Autism diagnosis rates are spiking, and providers increasingly see technology as a means to increase access to applied behavioral analysis services in underserved communities.
Rising autism diagnoses are causing increased demand for applied behavioral analysis, a therapy also known as ABA that provides one-to-one services primarily for children with autism, That demand has strained the short supply of specialists. For families in areas with few providers and disproportionately high autism rates, children can wait more than year before a professional is available.
Autism prevalence affected 1 out of 36 children in 2020, up from 1 in 44 in 2018, according to data the Centers for Disease Control and Prevention released last month. Rates were higher among Black and Hispanic children.
Technology, especially telehealth, may be a solution to bridging this gap, which is why more applied behavioral analysis providers are testing this model while offering personalized services and rethinking reimbursement strategies. Critics are unsure if technology can replace in-person care and are waiting for better standards of care before investing in it.
“Access to care and access to diagnosis is really challenging in those communities,” said Justin Funches, president of autism services at Chicago-based applied behavioral analysis provider Learn Behavioral. “There is an unbelievable shortage of folks available to diagnose autism and there are really long waitlists.”
Learn Behavioral occasionally uses telehealth with its board-certified behavioral analysts, who virtually supervise caregivers delivering one-on-one services, Funches said. “Technology has a tremendous opportunity to break that cycle and allow diagnosticians to get into these communities [and] do it more efficiently and earlier on,” he said.
About half of its patients are Medicaid beneficiaries, he said. And poor access to high-speed internet in many communities with the greatest needs remains an obstacle, he said.
Kelly Bozarth, CEO of private equity-backed applied behavioral analysis provider Center for Social Dynamics, said her company shifted to telehealth during the early days of the COVID-19 pandemic.
After a positive response from patients, the Alameda, California-based provider expanded its offerings to include virtual reality sets from autism tech startup Floreo to provide personalized, interactive education services, she said. Technologies such as those allow for flexibility, said Bozarth, whose company provides services in urban and rural areas of California, Colorado, Hawaii, Oregon and Washington.
This approach also facilitates recruitment, Bozarth said. “Going virtual helps us because we can hire anywhere,” she said. “We don't have to hire [a role] where someone [has] drive to a home. Remote roles are quite coveted. People don't want to go back in person as much as they used to.”
Jackson Family Human Services, an applied behavioral analysis firm headquartered in Victorville, California, began using telehealth to mitigate a shortage of board-certified behavioral analysts available for in-person treatment. Yet founder and CEO Harry Jackson remains skeptical that remote care measures up to traditional therapy, he said.
“In-person is always better,” Jackson said. “Some areas just don't have the option. If we go out to our rural areas, for instance, it’s not realistic for me to have a person every single day there. There’s no way to exist without telehealth.”
Spooked by Elemy
Telehealth therapy can be more efficient, said Jeff Beck, CEO of Richmond, Virginia-based virtual applied behavioral analysis company AnswersNow. While many in-person clinics recommend 20-40 hours per week of applied behavioral analysis therapy, AnswersNow only asks for four hours, Beck said. Working with remote therapists also means no waitlist, he said.
AnswersNow offers care in Virginia and Georgia and many of its patients are Medicaid enrollees, Beck said. AnswersNow is looking carefully at expanding because it wants to preserve quality, he said. According to Beck, other companies that attempted to “blitz scale” applied behavioral analysis therapy have experienced difficulties that reflect poorly on the sector at large.
Elemy, for instance, encountered problems after making a splash and attracting more than $320 million in venture funding. Last year, the Miami-based company underwent four rounds of layoffs and cut off services without giving three months’ notice. Business Insider reported last month that the company is planning to abandon its autism services, which founder and CEO Yury Yakubchyk denied in an email to Modern Healthcare's Digital Health Business & Technology. Applied behavioral analysis continues to account for 100% of the Elemy's revenue, he wrote.
Nevertheless, observing Elemy made Ellen Herlacher, a principal at venture firm LRVHealth, reluctant to back virtual applied behavioral analysis companies, she said. “There was a disconnect between the intention of the company and its ability to actually deliver,” she said. “What needs to happen is these businesses to stabilize in a way that also maintains high-quality care.”
Health insurance companies are required to cover applied behavioral analysis services in person and virtually and are developing standards of care. Costs can reach $60,000 a year, according to the CDC. But the mandate to cover remote care has created a market for low-quality providers and high clinician turnover, said Yagnesh Vadgama, vice president of autism clinical care services at the insurer Magellan Health.
Technology can be part of autism care and inform practices that lead to better clinical standards, but isn't a solution unto itself, Vadgama said. Magellan Health is attempting to apply value-based models for these providers and will use its own set of clinical outcomes to determine reimbursement, he said.
“We just have to be cognizant of ‘What is that technological application going to do to advance the life of the of the autistic individual?’ If it’s only going to do something on the margins or there's no outcomes that are going to be associated with it, that's something that we have to really weigh,” Vadgama said. “What I worry about with technology is that we miss the human element of what we do.”