Association. She can be reached at president@speechpathologyaustralia.org.au.

 

 

A Controversial Proposal on Stuttering Treatment from Speech Pathology of Australia: What It Means and What Happens Next

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Editor’s note: This blog post was submitted by ASHA member Craig Coleman and does not necessarily reflect the views or position of ASHA. Here is the original release from Speech Pathology Australia that spurred Coleman to submit this post. It was published in the February 2015 issue of SPA’s publication Speak Out:

Speech Pathology Australia recently submitted a proposal to the Australian Government Department of Treasury for the federal budget 2015-2016. Given the difficult political and budgetary climate, and in anticipation of a government response to the recommendations made from the Senate inquiry—the budget proposal focused on a single budget initiative.

We argue that Medicare should be targeted towards health interventions that are evidence-based, effective, safe and minimise future health treatment needs. Our proposal focused on an internationally recognised intervention, developed in Australia and based on the most robust scientific evidence of effectiveness—the Lidcombe Program—to treat stuttering in young Australian children.

Tomorrow, we will run a post on this proposal from two of the originators of the Lidcombe approach, Mark Onslow and Ann Packman, along with a statement from the president of SPA, Deborah Theodoros. We encourage your comments on this issue, which you can post below this post from Coleman.

 

Recently, Speech Pathology Australia (the national speech-language pathology association of Australia) submitted a proposal to the Australian Government Department of Treasury that would require Medicare rebates be made available for children who stutter, but only if they are treated using the Lidcombe Program.

I feel this action gravely limits the scope of treatment for stuttering. Many interventions for preschool stuttering have shown to be effective. What happens when a child receives treatment with the Lidcombe program and doesn’t make progress? Does the child have other treatment options? From this proposal, it would appear that is not the case.

How are new (and perhaps more effective) treatment approaches expected to emerge when only treatment with an existing evidence-base is funded? Imagine if all infections were still treated using penicillin because it was an early treatment option. Would the government and medical associations support such a position? Perhaps a clearer question is would pharmaceutical industry lobbyists allow legislators to even remotely consider the idea? Do we think less of ourselves as a profession to allow this to happen?

This proposal also highlights a concerning trend of what constitutes “evidence.” While certain treatments might have more data than others it doesn’t always mean that treatment is more effective. Evidence-based practice includes current scientific evidence, clinician experience and client /family values. What if the clinician is not properly trained in the treatment approach? What if the personality of the client, family or clinician is not a good fit for one particular approach? Surely, the best “evidence” comes not from group data, but the individualized outcome of each client we serve. While group data certainly present scientific evidence, individual outcomes present actual evidence-based practice. That type of data takes into account all aspects of the evidence-based practice triangle.

After this precedent has been established, we would be naïve to think this could not happen with other disorders in all parts of the world. This is not an issue for the stuttering community of Australia to deal with. It is an issue for the speech-language-hearing community of the world to deal with.

So, where do we go from here? Here is a potential plan I would like to suggest:

  1. Advocate for reimbursement for stuttering. The state of reimbursement for stuttering treatment in the United States can best be described as dire. One of our missions as SLPs should be to work with insurance providers and demand that they pay for stuttering treatment. Somewhere along the way, we have allowed insurance companies to dictate that stuttering treatment should not be reimbursed. We must reverse that trend.
  2. Create a consortium of professionals. This would allow a database of treatment outcomes to be collected from clinicians in the field. Not only would this help with reimbursement, but it would also allow publication of data collected from individualized treatment approaches. We are professionals, not technicians. Our clients deserve better than “follow-the-manual” based programs and protocols.
  3. We need to educate our professionals and the public about stuttering. Stuttering is not merely a disruption in the flow of speech. It is much more than that.

As concerning as this proposal is, it can be a positive if we choose to act with reason, courage and passion.

In order to provide both sides of the discussion, I am including a recent statement from Speech Pathology Australia. While this statement seeks to clarify that this is not an endorsement of one approach, advocating for reimbursement for only one approach certainly seems to send the opposite message. Many insurance companies will not pay for stuttering treatment here in the United States. But responding to that by supporting a policy that would cover only one approach would be very dangerous and erroneous.

