The Forces Shaping the Next Round of Innovation & Investment

The Delicate Balance Between Clinical Excellence & Reimbursement

The Delicate Balance Between Clinical
Excellence & Reimbursement

Across behavioral health, and crucial to the advancement of ABA therapy, is the growing need to define clinical excellence through patient outcomes. The pursuit of standardized reporting, diagnostic tools, and streamlined processes shines a light on the industry’s aspirations for enhancing the patient care experience, while proving to payers and families that ABA therapy should be the market standard for care.

Outcomes measurement has been a historically challenging concept across behavioral conditions, and particularly for individuals with autism.

While autism diagnoses are formed from standardized assessments, there are a series of critical steps and decisions that affect care plans and development goals. Even before therapy begins, there can be a wide range of factors that impact future development, from the age of diagnosis to the often months-long lag between treatment authorization and access to the requisite care. Furthermore, constraints on access to care can be an impediment to timely and consistent treatment. Additionally, care plans can vary substantially on a case-by-case basis and take a variety of forms.

To start, there is a wide variety of acuity levels across the autism spectrum, which can be difficult to define and often requires discussion with providers and insurance around the requisite amount of authorized treatment.

Once a care plan is created, there are various care modalities including in-home, center-based, school-based, that impact both the type of therapy that can be delivered (e.g., socialization techniques that are more difficult to bring in-home), and the frequency of care.

Alongside ABA therapy, individuals may also receive care plans for speech, occupational, or physical therapy to augment their behavioral sessions. Each individual on the autism spectrum requires a unique and individualized care program, adding layers of nuance and complexities to creating comprehensive standards and benchmarks for providers to follow.

While the industry is still in the early innings of outcomes management, the growing attention from all stakeholders is driving operational investments forward. Providers (helped by private equity infused capital) have continued to invest in technologies and operational efficiencies to support outcomes measurement and management. The integration of technology into the continuum of care is central to achieving more data-driven and impactful insights. To create accurate benchmarks, both providers and operators need to be able to collect, synthesize, and interpret a time series of data sets across their populations.

While many clinic-based programs have integrated operational KPIs and benchmarking around areas like attendance, authorization fulfillment, and program completion rates, the industry is just scratching the surface of clinical outcomes management and reporting.

Across behavioral health verticals there is excitement around the enhancements that newer technologies, such as generative AI, that can help deepen our ability to analyze outcomes data and create industry standards for clinical excellence.

Developing sophisticated benchmarks for autism therapy, will require alignment from all stakeholders including BTs, diagnosticians, and the medical research community, and will require buy-in from parents, caregivers, payers, and healthcare administrators.

While the common goal for developing standards for clinical excellence based on the quality of care delivered is generally accepted, the reality is that when benchmarks are created there will always be pushback from industry players that fall in the bottom buckets.

Grounding research in a diverse set of both quantitative and qualitative data will be key in projecting credibility to the markets and the broader autism community. Ultimately, the shift towards outcome-based care will play a critical role in advancing the relationship between ABA providers and payers. Historically, the tension between ABA providers and healthcare insurance payers primarily stems from disputes over reimbursement rates, coverage criteria, and administrative complexities (See Figure 6).

ABA providers often contend that insurance companies offer inadequate reimbursement rates for their services. As noted previously, ABA therapy requires specialized training, materials, and skilled professionals, and providers may argue that reimbursement rates don’t accurately reflect those expenses. Furthermore, disagreements arise over coverage criteria, as insurance payers might have strict requirements for diagnosing and treating autism, potentially limiting the number of sessions or types of therapy covered.

FIGURE 6: AUTISM PATIENT EXPERIENCE & OUTCOMES

Providers often believe these restrictions hinder their ability to provide the most effective and individualized treatment plans for their clients. Compounding the care delivery tensions, administrative hurdles, such as obtaining pre-authorization, submitting claims, and navigating complex billing processes, can also create friction between ABA providers and insurance payers. The administrative burden can slow down the delivery of care and place additional stress on providers’ resources. Overall, the tension revolves around finding a balance between providing comprehensive and effective ABA therapy while dealing with insurance companies’ regulations and reimbursement practices.

From the insurance perspective, payers, tasked with ensuring the financial stability of their health plans and providing equitable coverage, face complex challenges in determining appropriate reimbursement rates. Payers’ primary concern lies in effective cost management and maintaining consistency across their policies.

Alongside the necessity of curating a base of accessible providers for therapy services, payers also need to balance the needs of their members while controlling premiums to prevent dissatisfaction and potential attrition in their customer base. Adjusting reimbursement rates can directly impact premiums, potentially leading to varying costs for policyholders, a scenario payers aim to avoid. When making determinations on coverage and creating networks, evidence-based practice serves as a cornerstone for payers’ decisions. Payers are responsible for allocating resources judiciously, and they require assurance that the therapies they cover yield meaningful outcomes for individuals. A robust body of data-driven evidence can influence payers to consider adjusting reimbursement rates in recognition of therapies that deliver substantial improvements in quality of life.

Given these realties, it’s critically important for providers to demonstrate the efficacy of ABA therapy. The advancement of outcomes-based reporting can help drive the alignment of providers and payers together. Through the increased investment in clinical research and technology that has come alongside the groundswell of support for behavioral health, providers and therapists can create data-backed, clinically relevant standards that form the basis for benchmarks, aligning payers and providers, and therefore expanding access to quality autism care.

As the care gap closes, the opportunity for outcomes-based reimbursement will increase and set the stage for value-based care contracts and alternative payment models. As mentioned earlier, individuals with autism often receive a wide variety of treatments across occupational therapy, physical therapy, speech therapy, and medication plans alongside their behavioral treatments. This complex array of support and resources provides an opportunity for bundled payments structures incentivizing care teams to work collaboratively to improve treatment outcomes for their patients.

While the industry has begun to experiment with value-based care (VBC) contracts in autism, there is skepticism that we are too early on the curve of outcomes tracking and benchmark for payers and providers to get comfortable with the risk appetite associated with VBC programs. As macro healthcare themes around enhancing care quality and cost containment converge with the behavioral health market’s advancements in technology and outcomes management, the opportunity for innovation and platform differentiation will grow.