Obstacles ABA Providers Must Overcome to Successfully Transition to Value-Based Care

Across the health care spectrum, the value-based care movement continues to gather steam, as stakeholders warm up to the idea of payments based on quality rather than quantity of services.

But in the autism space, providers and payers are still trying to find their footing as it relates to value-based care. Nevertheless, the model has the potential to improve outcomes for patients and bottom lines for organizations in the space — it’s just a matter of overcoming obstacles to make it all possible, according to industry stakeholders like Ivy Chong, senior vice president of the Randolph, Massachusetts-based May Institute, a nonprofit provider of autism schools and services.

“Value-based health care will push clinicians towards [the] integration of wraparound services [and] quality services … ensuring that we’re benchmarking what we’re doing, not just to the patient themselves, but to others,” Chong said.


She made those comments during a recent panel at the third annual Autism Investor Summit, a three-day online event that brought together industry leaders, investors, providers, advocates, legislators, payers, patients and researchers. The event was put on by Los Angeles area industry professionals Sarah Litvak and Ronit Molko.

A large segment of the autism treatment industry revolves around the evidenced-based practice of applied behavior analysis (ABA) therapy, which is widely considered to be the gold standard of care. As more children are diagnosed with autism spectrum disorder, funding continues to pour into the market, which is estimated to reach over $4.5 billion by 2026.

Traditionally, ABA services are reimbursed on a fee-for-service basis. But research has shown that value-based payment structures can improve care coordination and bring down the cost of providing services to children, which for autism providers currently tends to be expensive.


Proponents of value-based care celebrate the fact that the model prioritizes the patient experience, which they say isn’t always the case in fee-for-service.

“I truly believe that transparency of quality measures is really important,” Hanna Rue, the chief clinical officer of Baltimore-based ABA therapy provider LEARN Behavioral, said during the virtual event. “There’s a lot of areas in the US specifically that are saturated with providers, and how is a consumer supposed to choose one provider over another? I think moving to a value-based framework would provide more information about the providers that they’re considering.”

While health care leaders and policymakers have expressed the need to transition to a value-based payment structure for decades, the vast majority of the U.S. health care system still operates under a fee-for-service model.

Not only does that adversely affect patient outcomes, but it also has negative consequences for providers’ bottom lines, according to Lori Geary, the chief health outcomes officer of the Behavioral Health Center of Excellence, of which Litvak is CEO.

“[Fee-for-services] translates into a reduced focus on preventive care … and more focus on acute situations, … which in turn drives costs,” Geary remarked during the discussion.

Obstacles to value-based care

ABA providers have long struggled to measure the quality of their outcomes, given the fact that autism symptoms and progress vary considerably from one child to the next. In turn, that makes value-based care tricky to adopt, as the model is built around rewarding outcomes.

“To use any quality outcome measures in a value-based care program … or payment model, you need to be able to adjust for things at the patient level,” Geary said during the discussion. “You [also] need to be able to adjust for [the] clinical severity of a case.”

While Geary believes some ABA providers will be resistant to the standardization of practices required for value-based care models, she said such hurdles are not insurmountable. She said the industry needs to develop standards for the organization and reporting of data at state and national levels, which it currently lacks.

“It’s just a gap, but I think we have to start there,” she added during the discussion. “I think we all need, … as an industry, [to] … start at the basics, which is getting data together and sharing it with each other.”

In addition to data, access currently stands in the way of ABA’s successful transition to value-based care. Nationwide, there’s a shortage of providers in the space, and demand for services far outpaces supply.

As such, autism treatment has historically been out of reach for many, especially lower-income families. More of those low-income families tend to be Black and Hispanic, and various studies have shown that Black and Hispanic children with autism tend to receive later diagnoses and less attentive care compared to white children.

Geary believes that the move toward value-based care — which is seen as a more equitable payment model — stands to address access issues associated with race and class. The failure to do so could leave a significant number of children without quality services, she said.

“[W]e have to create a culture where [people] feel … comfortable talking to us about what those access issues are,” Geary said during the discussion. “[W]e have to bring a diverse group of people — real people that have autism or real people that have cared for someone with autism — to the table to help us understand those access issues better, so that we can address them.”

Improving diversity

The ABA industry has also long faced criticisms about the lack of diversity in its workforce, which industry leaders tackled on a separate recently panel at the Autism Investor Summit.

During that discussion, LEARN Behavioral President Justin Funches noted that diversity can significantly benefit providers’ bottom lines.

“When you think about building an organization in ABA, … three really important things … are key to the returns investors get,” Funches commented. “You want to see client growth, you need really great talent and you need really great leadership. … One of the things that … is really powerful about diversity is it can help across all three of these dimensions. … [It] is a really great way to build your client base and to grow the top line.”

Meanwhile, Chong believes the industry can cultivate a more diverse workforce by providing tuition assistance to students of color — many of whom come from less well-off families than white students — as well as making more of an effort to develop and retain diverse workers.

Doing so can help ABA providers make headway in overcoming the tacit racial bias that exists in the industry, Chong said, as it does in other industries. The failure to do so, she believes, will continue trickling down and mean a lack of adequate services for children of color.

“For the longest time, we thought, ‘Well, behavior’s behavior, so … as long as you’re using reinforcement and … the principles, [the care to children] is going to work,’” Chong said. “It completely ignores diversity, culture and access. We need to consider all of those variables.”

Rue also believes that the industry’s shift to value-based care should accompany more diversity among clinicians and board certified behavioral analysts (BCBAs), some of whom might have what it takes to eventually land C-suite level positions.

Like Chong, Rue said investment in a more diverse workforce should start with recruitment out of college, as well as professional mentorship and development once those students begin their professional journeys.

“It’s incumbent upon those of us who have the resources to provide more support and a trajectory for them to become behavior analysts and clinicians.” Rue said.

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