Autism therapy providers often feel like they find themselves clashing with payer partners to get their clinical hour recommendations.
While actions by health plans appear to be pressuring autism therapy providers to provide fewer clinical hours, providers are hoping to get payers onboard with increasingly customized and sophisticated treatment plans. The proliferation of care outcome measurement is making providers more confident that their approach will be what is right for a patient, making them ever more resolute in their clinical recommendations.
“We take a really serious stance around not altering the clinical recommendation or the prescription for a specific learner based on what a payer stakeholder as to say about what may or may not be appropriate for that child,”‘ Krista Boe, chief clinical officer at Miami-based autism therapy provider Acorn Health, told Autism Business News.
Treatment plans at Acorn Health, on top of being based on a clinician’s best judgment, are also backed by about seven years of the company’s outcomes data. The company is developing a tool to help standardize its hourly dosages. The tool accounts for several patient factors and delivers a recommended range of hours. The move also helps support new and young board certified behavior analysts (BCBAs).
“It takes time to be able to get proficient in what makes sense for prescribing hours,” Boe said. “I, in the beginning [of my career], was just cut completely loose, and we want to make sure that we’re not doing that to the best extent possible.”
On top of gathering and assessing its data, Acorn Health established an independent clinical advisory board to help keep the organization’s internal learnings rooted in the wider world of clinical research. That board includes Greg Hanley, the CEO and owner of FTF Behavioral Consulting.
“We are a practitioner group that is not scouring the literature — myself included — nearly as often as we should because we’re busy providing care to people,” Boe said. “When we generate ideas or develop new tools, we’re sending them back to them to make sure that they’re in tune, in line with then-current literature.”
Data-driven assessment decisions may still lead to the intensive hours that health plans seem eager to diminish, and industry critics decry. Intensive hours may still be clinically necessary in the case of young patients with speech challenges, Hanna Rue, chief clinical officer for Baltimore-based autism therapy provider LEARN Behavioral, told ABN. Things may look different for older patients. Outside of early intervention, lower-hour programs focused on coping, social or other behavioral challenges may be more appropriate.
Parents and families may not be able to or initially willing to engage with higher-hour treatment plans, requiring clinicians to ease families into a program until they reach the prescribed dosage of hours.
Still, Rue acknowledges that some autism therapy providers push the maximum hours. But that’s not the approach LEARN Behavioral has taken. It has been able to generate respect from health plans for their tailored clinical recommendations.
“What we’ve been able to show payers is that we have kids that are [progressing] in their care and can actually decrease hours in a systematic way,” Rue said. “If they allow us to be successful with our clinical recommendations on the front end, then we can demonstrate clinical excellence.”
Firmly sticking to treatment recommendations requires security from following clinical best practices and a willingness to prove outcomes through sharing data. Being on top of data and sharing it with stakeholders should be a “no-brainer,” said Themis Gomes, the CEO and owner of Omaha, Nebraska-based autism therapy and pediatric services provider Behaven Kids. Organizations that do what they say they do will be able to prove their positive impact, she added.
“What we need to do is just show the outcomes and the data,” Gomes said. “At the end of the day, we should be focused on effectively improving that child’s life, and therefore the family’s life, and therefore the community’s life, and therefore reducing costs down the line for an insurer or even the government.”
Historical concerns about maximizing hours in autism therapy don’t come from nothing. Gomes acknowledges that payers’ scrutiny stems partly from fears of fraud, waste and abuse. But for her, the overwhelming demand for services in the rural Nebraska market leaves her and Behaven Kids with more than enough work.
What’s more, the shortage of BCBAs in the state limits options for autism therapy organizations like Behaven Kids when it comes to finding clinicians whose style fits with the needs of patients.
“It can’t be a cookie-cutter approach,” Gomes said. “It’s about getting the right dosage for that child and the personalization of care.”
