This week I am talking to Jamie Pagliaro, EVP and Chief Learning Officer at RethinkFirst (@Rethink_First), a software and solutions provider in behavioral health that offers evidence-based treatment tools, training, and clinical support. Jaimie has an interesting origin story that set him on the path of treating autism and spectrum disorders leading to creating the ReThink First Company
We discuss the history and increasing numbers of people being diagnosed with autism and associated disorders. Right now approximately 1 in 44 children in the U.S. have autism and as he shared no two people with autism are alike, requiring tailored care plans for each individual patient to be truly effective.
We talk about the various approaches to autism including Applied Behavior Analysis (ABA) therapy which is used to treat children with autism. There are other services that are as important but in our current system often separate and delivered by other groups such as speech and language therapy and occupational therapy.
Wild West Sheriff in Town
We discuss the wild west that has developed as a result of the big expansion and their approach to reigning in some elements of control and oversight to bring about a better research-backed Medical Necessity Assessment as part of their online marketplace and support tool
Listen in to hear how they are gathering huge amounts of data that is already helping drive better clinical decisions and improving the availability of access, especially to the underserved, and breaking down many of the barriers to equitable access to the burgeoning need
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Raw Transcript
Nick van Terheyden
Today, I’m delighted to be joined by Jamie Pagliaro. He’s the Executive Vice President and Chief Learning Officer at Rethink first, Jamie, thanks for joining me.
Jaimie Pagliaro
Hey, Dr. Neck. So happy to be here with you today. Thanks for inviting me.
Nick van Terheyden
So, for the benefit of people listening, I think it’s always important to get a little bit of background. Tell us how you arrived at this point, I’ve got to say, I think you’re the first chief learning officer I’ve met. So I’m curious about that title and role. But tell us a little bit of your background and your journey to this point. Sure. Well,
Jaimie Pagliaro
back about 25 years ago, I had the privilege as a psychology undergrad in college of of getting hooked up with a team that was working with a young child in the local community where I attended school, who had autism and who was receiving, at the time, what was a sort of new, innovative treatment coming out of the research literature called Applied Behavior Analysis, which is also now known as ABA. And I had one of the most remarkable life experiences watching the transformation of this child over several years, the impact on his family. And I guess it really became sort of a personal mission of mine to see how can we help more kids like this. And so over the years, I worked in various service organizations delivering care to children with autism in schools, residential settings, I moved up to New York City in the early 2000s, to open the first charter school dedicated exclusively to serving children with autism. And then I had a unique opportunity to partner up with a couple of other serial entrepreneurs who saw the massive growth increase in the prevalence of autism and the dearth of services available to meet the growing need. And we came up with an idea 14 years ago to build a technology company that could help address these problems. So rethink first now works in several sectors, we work with public education system, we work with employer groups, supporting employees that have children with special needs, we support providers delivering care, and we even work with insurance companies and payers who are funding services. And so my role as executive vice president, Chief Learning officers, I oversee the operations of our provider branch of the business. And as the chief learning officer, I continue to play a role in the overall strategy in the business and how we build our culture as an organization.
Nick van Terheyden
Fantastic. I mean, there’s, there’s a lot in there that I want to just get into, because I think there’s some important points, let’s start off obviously, you know, it’s, it’s, I guess, not surprising to me anymore. The the number of folks that I talked to their origin story is often a big driver clearly for you. And what I think is interesting about it is that you talk about autism, which, you know, at the time that you’re referencing, wasn’t as big of a, I’m not going to say problem. I think it was still a big problem. But we didn’t have as much, you know, and I think you rightly describe it prevalence. But we’ve seen that explode. Tell us a little bit about where that’s gone in, in history and what you see in terms of the numbers, because that’s part of the problem that you’re trying to fix, right.
Jaimie Pagliaro
Yeah, I mean, the, the prevalence numbers when back when I was in school, and even going back to the 70s and 80s, people talked about autism being something that was one in 10,000 children and largely unknown. I think that the first reference point a lot of people had in the public was a movie called Rain Man, but Dustin pop, and that was sort of the first portrayal of a person with autism that really reached the masses. But definitely, when I started in this field, it was pretty unknown. And if I talk to people about, you know, working or providing services to children with autism, that was usually followed what is autism? Thankfully, there has been so much incredible work done by by national organizations, by local organizations, by parent advocacy groups to really raise awareness of this disability and the behavioral profile of individuals with autism. And the result of that has been the, you know, the removal of the stigma, which I think you know, is one of the challenges a lot of families face and access to so many more services now in school systems through your health insurance. And so yes, those prevalence numbers have skyrocketed in the last 20 plus years that I’ve been doing this and just within the past year, the CDC updated their statistic once again to autism now impacting one in 44 children in the United States, which is just a staggering number.
