“There are notable tailwinds driving demand.”
This observation was made earlier this month at The 2019 OPEN MINDS Strategy & Innovation Institute during the session Opportunity & Innovation In The Autism Market: The Beacon Health Options Strategy, given by James Craig, Vice President, Corporate Clinical, Autism Solutions, Beacon Health Options. And the state of the market—and the chances for opportunity—has truly changed a lot in recent years.
First there is the legislation demanding coverage. In 2014, the Centers for Medicare & Medicaid Services (CMS) clarified that every state Medicaid program must at minimum cover autism services through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provision (see CMS Clarifies Autism Services Requirements In Medicaid EPSDT Benefit). In 2017, the Federal Employee Health Benefit directed its carriers to no longer exclude coverage of Applied Behavior Analysis (ABA); and 33 states and the District of Columbia (DC.) have included ABA in their essential health benefit package governing health insurance marketplace plans (see FEHB Will Offer Autism Coverage In 2017 and Marketplace Health Insurance). Most recently, Wyoming became the 49th state to release guidance on the coverage of autism benefits in state regulated health plans—Tennessee is now the only state without coverage guidelines (see Wyoming Becomes 49th State To Require Coverage Of Autism).
The prevalence of autism is also rising. The Centers for Disease Control and Prevention (CDC) released new prevalence estimates last year, which showed an increase from 1 in 68 children in 2014, to 1 in 59 children in 2018. Rates of autism also vary by state—New Jersey has the highest estimated prevalence of 29.3 per 1,000 children and Arkansas has the lowest at 13.1 per 1,000 children. Of course there are a number of factors that go into these rates including demographics, insurance coverage, and ability to receive a diagnosis (see 1.7% Of U.S. Children Have Autism Spectrum Disorder, Up 15% From 2012).
The two major drivers of cost in the autism space are therapy and co-morbid diseases. The CDC reports that the average cost for ABA therapy for a child is $40,000 to $60,000 per year from roughly age three, until entering school at age 6 or 7– amounting to roughly $240,000 (see Autism’s Cost). Additionally, the cost of treatment is being driven by the shortage of board certified behavior analysts (BCBA) who are responsible for assessment and treatment planning. Even though the number of BCBAs has risen from 13,000 in 2012 to 32,000 in 2018, there is still a nationwide shortage and uneven distribution.
Individuals with autism also have a higher likelihood of chronic diseases. 95% of children with autism have one common co-morbid condition and over half have at least four chronic conditions. As a result, medical costs are 4.1 to 6.2 times higher for children with autism compared to children without autism (see Medical Expenditures For Children With An Autism Spectrum Disorder In A Privately Insured Population).
Beacon administers autism benefits for health plans and directly for states and counties. Management of autism services can be on a risk or non-risk basis depending on the contract. Overall, Beacon covers more than 14 million individuals for autism services and manages approximately 14,000 cases with a diagnosis of autism.
What is Beacon doing to manage demand and cost?
During his keynote, Mr. Craig explained that Beacon is addressing the dual issues of cost and demand through early intervention and screening, collaborative care with care managers, and partnering with multi-state, scalable provider organizations.
Early intervention and screening – Beacon prioritizes early diagnosis and intervention with autism because it is associated with improved learning, normalized patterns of brain activity, and reduced maladaptive behaviors. To ensure early diagnosis, Beacon helps train primary care providers in administering autism screenings. Additionally, Beacon is working to increase the number of clinical professionals that can provide diagnostic tests. In the past, Beacon has also offered free training to psychologists to utilize the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2).
Collaborative care with care managers – Due to the high level of co-morbid conditions and cost of care for children with autism, Beacon Health Options is looking for provider organizations that can coordinate care for the whole child – not just for autism services. Right now, Beacon is working on standardizing care coordination at the health plan level, but believes that this role belongs with the provider organization. Provider organizations should be looking to ensure that they have the data and systems to be able to provide this service.
Partnering with multi-state, scalable provider organizations – Mr. Craig noted that Beacon often enters a state or area that lacks the capacity to provide the needed treatment for autism services. If local provider organizations are unwilling or unable to expand, Beacon Health Options will bring in outside, multi-state provider organizations with demonstrated value that are able to scale quickly and begin operations in 12-18 months.
Tech solutions for autism – Mr. Craig sees the use of technological solutions as necessary to the delivery of autism treatment. Some technology is already making a difference such as the use of telehealth to assist in the delivery of applied behavior analysis and Project ECHO to provide expert advice to clinical professionals. Beacon Health Options is also looking to technologies that are still in development such as a blood test for diagnosis of autism, wearables, and virtual/augmented reality (look for more on this in a future circle post).
My takeaway, autism services cannot continue to be delivered as they are today – in a fee-for-service (FFS), uncoordinated environment. In the future, provider organizations providing autism services are going to be expected to participate in value-based arrangements and have the competencies to manage performance. Additionally, organizations like Beacon will most likely be looking to develop preferred provider networks which would allow for expedited credentialing, reduced paperwork, etc. Provider organizations should begin to prepare for this future now, reviewing their competencies for value-based reimbursement and performance (see How To Build Your Tech Infrastructure For Value-Based Reimbursement and Are Your IT Systems Ready For Value-Based Reimbursement? Take The Quiz).
For even more, join us at The 2019 OPEN MINDS Management & Best Practices Institute in Long Beach, California on August 13 for the session, “Building A Value-Based Sustainability Strategy: How To Develop Innovative Programs & Manage Your Service Line Portfolio.” The session will feature Kim Scott, Chief Executive Officer, and Jamie Vandergon, LPC, President, Trillium Family Services, and Faith Richie, Senior Vice President, Development, Telecare Corporation.