Should your organization consider introducing or expanding an autism program? It’s a question many specialty provider organizations ask during strategic planning sessions and the reason is clear: Autism spectrum disorder (ASD) is the fastest-growing developmental disability in the U.S. with one in 40 children ages three to 17 diagnosed annually, and spending on treatment is expected to reach $2.23 billion by 2022 (see The Prevalence of Parent-Reported Autism Spectrum Disorder Among US Children, The Autism Treatment Market).
Three key questions that should be answered when considering this type of investment: What are the underserved segments of the market for ASD services? What are the constraints to entering the market? And what are health plans looking for that would make a new market entrant a success?
Increasing demand for ASD services—incidence rates grew by 152% from 2004 to 2014—and the changing profile of people diagnosed with ASD create opportunities for growth in the ASD market (see Disrupting ASD Treatment: Opportunities & Challenges). “A lot of doctors have a one-size-fits-all approach that doesn’t work when you’re dealing with autism,” said Sean Klutinoty, OPEN MINDS senior associate, who has 28 years of experience in child mental health circles that includes work with ASD patients and families. “You’re not only treating the child,” he adds. “In a way you’re treating the whole family.”
For specialty provider executives considering a new service line in this area, Mr. Klutinoty noted several underserved needs during The 2019 OPEN MINDS Children’s Services Leadership Summit including case management for adults, guardianship, housing/shared living, and vocational training and support. New models for evidence-based training for new board-certified behavioral analysts were highlighted during the summit by several provider organization executives.
Barriers To Launching New Services
The most common barriers to successful market entry are lack of understanding about ASD, awareness of ASD-specific consumer needs among team members, and funding challenges, according to Mr. Klutinoty. Staff issues are also frequently cited as a barrier though industry data show that the number of board-certified behavior analysts is keeping pace with demand (see U.S. Employment Demand For Behavior Analysts: 2010-2017).
Three provider organization executives who presented during the summit shared innovative approaches to educating team members about the unique needs of ASD consumers. For example, Lecia M. Anzaldo, MPA, BCBA, director of autism services for Easterseals UCP North Carolina and Virginia, outlined their organization’s comprehensive training for team members to ensure that all service lines are ASD-friendly. The organization is building a team-based approach to care that enables staff to build skill sets and gain practical experience for professional growth (see New Approaches For Autism: Early Intervention, Telehealth & More).
When it comes to funding, Medicaid is a primary payer for ASD treatment, and the Centers for Medicare & Medicaid Services started mandating coverage of all medically necessary care for children with the diagnosis through age 21. A growing number of states also require commercial payers to cover these services. Mr. Klutinoty pointed to reimbursement caps on spending and services across the country. Seven states have no age or reimbursement cap for ASD treatment, 10 states have varying annual reimbursement caps based upon a consumer’s age, and five states have limits on the number of hours per week available for behavioral interventions. In states that require ASD coverage, evidence-based approaches—such as applied behavior analysis (ABA), augmentative and alternative communication, and psychotropic medication—are most commonly reimbursed. One common frustration among provider organization executives is that reimbursement models do not cover telemedicine or other technology-enabled approaches.
What Do Health Plans Want?
Health plans are looking for more collaborative partnerships with provider organizations that ensure a holistic, customized approach to care using metrics that prove how care influences outcomes (see Are Bundled Payments The Future Of Autism Reimbursement?). Whatever the service and the reimbursement model, the key issue is performance measurement and demonstrating value, according to the executives from Cigna, Magellan, and New Directions, who participated in the summit (see Payer Perspectives On Autism Benefits).
“I would love for there to be a simple measure, like blood work, that shows you’re making progress; there isn’t,” said Yagnesh Vadgama, BCBA, vice president of clinical care services for autism with Magellan Health. “There continues to be subjectivity in our industry and that may be holding us back. We need simple measures we can look at, such as an algorithm for utilization or standardized goals. Every time we ask a question it opens up a Pandora’s box for another one.”
The interest in developing standardized measures was echoed by Katherine Wooten LCSW, BCBA, clinical director of corporate programs for New Directions Behavioral Health, and Vikram Shah, M.D., MBA, lead medical director for Cigna.
“Outcomes have to be tangible,” something easily recognized by parents, clinicians, funding sources, and insurers, said Dr. Shah. He suggested the following examples, which can be measured to show progress: Socially significant areas such as the number of social interactions or tracking how many instances of repetitive behaviors have occurred from month to month. “Anything that can be measured over time and is appropriate for the child in treatment” allows for a clearer recognition of improvement and understanding of challenges that may benefit from continued support. An example of broader positive outcomes that require no further interpretation: A child who transitions to a regular school with an aide from a special education school due to success with ABA.
An example of a trackable metric is intelligence quotient year over year. “Outcome metrics have to be something that doesn’t require a clinician or a scientist to interpret it and determine, ‘ok, this is important,’ but rather something that is self-evident to the parent and demonstrates progress year over year,” said Dr. Shah. “It reminds me of the old saw; ‘What gets measured gets done.’ When you set up outcome metrics and measure progress against the metric, you have the ability to hold yourself (and others) accountable for the resulting success or failure.”
The autism market presents many opportunities for diversification and new revenue streams – with planning. Thinking through the market niches – and addressing the new health plan perspectives on value will be the keys to success. For more about ASD treatment and reimbursement, check out these resources in the OPEN MINDS Circle Library:
- Another Boost in Autism Funding
- Are Bundled Payments The Future Of Autism Reimbursement?
- Autism Rates & Costs: A Future View
- Are You In A ‘Technology First’ State?
- Opportunities In The Autism Market Shift With More Managed Care
- One in 40 United States Children Has Autism Spectrum Disorder
- New Opportunities Serving Adults With Autism
- Annual Health Care Costs For Adults With Autism 55% Higher Than General Population
- Prevalence Of Autism Spectrum Disorder In U.S. Stable In Recent Years
- Designing & Implementing Innovative Treatment Programs: An OPEN MINDS Executive Summit & Showcase
And join us February 13 to hear more about The Payer Perspective: An OPEN MINDS Forum On The Performance Management Metrics Health Plans Are Looking For From Providers during the The 2020 OPEN MINDS Performance Management Institute in Clearwater Beach, Florida.