The shift toward value-based autism therapy is reshaping many areas of healthcare, including autism treatment. Unlike traditional fee-for-service reimbursement models—where providers are paid based on the volume of services delivered—value-based autism therapy links payment to patient outcomes and overall quality of care. For autism therapy providers, this means taking on financial risk but also gaining new opportunities to innovate and deliver more efficient, effective treatment.
Many industry insiders agree that value-based autism therapy can be “wildly beneficial” when done right, potentially driving better outcomes for children with autism, improving resource allocation, and creating a sustainable financial model for providers and payers. However, the journey from concept to practical implementation is complex and requires collaboration, trust, and strategic planning.
Why a Value-Based “Skeleton” Matters
One of the biggest challenges in adopting value-based autism therapy contracts lies in their complexity. Each payer-provider relationship has unique needs, data systems, and administrative processes, making the contracting process difficult and time-consuming. To streamline this, some payers are developing a value-based “skeleton” or framework to guide these agreements.
Magellan Healthcare, a key player in managed behavioral health care, has been at the forefront of this effort. In late 2022, Magellan partnered with Kyo Autism Therapy to pilot value-based autism therapy models. Yagnesh Vadgama, Magellan’s vice president of autism, explained that the goal was to create a foundational contract structure that could be used consistently across multiple providers and payers.
“If we were to have a conversation with any provider in the room, it’s the same skeleton,” Vadgama said. “Now, there might be some other little mechanisms in place that will be differentiators and that’s okay.”
This “skeleton” ensures consistent data collection, reporting, and payment triggers, which helps reduce administrative burden and enables scalability across different markets and partners.
The Importance of Collaborative Negotiations
The success of value-based autism therapy depends heavily on the relationship between payers and providers. Kyo Autism Therapy’s CEO, Colin Davitian, stressed that the contracting process must begin with trust and a collaborative mindset.
“You have to come into it from a non-antagonistic point of view,” Davitian said. “You have to understand that each side has legitimate needs and gripes with the existing system. If you’ve come from that place, it will be much easier to design a solution that works for both sides.”
This approach was foundational for Kyo’s partnership with Magellan. Instead of starting with rigid demands or adversarial negotiations, both sides worked together to identify issues within Applied Behavior Analysis (ABA) therapy reimbursement and explore solutions to enhance outcomes and financial sustainability.
Tracking Utilization and Managing Challenges
Despite the shift away from fee-for-service models, utilization tracking remains crucial. Medicaid plans and actuaries still use service utilization data to inform case rate calculations, meaning providers and payers must have robust mechanisms in place to track claims and therapy hours accurately.
Vadgama acknowledged the difficulties involved:
“There have been challenges, no doubt about it. But it was important for us to be able to hit the ground with something, learn the challenges along the way, fix it, iron it out, and then start to move forward so that in the future we’re not going to see those same challenges.”
This iterative process of trial, learning, and improvement is a hallmark of pioneering value-based autism therapy models.
The Measurement Conundrum: Finding Common Ground
Perhaps the most significant barrier to broader adoption of value-based autism therapy is agreeing on how to measure progress effectively. Value-based reimbursement hinges on outcome measures, but the autism therapy industry lacks a universal “language” for these metrics.
Many providers currently rely on the Vineland Adaptive Behavior Scales (Vineland)—a standardized tool used for decades to support diagnosis and track patient progress. However, Vineland isn’t perfect; it may not fully capture progress across all populations or treatment periods.
Vadgama acknowledged these limitations but emphasized the need to start somewhere:
“Vineland is imperfect, but you have to start somewhere.”
Kyo Autism Therapy uses Vineland data within its contract with Magellan but evaluates results at a population level rather than focusing exclusively on individual measurement periods. This approach recognizes that progress may not be uniform or immediately visible for every patient.
Davitian added:
“As an organization, we’re very open to other measures that do emerge that might be complementary or substitutes for Vineland.”
Meanwhile, Acorn Health participates in the National Autism Data Registry (NADR), an industry effort to create comparable benchmarks for outcomes across providers. This initiative, led by the Behavioral Health Center of Excellence, aims to move beyond internal benchmarks and enable true “apples-to-apples” comparisons to fuel continuous improvement.
Still, complete agreement on how to measure progress may never be fully achieved—and that’s not necessarily a dealbreaker.
“The autism therapy industry may never agree on how to track the frequency of behaviors. And that’s okay,” Vadgama said. “We have to move past that and start to look at how else we can start to look at autism holistic care.”
The Potential Impact: Efficiency, Flexibility, and Better Outcomes
Value-based autism therapy contracts can produce a range of outcomes for providers. If the negotiated case rates closely match traditional fee-for-service reimbursement, financial results may look similar. But even in those cases, value-based models can drive improved efficiency and resource use.
Providers gain more flexibility to allocate therapy hours based on clinical need rather than strict billing codes or volume requirements. This ability to tailor care has significant benefits for patients, payers, and providers.
Vadgama described this potential upside:
“You have a right to be able to say, based on the clinical presentation of the individual, ‘how much resources do we need to allocate to the individual?’ … That is a very encouraging incentive if you’re starting to look at the potential upside of the case rate model.”
Such incentives encourage providers to focus on high-quality, individualized care that aligns with outcomes rather than service quantity.
Looking Ahead: Progress Requires Partnership and Patience
The shift to value-based autism therapy is still in its early stages. While the path forward is not without obstacles—measurement standardization, utilization tracking, and negotiation complexities—leaders across the industry are making meaningful progress by fostering trust and collaboration.
This evolving model holds great promise to improve the lives of children with autism, offering more personalized care and better long-term results. As more payers and providers embrace value-based autism therapy, the industry can move closer to a system that rewards real progress and value.
