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Payers are increasingly expecting autism service providers to demonstrate their value proposition.

This comes as the payer costs associated with applied behavior analysis (ABA) services have increased over the past decade, coinciding with increased autism diagnoses and expanded access to services.

“I think there is a real trend right now of payers saying, what are we getting for what we’re paying for? How do we know that the care that’s being delivered is efficacious and is improving the quality of life for the young learners that we’re serving?” Jim Spink, CEO of Autism Care Partners, said during a recent Behavioral Health Business webinar. “So, whether it’s on the technology front, diagnostic and clinical, or moving towards whole person care, [there is a] real emphasis on outcomes.”

Autism Care Partners is a multi-specialty autism therapy provider operating in Massachusetts, Vermont, New Hampshire, Rhode Island and New York.

This has put pressure on providers to demonstrate their value and set themselves apart from their competitors.

“I really think we’re at a point where all providers need to figure out what their identity is when it comes to value proposition, what differentiates you from other providers in the space, but also to be forward thinking about more diverse service offerings and integrated approach to caring for these learners with autism care spectrum disorder,” Scott Semmel, senior vice president of payor relations at Acorn Health, said.

Acorn Health is an autism service provider that operates in Florida, Illinois, Maryland, Michigan, Pennsylvania, Tennessee and Virginia. It is backed by the Ontario Teachers’ Pension Plan (OTPP).

Semmel noted that offering a variety of services in addition to ABA, such as speech therapy and occupational therapy, could help differentiate providers and move towards whole-person care.

Payer trends

Providers should be on the lookout for how payers are planning to manage rising costs. Spink noted that during Centene Corp.’s (NYSE: CNC) last earnings call CEO Sarah London cited ABA as a key driver as to why the payer missed its earnings expecations and said the organization is going to be aggressively managing this trend through a multipronged approach including: requiring providers to demonstrate quality, promoting evidence based guidelines within their network, rate adjustments and cracking down on fraud waste and abuse.

“I would underscore the need to have a very strong quality department where you’re managing appeals and grievances that might be in your clinical department,” Spink said. “Your notes, your documentation and your clinical justification have to be in order.”

It’s also essential for providers to be supported in demonstrating and justifying a patient’s clinical need differently than in previous years.

This comes at a time when payers are looking to compress rates.

“We’ve seen state Medicaid authorities reduce their rates, and then commercial payers try to follow suit, despite the increasing pressure on access,” Spink said. “So for the provider, it’s really difficult.”

Value-based care

One potential solution could be moving to a value-based care contracting or an alternative payment model. Payers are, overall, looking to move towards this type of relationship in the future.

Still, the autism services industry faces a number of challenges in moving towards value-based care.

“The payers are generally reducing reimbursement rates, but the requirements of having to demonstrate your clinical efficacy are increasing, and it is an area that, as an industry, is going to require significant investment,” Barbara Gromacki, president of Lighthouse Autism Center, said.

Lighthouse Autism Center offers ABA services across Illinois, Indiana, Iowa, Michigan, Nebraska and North Carolina.

Another key challenge in the move to more value-based reimbursement is the fact that there is no set of standardized measures that every ABA provider uses.

Autism Care Partners has three value-based care contracts. However, Spink noted that all of the contracts are structured as multi-year contracts, and the first few years are focused on process measures, such as how long it takes to get a child into care and parent satisfaction scores.

Still, the north star in value-based care for autism services is being able to demonstrate clinical outcomes that will justify treatment intensity.

“Given that treatment plans are so individualized, and the effectiveness of value-based care that you see is when you can prove downstream cost savings […] we’re just not there yet as an industry,” Semmel said. “It’s going to take quite a bit to get there before we’ve got those data points that can really lead to something meaningful in terms of partnerships with the payers.”