Pressure On Applied Behavioral Analysis

In what is the latest salvo in the push to contain rising national spending on applied behavioral analysis therapy for children with an autism spectrum diagnosis, insurer Anthem has moved to authorizing units or hours every week, not months-long like many insurers do. Will others follow? Answer is yes, at least directionally, although managing these services and deciding the right level of care and amount of hours so frequently comes with more challenges, both for parents and businesses. Parents want to see progress ahead of their kids getting into 1st grade and if the hours change or the amount of insurance coverage changes each week, this can be disruptive. The businesses running these services need to recruit the behavioral analysts and keep the business functioning well, which is why many set up programs for 6-8 hours a day. Insurers and states want to make sure they are paying for actual therapy. There’s the rub. Many we’ve interviewed say kids under 5 barely can sit still and benefit from 30 minutes of therapy - be it speech therapy or occupational, much less behavioral. While applied behavioral is evidence based and considered a gold standard for helping people manage their autism diagnosis, there are questions on how much should be paid for by insurers vs. the parents themselves, and how much is truly medically necessary. These are not new questions but they come amidst meaningful growth in spending nationally on applied behavioral analysis which may be just ~1-2% of total medical spending but it’s a growing portion of total behavioral health spending, so there is now more policy discussion on how to sustain these benefits. Insurers likely use AI to operationalize the process, but for operators relying on 1-3 years of ABA at 30+ hours a week for children, it’s a signal that there likely needs to be variation in the hours across kids served, tapering of those hours, meaningful progress, and justification that every one of those billed hours or units involves actual behavioral analysis.