Clinical services at URMC began to change as early as the mid- 1980s as managed care began to influence financing of health care. The driver for primary and subspecialty care in all disciplines shifted from providers to consumers. As health-care expenses continued to rise, insurers began to play an increasingly influential role in service design. By the year 2000, competition for covered lives intensified in Western New York, eventually creating three, and then two health systems, one managed by Strong Health and the other by Via Health. There was a re-alignment of primary care practices and referral networks with one or the other health system, and a dramatic expansion of community-based options for care. This shift is still occurring and has dictated the need for more primary care practices in the community and more clinical time from providers based in tertiary care centers such as Strong Memorial Hospital. Reimbursement for services was now based upon specific metrics such as Relative Value Units (RVUs); the more RVUs provided by a clinician, the more revenue generated from public and private insurance payers.

DBP had successfully negotiated with Blue Cross-Blue Shield several times during the 1980s and 1990s for comprehensive coverage for interdisciplinary services. It was now necessary to build similar comprehensiveness into the new reimbursement schemes. Third-party payers and health systems both recognized the need for such mechanisms in order to assure availability of clinical services to children and adults with ASD. Hence negotiations involving RVUs for comprehensive developmental services were now championed by administrative units within the Medical Center. So now there existed a perfect storm of sorts: demand from families for service and better mechanisms for reimbursement. Much of DBP's service expansion, even with better reimbursement, has been funded at least in part from state and local grants.