It is also important to understand that once Medicare programs establish a policy, private payers soon follow suit. It’s very naive to believe this policy won’t have major negative ramifications in the long run. While it may benefit some children in the short term, there is no doubt in my mind it will not benefit people who stutter or our profession in the long term.

You can read Coleman’s original blog post in full here.

 

Craig E. Coleman, MA, CCC-SLP, is an assistant professor at Marshall University and a board-certified specialist in fluency disorders. Coleman is also an adjunct instructor at Indiana University of Pennsylvania and co-director of the Stuttering U. summer program for children who stutter, their families and SLPs. He is coordinator of ASHA Special Interest Group 4, Fluency and Fluency Disorders. He can be reached at craig.coleman@marshall.edu

New Global Campaign Takes on Noisy Leisure Activities

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Worldwide, the statistics are sobering:

  • 360 million people have disabling hearing loss.
  • 43 million people between the ages of 12–35 years live with disabling hearing loss.
  • Half of all cases of hearing loss are avoidable through primary prevention.

Of course, none of this likely comes as a surprise to ASHA members, particularly audiologists, who are on the front lines of care for people with hearing loss. The good news is that we are going to hear a lot more about this serious health issue with the help of a high-profile group.

Today, on International Ear Care Day, the World Health Organization is elevating the profile of hearing loss—specifically noise-induced hearing loss—by launching a new campaign called Make Listening Safe.

The campaign educates the public about hearing dangers posed by noisy leisure activities and promotes simple prevention strategies. Young people are the focus because an increasing number are experiencing hearing loss. As the creator of the highly successful Listen to Your Buds campaign, WHO asked ASHA experts to advise on Make Listening Safe. A role the association enthusiastically embraced.

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ASHA used Listen to Your Buds to provide an early warning on potential hearing dangers from misuse of personal music players and the need for safe listening. Today, as this technology is nearly ubiquitous, the campaign is going strong on a variety of fronts.

One of ASHA’s most successful ventures is its safe listening concert series. The series educates young children about protecting their ears in a fun, interactive way by bringing innovative musicians and performances to U.S. schools. A new video showcases the most recent concert series, which took place in six Orlando-area schools in conjunction with ASHA’s 2014 convention.

Misuse of personal audio devices is also a key area of focus for Make Listening Safe. According to WHO, among teenagers and young adults aged 12 to 35 years in middle- and high-income countries, nearly 50 percent are exposed to unsafe levels of sound from the use of these devices.

This is one of the new global estimates being released with the launch of Make Listening Safe. In addition to a high-profile unveiling in Geneva, WHO is issuing a variety of materials featuring statistics on the problem’s scope, the hearing loss consequences and action steps that parents, teachers, physicians, managers of noisy venues, manufacturers and governments can take to make listening leisure activities safer.

ASHA asks members to take up the campaign. Here are just a few ideas on how you can get involved:

  • Utilize the WHO’s eye-catching public education materials—including posters, a fact sheet, and an infographic—with peers, patients, friends and loved ones.
  • Engage in grassroots public education, such as sharing statistics and prevention tips on social media or holding a free hearing screening.
  • Approach local media to pitch a story. The campaign’s launch with accompanying statistics is a great news hook. You can tie the story to your local community by highlighting an event your practice is hosting or offer tips for safe listening at local noisy venues (e.g., stadiums, concert venues/clubs). This is also an excellent consumer health story for a television station, particularly because it offers “news you can use” such as easy prevention tips.

The focus on noise-induced hearing loss in young people is not limited to March. While the WHO campaign will be ongoing, ASHA will also poll the public about safe listening practices. Our results will provide more opportunity for outreach during Better Hearing & Speech Month in May and beyond. Stay tuned!

Click here for more information. Questions may be directed to pr@asha.org.

 

Judith L. Page, PhD, CCC-SLP, is ASHA’s new president. She served as program director for Communication Sciences and Disorders at the University of Kentucky for 17 years and as chair of the Department of Rehabilitation Sciences for 10 years.