‘It’s a Copout’: Why Payers Shouldn’t Say Value-Based Care in Autism Therapy Is Impossible

Value-based care in autism therapy doesn’t exist in a meaningful way.

Several industry challenges create an urgent need for innovation in payment models. Stagnant fee-for-service rates and workforce pressures are at the forefront of those issues. Common value-based care challenges, like tracking and quantifying value, have also stymied many conversations. Yet, this type of innovation is possible and needed today, autism therapy leaders told Behavioral Health Business.

“I don’t think it’s fair for a plan to say, ‘Hey, we can’t do this because no one can agree on what outcomes to measure,'” Neil Hattangadi, CEO of Cortica, told BHB. “To be blunt, it’s a copout.”

The autism therapy segment and its payer partners know enough to establish the outcomes needed for value-based care, he added.

“I don’t think it’s appropriate, fair or rational to say that there is disagreement on what constitutes quality and, therefore, we can’t do outcomes-based value-based care,” Hattangadi said. “That thinking is laziness on the part of health plans.”

San Diego, California-based Cortica has developed a battery of standardized assessments and process measures to use as the basis for value-based care arrangements. And payers have gone for it. For example, Cortica and Massachusetts health plan Point32Health announced such an arrangement in September 2022.

“I’m grateful to the many forward-thinking individuals at forward-thinking health plans who want to control their own destiny in autism care, and so are making outcomes-based VBC a reality,” he added.

Cortia’s business model differs from most in the autism therapy space. It offers a wide range of specialties relevant to autism care, including psychiatry and medication management, gastroenterology and developmental pediatrics. Hattangadi says this model enables true outcomes-driven value-based care. Other models, often based only on applied behavior analysis (ABA), simply can’t provide holistic care.

“As an ABA-only provider, your hands are tied; there’s just no way to deliver that performance … with 15 hours a week,” Hattangadi said.

Cortica’s model was inspired by the International Consortium of Health Outcomes Measurement (ICHOM), and other academic medical center programs.

Its assessments come from well-established clinical algorithms in neurology and developmental pediatrics. They also include wellness scores, Net Promoter Scores, the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) and Vineland Adaptive Behavior Scales (VABS or Vineland).

Where to start

At the core, value-based care presents a sticky issue for providers and payers for two reasons. First, it’s difficult to track care, assess quality and tie in reimbursement. Second, developing and implementing widely relevant models is also very difficult.

Such encompassing approaches like Cortica’s may appear daunting. But anything less could cause more problems for the segment, Hattangadi contents.

Some in behavioral health suggest a stepwise approach to developing value-based care. This would allow the industry to ease into new models and allow time for greater adoption of technology that tracks and assesses care.

“I don’t believe process measures are at all the right thing to do,” Hattangadi said. “I think they will create perverse incentives.”

Process measures could incentivize autism therapy providers to ask for fewer authorized treatment hours or to transfer as much care as possible on families, he added.

Still, behavioral health as a whole is lagging in technology adoption. Tracking and assessing care and outcomes require electronic health records (EHRs) and other purpose-built tech tools. The behavioral health industry falls well short of EHR usage in other health care specialties.

Larger and more sophisticated organizations recognize the need for these tools. However, it’s associated more with increasing operational efficiencies and clinical effectiveness.

Helen Mader, founder and CEO of Behavior Frontiers, told BHB her organization launched its own care data collection system. Before this, the company tracked process measures such as speed-to-care and authorized hours used. This includes care outcomes and scores from standardized assessments, and tracking skills attainment, interventions and hour usage.

From these data, the El Segundo, California-based organization finds a 60% reduction in severe behaviors over 11 months of care. And after two years, patients see a 141% improvement in VB-MAPP scores.

“That information is the starting point for being sophisticated enough to pick out from those different metrics what we should develop value-based care around,” Mader said.

Mader says payers must identify what is relevant to them for value-based care models. However, she maintains that fee-for-service rates should improve before serious value-based care implementation.

Scaling models

Sara Litvak called for introducing an “intermediary” to the value-based care conversation. Her organization, the Behavioral Health Center of Excellence (BHCOE), seeks to fill that role. Litvak is the CEO of BHCOE, an autism accreditation body, and the co-founder of the Autism Investor Summit.

“If you want to engage in value-based care, there needs to be [a] national standard of what measures are,” Litvak said. “It’s going to be very challenging for the payer to put those metrics together. And it’s going to be very challenging for the provider to put those metrics together.”

Payers can develop one-off models with leading provider organizations. Magellan Healthcare, now part of Centene Corp. (NYSE: CNC), is working with Kyo Autism Therapy to develop autism outcome standards.

But those models might not scale well across networks, Litvak said. Further, providers may not be willing to accept payer-developed value-based care models. Concerns may include how providers compare others or how models address utilization and costs.

BHCOE has developed 10 measures it feels adequately assess care quality in autism care. It has not yet released details about those measures.

The organization developed the standards through three workgroups. Each garnered feedback from autistic people, the caretakers of autistic people and payers. In the latter group, BHCOE included two of its payer partners: Centene and The Cigna Group (NYSE: CI).

In April 2022, BHCOE announced a collaboration with The Cigna Group’s services entity Evernorth. A month later, it made a similar announcement about working with Centene.

Litvak pointed to the outpatient mental health space as an example. Portland, Oregon-based Owl Insights Inc., branded as Owl, provides outcome measurement tools. It also has compiled real-time data for organizations to benchmark the impact of their care.

“I think that’s the key,” Litvak said.

What’s at stake in autism therapy

The push for higher fee-for-service rates could lead the industry closer to value-based care. Payers want to see a justification for higher rates, Melissa Reilly, chief growth officer at Evernorth Behavioral Health, told BHB.

“There is a lot of pressure in the community on those rates going up,” Reilly said. “I understand inflation and everything that’s happening. Taking care of patients is very challenging. We want to make sure there’s fairness and equity in the right justification.

“But [providers] also need to be able to prove value in exchange for these higher rates.”

Providing outcomes data tracked by technology helps providers make that justification, Reilly said. In addition, having those data reflect a provider’s sophistication and competence.

The lack of standardized outcomes is a major concern, according to Reilly. Specifically, there is a risk of moving forward without a clear industry consensus.

“I think there’s a little bit of an overestimation, maybe a dangerous one, in the industry that all of these provider groups are really ready for value-based care,” Reilly said.

NeurAbilities Healthcare CEO Kathleen Stengel has secured higher rates from payers. These negotiations have focused on the outcomes NeurAbilities Healthcare tracks, she told BHB.

The company, which offers several care specialties, has secured some alternative payment models. These are enhanced rates based NeurAbilities Healthcare’s performance on three things — speed to care, rate utilization and satisfaction scores.

“Those are the three that I can take them to the payers that they care about, that I care about and that, at the end of the day, families find value in,” Stengel said.

The data-informed approach and talking about value has shifted her relationship with payers. Now, payers feel like “my partners,” Stengel added.

Stengel sees connections between the payer holding or cutting rates for autism therapy and their concerns over questions about care quality. Further, stagnant fee-for-service rates limit the viability and economic potential of the segment, she said.

“Where you see the rates getting cut are those areas where they’re overpaying and underperforming,” Stengel said. “[Payers] are doling out good money after bad money, and [they] don’t have anything coming back that says things are getting better.

“I think that’s the biggest threat, if we can’t prove out together as a field. … We as a field have to come together and agree that access matters and then take that to the next set of data. It’s the only way to move forward.”