The next chapter of the autism therapy industry’s story will look very different from previous ones.

Already, the industry has gone from obscure and mom-and-pop to mainstream and private equity backed. Now, the forces driving the industry require it to do much more than ever before. To some degree, these forces will require the industry to step beyond its core therapy: applied behavior analysis (ABA).

“We’re trying to transition the field from being fragmented and siloed to being whole-child and integrated,” Neil Hattangadi, CEO of the San Diego-based multispecialty autism therapy provider Cortica, said during a panel at the BHB Autism & Addiction Treatment Forum in Chicago.

Mark Shalvarjian, the CEO of Gracent, also a multispecialty autism therapy provider, shared similar sentiments. He described the company’s objective of being a one-stop “pediatric therapy company.” At the time of the panel, ABA generated a majority of the company’s revenue.

“We have neuropsychology at the front end,” Shalvarjian said. “Where we are really focused is on bringing together speech, occupational therapy, mental health and ABA services all at once and working with the families of the children that we serve to determine the best care plans for the whole child.”

The vast majority of children with autism also have comorbidities. One study placed the rate of those with any comorbidity at 74%. Other research finds that the most common comorbidities include developmental coordination disorder (87%), sleep-wake problems (43%), gastrointestinal problems (39%) and ADHD (37%). 

Often, autism therapy companies zero in on one modality and population, often intensive early intervention for the youngest patients. This myopic focus was at the heart of some of the largest autism therapy platforms in the U.S. However, it does not account for the lived experiences of patients and their caretakers, who often spend several hours a week in multiple, different clinics to get various therapies.

“We work very hard to listen to the parents of the children that we take care of and meet them where they are and meet their needs,” Shalvarijan said.

Renewed focus on quality

Another likely defining element of the near future of the autism therapy industry will be care quality. The infusion of capital has created more autism therapy companies for consumers to choose from. Payers are increasingly interested in managing increased utilization of autism-related benefits. Both parties are going to want to be assured they are getting what they pay for.

And that doesn’t even consider the increasingly potent voice of anti-ABA groups.

Shalvarijan pointed to Gracent’s quality initiatives as being the most meaningful undertakings of 2024. Previously, the company appointed a senior director of training and quality to spearhead the daily management of clinical quality. This person works directly with segment and clinic-level clinical directors to measure and assess quality outcomes.

“We really believe in making sure that we’re tailoring all of the therapy that a child is receiving across all the disciplines that we practice to their specific needs,” Shalvarjian said. “It takes up more time up front, but ultimately, we think that it’s a more efficient care model, a more appropriate care model, and results in higher quality outcomes.”

At Cortica, the company has built a “whole-child scorecard” that spans 10 different domains that address medical, behavioral and developmental measures, Hattangadi said. This helps to keep care quality at the forefront and to ensure coordination of care. Cortica offers medical services where Gracent does not.

Increasing care quality via holistic models is getting traction with payers, Hattangadi said.

“All payers are talking about whole person care,” Hattangadi said. “That collaboration with really thoughtful, engaged payer counterparts has been great for us this year.”

Value-based care is still very rare in the autism therapy space. Cortica happens to be an exception: It has a number of alternative payment arrangements that embrace principles of value-based care.

Much of the discussion about value-based care in autism therapy focuses on utilizing technology to track outcomes and make assessments about the effectiveness of care relative to clinical outcomes and financial standards.

Investments in staff

New data from the autism and IDD industry software provider CentralReach shows that employee turnover remains remarkably high. Projecting through the end of 2024, the firm estimates that provider companies with more than $30 million in revenue will experience 104% turnover, those with between $5 million and $30 million will experience 90% turnover, and those making less than $5 million will experience 78% turnover.

This demonstrates why workforce issues are the primary challenge of the autism therapy industry. The highest rates of turnover are seen among registered behavior technicians (RBTS), who are the frontline care force and work with and at the direction of board-certified behavior analysts (BCBAs).

“[ABA] the only field of medicine I’ve experienced where the main caregiving practitioner is often undertrained relative to the need and leaves the field within six to 12 months,” Hattangadi said. “I think we together need to figure out how we make this a sustainable field [in partnership with payers].”

Another compounding factor in employee retention is low and/or long-stangant fee-for-service reimbursement rates leading to relatively low wages for RBTs.

While BCBA turnover is lower, there is a steep shortage relative to demand. According to one study, the number of unduplicated job postings for BCBAs totaled about 65,000 in 2023; the total number of professionals who have ever become BCBAs totals about 66,000. The number of job postings was up 9.2 times compared to 2017 levels.

Both Hattangadi and Shalvarjian said their models slightly deemphasize ABA compared to the rest of the industry by providing for more and more specific needs. But they also said that investing in RBTs is vital to ensuring they have enough BCBAs. Their holistic models also help ensure that workloads for BCBAs and RBTs remain manageable.

At Cortica, BCBAs and RBTs spend less time with each individual patient since they are giving treatment in concert with other clinicians.

Gracent has also made significant investments in training both clinicians and businesspeople alike in the specifics of managing a multidisciplinary company. Many professionals that start off as clinicians often lack training in being a corporate team member or lack other managerial skills. Shalvarjian said the company is pushing its leadership via training to enable decision making “down through the organization so that we can grow in a very disciplined way.”