300% increase in Medicaid covered ABA services 2019 to 2024

https://bhbusiness.com/2025/12/22/aba-volume-skyrocketed-by-267-from-2019-to-2024/

A new analysis finds that nonclinical force drove the outsized, if not explosive, growth of applied behavior analysis utilization in the U.S.

Trilliant Health’s recent analysis of Medicaid and commercial health claims shows that overall ABA “visits” increased 267% from 2019 to 2024, with a notable divergence in growth rates between Medicaid and commercial beneficiaries. Medicaid-covered service delivery increased by 298%, while commercially covered services increased 249%.

“Some of this variation may reflect legitimate differences in access, provider availability and population characteristics,” the report states. “However, the data raises concerns about whether diagnostic standards are being applied consistently, whether financial incentives are driving inappropriate utilization and whether finite, yet growing, specialized provider capacity is reaching the children who need services most.”

During this period, the report states that the autism therapy industry drove similarly large increases in the number of clinicians providing ABA services. To a degree, the increased supply of services likely had some small part in boosting demand. It describes “supply-induced demand” as “a well-established phenomenon in health care economics where greater provider availability leads to higher service utilization independent of underlying need.”

All told, the report says the data “suggests that systemic factors beyond clinical need are likely contributing to the increase in use of autism behavioral therapy.”

It also gives considerable consideration to the “perverse” incentives of lax oversight of care quality, claims process rigor, the general lack of fixed standards for the industry and the present fee-for-service paradigm of health plans administering behavioral health benefits.

Many of the report’s recommendations align with what executives in the autism therapy industry have advocated for with increasing intensity in recent years as stepping stones to value-based care: mandates to collect and report on care outcomes, reporting and comparison of care delivery to norms and better parameters for assessing the progress of treatment.

The number of ABA-related clinicians more than doubled in this five-year time, up 135%, with significant variation across states. The number of providers in Wyoming decreased by 32%, while neighboring Nebraska saw a 761% increase. There were 147 BCBAs in Nebraska in 2019, according to the Behavior Analyst Certification Board data. The workforce in larger states grew at rates that were closer to the national average.

The report notes that runaway costs degrade the viability of service coverage, especially with Medicaid programs. Several have taken action to reduce spending. In Nebraska, for example, state officials rolled out cold, hard rate cuts to services to tamp down costs. Indiana instituted cuts in 2023 and later proposed limits on care, such as lifetime-service-hour maximums. Additionally, several other initiatives intended to protect care quality and revenue cycle compliance have been proposed.

The specific findings reveal that individual therapy, accounting for 85% of all measured claims, dominates the industry’s services.

In 2022 and 2023, the rate of growth in Medicaid programs rocketed past the growth of commercial claims. In 2023, services for Medicaid patients increased 341% relative to 2019. The rate of growth for that year among commercial claims was 169%.

“The current payment structure, which reimburses based on service volume rather than outcomes, creates misaligned incentives. Providers benefit financially from maximizing billable hours regardless of whether treatment produces meaningful improvements in children’s functioning,” the report states. “Without systematic tracking of diagnostic processes or treatment outcomes, states lack the data necessary to determine whether spending increases reflect appropriate expansion of services or systemic problems with overdiagnosis and unnecessary treatment.”

In addition to financial considerations, the report notes that weak oversight of providers may harm patients by limiting access for those who genuinely need care.

“The goal must be ensuring that every child who meets diagnostic criteria for autism can access appropriate, high-quality services delivered by qualified providers, while preventing the diversion of finite resources to children who would benefit more from alternative interventions or to providers prioritizing billing optimization over therapeutic outcomes,” the report states.

It further recommends that states consider standardized diagnostic evaluations be conducted by clinicians that are independent of treatment providers; mandatory reporting of treatment hours relative to some to-be-established guideline; greater investment in audits and case-level investigation of impropriety; and tying reimbursement to care outcomes.