The big news in the autism sector is that last week President Trump has signed the Autism Care Act (see Trump Signs $1.8 Billion Autism Funding Bill) providing $1.8 billion in funding for autism over the next five years. While there hasn’t been a complete analysis of the bill, it will likely focus funding on research, education, early detection and treatment, and challenges posed by “aging out” of existing programs. This influx of new money and new attention will likely amplify the current trends in autism treatment financing and service delivery—expanding state-level benefit mandates with more specialty managed care and new service models.
State-Level Benefit Mandates—Currently all 50 states have some type of mandated coverage of autism treatment services. Most recent, we covered the changes in New Mexico where The State of New Mexico Office of the Superintendent of Insurance removed benefit caps under state-regulated health benefit plans. The state’s modified autism insurance mandate expands coverage for autism therapies to transition-age youth and adults with autism covered by private, state-regulated health benefit plans; removes age and dollar caps from the state’s current autism insurance mandate; and prohibits coverage for included treatments based on an enrollee’s age (see New Mexico Removes Benefit Caps For Autism Insurance Coverage).
And earlier this year in Virginia, the state removed the age cap on autism coverage under private insurance plans. The mandate applies to fully insured large employer groups, and to health insurers, health care subscription plans, and health maintenance organizations that provide coverage for the diagnosis and treatment of autism spectrum disorder in individuals of any age, including adults (see New Virginia Law Removes Age Cap On Autism Coverage Under Private Insurance Plans).
More specialty managed care and new service models—The driver of specialty managed care for autism treatment services and in new service models is being driven by the increasing prevalence of the disorder and the increasing costs of serving the individuals with the disorder (see Autism—Increasing Demand, Increasing Cost & New Service Models, Enrollment Of The Medicaid I/DD Population In Managed Care For Acute Care Services: An OPEN MINDS Market Intelligence Report, and State Medicaid Programs With MLTSS: The 2019 OPEN MINDS Update). The prevalence of autism appears to be rising. The Centers for Disease Control and Prevention (CDC) last year that found a prevalence of 1 in 59 children (see Data & Statistics On Autism Spectrum Disorder). And there are some state differences in autism prevalence. In New Jersey, the autism rate was 28.4 per 1,000 in 2014. In Missouri it was 8 per 1,000 children (see New Jersey Autism Rate Among Four-Year-Olds Rose 43% Over Four Years).
Individuals with autism also have higher health care resource use costs than individuals without autism. About 50.2% of children diagnosed with autism spectrum disorder (ASD) have high rates of co-occurring medical conditions and 26.5% have high rates of co-occurring developmental delay and seizures. Another 23.7% have high rates of co-occurring auditory disorders, gastrointestinal disorders and symptoms, immune disorders (such as asthma or allergies), psychiatric disorders, and sleep disorders (see About 50% Children With Autism Have High Rates Of Co-Occurring Medical Disorders). According to Michael Hammond in his 2019 OPEN MINDS Executive Leadership Retreat keynote, The Future Of Medicaid Managed Care: Building A Comprehensive Care Solution For The Complex Consumer Population, children with intellectual/developmental disabilities (I/DD) are four times more likely to have mental disorders than other children, three times the physical issues, and three times more likely to suffer abuse.
This market landscape, with increasing prevalence, benefit mandates, and rising costs, is the perfect situation for entrepreneurship. Families are looking for the same access to convenience in autism services as they are in all health care services. Payers and health plan mangers are looking for creative approaches to addressing rising co-morbidities and costs in new models of care coordination, home- and community-based services, and specialized integrated service delivery models (see Living In The Community-The Landscape For Adults With I/DD and Finding The Opportunities In Serving The 1 In 68). And, like innovative programs addressing other disease states, leverage of new technologies—mobile apps, telehealth, wearable tech, robotics aids, and more—will be essential for success (see Nine Technologies Likely To Reshape Autism Services).
For more on new service line development, check out these resources from The OPEN MINDS Industry Library:
- New Service Line Development: The OPEN MINDS Step-By-Step Approach To Developing Innovative Programs
- Do Something Different, “Differently” – A Specialist Provider Organization Guide To Building A New Strategy For Service Line Sustainability
- Diversifying Your Revenue Streams: How To Successfully Launch A New Service Line
- Cutting Edge Telepsychiatry: Sustainable Program Models In Practice
- Designing & Implementing Innovative Treatment Programs: An OPEN MINDS Executive Summit & Showcase
- Considering Cash-& Consumerism-In Service Line Planning
- Diversification & New Service Line Development
- New Service Line Development In Four Slides
- A Structured Process for New Service Line Development
- New Service Line Development From A To Z: Tips, Tricks, & Advice
And don’t miss our deep dive on the autism market on October 28, 2019 in Philadelphia for The 2019 OPEN MINDS Children’s Services Leadership Summit. Key executives from payer and provider organizations, market trend setters, and industry thought leaders will include:
- Richard G. Allen, Psy.D., BCBA-D, NCSP, Supervising Psychologist, Devereux Advanced Behavioral Health
- Lecia M. Anzaldo, MPA, BCBA, Director of Autism Services, Easterseals UCP North Carolina & Virginia
- Bryant Edgerton, Vice President, IDD Services North Carolina, Easterseals UCP North Carolina & Virginia
- Todd Harris, Ph.D., Executive Director of Autism Services, Devereux Advanced Behavioral Health
- Shanun Kunnavatana, Ph.D., BCBA-D, Director of Clinical Development, Autism Services, Easterseals UCP North Carolina & Virginia
- Boyd H. Mark, Director of Telehealth Services, The Scott Center for Autism Treatment
- Daniel Openden, Ph.D., BCBA-D, President & Chief Executive Officer, Southwest Autism Research & Resource Center (SARRC)
- Vikram (Vik) Shah, M.D., MBA, Lead Medical Director, Cigna
- Yagnesh Vadgama, BCBA, Vice President, Clinical Care Services Autism, Magellan Health
- Katherine Wooten, LCSW, BCBA, Clinical Director – Corporate Programs, New Directions
The summit will focus on the market factors that are reshaping service delivery in the autism space and the new opportunities for provider organizations serving the autism population. The day will close with a panel discussion on the new technologies that are shaping the course of autism treatment.