By: Jim Laughman
Americans are obsessed with numbers. We love to quantify things. We love rankings, statistics, and percentages. We always know the league standings of our favorite baseball team and how many Super Bowls our favorite NFL team has won. Since the advent of prediction markets, we have tried to put numerical odds to such unknowables as whether the next Marvel movie will top the box office, whether the iPhone release will break sales records, or who will win an election. Ours is the nation that invented the Top 40 countdown.
In discussions about Applied Behavior Analysis (ABA), the conversation has skewed far too often to the numbers: how many hours of therapy autistic children should receive weekly, how much providers should charge per hour of therapy, and so forth. Costs for ABA have skyrocketed over the past several years, driven by enormous increases in utilization—a nearly 300 percent increase in service volume between 2019 and 2024. There is no question that there is fraud and abuse in the system, and the recent, very public “fraud takedown” in Minnesota demonstrates that the federal government is paying attention—as well it should. Bad actors should be identified and deterred.
But in calling for the deterrence of bad actors, health plans that provide behavioral health benefits, including ABA coverage, often are accused of focusing solely on costs.
There is more to the conversation. The corollary to quantity in ABA is quality, and about that I have significant concerns. High-quality ABA is not defined by the volume of services delivered, but by whether care is clinically appropriate, accountable, and helping individuals make meaningful progress.
The Association for Behavioral Health and Wellness (ABHW) is working to realize that vision. Over the past several months, ABHW has brought together clinical experts and other SMEs to examine ABA therapy specifically and autism treatment more broadly. This working group, which I chair, has collaborated on a set of principles to ensure quality in ABA:
- Individualized, patient-centered care
- Evidence-based assessment and outcomes
- Consistent, transparent standards
- Qualified providers and accountability
- Coordinated whole-person care
We have also developed specific recommendations about ABA that we have shared with the U.S. Centers for Medicare and Medicaid Services (CMS), many of which were included in the department’s recently launched ABA Toolkit. This is an encouraging step, but we continue our efforts to educate wide audiences about quality treatments in ABA.
The conversation about ABA must shift. It’s not just about more or fewer hours in ABA. It’s primarily about providing quality, goal-based, multidisciplinary care—occupational therapy, speech-language therapy, play therapy, etc. —to the patients who need it. To that end, it’s crucial to create an environment that promotes innovation and improves treatment.
We owe it to families to keep striving for better, quality care.