Nick van Terheyden
Wow, that’s, that’s really significant. And obviously, that number of contributing factors, I think one of the big ones that you describe as important is that we’re just more aware of it, and we can identify it. And, and that’s important in the context of this, because you talk about ABA. And I think, first of all, if you would help people understand briefly what that is. And then we’ll talk about that application, you know, in, in the case of autism.
Jaimie Pagliaro
Yeah, I mean, ABA in a nutshell, is a scientific approach to trying to change or improve socially important behavior. And so when applied to individuals with autism, it’s really about looking at the current Developmental Profile of the child. And typically, in kids with autism, we see significant deficits in their communication, their social skills, we also see the presence of sometimes repetitive or even disruptive type behaviors. And then those core deficits, then impact an even broader set of of life skills, and whether that’s learning to eat, get dressed, being able to go to school and learn reading and writing math, we start to see that the the lack of these early developmental skills starts to impact an even broader set of skills. And so really, what ABA is doing is it’s trying to come in very early, look at those developmental skill gaps and apply principles of behavior, namely, things like positive reinforcement to really target and teach and improve and help that child catch up to where they should be with their developmental profile.
Nick van Terheyden
And I think that’s one of the important points for people to understand here is that the earlier pretty much you catch this? And then importantly, apply the relevant therapy, the better the outcome, is that true? What’s the case that?
Jaimie Pagliaro
Absolutely, I mean, the the most compelling research shows that if we can apply ABA, early intensively, for a specific period of time, and with a high quality, that we can have really a life changing impact on a significant number of children, the challenge is getting to that diagnosis. So those services can begin to happen. And you know, there’s a lot of tremendous work being done right now by researchers throughout the United States to to get better screening tools in the hands of pediatricians. There’s now technology companies that are looking at ways to do the diagnosis even earlier through parent videos, and through telehealth, and, you know, still the average age that kids begin getting that diagnosis that hovers around four years old. So we know that if we can get to kids earlier, the better chance we have at reaching sort of that optimal outcome. Now ABA can be an effective methodology to help kids throughout their childhood and even into adulthood, learn a variety of skills. But when we think about it as sort of early intensive, ABA, getting in there as soon as possible is definitely a critical factor.
Nick van Terheyden
Right. And, you know, again, one of the sort of, I think, important points for those that don’t have exposure to this indirect form is that it’s actually quite difficult, despite I think there’s been some investment some, you know, there’s certainly a lot of focus, let’s be clear, behavioral health is like the hot topic for investment, all of those things. But that still hasn’t solved the problem. There’s a challenge in terms of access, what’s going on there?
Jaimie Pagliaro
Well, I mean, because you have a service now that’s covered by insurance, you’ve sort of seen an explosion of a new industry of clinicians getting certified to be able to provide this treatment method. And I was, I was poking around looking at some statistics earlier today. And currently, there’s just north of 58,000, board certified behavior analysts, and those are those clinicians that are typically assessing and writing the treatment plan. Nearly half of those 58,000 certificates were granted within the last five years. So this is a certification that’s been offered since 1999. And yet, just in the last five years, we’ve seen this this huge explosion. And so, you know, the good news is, you know, the field is trying to keep up with the number of kids it’s still behind, which is leading the kids on weight. Less service providers not being able to treat more patients. It’s also created a bit of a wild west in the sense that this has never been a service model covered by insurance. This has never been a service that providers have had to prescribe and get authorized from an insurance plan. And there’s really a lack of standards of care. And that is problematic because one, we want to make sure kids get access to quality care across the board, regardless of their socio economic background, we want to make sure kids are getting access to quality and the right level of care. And to you know, making sure that once that prescription is made, that it’s delivered with a level of fidelity, because if I if I gave you a medication, and you only took the medication every few days, but it was prescribed as something you should take every day, if then we stood back and said that medication isn’t working, you’d have to also look at well, is the issue that the medication wasn’t the right medication, the dosage wasn’t right about? Or was the fact that the medication wasn’t delivered with a level of fidelity, there was a compliance with the protocol, is that contributing to the lack of outcome? So you have an industry that’s, that’s grown so quickly here, and there’s a dire need for better outcome measurement and better standards of care?
