Optum is reportedly executing a multi-pronged plan to curb spending on applied behavior analysis (ABA) provided to patients covered by Medicaid.
The insurer targets its Medicaid-contracted autism therapy networks in Arizona, Nebraska, Tennessee, Virginia, New Jersey, Indiana and Louisiana, according to a report by the nonprofit investigative journalism outfit ProPublica. The plan is a response to increased rates of diagnosis and increased utilization of, and, therefore, spending on, autism therapy.
Optum has seen significant increases in Medicaid autism therapy networks. Members seeking coverage of ABA have increased 20% over the past year, while spending on ABA has increased by $75 million. ProPublica reports that Optum expects to spend $290 million on ABA in 2023. The report states that Optum’s plan includes cutting “40% of Louisiana groups that offer ABA therapy.”
Citing documents it claims it obtained from Optum, the report states that Optum will cut costs through a combination of the following: ceasing to add new providers to certain networks across all markets, canceling provider contracts with providers deemed to be “outliers” and renegotiating rates that are “significantly higher than Medicaid natl (sic) average.”
Representatives from Optum and UnitedHealthcare, both entities within the UnitedHealth Group (NYSE: UNH) conglomerate, said in a statement that the ProPublica article “grossly misrepresents our efforts to ensure the people we serve are getting the most effective, evidenced-based care for their needs.”
The article details the specific experience of a mother-child duo and their provider, who have experienced severe challenges in getting coverage for what the provider deemed medically necessary care. It also collates reactions to ProPublica’s findings by several experts, many of those cited question the validity of Optum’s plans.
While Autism Business News cannot specifically confirm some of the specifics of the report, what ProPublica reported on Friday illustrates and illuminates many challenges autism therapy providers describe to us.
Previous reporting has shown that payers evolve their tactics in what providers perceive as bad-faith efforts to put off paying legitimate claims. Last year, sources described a new tactic called “payer ghosting,” where payers simply don’t respond to provider communications instead of outright denying a claim.
Throughout the year, health plan executives have highlighted increased benefits spending in Medicaid, which includes autism-related services. During the third-quarter earnings call season, several executives at the largest payers noted that increased behavioral health spending was impacting their bottom lines. David Cordani, the CEO The Cigna Group (NYSE: CI) noted then that behavioral health therapy utilization had nearly doubled over the previous five years.
Optum’s reported moves in the Medicaid space are especially profound relative to other segments of the insured population. Previous research finds that children with Medicaid coverage experience autism at twice the rate of those with no coverage or private coverage and seek care at slightly higher rates. And the trends that are the impetus for the decreased access are likely to remain constant at best or increase at worst. Overall, autism diagnoses have increased at a staggering rate. An analysis of claims data finds that as many as 6.3 persons in 1,000 have an autism diagnosis, marking a 175% increase from 2011 to 2022.
