Autism Therapy Providers Tie Upskilling to Beating Turnover, Serving More Families

Staffing challenges in autism therapy are driving providers to invest heavily in training and upskilling registered behavioral technicians (RBTs).

In recent years, inflation and a red-hot job market made hiring and retaining staff harder, especially for RBTs Further, investors have tied staff retention to the company’s value as an investment and as a provider of health care services, several sources attending the Autism Investor Summit to Behavioral Health Business.

“The number one thing that we’ve heard from investors on what will drive valuation and what they’re looking for is a stable, reliable workforce or good retention plan, good recruiting strategies because they understand that is the business,” Rob Marsh, CEO of 360 Behavioral Health, told BHB. “Without the people to do the work, there is no business.”

The Chatsworth, California-based autism therapy and support service company operates 17 locations in California.

The sentiment Marsh shared parallels another put forward by Dexter Braff, the president of the M&A firm the Braff Group.

Strong employee retention signals business consistency to investors, a key to achieving a favorable deal multiple, Braff said during a keynote presentation at the Autism Investor Summit. The draining of jobs from the economy during the pandemic provided companies the chance to prove the efficacy of their retention and hiring practices, Braff said. Companies staffed at or above pre-COVID levels can argue for higher valuations.

“If you can show that you’re keeping your people, that’s a very good predictor of being able to sustain the revenue base,” Braff said.

Staffing challenges come from several sources; some are systemic to the behavioral health industry and the wider economy. However, by investing in upskilling and providing clear career pathways within an autism therapy organization, providers can mitigate or even directly address these challenges.

And on top of it all, the autism therapy space faces crushing demand for services, resulting in provider shortages and months-long waitlists in most markets despite a flood of investment in the space.

These dynamics have previously led some of the top leaders in the autism therapy space to level wary projections about 2023, with one predicting it will be a “year of reckoning” for the segment.

“If you don’t address it, we are going to just run out of providers like everybody else does,” Cheryl Tierney, medical director for virtual neurodivergent diagnostics and youth mental health provider Meliora Health, told BHB.

A position under pressure

While RBTs spend the most time with autism patients, the role is often considered entry-level, hourly wage-based and at the bottom of most organizational charts. RBTs must have a high-school degree or equivalent. They work under the direction of board-certified behavior analysts, a graduate-level certification, according to the Behavior Analyst Certification Board.

Turnover in these roles can be very high. Approximated turnover rates from industry observers range from 45% to 75%. Unfortunately, the research on RBTs specifically is thin. But the role does align with well-established research on turnover rates for technicians who work with people with intellectual disabilities in facility settings.

These roles are often demanding, require a merit-based credential and offer entry-level wages.

The wages for these roles in the national aggregate are comparable to retail, logistics and food services. Wages vary significantly across organizations and regions, according to career information aggregator websites. The average hourly wage for an RBT is $21 an hour, according to ziprecuiter.com, and Zippia.com places the average rate at $18.28.

The number one thing that we’ve heard from investors on what will drive valuation … is a stable, reliable workforce or good retention plan, good recruiting strategies…

Rob Marsh, CEO of 360 Behavioral Health

The U.S. Bureau of Labor Statistics doesn’t track RBT wages. A potentially comparable role tracked by BLS could include psychiatric technicians. The national average wage, according to BLS, is $19.60.

COVID prompted a national acceleration of wage growth, the fastest in the nation’s history. But the fastest wage growth was among entry-level workers. Workers at this level of pay have seen wages increase by 7.4% over the past 12 months, according to data from the Federal Reserve Bank of Atlanta.

“Eighteen months ago, the labor market was so hot it was hard to attract and retain because you had lots of folks hiring,” Neil Hattangadi, CEO of San Diego-based Cortica, told BHB, adding that hiring pressures have somewhat lessened in recent months.

Several other sources noted fewer hiring struggles in recent months and attributed it to the rumblings of a national recession and the rise of consumer prices via inflation.

Those pressures stressed the autism therapy market to a breaking point of sorts in the latter part of 2022. 360 Behavioral Health laid off staff to cope with market dynamics, and Plano, Texas-based Center for Autism and Related Disorders rolled out a 10-state reduction in markets. Also, the behavioral health start Elemy shuttered its clinical business and pivoted to a software/marketplace model of autism and other neurodivergence services.

On top of the wage issues, the work of RBTs can be grueling and isolating, especially for RBTs that work with patients in their homes.

“At a center, you’re going to work … and there’s family and camaraderie,” Chris Tillotson, CEO of Prospera Healthcare, told BHB. “When you’re in the home setting, a lot of them are on an island by themselves.”

Prospera Healthcare was founded in 2021. It operates in the Dallas and El Paso, Texas areas and Oklahoma. It cares for about 50 clients today and employs 60 people. It presently serves clients in their homes with plans to open a center in Lake Dallas, Texas.

Wages are stuck

Inflation and wage pressures present a conundrum for health care providers, especially those in behavioral health. Unlike in other segments of the economy, third-party payers, i.e., health insurance plans, prevent most health care providers from upping prices.

Hattangadi says his company has secured higher rates and alternative payment models because Cortica offers several medical specialties autistic patients need in each clinic. This, combined with a focus on tracking care, has helped Cortica differentiate itself from other providers.

“The other thing we have to do is go to our payers and say, ‘The No. 1 thing we’re trying to solve for with our rates is not profitability …we are trying to create a sustainable workforce that can grow in this field, and you can’t do it if you’re paying bottom-of-the-barrel reimbursement rates,'” Hattangadi said.

