The autism therapy industry needs to continue its strategic and cultural evolution. That goes for all its constituents — providers, payers and investors alike.
This evolution has been ongoing to varied degrees for years now. The expansion of the industry through private investment accelerated it. Today, the industry must take care to ensure an ethical culture, sustainability and progress.
These concepts are at the core of several things that have been on my mind in recent weeks. To me, they seem to be the keys to the autism therapy industry’s success in the future. Attending and working at BHB’s Autism & Addiction Treatment Forum crystallized my thinking.
While at The Forum, I hosted three panels and networked with dozens of the top autism therapy industry leaders. The conversations included a wide variety of professionals. They dove deep into the pressing issues of the day.
It’s impossible to measure the extent to which ethical culture, sustainability and progress are enshrined in policy. Based on what I learned at The Forum, it’s clear to me that these concepts are on the minds of a lot of executives.
But what is the key to achieving and assessing the progress of instilling these principles? One way to do so comes down to this: a serious examination of relationships.
In this week’s BHB+ Update, I break down how an examination of relationships within the industry can:
— Impact company cultures and lead to better retention
— Facilitate a necessary evolution of autism therapy’s engagement with capital
— Further erode rhetorical barriers preventing value-based care implementation
Relationships establish culture from the top down
The fundamental challenge of the autism therapy industry is clinician retention. The red-hot demand and shortage of clinicians make it priorities No. 1, 2 and 3 for most providers. The severity of the problem increases exponentially with the size of the organization. Despite the significance of the problem, a subtle approach is clearly the best one.
Consider the relatively low and stagnant nature of payer rates for autism therapy. These rates curtail any provider’s ability to use the blunt hammer of cash to fix this problem.
The next path to success is establishing a culture that motivates clinicians to stay. Here, relationships are the key. Why? At the most basic level, behavioral health work relies on relationships of trust between clinicians and patients. When it comes to the autism therapy world, this includes patients’ families. Clinicians know this. It’s at the core of their training. Executives must understand this. They then need to center provider-patient relationships in their workforce strategies. Another benefit of this approach is likely patient retention. Patients are likely to stay where they feel like they need to be.
Behavioral Health BusinessTop executives must communicate and demonstrate this. The simplest way is for chief executives to get out into clinics as much as possible. This approach came up in two different panels I hosted.
“I try to have as much presence as I can in our centers,” Mark Shalvarjian, CEO of the Des Plaines, Illinois-based pediatric therapy provider Gracent, said on a panel. “All our area directors and other key leaders are expected to have a fair amount of physical presence. One of my tenets is that you just can’t lead if you don’t show up. So showing up is really important.”
Kyle Seco, president of Dallas-based Apara Autism Centers, echoed a similar sentiment. For him, it also includes being present in the digital spaces where his employees work and communicate. That includes work stuff. But he also shares memes and GIFs. (If you’re scratching your head at that, please go spend time with your younger clinical workforce.) Seco previously worked for the private equity firm that backs Apara, Havencrest Capital Management, also based in Dallas.
“This is a people business, and you really want to make sure that they (clinicians) trust you,” Seco said on a panel. “I think it goes a long way; staff like to see that their president is working at a clinic. So then, having a presence in these clinics is really important. So many times people go, ‘You know what? I’ve seen you more in the past two months than I’ve seen other people in the past three years.'”
Developing a culture that retains staff has to involve obvious and tangible activity. This can take the form of training, especially training that advances the careers of clinicians.
The corporatization of autism therapy has also highlighted a void that the industry was altogether unprepared to address: the rise of the clinician manager. Sure, the industry has always had clinical directors to spell out the vision for the clinical staff. But increasing layers of management and oversight to better wield organizations of vast scale necessarily creates increasing numbers of leadership roles. While prepared to develop and implement care strategies, clinicians at large are wholly unprepared to take on the role of business manager. It’s simply not part of their training or daily experience.
“I know that personally: I never went to business school and have had to learn the hard way what it’s like to transition from a practitioner to a leader,” Neil Hattangadi, the CEO of San Diego-based Cortica, said during a panel.
Cortica, which integrates various medical and behavioral specialties relevant to autism therapy, now invests more in training its top clinicians to be managers and leaders. It’s an expensive prospect, in no small part, because that clinician is no longer generating revenue. However, committing to this training is critical for the organization.
“It’s so critical to have leaders on the ground who can balance clinical objectives with financial sustainability and can translate that down to the clinicians who are on the ground.”
CEOs and other top executives can also boost retention by working in all earnestness and seriousness to rebuild trust that has been weathered since the introduction of massive amounts of capital into the industry.
One of my tenets is that you just can’t lead if you don’t show up.
— Mark Shalvarjian, CEO of Gracent
In a very short time, the autism therapy space has gone from a highly fractured but intimate industry to one of rapid corporatization.
