As autism diagnoses rise and Medicaid and commercial payers face growing cost pressures, some providers are pushing for broader therapy options beyond applied behavior analysis, which has historically been the principal therapy option offered.
McLean, Va.-based Positive Development President Chad Pomeroy told Becker’s evidence-based developmental therapy could help expand access, offer lower-intensity care models and provide families with additional treatment options — though he acknowledges measurement of quality and outcomes across autism care remains complex and still evolving.
“It’s because [ABA therapy] is skill development, it’s repetition driven, which means it’s high utilization. If you look at the ADA manual and the approach most of the time that recommends 20, 30, 40 hours a week, there’s a lot of engagement,” Mr. Pomeroy said. “As the number of individuals diagnosed with autism increases, you multiply that times those kinds of hours — that’s the expense that you’ve seen.”
Developmental therapy differs from ABA in both structure and clinical philosophy, particularly around intensity and relationship-building, and requires about six to eight hours per week.
Mr. Pomeroy said ABA therapy focuses on behavior modification and skill attainment. Developmental therapy is a relationship-based intervention in which the clinicians build interaction and communication through relationships rather than repetition-focused skill training, beginning with regulation and engagement around a child’s interests.
“It’s two fundamentally different approaches,” he said. “Neither is right or wrong, they just do different things.”
The broader issue is whether autism care should rely predominantly on one therapeutic approach for a complex condition. Therapy diversification can increase access at a lower cost as well.
“It never made sense to me that you could have a spectrum of a disorder and one therapeutic option,” Mr. Pomeroy said. “I don’t know anywhere else in healthcare where we have one antibiotic. We don’t have one surgical solution to a knee problem.”
The discussion comes as states increasingly scrutinize Medicaid autism therapy spending and providers face questions around utilization, outcomes and long-term sustainability. From 2019 to 2024, ABA therapy visits increased by nearly 267%. In 2023, Medicaid ABA utilization peaked at 341% of 2019 visit volume.
The healthcare system has deployed the “highest utilization” therapy model to individuals diagnosed with autism, which he said may be the primary driver of cost.
For example, North Carolina’s spending on ABA therapy rose from $122 million in fiscal 2022 to a projected $639 million in fiscal 2026, a 423% increase. In recent years, Nebraska reported a 1,700% increase in spending, while Indiana saw a 2,800% rise.
Against that backdrop, Positive Development recently released claims analysis data comparing its development therapy model with ABA spending trends among one regional payer partner.
The organization said its three-year claims analysis with a regional nonprofit payer found its developmental therapy model cost 68% less per member per year on average than comparable ABA therapy cost averages during the analysis. ABA costs for the payer increased at a compounded 28% year-over-year rate during the period. Its model also operated at lower annual per member costs despite higher overall reimbursement rates because the therapy used fewer hours overall.
Even as providers and payers debate cost sustainability, leaders across behavioral healthcare continue to grapple with a larger question: how to consistently measure quality and outcomes.
With the industry still lacking a broader agreement on standardized quality metrics, he said a national perspective on what metrics can and should be measured at the individual and population level need to be agreed upon.
“Eventually we’ve got to say for that expenditure, how effective are we in helping these kids?” said Mr. Pomeroy.
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