Cortica is based in San Diego and was founded in 2013. It recently secured two acquisitions and a $75 million funding round.

Sara Litvak, the CEO of the autism accreditation body the Behavioral Health Center of Excellence (BHCOE) and co-founder of the Autism Investor Summit, told BHB that wage pressures and stagnant and low payer rates create a chicken-or-the-egg conundrum for autism therapy providers.

“The best way to retain people is to pay them a wage that’s sustainable, but you can’t pay them wages that are sustainable if you aren’t able to negotiate a higher rate,” Litvak said. “But then you’re not able to have a higher rate if your turnover is high.”

Payer rates in autism therapy have remained at similar levels for years, Helen Mader, CEO of El Segundo, California-based Behavior Frontiers, told BHB.

Rates also rarely have escalators or define renegotiation periods. Providers may go years without negotiating rates and, given the fragmented nature of the autism therapy space, many don’t have the leverage to extract significant rate increases, Mader said.

“At this time, receiving rate increases is critical for the field to continue to provide quality service,” Mader said. “The field of [autism therapy] needs the payers to be great partners with us at this point. … The pay rates are just not keeping up at this time.”

Mader pointed to economic pressures driving up costs and increased regulatory and compliance burdens, often instituted by payers. These, on top of the pressure to advance the use of data in the field, inflate technology costs.

Founded in 2004, Behavior Frontiers now operates in 12 states and holds insurance contracts allowing it to operate in 20. It employs about 1,300; recently hired 100 RBTs in a week; and opened 12 centers in the last 18 months.

The field of [autism therapy] needs the payers to be great partners with us at this point.

Helen Mader, CEO of Behavior Frontiers

Solutions for RBT turnover

While sources offered a mix of opinions on the centrality of competitive wages, all agree that they play an important role in attracting workers in the first place and play a role in keeping workers at a company.

Behavior Frontiers, a year ago, created a loyalty program for RBTs, giving them quarterly raises.

“We know it can be a challenging job at times, and we want to reward them for being with us,” Mader said.

This helps workers through the most precarious phase of their employment when employees turn over the most. It also helps get workers to the point where they not only stay in a role long-term but can make more serious career considerations in autism therapy.

“At that point, they would likely be promoted to a senior behavior technician with another pay raise and additional responsibilities,” Mader said.

Education efforts also go a long way toward attracting and retaining RBTs. This includes skills training, safety training, scenario planning and even certificate progression. Nearly every source told BHB that education and training efforts help RBTs feel supported, improve the quality of care and even create a pipeline for leadership or higher-skilled workers such as BCBAs.

But early and frequent training, especially early on, can help get at more foundational issues many RBTs face — unclear expectations.

“The first [challenge] is that an RBT comes in not even knowing what the industry is,” Simcha Feller, CEO and co-founder of Triumph Behavior Support, told BHB. “They have zero background. They’re not even sure if they want to work [with] kids. They like the idea of it. Maybe they want to test it and try it.

“But sometimes those people, after a year or after six months, just go and work at Amazon. They literally go to a different industry, it’s not like they go to a competitor.”

Triumph Behavior Support, founded in 2018, cares for over 1,000 largely on an in-home basis in New York and New Jersey. It employs about 100 BCBAs and 1,000 other employees.

Rachel Boynton, managing director and partner at the M&A consulting firm Vertess, added that while RBT wages may be outside of providers’ control, investing in the culture, skills, leadership opportunities and other incentives for workers is something all providers can do.

“The most successful providers that I see are very involved with leadership growth,” Boynton said. “If you can have a strong HR component … and you’re making them feel good about what they do, I think that’s the best thing you can do for retention.

“There’s always going to be someone who can pay a little bit more than you can. I’ll guarantee it.”

Building culture and infrastructure in autism therapy

In addition to formal training, Prospera Healthcare fosters feelings of connection by creating digital communities for RBTs and holding monthly get-togethers, Tillotson said.

Training, pay increases and career advancement transform an entry-level role into a clear career opportunity in a high-demand, fast-growing field. Even if RBTs don’t want to remain RBTs or begin BCBA training, staffers at Cortica have used their work as an RBT to gain experience and then train to become a physician or other graduate-level clinicians, Hattangadi said.

“There’s a very good career to stay as an RBT,” Hattangadi said, adding some RBTs have been with Cortica since its inception in 2013. “It shouldn’t be this perception that your career fulfillment only happens when you leave the role.

Speaking of Cortica’s long-time RBTs, Hattangadi added, “They are incredible clinicians who, honestly, would have less impact in the field if they moved [on] and became BCBAs.”

Litvak echoed a similar sentiment about the need to make RBT work as much of a career destination as it is a stepping stone.

“Not everyone is gonna get their master’s degree,” Litvak said. “You also need to make sure that those people feel supported and invested in.”

Other systemic efforts include tighter partnerships between colleges that graduate aspiring behavioral health providers. Litvak pointed to the BHCOE’s partnership with Pepperdine University and its remote learning vendor 2U Inc. (Nasdaq: TWOU), which routes supervised fieldwork to BHCOE-accredited organizations. The program, announced in May 2022, also came with a corresponding scholarship.

“What we’ve been trying to do is create infrastructure for those organizations that are accredited, to be able to have a direct pipeline to talent,” Litvak said. “So they’re getting RBTs. But those RBTs are in a master’s program. … You basically have an RBT that in [a few years] is going to move up in your workforce.”