Least costly equally effective alternative, or LCEEA, is a valuable phrase to understand when putting together evaluation report.

LCEEA is defined as the least costly, equally effective SGD alternative that will achieve the treatment goal (see https://www.isaac-online.org/wordpress/wp-content/uploads/2018-02-08-USSAAC-Slides-golinker-website-upload.pdf). This is often the measure by which funding sources, including private insurance and state Medicaid programs, determine whether or not they will approve or deny funding of an SGD.

Many health plans will authorize funding of a requested SGD, "that is not more costly than an alternative that is at least as likely to produce equivalent therapeutic results for the treatment of the plan member's condition. Documentation must show that all least costly alternatives have been considered and ruled out before funding of an SGD will be authorized." (Fallon Health, Speech Generating Devices, Clinical Coverage Criteria). Knowing that most, if not all, SGD funding sources will be looking for a discussion of LCEEA can help to inform what an SLP must consider, evaluate, and include in an SGD evaluation report.

The following discussion will look at ways of thinking about LCEEA while evaluating and discussing various device options in an SGD report. When thinking about the concept of LCEEA, it is of utmost importance to keep in mind that "least costly" does not necessarily mean "cheapest."

With that idea held firmly in mind, how does an SLP narrow down the SGD options available and show that the chosen device is the least costly equally effective alternative to meet the client's needs, especially when the best choice for a client, may carry a price tag of many thousands of dollars?

According to Lewis Golinker, Esq., "SGD models are functionally and qualitatively distinct. SGD models do not merely copy each others' capabilities. Instead, different models seek their own niche: to address still-unmet needs among patients' enormous range of physical, cognitive, sensory and linguistic functioning. For this reason, SLPs make SGD recommendations on the basis of ‘feature-matching' between patients' abilities and needs and the distinct functional capabilities and limitations of various SGD models." (see link). There is not a single SGD that matches all of the features that every potential device user will need to achieve effective and efficient communication.

Therefore, SGD's are divided into three distinct categories which are coded separately. The key distinguishing features among the categories of SGDs are:

• the type of speech output (digitized or synthesized)
• the methods of message generation
• device access options

Each category of device offers features that can be matched by the SLP to the unique individual to find a reliable, effective and efficient communication alternative.

Digitized SGDs coded E2500, E2502 - E2506, are devices that contain words or phrases that have been recorded by someone other than the SGD user for playback by the SGD user. These types of devices provide the user with an entire phrase, sentence, or message that can be accessed by a single selection on an AAC device. They are typically used by individuals who do not have the linguistic skills yet to formulate messages independently. Examples of such devices are the GoTalk from Attainment Company, TechSpeak from AMDi, or BigMack Communicator from AbleNet.

Synthesized SGDs, coded E2508 or E2510, take the inputs of the user and translate them into computer generated speech. Users of synthesized SGDs are not limited to pre-recorded messages. They can independently generate utterances that are individualized and unique to themselves and their own thoughts.

E2510 devices, such as the Accent series or the NovaChat series of devices from PRC-Saltillo, differ from E2508 devices, such as a Lightwriter SL40 from TobiiDynavox, in that they offer the user multiple methods of message formulation (e.g. letters, words, pictures or symbols), and multiple methods of device access, coded E2599:

• Direct Selection: touch, joystick/mouse, head tracking, or eye tracking
• Indirect Selection: switches with scanning
  (see http://www.augcominc.com/whatsnew/ncs5.html)

Many funding sources will require documentation show that all LCEEA have been considered and ruled out before will authorize funding of any SGD. Here are some tips for ruling out broad categories of devices and also how to mention specific device alternatives.

Ruling out Least Costly Equally Effective Alternatives:

1. No-Tech Options (i.e. manual communication boards/books, sign language): Can your client meet all their communication needs without a voice? It is not likely that all caregivers, first responders, and medical professionals in the area will understand communicative attempts from a board, book, or sign language. Therefore, most communication boards/books and sign language require the assistance of others to be held and manipulated, or interpreted to be effective. This is dependent communication as it relies on another individual who knows the system to be present and available to facilitate the communicative exchange.
2. Low-Tech Digitized Options: With low-tech options, the individual is restricted to a limited number of pre-determined messages that have been stored by caregivers, and it is not likely that all medical needs/vocabulary were identified and included. Also, low-tech options might prove difficult for the client to access independently (i.e. changing pages or overlays in order to access the messages). If the client has alternative access needs, you can rule out low-tech digitized options. (see https://www.isaac-online.org/wordpress/wp-content/uploads/2018-02-08-USSAAC-Slides-golinker-website-upload.pdf) .
3. High-Tech Synthesized Options: Oftentimes, comparing synthesized SGDs comes down to discussing the hardware/software features and performance, as well as support from the device manufacturers/suppliers. It is important to compare the various aspects of each device that are relevant to the client's specific needs. Such a comparison will show how some options are not equally effective for that client, and thus, must be ruled out. Performance measures include rate, accuracy, quantity, and quality of message generation, ease of use and programming, ease of generalization into various communication environments
   • What about devices that are no longer made or sold? To be considered for funding, a device must be available for sale by the manufacturer. If a device has been discontinued, it cannot be considered an LCEEA.
4. Consumer Tablets with Communication Apps: This option must absolutely be ruled out, even if your state funding program doesn't cover these devices. Tablets are not engineered, as SGD's are, for the primary purpose of communication. They are not dedicated communication devices and they have access to other non-communication functions such as games or entertainment which can be highly distracting and can interfere with communication. Issues such as these leave the client at a huge disadvantage which can lead to device abandonment:
• lack of durability
• poor amplification (speakers are not loud enough to be heard in noisy or acoustically challenging environments)
• lack of adaptability for varied access needs (no keyguards, can't use eye tracking or other access methods
• limited or no training and support
  Therefore, consumer tablets with communication apps are often ruled out as LCEEA.
5. What about tablet-based devices offered by some SGD manufacturers, such as the PRiO or TouchChat Express from PRC-Saltillo? These are engineered as dedicated SGDs which means they are locked from computer access and all other non-communication functions. They are also engineered to be durable and have adequate auditory amplification, as well as some features to improve access such as keyguards and switches.
   
   Additionally, support and training are available from the manufacturer for these dedicated tablet-based devices. These devices can be a cost-effective dedicated alternative to other E2510 options. It is important to keep in mind that most funding sources (private insurance or Medicaid programs) want to see that this subcategory of E2510 devices (tablet-based devices) have been considered and ruled out.

One final note on this topic: It is important to remember that cost is considered only after options are found that offer equal benefit or effectiveness for the client to meet their functional communication needs. After the options have been narrowed down and devices identified that will most effectively meet the client's needs, then cost is taken into account.

With a clear understanding of the meaning of the phrase least costly equally effective alternative, and what funding sources are looking for in establishing LCEEA, you are well on your way to navigating a successful path through the funding process, and securing funding for an SGD for your client.

– Beth Studdiford, M.S., CCC-SLP. Read additional articles by Beth.