Value-based care models won’t necessarily be the fix that either the industry or its payer partners are looking for.
However, payment innovations tied to care outcomes will go a long way toward establishing a structure that leads more to quality outcomes than to the maximization of clinical hours. While still a long way off from being mainstream, value-based care and similar payment models help address the structural factors that have led to the moment the industry faces today. That moment is defined by ballooning costs and dramatic actions, especially by state Medicaid programs, to curtail those costs.
“I think value-based care can drive quality, but it’s not guaranteed if it’s not designed well,” Deepa Shah, chief growth officer of Kyo Autism Therapy, said during a VALUE 2026 panel discussion in March. “Incentives shape behavior. … If the metrics are well-designed and not narrowly defined or overly prescriptive, which can then distort care, we have seen it drive immense quality.”
Kyo Autism Therapy, founded in 2005 and based in Daly City, California, has operated a value-based care program with Magellan Healthcare for over three years in California. The model assessed longitudinal quality based on the Vineland Adaptive Behavior Scales and capitated payments for members on a monthly basis. In the years after initiation, about 80% of patients show progress on Vineland measures even as care hours are titrated down based on the progress.
“We didn’t see a reduction in outcomes, but we saw a reduction in hours, and that’s a powerful example of how those payment incentives were able to shape that behavior,” Shah said.
Under the current fee-for-service paradigm, autism therapy providers are incentivized to maximize the lifetime value of patients, Themis Gomes, CEO of Omaha, Nebraska-based pediatric behavioral health provider Behaven Kids, said during the panel.
The fee-for-service paradigm also creates inherent risks for autism therapy providers, a factor at play across the nation today. Nebraska and its Medicaid managed care organizations dramatically cut rates for autism therapy services in August 2025 with a 30-day notice. That has led to the entire market having to reset their business models. At Behaven Kids, this has led to lower wages for behavioral technicians and board-certified behavior analysts.
The present paradigm also incentivizes providers — and the investors that back them — to push for scale that might, in turn, be used as leverage in fee-schedule negotiations with payers. For smaller, locally focused organizations such as Behaven Kids, this creates a notable disadvantage.
It also fails to account for the spectrum of needs that present within the diagnosis of autism spectrum disorder, at the financial detriment of the providers that take on patients with intensive needs.
“It’s not one size fits all. A child may come in with a higher acuity level and sometimes needs a two-to-one ratio because their behaviors are actually dangerous to their family, to themselves and their community,” Themis said. “How is that considered? All these elements should be discussed so we can actually move into value-based care that is significant.”
Reassessing billing, reimbursement and care models based on severity of needs may provide nuance in the current fee-for-service model the industry operates under as well as a bridge into more sophisticated payment arrangements, Themis said. She proposed developing billing codes that bifurcate based on diagnosable severity.
Providing more nuance for clinical need also allows for providers and payers to account for local variations in patient populations. Themis said that patients tend to get diagnoses with autism later, closer to six to seven years old. That may require additional hours than what the current paradigm would allow to help patients establish the necessary skills.