It’s dishonest to say that the industry hasn’t had a problem operating in keeping with the ethics that clinicians and entrepreneurs who built the industry to what it was before the increasing number of private equity-backed platforms blitzed the industry, buying up practices left and right. In that process, clinicians have seen their individual relative importance to an organization. diminished, and businesspeople they see as clueless to the reality of their work are setting unrealistic expectations for them and their coworkers.
Reworking the autism therapy industry’s relationship with capital
Many clinicians are wary of their corporate managers. Some executives are addressing it. More needs to be done to address it and ensure that fissures in trust don’t further erode the industry’s shared workforce.
“I have seen both the investing side and now the operating side, and I get to see the unrealistic expectations PE sponsors can sometimes put on you,” Seco said. “I’m always getting told that we need to push our BCBAs harder. But I’m like, ‘Guys, I don’t want to push them too hard because there’s so many options for them; they can go to any competitor down the street and get a job within two weeks.”
There are so many reasons why the go-to tools of private equity, even those geared generally toward health care, don’t fit within autism therapy. At its root, behavioral health is a fundamentally different industry. The nature of patient engagement with providers is unlike that in the physical health sector. Further, payers treat it much differently and, as many providers would put it, out of parity with the physical health care sector.
Behavioral Health Business“Given where the industry is — it’s a very young industry — I’m not sure that [autism therapy] fits into any of the boxes that a lot of investors have seen, and therefore, the playbook operationally is just entirely different,” David Iklodi, vice president of strategy and corporate development for Behavioral Framework, said during a panel.
Reworking the industry’s relationship with capital is also crucial to addressing the anti-ABA movement head-on. On top of the small but very effective group of advocates that needle the industry on the grounds of patient harm, this movement has a very easy time painting monied interests as villains in their narratives, especially at a time of rising populism and distrust in American institutions. On that latter point, large corporations and the banking/financial industry have the highest levels of negative perception among the American public of all major institutions, according to the Pew Research Center.
Brett Blevins, CEO and founder of Commonwealth Autism Care, demonstrated that relationships can trump even the mighty dollar when it comes to scaling a new company. While a likely exception given Blevins’ unique situation, edge cases and outliers can demonstrate where we could or should push what is considered average.
Commonwealth Autism Care established 12 centers in just 17 months, largely through Blevins’ time investment in establishing a network of BCBAs in underserved (nearly all rural) communities who shared his passion for expanding access to care. The company was bootstrapped, aided by some debt financing from a local lender. Blevins led a successful exit from a previous youth mental health company he founded.
Relationships make value-based care come to life
One near-universal thought ran through the panels I moderated and my networking discussions: the fee-for-service paradigm is a millstone around the industry’s neck.
Several of the panelists who joined the Autism & Addiction Treatment Forum are working on or offering holistic care models of various types — all of which seek to do more than simply drive claims to collect. They seek to encompass some aspect of the complicated care journey that those with autism and their families face. But they do so at their own financial risk.
The fee-for-service model simply doesn’t account for the value these models deliver. They often don’t compensate for the added clinical or nonclinical support. They also can’t conceptualize the importance or significance of a holistic approach beyond the sum of the various parts. The incentive payers place before providers is to simply narrow their focus, despite the clear benefit of looking at care through a wider lens.
I never went to business school and have had to learn the hard way what it’s like to transition from a practitioner to a leader.
— Neil Hattangadi, CEO of Cortica
The intellectual failing here is recognizing the relationship between several concepts. A short list includes the relationships between patient experience and outcomes, behavioral health and physical health providers, administrative burdens and outcome tracking.
It also fails to understand the relationship between care and health plan benefits. While health plans may make much ado over the rising use of autism therapy-related benefits, they often don’t value the relationship that quality care earlier in life can have on expense later in life.
Granted, about 20% of Americans change health plans each year, creating a substantial number of beneficiaries — and therefore spending — that gets lost each year. But that’s just the relationship that Americans have with health plans. It’s just a given and part of the buy-in to operate in that industry. However, about a third of people will come back to a plan they left within 5 years, meaning that most health plan spending isn’t totally lost when there is a disenrollment.
Practically, several of the providers that I’ve engaged with largely succeed in contract negotiations by making huge investments in personal and institutional relationships between their organizations and payers.
Jennifer Riha, chief strategy officer at the multispecialty nonprofit intellectual and developmental (IDD) care and services provider I Am Boundless, said it took her organization years to get the contracts it has that enable it to provide primary care, dentistry, psychiatry, ABA and several other medical specialties and social services.
“It didn’t automatically happen,” Riha said during a panel, adding that the company started its current relationship building with payers in 2018. “That initiative and the things that have grown out of all of that were what brought us to the place of being able to engage in these different kinds of contracts and being able to negotiate for enhanced rates.
“We had to spend a lot of time building that rapport and sort of proving to them that we were what we said we were.”
Companies featured in this article:
Apara Autism Center, Behavioral Framework, Commonwealth Autism Care, Cortica, Gracent, Havencrest Capital Management, I Am Boundless
