Value-based contracts that involve autism therapy providers taking on risk can be “wildly beneficial.” The contracting process, however, has its challenges.
To ease the complicated process, payers may benefit from creating a value-based “skeleton,” or framework for value-based agreements with payers. Industry insiders stress the importance of providers approaching value-based negotiations with a collaborative mindset.
Although these tactics may aid conversations between providers and payers, the industry still needs to agree on a universal approach to progress measurements, which are required to determine value-based reimbursement rates.
While many providers currently use similar approaches to measurement, there is no universal language of measurement. However, such standardization may not be necessary for progress toward a more value-based autism therapy industry.
Negotiating value-based contracts
Switching reimbursement systems from fee-for-service to value-based models can have long-term benefits, but the process is complex and requires careful planning and execution. Some providers have said that the best way to implement value-based care is to start the company from the ground up with value in mind.
For the managed care organization Magellan Health, tackling the transitions from fee-for-service to value-based is aided by having a framework in place. The organization’s behavioral and specialty health care segment, Magellan Healthcare, aimed to do just that when it partnered with Kyo Autism Therapy in late 2022.
The partnership was designed to test and develop best practices for value-based care models between autism therapy providers and payers.
“With Kyo, we were able to develop a skeleton for what the value-based model looks like,” Yagnesh Vadgama, vice president of autism for Magellan, said at Behavioral Health Business’ VALUE conference. “If we were to have a conversation with any provider in the room, it’s the same skeleton. Now, there might be some other little mechanisms in place that will be differentiators and that’s okay.”
The “skeleton” was created to ensure Magellan could capture data, report and trigger case rate payments consistently across different payers.
For Kyo, the value-based relationship with Magellan began as conversations about the problems with ABA therapy and brainstorming solutions. The contracting process itself “started with trust,” Colin Davitian, chief executive officer of Kyo Autism Therapy, said at VALUE.
“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.”
Daly City, California-based Kyo Autism is an applied behavior analysis (ABA) provider focusing specifically on children. The company has locations in nine states and offers in-home, center-based and school-based ABA services.
Even when all parties come to the table with an open mind, there can still be challenges associated with the process. Utilization of services still must be tracked even with value-based arrangements because actuaries and Medicaid plans still base their case rates.
“There are places where we could disagree, as stakeholders coming at something from slightly different perspectives,” Krista Boe, chief clinical officer of Acorn Health, said. “But what I’ve found in these conversations is, if the basis is trust and the common goal is excellent care for these kids we have the privilege of serving, it becomes really easy to find the common ground first.”
Coral Gables, Florida-based Acorn Health offers in-home and center-based ABA therapy and has more than 70 centers located throughout Florida, Illinois, Maryland, Michigan, Pennsylvania, Tennessee and Virginia. In August, the company named Richard Hallworth its new CEO.
Magellan and Kyo had to have a challenging discussion of how best to track utilization, including determining claims processes.
“There have been challenges, no doubt about it,” Vadgama said. “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”
Agreeing on measures
Before value-based care arrangements can be solidified, payers and providers must agree on measures of progress.
Many providers in the autism field use Vineland Adaptive Behavior Scales (VABS or Vineland) to support diagnoses and measure patient progress. The industry has, to an extent, coalesced around this measurement system because it has been in use for decades.
Vineland is an imperfect system, Vadgama said, and is not sensitive to all populations. Still, Magellan has to “start somewhere,” he said.
Kyo leverages Vineland in its contract with Magellan, but analyzes data from a population standpoint rather than on an individual level. While Kyo’s patients reliably show progress, Davitian said, they may not demonstrate it for every measurement period.
“As an organization, we’re very open to other measures that do emerge that might be complementary or substitutes for Vineland,” Davitian said.
Complete agreement on a universal language of measurement may be unnecessary to get started down the path to value-based care, but it will be required to have “apples to apples” comparisons to other providers, Boe said.
One current attempt to establish an “apples to apples” benchmark is the National Autism Data Registry (NADR), which was spearheaded by the Behavioral Health Center of Excellence. Acorn is a founding member of the registry.
“Up until this point Acorn has been benchmarking against ourselves from an overall outcomes and progress perspective,” Boe said. “By pairing with a couple of other organizations of scale as part of this NADR project, we’ll be able to do some apples-to-apples comparisons with other organizations which I think will continue to fuel this conversation.”
Despite the efforts of organizations like the NADR, the autism therapy industry may never agree on how to track the frequency of behaviors.
“And that’s okay,” Vadgama said. “I think we have to move past that and start to look at how else we can start to look at autism holistic care.”
Outcomes of value-based arrangements in autism therapy
Taking on risk means that autism therapy providers can experience a wide range of outcomes.
If providers have value-based case rates that are comparable to fee-for-service models, there may be little change in reimbursement rates, according to Davitian. Regardless of rates, value-based arrangements can still make ABA therapy more efficient, which is in the best interest of patients, payers and providers.
There is potential, however, for “wildly beneficial” outcomes.
“It depends on how you want to allocate and utilize your hours,” Vadgama said. “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 for you all if you’re starting to look at the potential upside of the case rate model.”
