The autism therapy industry’s advancement toward holistic autism care models embodies a powerful through line in the collective story of behavioral health.
That through line, in part and in brief, is the fact that behavioral health must do more and be more than it ever has before. The need and opportunity for the industry to do well by doing good is staggering. How that ideal translates into objectives depends on which aspect of a behavioral health operation you consider. A clear theme emerges when it comes to service offerings.
After hearing from several autism therapy leaders in private conversations and on panels at INVEST, I’m convinced the myopic view of the autism therapy industry as the applied behavior analysis (ABA) industry is swiftly going the way of the buffalo. (That’s also the title of one of my all-time favorite albums: If you know, you know.)
Instead, the autism therapy industry is increasingly reflecting the complexity of the condition it seeks to address in its services. This makes holistic-care models, or at least packages of diverse services, ever more relevant.
This is a long-term development that will challenge the industry at a deep and potentially painful level. But it’s one that must happen for — if not for the sake of the industry itself — the sake of the vulnerable population for which the industry asserts it cares for.
The concept of wide adoption of holistic autism care models also has bearing on other big-time trends and forces in autism therapy specifically and behavioral health generally.
In this BHB+ Update, I go through three lines of thought:
- The connection between value-based care and holistic autism care models
- Investment and dealmaking considerations
- Always keeping the right things in mind
Value-based care is the industry’s stretch goal
Broadly speaking, I see the autism therapy industry swiftly moving toward something that resembles holistic autism care models at large. At the very least, it’s typical for providers to offer some combination of services. At least in my half-baked conception of the term, these models require more than multiple service types within a company. It requires all those services to be integrated, coordinated, closely tracked and available at all service sites where practicable.
At a practical level, behavioral health’s movement toward value-based care requires some level of action on aspects of care that are not squarely in the specialty of a behavioral health provider. Mental health and psychiatric providers need to ensure that chronic conditions like diabetes are being addressed. Addiction treatment providers need to account for underlying psychiatric and housing issues. Each of these examples shows the enormous bearing other aspects of care and health have on outcomes — outcomes for which a value-based contracted provider is accountable.
Tactically, a provider could make the unconvincing argument of justifying wide latitude on underperformance or outs for accountability measures. After all, a behavioral health provider is only looking at the behavioral health of a patient. Alternatively, a provider could try to pull physical health care providers into a value-based care arrangement. But who gets the financial value of improvements in health on either side of the physical-behavioral health divide? Plus, adding another party to negotiations does not just add to the complications of the conversation; it multiplies them.
In theory (definitely not in practice), it’s simpler to provide services that complement a behavioral health provider’s core offering. In the case of the autism therapy industry, this means considering adding speech, physical and occupational therapies (SPOT therapies), psychiatry, developmental pediatrics, dentistry, gastroenterology and even (perhaps especially) human services.
In that model, a company has insight into every aspect of a patient’s care. There is no waiting on reporting from a partner, no dysfunction with translating operations across separate enterprises. It gives providers the opportunity to, in the first place, speak with authority about the overall health of a patient and make the argument that they could be paid a premium for doing more to get better results. If not a premium, it demonstrates that a provider is deserving of other considerations like prospective payments, shared savings, bundled payments, etc.
Making this work requires investment in infrastructure. There’s no cutting corners on this. If you don’t have a proverbial conductor keeping everyone on the same sheet of music, you don’t have a choir. Making sure each service sings its part in harmony with each other requires capital to be pumped into technology and operations.
At the very least, the models demand software and staff to track outcomes, protocols for coordinating care, something like grand rounds to ensure providers are considering the big picture of a patient’s progress, multi-specialty revenue cycle management and any number of systems to try to tie it all together.
Taken together, the process of building the underlying structures and pushing toward value-based care demonstrates a lot. At the very least, it demonstrates sophistication and competence. And that has resonance across several constituencies.
Separating from the herd with investors
Behavioral health investors are more savvy than ever when it comes to the autism therapy space. There is a wide recognition that the early movers with the arrival of en masse private equity investors didn’t really think through what could go wrong by investing in a company in this industry. Many saw an unconsolidated industry with incredible characteristics, and that was enough for them. But that was then. This is now.
Now, these investors want to know that they are putting their money into companies that know what to do with it. That requires compiling a list of meaningful accomplishments outside of opening centers, hiring staff and growing a census. The “if you build it, they will come” nature of the industry makes scale or speed to scale unimpressive. What is impressive is building infrastructure and protocols that deliver replicable, high-quality clinical.
Leaning into holistic autism care models helps companies stand out in two ways. First, it shows the business itself is at a high level of maturity already. Second, it shows the business is oriented toward the future. In short, it shows sophistication.
There are several examples to turn to when it comes to investors backing these models. Just a few include Cortica, Gracent, MySpot, Lighthouse Autism Center and Hopebridge. Near the most intense realization of this model, nonprofits like I Am Boundless are winning over payers and government entities and building out margins in the process.
I do envision a world where autism therapy providers can get away with an archaic model of care. However, the pressure to do more will whittle down space for these types of providers. I would posit that increased demand for holistic care approaches forces any and all of the pure-play ABA providers to consolidate in a very small handful of very large organizations that need huge scale to make their model work. Even then, in the communities where they dominate ABA access, they will need to be the go-to partner in the wider, local autism care ecosystem.
Doing right by patients
As a parent, one of the most compelling aspects of holistic autism care models is the potential ease it brings to the patient experience. Rather than running all over a city, parents and caregivers can simplify their time spent on their children’s care.
The immense stress of caring for children with autism manifests in profound ways. Tragically, this can, in turn, impact the health of the child. Divorce rates for parents of autistic children are double that of other couples, according to one study. While not accounting necessarily for children with autism, children whose parents divorce often experience worse physical and mental health outcomes than those of children of continuous relationships.
Going beyond travel convenience, it simplifies the administrative burden placed on caregivers. Rather than tracking multiple providers that are in-network with a health plan, having one place to go can take a load off of already burdened people.
And all that says nothing about the potentially improved outcomes of the patient. Taken together, easing and improving the condition of both families and patients is the prime directive for autism therapy providers. If it isn’t for some, it’s time for those folks to find other work. And they will. The industry has a remarkable immune system for those not all in on this mission.
Given the retention challenges of industry, I feel confident that only the true believers — at least those of remarkable constitution — can remain in the autism therapy industry for a meaningful amount of time. This applies to investors and executives, too. Several have made a flight from the industry after being stung for ill-timed at least and ill-conceived at worst incursions in the autism space. Those that remain, in their own way, are pushing to some manifestation of the idea of the autism therapy industry recognizing the wholeness of its patients’ health. Holistic autism care models, however they look, show that at least some portion of the industry is heading in the right direction.