Nick van Terheyden
Right. And, you know, let’s put to one side, the very small minority and in my belief of the world of people that are, you know, trying to misbehave I think everybody comes in with the right intentions, but it’s challenging, right, as you described, it’s this explosion, you know, people are jumping in, they want to be supportive. And that’s part of what you’re trying to do is to bring, I guess, you know, brings your the sheriff in town for for behavioral health, is that a reasonable assessment? You know,
Jaimie Pagliaro
I like to think of us as Switzerland rather than a sheriff walking around
Nick van Terheyden
and I see sheriff’s in a good way to be clear.
Jaimie Pagliaro
Well, you know, everything we see tremendous opportunity to to help bring water to the chaos, and to help the industry establish and refine those standards of care. One thing that we’ve done over the last few years is we developed a proprietary medical necessity assessment tool, a dosage calculator, if you will, that provides a format and a decision making logic to help a clinician assess that child where they are what they need. And to translate that into a prescription or dosage of ABA services. First of all, is is the child appropriate for that treatment. And second of all, there’s a big difference between five or 10 hours a week of treatment versus what some kids are getting 3040 hours of treatment per week. And so we believe that helping to bring standardization to how that prescription process takes place is a first step. We also through our practice management software that providers us throughout the US, we have clinicians inputting, I think in the last year, 20 million data points on the patient served on our platform. And that’s looking at their treatment goals, looking at the people that are actually delivering care day in day out and putting that information into a mobile app. And you know, our product provides all kinds of great reporting and data visualization to help the clinician evaluate the progress. But what’s really exciting to me is this massive data set that we’ve amassed that we’ve built over the last 14 years. And we’ve now started to bring in data scientists to help look at those data so that we can see beyond that initial prescription of care what’s actually working, what’s not working, so that we can help better inform providers, payers, and most importantly, empower the consumer.
Nick van Terheyden
Right? For those of you just joining, I’m Dr. Nick the incrementalist today on talking to Jamie Pagliaro. He’s the Executive Vice President and Chief Learning Officer with rethink first, we were just talking about, you know, bringing order to the Wild West and, you know, some of the work that you’ve done. Sounds like, you know, you’ve amassed this huge data set that encompasses treatments, actual assessments of the individuals showing, you know, potentially some guidance for future opportunities in terms of what would be the most appropriate because my sense of this is we’re still exploring a lot of this. This is not, you know, there’s no cast iron recipe to actually resolve this and finding perhaps some of those pathways. So, tell us if you were a little bit about the platform and some of the insights that you’ve started to see as you’ve gathered all of this data.
Jaimie Pagliaro
So our platform for providers consists of an electronic medical record clinical data collection tools. There’s also an extensive library of 1000s of treatment protocols that were developed and overseen by an independent scientific advisory board consisting of some of the leading experts in the field of autism, and autism service delivery. And then we pair that up with all the business functions that a clinician needs, you know, scheduling of appointments, billing, paying their therapists through a payroll system, which also becomes a really rich data set to look at the cost of services, and the compliance, the cancellation rates of the services. And so we’re still really in the early days of mining this data set to garner insights, some things that we’ve learned right out the gate with our work with the dosage prescription assessment is validating the fact that there is tremendous variability in how clinicians prescribe care from one organization or practice group to another and even from one clinician to the other. And that really, is why we made that a starting point to bring order to that step in the process, and then to continue building out from there.
Nick van Terheyden
And, you know, let’s dig into that a lot of it, because from a clinical perspective, as a physician, I think about prescribing drugs, you know, and we talk about a dose response and, you know, a line, do you see that, can you see is the value to actually increasing? You know, the amount of therapy and in some all cases, what’s the status there? Well,
Jaimie Pagliaro
I think, you know, we do look at what that initial dosage is, we do look at what is authorized by a health plan. And then it gets messy, you know, when you’re talking about providing a child 20 3040 hours of treatment for six months at a time, and typically, they’re repeating those six month authorizations, sometimes for a couple of years. You know, you’re dealing with humans, kids get sick, therapists can’t come through our parents have competing demands. So it’s not as simple as just making sure that you remember to take your pill in the morning. And so, you know, we noticed that, you know, when somebody gets an authorization for service, a lot of times they may only be getting 60 to 70% of that recommended or prescribed service. So that’s something that we really need to look a lot more closely at, first of all, are there ways to enhance that that utilization and get better fidelity? And then how do you help problem solve with with families and just the logistics of the provider practices to help optimize and ensure that kids are getting that level of care that was actually prescribed?
