This is an exclusive BHB+ story
The autism services industry is getting its groove back after some high-profile hiccups over the last few years.
Specifically, investors have reupped interest in the space after a two-year lull. But as the industry comes into the limelight, providers continue to face significant challenges, including potential reductions in Medicaid funding and exchange-marketplace subsidies, while simultaneously working to develop emerging leaders from a workforce with less experience.
Earlier this week at the Autism Investor Summit, the Behavioral Health Business team sat down with industry insiders to talk about quality, reimbursement and what’s next for the autism industry.
In this latest edition of your exclusive BHB+ Update, I’ll explore some of those takeaways, along with the following questions:
– Why all providers (even those not accepting Medicaid) should keep an eye out for federal regulation changes
– What it takes to get business and clinical staff on the same page
– How data capture is critical in establishing quality
The perfect storm
All eyes have been on Medicaid when it comes to the future of autism services. And it’s true any changes to Medicaid would have significant implications, as Medicaid covers nearly half of all children with autism and pays for most adult residential programs, according to Autism Speaks.
But that’s not the only change in health care coverage that could impact the coverage of individuals with autism.
The Affordable Care Act (ACA) mandated health exchange marketplaces where members can compare plans. Many families sought coverage through these marketplaces. However, there may be shakeups in this coverage as well.
“Not only are we monitoring to see what’s going to happen with Medicaid cuts, which is obviously going to be devastating, beyond imagination,” Yagnesh Vadgama, vice president of Clinical Care for Autism at Magellan Health, said at AIS. “But also, under Biden’s Inflation Reduction Act, there were subsidies for people to get into the exchange market, and that’s going to be important for us all to monitor as well, because through adverse selection for our actuaries, what we’re able to see was shifting of membership from one benefit to another when one benefit ends. So you think about when the ACA first went live, how many people overnight jumped into the exchange market, largely driven by this new benefit.”
Those subsidies are set to expire at the end of the year. And there are still a lot of unknowns when it comes to what the Republican-led government will do regarding the expansion of these subsidies.
If there are cuts to Medicaid and subsidies for health plan marketplaces expire, it could jeopardize coverage for millions of families seeking autism care.
The potential end to marketplace subsidies means that even ABA and autism service providers that do not accept Medicaid could be impacted by large-scale cutbacks to health care programs in the country.
“I think it’s going to be terrifying because what we have seen on the exchange market is many people getting in and just accessing ABA,” Vadgama said. “So we’re seeing people getting services, and they’re only getting [health plan coverage] because they need access to [one] thing, which is good and what you’re supposed to do. But if both Medicaid and the subsidies [are cut], I think it’s going to be big trouble right away.”
At the end of the day, more cuts to Medicaid and marketplace subsidies will just mean fewer kids accessing autism services. It’s a loss for families, and it could be a loss for businesses – especially those treating vulnerable populations.
Training for a younger, inexperienced BCBA workforce is critical
More than 50% of BCBAs were certified in the last five years. There are few other industries where the bulk of the workforce has five years of experience or less.
This can make it a challenge to find new leaders. Still, some providers are more interested in leadership potential than in the number of years they have spent in the field.
“On the clinical director side, we’re not looking for the person with the longest BCBA experience,” Michael Cairnes, CEO of JoyBridge Kids, said at AIS. “We’re looking for the person who has leadership acumen, and we are constantly looking and interviewing, and still searching for those folks.”
Mount Juliet, Tennessee-based JoyBridge Kids is multidisciplinary autism therapy with a dozen centers in the south eastern part of the country.
Even with critical leadership potential, the move from clinician to director is a big jump. BCBAs who are highly skilled on the clinical side often lack the business savvy or need education to easily transition.
“We promote clinicians to leadership positions and roles on the executive team because they’re excellent at what they do,” Jamie Bassos, executive vice president of BrightBridge ABA, said at AIS. “They’re excellent clinicians, but leading a team, managing people and operations is a completely different skill set than the actual clinical work that they do on a day to day basis. So you’ve got clinicians who are put into leadership positions that are now reactive, which leads to high burnout, and then high turnover.”
North Carolina-based BrightBridge ABA is an autism service provider with three locations in the state.
Training and supporting new leaders as they learn about operations and the business side of health care can be critical for overall success. And while it does take time and resources to invest in these efforts, at the end of the day, it can avoid turnover and frustrated teams.
“[Clinicans and business professionals] are speaking completely different languages, and you’ve got to get everybody on the same page,” Bassos said. “But in order to do that, everybody needs support and training. It doesn’t just happen magically. It’s not a learn-on-the-job type of position. There has to be some succession planning. There has to be some training and support for those clinicians that are moving into those roles so that they can be successful and that their teams feel properly supported.”
My take-home message was that hiring great clinicians with leadership potential can be a smart move, but only when done properly with the right support in place. If BCBAs are hired for leadership roles with no training wheels it can lead to frustration for everyone.
We need a definition of what quality is
Quality discussions in behavioral health frequently resemble philosophical dialogues rather than practical how-to guides.
However, providers are stressing the importance of having standardized quality metrics in the future – to help not only improve care but also get on the same page as payers for reimbursement.
“I’ve spent most of my career running hospitals, medical groups, and health plans where we measured everything we thought we knew about quality, and there were publicly reported core measures for processes and outcomes. And I’ve been astonished … at how we haven’t defined what quality is,” Jason Barker, CEO of ABA Centers of America, said at AIS.
Fort Lauderdale, Florida-based ABA Centers of America, founded in 2020, grew its revenue over a three-year period ending in 2023 by 32,192%, according to the Inc. 5,000 list of the fastest-growing private American companies.
“How are your clients doing on a map from one assessment to the next? And the fact that you asked the question, begs the question, why are we not, as an industry, doing that? Because my guess is, everybody in this room who’s a provider is probably an outstanding provider,” Barker continued. “There’s a lot of people in the field who are not. And why wouldn’t we want to be able to differentiate ourselves from them by being able to demonstrate their quality?”
Without standardized quality metrics, it can also be more difficult to negotiate with payers. Vadgama noted that because the industry lacks standardized quality metrics, what is and isn’t exceptional care is highly subjective.
What’s more, some providers put quality into two buckets: operational and care. And each one could benefit from more standardization.
“The quality suffers in different size organizations in different ways. Some of the larger organizations have grown so quickly that they’ve lost track of quality along the way. Again, standardizing health in a big way,” Molly Ola Pinney, founder and CEO of Global Autism Project, said. “And then on the other side of it, we see clinician owners who are prioritizing quality, which is great, but sometimes at the expense of running a sustainable business and organization.”
Data capture could be a key solution in proving efficacy in treatment and keeping the books in order.
“Our organization is very data driven and disciplined, and I think that’s helping us a lot. So when you think about growing quickly, and you could possibly lose your clinical quality because we’re so data-driven, we literally capture every bit of data, whether it’s through our Catalyst or assessments,” David Harbour, CEO of Centria Autism, said. “We keep it in a database where we can track and trend over time, to see if we think our quality is flipping, whether it’s just the delivery of the treatment, hours and actual outcomes and the therapy. So to be very data-driven, you have to be very disciplined as well with respect to growing in a way that doesn’t hurt financially.”
Farmington Hills, Michigan-based Centria Autism is an autism provider with locations across 12 states.
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