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Time has Come for a Value-Based Approach to Autism Therapy
Prior to my current role in managed care, I worked for more than a decade as a therapist providing applied behavior analysis (ABA) therapies to children with autism—a role I continue in today as a volunteer. I have firsthand seen the value of ABA and its potential to help children with autism live happier and healthier lives.
Recently, though, I have come to believe that a fundamental shift must be made to retain trust in the effectiveness and applicability of ABA in the future—not only among providers, payers, and families, but most importantly among those who receive care. It is important that the field relies on evidence-based practice and meets individual needs through individualized treatment interventions, including ABA hours.
We may soon witness a change in the quality and effectiveness of ABA therapies in the face of changing trends: The continued shortage of behavioral health professionals at every level and the influx of private equity funding that took place prior to the pandemic may lead to lower quality of care. Alternatively, the movement toward integration models of behavioral and physical health and changing managed care norms will support better effectiveness.
The shortage of behavioral health professionals isn’t ending anytime soon, nor is it new.
In 2019, researchers for the American Psychiatric Association found that the number of certified ABA providers in most states was insufficient to “meet the needs of children with autism spectrum disorder.” The situation now is worse, particularly when it comes to registered behavior technicians (RBTs) on which providers depend. Prior to the pandemic, the industry benefited from a large pool of RBTs that is no longer available in today’s tight labor market. While this work is incredibly rewarding, it can be emotionally and physically stressful.
Wages for these roles were always low. The pandemic and the “great resignation” that followed, combined with the financial realities of payer mixes and private equity investment, only exacerbated the issue. Employee churn is a serious problem in nearly all fields in which low-wage positions play a crucial role. Ours is no exception.
Some point to technology as a solution, but technology can only supplement autism treatment modalities, not replace them. Telemedicine, virtual reality, and other digital solutions offer promise and should be used to help individuals with autism. Technology will not solve the challenge of finding enough qualified behavioral health experts to provide that essential human element. No technology or overreliance on it can replace trust, warmth, kindness, and scientific integrity. In-person, individualized therapy is imperative for those with autism.
Private equity’s pressure to provide one-size-fits-all ABA therapies will only increase.
Much is being written about the transformative impact of private equity in the healthcare arena. Within the autism community, the results are increasingly apparent. In the years before the pandemic, private equity firms saw in autism a market of virtually unlimited possibilities. The number of autism diagnoses was increasing rapidly, and those who provided needed therapies could draw on an almost never-ending revenue stream in a fee-for-service environment. Regardless of severity level, the norm for therapy was 40 hours per week. More than 60 firms invested billions of dollars, and the trend continues.
Now those same organizations are understandably looking for a return on their investment while dealing with the complexity of the workforce shortage exacerbated by the pandemic. They are focused on gaining efficiencies through the standardization of therapies and increasing fee-for-service billing for more treatments. In fact, ABA therapies for autism have come to represent the very essence of a fee-for-service approach to care, regardless of the level of need and individualized treatment planning. At the opposite end of the treatment continuum have been the managed care organizations with stringent utilization management practices. Low reimbursement rates, particularly for those persons enrolled in Medicaid, also drove increased fee-for-service billing. Low rates were made up for by volume of charges.
Value-based care is the way forward.
Considering these challenges, it is time to embrace a value-based care approach to ABA therapy, one that rewards providers for outcome-driven, holistic care. Value-based care is not new, nor is it easy. It must be accompanied by a significant shift in thinking, and providers’ willingness to accept a level of risk—something that rightfully must be carefully considered.
As we have seen with Medicare Advantage plans that utilize a value-based model, patient outcomes improve when providers and payers are incentivized to keep patients healthy by aligning the type of intervention and the “dose” of intervention to drive measurable outcomes. Recent research indicates that providers working with Medicare Advantage plans scored significantly higher than their fee-for-service colleagues in efficiency and patient outcomes across 8 quality measurements. While the population studied was markedly different than the typical population of persons with autism, these risk-adjusted analyses support a value-based approach.
In autism therapies, outcomes will come in the form of gains for some individuals or the maintaining of agreed upon benchmarks for others. Outcomes must be attributable to the services being delivered through ABA, and other services coordinated by the ABA provider. The “bundle” of services must be defined, as does duration for an episode of care. Standardized assessments such as the Parental Stress Scale and risk adjustment will allow comparison across provider groups. Newer technology may be able to profile phenotypic behaviors from the onset, allowing providers the ability to effectively align the right level of service to achieve a clinical trajectory.
Value-based payment models encourage collaboration among all providers involved in caring for an individual, encouraging improvements in physical health conditions alongside those in behaviors. This approach will result in measurable improvements not only as it relates to behaviors, but also around comorbid health issues. We expect to see gains in quality of life and daily functioning.
The following example demonstrates how a team-driven value-based care approach can better support a child with autism and may lower costs and align the right services.
Imagine having a horrible stomachache but you can’t tell those around you how you feel because you can’t verbalize the pain. Your expression of pain comes in the form of agitation. Now imagine if you are expected to follow instructions geared toward agitation, not toward the root cause of pain. That’s exactly what we expect many children with autism to do when they experience physical symptoms such as gastro-intestinal issues. Rather than thinking more broadly about the causes of agitation, it might appear that ABA is failing and more hours are needed, or additional pharmacologic interventions are warranted. A value-based care approach may foster a more multi-dimensional, team-driven, and holistic approach, including the needed medical evaluation addressed by a gastroenterologist.
Value-based care draws on a team-based approach and holistic programs.
The collaboration with a gastroenterologist touches on yet another powerful element of a value-based care approach to treating autism. Autism is not a condition that can be fully addressed by one doctor, one specialty of behavioral health, or even in a single clinical setting. Most people with autism experience various co-occurring conditions, many of which can cause discomfort.
Value-based care approaches, and their focus on outcomes, inherently recognize this. In fact, it is commonly stressed among value-based care providers in physical health specialties that clinical care only impacts about 20% of most health outcomes. This dynamic exists in behavioral health as well.
Addressing this reality requires cross-functional teams that include the primary care physician, the ABA therapist, gastroenterologist, a psychiatrist, the pediatrician, and others. Importantly, these teams ideally include other individuals who can also significantly impact the health and well-being of those with autism. Family members, professionals at community groups and non-governmental organizations, benefits coordinators from local, state, and federal agencies, teachers, and others can collectively help address the social determinants of health to also influence outcomes.
We must explore a different reimbursement model for autism therapy.
Many providers will understandably have concerns that must be explored, discussed, and addressed if we are to move to a value-based approach. Yes, there will be a learning curve, and the severity of an individual’s autism spectrum disorder will need to be gauged to determine fair standards of care, expected outcomes, and appropriate reimbursement. But we know the status quo isn’t working.
We must be proactive in our efforts and take the necessary steps to ensure that value-based care is a cornerstone of an overall effective approach that addresses the unique set of signs, symptoms, and behaviors for each individual with autism.
Yagnesh Vadgama, BCBA, is vice president of clinical care services, autism at Magellan Health.
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