Nick van Terheyden
Yeah. And, you know, you mentioned this earlier on. I mean, obviously, we see inequities in health care that are just really, truly devastating. And I think in this particular instance, I don’t want to say more. So I think everybody, you know, sees their own problems, but obviously, from a family standpoint, lack of access. How are you starting to address that? Are you able to drive down the cost of access? Are you able to provide some automation that sort of improves things? Can you extend care into these communities that just don’t have, you know, ready access?
Jaimie Pagliaro
Yeah, well, fortunately, due to mental health parity laws, you know, we’re now seeing state Medicaid programs, developing initiatives and creating fun, the funding that matches what children are receiving in that same state that are privately insured through through their families, you know, employer. I think that’s a really great first step. And, you know, we’re working with many providers that go and network with Medicaid, we’ve had many discussions, educating legislators, state childcare leaders, on the importance of delivering this service equitably to all children. And again, it’s another area where we believe that having standards of care like a dosage assessment or prescription assessment ensures that somebody’s not just getting better access to care, because they’re financially able to pay for that out of pocket. And so I think there’s still a lot of work to be done and absolutely from a technology perspective. We’re obsessive about can we help improve the productivity of therapists can we help optimize care, we can we help get results with kids faster by informing the care along the way. And we meet, these are all the the ambitious things that we’re looking to tackle and leverage our data set to derive insights from, but I think there’s still a lot of work to be done there. Rethink also is an education arm. And we work with many of the largest urban public school districts in the United States. And that also creates another avenue for us to get our tools in the hands of special education, teachers who, in addition to teaching, reading, writing, and math, are struggling every day to manage behavior, manage the life skills of children in their class, and even now, that’s extended into just the social emotional well being of students. So reading has done a tremendous amount of work, developing content and curriculum and getting that into the hands of public school teachers to make sure that, you know, we know kids are coming to school. And that’s a great place that we can help improve the quality of services that they’re receiving.
Nick van Terheyden
So you talked about ABA, and, you know, one of the predominant sort of forms of therapy. But one of the ways of sort of expanding this and, you know, certainly, there are other therapies that, you know, can be as helpful, if not more helpful, you know, like speech, language therapy, occupational therapy, are those Incorporated? Or is that sort of future plans?
Jaimie Pagliaro
Yeah, we do have providers that have moved to what we sort of think about as a multi specialty or multi disciplinary format. And have brought in clinicians from other disciplines, I would say, still, there’s a lot of siloing, that occurs. And I think that’s, you know, behavioral health versus physical health. And even within the category of behavioral health, these different specialty areas, it’s it’s another opportunity that we see for technology. You know, we’ve developed a lot of tools that empower families to engage other members of the care team using the technology to better share access to information, better shared data, to try to break down some of those silos and create better interdisciplinary collaboration. So yeah, I think, you know, that’s definitely a big focus for us is being able to support a range of clinicians and looking at how we can break down those silos.
Nick van Terheyden
Right. So as you think about the future, I mean, obviously, this is a long journey. And continues, I think we’re all on many of these paths. But this is obviously an expanding path, we, you know, talked about some of the expansion of the numbers. And, you know, the challenges around that. What are you excited about, you’ve obviously managed to achieve some significant success. But where do you see this going? What’s the opportunity? Well,
Jaimie Pagliaro
I think, you know, we’ve done a lot of work to lay the framework, the groundwork for standards of care. What excites me most is the opportunity with the data to start delivering insights back to providers, back to payers, funders of these services, and most importantly, back to consumers. There’s so much unknown still in this area, you know, everything from what, what is autism? And what are the causes of it, but also how do we help individuals with autism reach their fullest potential. And that may look different for every child, for every individual receiving treatment services and whatever therapy model that they’re going through. There is been so much evolution in technology in the 14 years that we’ve been doing this, I think when we started the company, we’re all walking around with Blackberry phones. And now, you know, to think about a day and age where we’re taking data and doing all this stuff on on phones is pretty remarkable. And now with machine learning technology, artificial intelligence, ways to go beyond just storing data and giving it back to people, but actually, you know, being able to derive insights from that I think, can be really transformational for this industry, and hopefully have a tremendous impact on many more lives.
Nick van Terheyden
Well, I Oh, such an important area, I think people would would agree, without any question that you know, this is a huge area of focus that’s necessary for us we’ve seen this you know, enormous expansion and you highlighted the fact that it requires this earlier earlier intervention changes the course for people you obviously saw, you know, some positive impact. So, you know, fantastic to see this progress, excited to see where it goes unfortunate. As we do each and every week we’ve run out of time so it just remains for me to thank you Jamie for joining me on the show thanks for coming
Jaimie Pagliaro
thanks so much for an engaging conversation document
