Over the past decade, thousands of autism clinics have opened across the country.
The growth has been fueled by rising autism diagnoses and a federal requirement that all state Medicaid programs pay for the treatment. The industry has recently received significant investment from private equity firms.
A New York Times investigation found that the clinics often prioritize billing opportunities in ways that may harm children and overcharge the government. Many overprescribe hours, and some discourage parents from enrolling their children in school.
Medicaid reimbursements to the clinics have strained state budgets. But legislatures have had a hard time curbing spending.
Here are five takeaways from the Times investigation:
Autism therapy is straining state budgets.
Autism therapy has become one of the largest and fastest-growing kinds of medical care for state Medicaid programs. In Colorado last year, Medicaid spent more on this care for children than on emergency room care for all patients.
Clinics can open quickly because the staff members that work directly with children do not need specialized medical degrees, and can be largely trained on the job.
The evidence behind the therapy is mixed.
The therapy, called applied behavior analysis, or A.B.A., centers on giving small rewards to children who perform desired tasks. It got its start in the 1980s, when a California psychologist ran a trial with 38 preschoolers. He reported that children who received the therapy for 40 hours a week improved their behavior and communication skills.
Subsequent research has been mixed, with some studies showing strong outcomes and others finding little change.
Other countries have split on whether the service is worth paying for. Canada covers A.B.A. therapy through its national health system. Britain does not.
Many children are spending all day in therapy.
As chains have grown, so have the hours children spend in therapy. Clinics that prescribe a standard 25 or even 40 hours of therapy a week to young children have become more common. Average daily appointments have gotten longer, too.
In order to bill for every hour of the day, many of these clinics do not allow young children to take breaks for naps or lunch.
The clinics operate with little oversight.
Behavioral therapy clinics typically do not need state licensure to operate. That exempts them from routine inspections that are common for day cares.
Experts worry that the lack of oversight may make children more vulnerable to harm. In Texas, a therapist was caught on video hitting a child with a shoe. A North Carolina clinic worker recently pleaded guilty to assaulting a 4-year-old girl, who came home with a bite mark on her arm.
States are struggling to crack down.
Many state governments are concerned about the rising cost of autism therapy, but few have taken steps to rein in the growing industry. Because federal rules require Medicaid to cover the treatment, it is hard for states to impose many limitations without facing legal risks.
The Trump administration, which has railed against Medicaid fraud, has not provided any official guidance to states on what restrictions it recommends.
Some states have begun instituting new policies, including North Carolina, where The Times focused its reporting. That change is likely to result in litigation, the legislation’s chief author said.
Sarah Kliff is an investigative health care reporter for The Times.
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