The demand for autism services continues to soar as rates of the condition rise. Yet in 2022, the burgeoning industry has faced a number of growing pains centered around staffing.
In 2022, roughly 1 in 44 children were identified with autism spectrum disorder, according to the CDC. That’s up from 1 in 69 children in 2012.
Providers have struggled to keep up with those inflated numbers. In fact, 49 states in 2019 fell below the per capita supply of certified Applied Behavior Analysis (ABA) provider benchmark, according to one study.
“We don’t have enough skilled clinicians, [or] licensed or certified clinicians. There are just simply not enough currently,” Kathleen Bailey Stengel, CEO of NeurAbilities Healthcare, said during the Behavioral Health Business INVEST conference. “So as a workforce, we have to actually develop them within our company. We have to train them up, we have to invest in them.”
This, coupled with the increase of private equity investment, put pressure on providers to show results.
Over the last few years, investors and ABA providers looked to quickly expand their footprint in order to gain market share and leverage in payer rate negotiations. But this plan had a few hiccups in 2022. Many of these providers were forced to scale back operations to match economic realities in local employment markets and limited reimbursement increases.
In 2023, executives are looking to new technologies and innovations to help scale their business and provide more care. These innovations include digital tools like virtual reality, as well as creative ways to retain their workforce, such as education reimbursement.
Read on for insights from the autism C-suite. BHB edited responses for length, style and clarity.
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The autism sector will continue to face headwinds in 2023 related to the labor supply and demand imbalance, leaving many individuals with autism without access to the providers and services they need. Given these access challenges will likely persist indefinitely, providers would be wise to increase their capacity to serve by leveraging available technologies (e.g., telehealth, virtual reality, robotics), as well as peer- and caregiver-mediated interventions that function as treatment extenders to address gaps in service.
While it remains one of the only effective evidence-based treatments for autism today, ABA has faced increasing backlash from former consumers who have characterized some forms of this intervention approach as coercive and punitive, or failing to respect neurodiversity and alternative perspectives. 2023 will be a year of reckoning, and these will be important voices to listen to and learn from to promote diversity, equity and more responsible ethical service delivery.
2023 will also be a year when we should expect to see more opportunities for partnerships among providers, regulators, advocacy groups and payers focused on improving the quality of services delivered and the outcomes achieved. For example, some managed care plans intend to launch pilots to help evaluate multidisciplinary integrated care models, and there’s an increasing focus on quality of life outcomes that can better address the physical, behavioral and mental health needs of individuals with autism and their families. This type of work should inform how the sector thinks about value-based payment models to ensure providers are rewarded for delivering outcomes that matter most to individuals with autism and their families.
– Doug Moes, Chief Clinical Development Officer, The Stepping Stones Group
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For health care overall, the greatest challenges will remain the ability to recruit, train and retain qualified health care providers. In the autism space, specifically, this continues to be the main barrier to growth, with both the overall need for medical and behavioral health diagnosticians and skilled therapists for ongoing treatment. While the rates of autism disorders continue to rise, clinical staff that treat this population are not trained at the same rate. For example, some studies show that behavior analysts would have to maintain a caseload of over 600 patients at a time to meet the national demand. While this may be concerning, it also presents an opportunity for innovation in service delivery.
While innovation sometimes evokes a thought on technology, technology alone will not provide the interventions we require to address the need. That requires clinical staff. Innovation in service delivery starts with providing entry into the field for clinical staff way earlier than college. For Example, NeurAbilities recruits seniors in high school, and provides training and opportunities for overall exposure to the field.
Once they graduate, they can enter into the Tuition Assistance Program (TAP) we provide that promotes education and career opportunities in the field. This increases awareness, retention and development in the field.
Technology, however, can address the efficiencies in service delivery. Additionally, the trend toward interoperability will continue to be a main focus for service providers. Many technology platforms in the field of autism do not provide a full continuum of services that allows clinicians and operations to be efficient. Streamlining technology and processes in an uncertain time in 2023 will be an overall emphasis to reduce cost and increase satisfaction for the end user (the clinician and the patient).
– Kathleen Bailey Stengel, CEO, NeurAbilities Healthcare
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The past year presented new challenges for many ABA providers, but we at 360 Behavioral Health are optimistic about the year ahead. Additional rightsizing may be needed for some providers who continue to face recruiting constraints and stagnant reimbursement rates; however, 2023 will be a year of growth and service line expansion for 360 Behavioral Health.
We also expect to see continued consolidation of service providers, continued demand for quality treatment, and, hopefully, continued progress toward improving accessibility of care to all in-need.
– Rob Marsh, CEO, 360 Behavioral Health
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There is still an unmet need for services across the nation, which is why Hopebridge provides access to care to help more children reach new opportunities. Looking ahead to 2023, we remain committed to our mission to serve additional families by reinvesting in our people, our patients, our community and our science.
Accessing care remains a challenge for many, but Hopebridge always works to bridge that gap by serving the underserved. We want to make sure every child can experience high-quality, compassionate care that is full of little everyday victories that lead to big impacts. This means listening to and advocating for the autism community, leaning into value-based health care, empowering future clinicians through our unrivaled Fellowship Program and investing in clinical research to advance clinical outcomes for our science as a whole.
The health care field has seen recent hiring challenges, but Hopebridge feels we can make a positive change here. As much work as we do to lift our kids to their full potential, we also want to invest in our team through a culture of appreciation, unrivaled learning and leadership-building programs, growing career paths, and – simply put – an environment full of fun at work. We’re connecting people with a purpose, but also supporting them in their goals and dreams in the process.
– Dennis May, CEO, Hopebridge Autism Therapy Centers
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While global economic concerns will affect providers of ABA services, I have an optimistic view for how our industry will fare in 2023 because the capacity gap remains too large and won’t be closed any time soon, and the services we provide are mission critical to the families and children we serve. There will be an adjustment period for some ABA providers as they work to manage increasing staff-related costs and account for increased debt costs for those that carry it.
Overall, our customer base continues to grow at a healthy rate, and I expect that to continue and even accelerate in 2023, with those that most aggressively adopt technology and invest in staff seeing the most success. I believe we’ll continue to see a shift towards center-based services. In 2022, we saw a 38% year-over-year increase in center-based billable charges, whereas in-home services only grew 3.1% year over year.
Staff retention is also going to be a focus next year. Currently, estimated turnover rates for RBTs range from 30% to 75%, so organizations that can retain staff at the highest rate by investing in staff retention programs will create a positive financial profile even with potential downward pressure.
–Chris Sullens, CEO of CentralReach