I still remember working as a home-based ABA therapist in college, sitting on the living room floor with a four-year-old boy and his mother as we worked through basic communication skills. He had limited language and would often become frustrated when he could not express what he needed. Much of our time together was spent helping him learn simple ways to communicate and reducing the behaviors that often followed. At the time, access to care was limited, and his family had to sue the local school district to get the intensive, home-based ABA program he needed. Many families in similar situations went without services entirely. Over the past two decades, I have watched that all-too-common reality change in a profound way.
Insurance mandates, expanded Medicaid coverage, and growing awareness of autism spectrum disorder have allowed providers to build clinics, hire clinicians, and reach hundreds of thousands of families who previously had no access to care.
That growth story, however, is now colliding with a new reality. Autism therapy has become the fastest-growing area of Medicaid spending, and with that growth has come increased scrutiny. A recent Wall Street Journal analysis found that states paid autism therapy providers $2.2 billion in 2023, up from $660 million just four years earlier. As spending has accelerated, so too has attention from regulators and payers. Across the industry, providers experience more frequent audits, tighter prior authorization requirements and growing pressure on reimbursement rates. These shifts reflect a broader change in how autism care is evaluated and funded.
None of this should come as a surprise. For years, the autism services industry has operated within a reimbursement structure that rewards hours delivered rather than outcomes achieved. That model played an important role in expanding access by making it economically viable for providers to build clinics, hire staff, and deliver care at scale, even in the absence of standardized outcome measures. It helped build the foundation of the field as we know it today. At the same time, it created a system in which the measurement of treatment outcomes is inherently subjective, often inconsistent and not scalable. This lack of standardized outcome measurement was largely tolerated because the priority, understandably, was expanding access to care. That dynamic is beginning to shift.
Today, payers are asking a straightforward but important question: How do we know whether treatment is working? The industry needs to have answers.
Throughout my career, I have seen providers rely on treatment goals, behavioral observation techniques, and developmental assessments to track progress. Assessment tools like the VB-MAPP or ABLLS-R, for example, can be incredibly valuable in breaking down skill acquisition and helping clinicians track incremental progress over time. They are essential and will remain central to high-quality clinical care, but they are also inherently difficult to standardize across patients, providers, clinics, and health plans. Scoring can vary based on clinical judgment, interpretation of behavior and the context in which assessments are conducted. As a result, they do not always provide the kind of consistent and comparable signal that payers and policymakers are increasingly looking for.
Now, contrast that to most areas of medicine, where signals are anchored by objective tests that create a shared reference point. A physician measures blood pressure, recommends changes, and then reassesses to determine whether the intervention has made a measurable difference. The test does not capture everything about a patient’s health or lifestyle choices, but it provides a clear and repeatable way to evaluate progress over time. Autism care has historically lacked that type of objective anchor, because evaluations rely on the observation of behavior over time and input from multiple sources, including clinician interpretation, parent reporting, and the context in which a child is assessed. These inputs are valuable, but they can vary based on the setting, the child’s presentation on a given day, and the experience and perspective of the clinician. The nature of these methodologies, and the inherent difficulty in measuring their efficacy, has made it more challenging to demonstrate outcomes in a way that is broadly accepted across the healthcare system.
That is starting to change as new technologies make it possible to measure certain aspects of autism in more objective ways. Advances in digital biomarkers, including the ability to measure patterns such as eye gaze, offer a way to quantify how children engage with social information and even predict language and nonverbal learning potential (Full Disclosure: My company, Earlipoint Health, has developed such a technology). Because differences in social attention are a core feature of autism, these measures can provide a baseline and allow clinicians to reassess whether those patterns shift over time.
These new approaches do not and should not replace behavioral data collection, nor do they promise to capture the full developmental picture of a child. They will not tell us whether a child has learned to communicate more effectively, gained independence in daily living skills, or improved their overall quality of life. Those outcomes remain critically important and must continue to guide clinical care. What objective measurement can do, however, is introduce a consistent reference point that helps answer a question that is becoming increasingly central to the conversation. Is there an objectively measurable change in the underlying condition we are treating?
Introducing this type of objective measurement into autism care raises legitimate concerns, many of which I share. There is a real risk that payers could misuse objective data as a blunt instrument to restrict services rather than support better care. There will be children who do not show measurable change on a given metric even when they are making meaningful progress in other areas. There is also a valid concern that complex developmental gains could be oversimplified if too much weight is placed on a single number. These are not trivial issues, and they deserve careful consideration as the field evolves.
At the same time, avoiding the conversation carries its own risks. If the autism services field does not develop credible and scalable ways to measure outcomes, those standards will ultimately be defined externally by regulators, payers and policymakers responding to rising costs. Having spent years in the provider ecosystem and now working more closely on measurement, it is clear that we’ve entered the era of accountability. The question now is what role will the industry play in defining it.
Will we help shape what meaningful outcome measurement looks like, combining behavioral, functional, and objective data, or will we wait for those definitions to be imposed on us? We have made extraordinary progress in expanding access to care, and I have seen firsthand the impact that access can have on children and families. I often think back to that four-year-old boy I worked with early in my career – who graduated college, now has a job and lives independently as a result of the services he received early on – and how hard his family had to fight just to get him the support he needed. Families like this should not only have access to care, but also confidence that the care they are receiving is making a measurable difference over time. The next phase of our evolution will require us to demonstrate that impact with greater clarity and consistency.
The providers who embrace that challenge have an opportunity to help define the future of autism care in a way that strengthens the field for the long term. Those who do not may find themselves adapting to changes that are already underway.
Acuity Media Network publishes contributed perspectives from industry stakeholders. The views expressed are those of the author.
This article originally appeared on Acuity Media Network and was syndicated by MediaFeed.org.
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