Applied behavioral analysis (ABA) is a relatively young field. Unsurprisingly, there is still a lot of variation when prescribing and reimbursing ABA hours.
Each payer sets its own reimbursement parameters, and providers across the country each have their own assessments. While some industry insiders call for more standardization, others are looking to technology to help guide clinicians on the correct ABA dosage.
“We’ve seen, and the research has shown, that even among individual providers, there’s variability depending on the geographic location in terms of number of hours and intervention being prescribed,” Daniel A. Etra, co-founder and CEO of RethinkFirst, told Behavioral Health Business. “From the provider perspective, you want standardization among the different locations of your centers, both in terms of prescription, as well as in terms of how the care is being delivered. So there [is] clinical efficacy of care, regardless of which clinician is going in the home and delivering it.”
Founded in 2007, RethinkFirst is a behavioral health tech company designed to help collect ABA data and provide clinical billing, scheduling and training solutions. The company’s valuation could be as high as $1.5 billion, Axios reported in 2022.
ABA is a one-on-one therapy focused on improving specific behaviors, and it has become the gold standard for treating autism. As a result, demand for ABA services are at an all-time high.
Autism spectrum disorder currently impacts about 1 in 36 children, according to the CDC. But the new ABA field is still evolving, particularly regarding prescribing hours.
How ABA providers are dosing
Typically, ABA dosage is defined as treatment intensity. It includes the number of hours, duration and how long the intervention will last.
“We actually take a look at the patient profile because we need to have that clinical pathway set,” Kathleen Bailey Stengel, CEO of NeurAbilities Healthcare, told BHB. “Our patient profile usually includes factors like comorbid disabilities, comorbid symptom complaints, or chief complaints, that could be medical as well as behavioral.”
Voorhees, New Jersey-based NeurAbilities Healthcare is a national ABA treatment provider. It has 18 centers in New Jersey and Pennsylvania.
Stengel noted that her team has a checklist of skill deficits to help determine what dosage to prescribe and the intensity and duration of the prescription. The team considers the patient’s age and if they are hitting their developmental milestones. Younger children typically get more services to help them reach their milestones.
Practitioners can then create goals for their patients around skill deficits. Typically, payers and practitioners have a corresponding number of service hours allocated for each goal.
Yet it’s important to note this isn’t standardized, and it can change payer to payer. And research is still emerging on best practices for this burgeoning field.
“Generally speaking, one skill deficit or one skill remediation goal is almost 1.5 hours per week assumption,” Stengel said. “But we don’t have a data set that we can pull from that says, ‘That makes sense. That’s right.’ You can pull from research to say a full Tylenol will evade a headache. We know the number of milligrams for dosage on the medical side, generally speaking, because we have years and years of data showing that it worked.”
Still, goals are king when it comes to getting reimbursed.
“Some payers say that we will not authorize services unless the child has a number of goals that require that number of hours,” Stengel said.
Exploring tech’s role
One tech company is looking to change the ABA dosage paradigm with its troves of data. In March, RethinkFirst announced a new product called RethinkFutures, which provides clinical data and analytics for payers and health plans to help optimize care.
“We sit on … the world’s largest data set of clinical outcomes related to ABA intervention for patients with an autism diagnosis,” Etra said. “And with some of the work that we’ve done on the data-analytics side, building out a team of data scientists, building a data warehouse, we can now predict – and this is the game changer – with 99% accuracy based on a set of criteria for a patient with an autism diagnosis what their outcome trajectory will look like.”
Etra stressed that the technology isn’t intended to give payers tools to deny services or even to give providers the ability to push back on health plans. The product’s goal is to help clinicians figure out the best dosage for a patient based on outcomes from other similar patients.
“We’re able to take the patient, assign them to one of 48 clusters, and based on the cluster predict the outcomes,” Etra said.
RethinkFirst has developed a proprietary medical necessity assessment, which can automate a dosage recommendation for each patient based on previous outcomes.
But Stengel said before dosage assistance, the industry first needs agreement on clinical pathways.
If a patient comes in with a broken arm, the medical field is pretty much in agreement about how to handle that situation, she explained. ABA needs a similar framework.
“What I’d like to see is agreement at the field level of: What is the clinical pathway that we all look at? We’re not all taking the same data, or in the same way on the front-end for assessment. We’re not all using the same types of assessments, which is fine,” Stengel said. “But we should have clinical pathways that set us off on a trajectory.”
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