This is an exclusive BHB+ article.
The era of high-intensity applied behavior analysis (ABA), with registered behavioral technicians (RBTs) logging 30 to 40 hours of services per week, may be coming to an end.
Last week at Autism Investor Summit West, experts from across the country gathered to discuss the industry’s future against a backdrop of state Medicaid cuts and a federal spotlight on improper payments.
To be clear, the conversation wasn’t about dethroning ABA from its place as the gold standard of care. It was more focused on alternatives to keeping children in therapy for a high number of hours with no end date in sight. Instead, providers expressed interest in models that demonstrate outcomes and prove operational efficiency.
Providers are also eyeing multidisciplinary care models — adding speech, occupational and physical therapy to their offerings — as a way to insulate their practices from the reimbursement headwinds facing the ABA industry.
In this exclusive BHB+ Update, I will explore:
– Why lower-intensity ABA models may be the future of care
– How occupational and speech therapy can be integrated into services
– How investors feel about the autism services industry
Lower-intensity models of care a running theme
It’s not uncommon to see ABA plans with children prescribed 30 or 40 hours a week of services. But this may be changing as payers struggle to keep up with rising costs of autism services.
“Payers are applying heightened scrutiny on billable hours,” Jessie Gentil, principal at Health Enterprise Partners (HEP), said at AIS West.
HEP is a private equity firm that has invested in several behavioral health providers, including Proven Behavior Solutions, Aware Recovery Care, Behavioral Centers of America, BrentCare and NOCD.
Jessie Gentil, principal at Health Enterprise Partners (HEP), talks at AIS West. Photo credit: BHB
This is particularly true when it comes to state Medicaid plans, some of which have already proposed a cap on either weekly ABA hours or even lifetime ABA hours. For example, Indiana implemented a 4,000-hour lifetime limit on the number of ABA hours. There are some exemptions.
To address this evolving landscape, the industry is shifting its focus from quantity to quality and developing concrete ways to demonstrate outcomes.
“Payers are looking at this and saying we don’t want to pay for hours anymore, we want to pay for progress,” Daniel Byrdsong, CEO of Surpass Behavioral Health, said at AIS West.
Surpass Behavioral Health is an autism provider with locations in Georgia, Kentucky and South Carolina. It offers home, school and clinic-based services.
Many providers are stressing that more hours don’t always correlate with better care for patients.
“We’ve lost our way with looking at ‘what does the research indicate,” Yagnesh Vadgama, vice president of payer strategy and network development at CentralReach, said at AIS West.
CentralReach is an AI-powered electronic health record provider for autism and IDD providers.
Yagnesh Vadgama, vice president of payer strategy and network development at CentralReach, speaks at AIS West. Photo credit: BHB
As a result, the pressure is on for providers to demonstrate meaningful outcomes, which is difficult in a field that has yet to establish industry outcome standards, as well as an end to treatment.
“We know when cancer treatment is done. We don’t know [that] in autism,” Timothy Yeager, chief clinical officer at Centria Healthcare, said at AIS West.
Centria Healthcare offers ABA and diagnostic services in 11 states. It provides in-home and in-clinic services.
As a result, we’ve seen a new wave of companies that are changing the focus from high-intensity hours to fewer hours with higher-level clinicians.
Anna Wang, an investor from mental health-focused venture capital firm GreyMatter, said that in the future, the ideal platform investment would move away from traditional high-intensity, therapist-led ABA models and toward more parent-mediated virtual interventions. She noted her firm’s investment in Luna Autism, a virtual ABA platform.
“It [requires] only five to 10 hours a week … versus some of the other models that may require 30-plus hours,” Wang said.
She noted this type of model can be delivered through telehealth and reach underserved populations that often struggle to access the traditional models.
But this isn’t the only type of platform that is cutting back on traditional high-intensity models. AnswersNow, which directly links families to BCBAs on its virtual platform, and Avela Health, also a virtual autism support provider, offer alternatives to the status quo.
Diversification of services key
Shifting ABA models wasn’t the only theme emerging from AIS West. Many providers are also looking to multidisciplinary approaches to care. This is driven by two factors: It helps diversify their service portfolios, and these models show stronger patient outcomes.
This is particularly important as ABA continues to see rate cuts across Medicaid plans. As a result, more providers are offering and very often co-locating services such as occupational therapy, speech therapy and physical therapy.
“By having a portfolio of services, if you’re getting pressure from commercial and Medicaid on the ABA side, then you can fall back on speech and occupational therapy,” Michael Cairnes, CEO of JoyBridge Kids, said at AIS West. “It [builds] a moat around the business.”
JoyBridge Kids is an autism service provider with practices in Tennessee and North Carolina. In November, it merged with Pediatric Advanced Therapy, adding multidisciplinary assets.
While many operators are turning to multidisciplinary care to insulate themselves from the regulatory and reimbursement headwinds associated with the ABA field, providers are also seeing improved outcomes as a result. And better results can mean better rates.
“Having multidisciplinary [care], … if you’re indeed finding better clinical outcomes, … we’re already witnessing it,” Cairnes said. “You’re going to get rewarded with payer increases because they are going to see that having a portfolio, that investment is actually going to cost them less in the long run because we are providing better outcomes.”
Still, it’s important to note that having several different types of services under one provider can create scheduling and billing complications. Speech and OT fall under medical coverage as opposed to behavioral, which means they come with different codes, policies and regulations. And the amount of time allotted to each appointment may be different depending on the specialty, which can make scheduling a challenge.
Investors bullish despite reimbursement headwinds
It would be fair to say the autism services industry has had a rough start to 2026. Numerous state Medicaid plans have slashed rates, and a slew of federal audits revealed that state Medicaid programs have done a poor job of overseeing autism therapy spending and documentation compliance.
“The regulatory market is probably one of the most negative that it’s been in the history of us investing in ABA,” Doug Shinkle, a partner at Lorient Capital, said at AIS West.
Lorient Capital is a private equity firm with a number of investments in behavioral health, including Behavior Frontiers and Centria Healthcare.
And while investors are aware of these new headwinds, they are, for the most part, still interested in pursuing more investments in the industry.
“We really like areas where there’s extreme supply-demand imbalance, and I don’t think right now there’s any category that exemplifies that more so than autism,” Gentil said.
That said, investors are looking for providers that can deliver on efficiency and margin.
“With reimbursement rates declining and commercial rates possibly falling, … operational discipline and rigor become critical,” Gentil said.
Yet, even that thesis is a balancing act. Shinkle noted that it is often easier to invest in a company with smaller margins, since there is more room to improve.
At the end of the day, investors can agree on one thing: “The name of the game is strong culture and operational rigor,” Gentil said.