This month, the Centers for Medicare and Medicaid Services (CMS) announced a new 173-page toolkit to help states ensure more effective and less costly autism care for children. The launch came as government data shows spending on care increased by 421 percent between 2021 and 2025, far outpacing the 67 percent growth in the number of children receiving services. It also followed recent investigations by the New York Times, The Wall Street Journal, and The Economist of profit-driven autism behavior therapy companies that engaged in outrageous billing practices and sometimes outright fraud, draining health care funds and causing clinical harm to children, including one that woke up napping preschoolers after seven minutes so it could keep billing and prescribing 40-hour-per-week programs regardless of clinical need.
I’ve spent twenty years as a pediatric neurologist treating autistic children. The real problem isn’t a few bad actors but an entire field of health care operating almost entirely without physicians in the room. Behavior therapy, also called applied behavior analysis (ABA), is essential for many autistic children, but it’s being used as a standalone treatment for what is fundamentally a medical condition. Instead, it should be delivered as one component of physician-led, interdisciplinary care.
The federal government is taking promising steps. In late July, the Department of Health and Human Services launched a national pledge on whole-person behavioral health care, including autism, signed by major health plans, provider groups, and medical societies. And CMS’s new ABA toolkit aims to rein in costs by setting strict standards for documentation, billing, and utilization review. These actions are necessary because ABA practiced in isolation is failing children and draining finite resources.
Some of the rise in spend in ABA is due to rising diagnoses. Autism diagnoses in the U.S. have increased more than 300 percent in the past 25 years. But the larger driver is a treatment model that defaults to maximum ABA hours without addressing the medical conditions beneath a child’s behavior.
In May, I presented Grand Rounds at WakeMed in Raleigh, North Carolina, one of the states that has identified ABA spending as a major driver of its Medicaid budget crisis, with spending projected to climb from $121 million in 2022 to $1.1 billion in 2027. The pediatricians at WakeMed told me they are increasingly seeing 40-hour-per-week programs delivered to children they don’t believe need that level of care, with no communication back to them once ABA starts. Behavior analysts are ethically required by their certification board to collaborate with a child’s other providers, but ABA and medicine operate in separate silos: different organizations, different record systems, no shared infrastructure. More than 50,000 certified behavior analysts oversee ABA programs nationwide, delivering essential health care in near-total isolation from the rest of medicine.
Autism behaviors are the expression of underlying neurology. Children receiving ABA for hours each day are often coping with unmanaged sleep disorders, gastrointestinal symptoms, seizures, and genetic, metabolic, or immune conditions. These are not behavioral problems; they are medical ones. Behavior analysts, whose training is in behavior, not medicine, do not diagnose or treat them. Routing children into ABA without addressing their medical needs is a failure of our system.
The solution already exists. In rehabilitation medicine, oncology, and other complex care fields, physicians lead interdisciplinary teams and are accountable for the quality of care patients receive across the health care system. Autism should be no different. The right model is an integrated team (physicians, therapists, and care coordinators) working together toward shared goals for the same child. Today, more than 2.7 million autistic children live in the U.S., the vast majority without access to this kind of care. Physicians shouldn’t wait for these changes to come; they can begin closing the gap now.
First, physicians should decide if an ABA referral is appropriate. An autism diagnosis alone is not enough. Physicians must determine medical necessity: whether a child has difficulty with essential functions like communication, socialization, daily living skills, or safety; whether their behaviors risk harm to self or others; and whether ABA is likely to help. That likelihood depends on whether medical conditions that interfere with learning have been managed; whether the specific ABA approach engages the child positively rather than causing distress; and whether the family is able to participate meaningfully by attending caregiver training and consistently implementing strategies at home.
Second, physicians should be selective about which ABA providers they refer to, choosing those who individualize hour dosage, service location, and therapy goals to a child’s developmental profile and age. This means providers whose treatment plans look meaningfully different from one child to the next, who deliver services where a child needs them (at home, at school, or in the community, not just at a center) and who have clinically sound plans for reducing hours gradually as a child progresses. They should refer to providers who collaborate closely with speech, occupational, medical, and family support services and who participate in shared, interdisciplinary care discussions.
Finally, a child’s primary care physician should actively monitor and treat the co-occurring medical conditions that limit what any behavioral intervention can achieve. They can request that an ABA supervisor join a medical appointment, often accomplishing more than months of filtering messages through parents.
Decades of research and expert consensus point to coordinated, interdisciplinary care as the best model for autism. The U.S. government is taking encouraging steps to reform how providers are compensated for care. Physicians should lead a similar shift on the treatment side and create a new paradigm in which they are no longer sitting on the periphery, but collaborating to provide the best autism care possible.
Suzanne Goh is a pediatric neurologist.
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