ABA in Crisis

Private equity has entered the ABA services game with great fervor, making a tremendous impact on the field as a whole. In this episode, Mike and Dan take a close look at some 'crisis' elements created by the infusion of private equity and an aim to generate revenue, at times at the expense of the quality of services and client outcomes. At the same time, it can be discerned that ABA practitioners had developed some less than desirable habits prior to private equity, but certainly exacerbated now by the focus on fiscal health over developmental integrity. Moreover, while one would expect private equity to help make services more accessible, this episode also explores the tendency for private equity to turn a profit, then take the money and run, leaving clients and professionals alike with no recourse.

This brew delivers a lot of different flavors and aromas, so be prepared. As always, we promise a smooth finish to wrap up this topic and hint at a continuation episode, as their is much to explore and reconcile within this idea of 'ABA in Crisis.'

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Transcript

SPEAKER_02: 0:00

Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_00: 0:52

All right. All right. Welcome back. To get another installment of ABA on Tap, I am your co-host, Mike Rubio, along with my dear friend, Daniel Lowry. Dan, how you doing?

SPEAKER_02: 1:04

Good to see you again, Mike. It's been a little while.

SPEAKER_00: 1:06

It's been a little while. This is a really, really cool... Well, let's see. A lot of things to mention here. We are recording our ninth episode, which is one more than... We've done for any other season. Congratulations, sir. All right. Glad we're on track. We're on track. Still

SPEAKER_02: 1:22

on track for our 12. 12.

SPEAKER_00: 1:23

12 for this season. Once a month. So those are all really, really good things. Today, we've got quite a topic. I'm not exactly sure. I think you're... Settled on a title. I think it's a good title. I think we've got an expansive topic to discuss. I'm going to give it a quick 30-second intro and then I'm going to pass it right over to you because you're fresh out of the rabbit hole on reading about this topic. I'm

SPEAKER_02: 1:49

living it and reading

SPEAKER_00: 1:49

it. Now, we've alluded to a lot of variables around this particular topic. I'm going to boil it down to what I think we're talking about today and then, again, I'm going to let you expand on that. So... We've talked about integrity of practice and programming in terms of procedures and the tendency to make things very templated, very cookie cutter versus actually innovated and individualized toward the treatment of every specific client. We've talked about materials and some of the strange technologies that maybe are influenced by this variable that we're talking about today. We've talked about Recommendations toward client hours. We've talked about RBT being a person or a service most recently. And I think what all this kind of boils down to is the idea of reimbursement rates. How much? Are we collecting for providing the service? And how does that meet our bottom line from a business perspective? Now, let me be the first to say that I am not a businessman. Clearly, I have dedicated my life to treatment and medical service that we now, what we call ABA, now a medical service.

SPEAKER_02: 2:56

Although you did run some businesses. I did

SPEAKER_00: 2:58

attempt at running the ABA business. But one time or another, that's a whole separate conversation, which we will likely never get into. Not that I didn't do well. It just didn't end well. It wasn't because I wasn't good at it. But anyway, again, I digress. Mr. Dan, let me hand it over to you because, again, I sort of boil it down to reimbursement rates. But you've got a lot more knowledge and you're much more well-versed than I am at this point, given your recent delve into the rabbit hole. Tell us what you've emerged with.

SPEAKER_02: 3:27

Yeah, yeah. So, you know, if I have any say about this, this series will be talking about, you know, ABA in crisis. And I think it's... I have probably almost 20 years in the field now, and I know you have even more than that, Mike.

SPEAKER_00: 3:41

I'm entering my 27th year in the field this fall. Yeah. And again, not necessarily just solely ABA, but in and around development and special needs and so forth. So let me qualify that.

SPEAKER_02: 3:51

Yeah. And I feel like it's always easy in any situation, right? You move from a small town and you move back and you're like, oh, this isn't the town I know. Yeah. I feel like ABA is starting to get hit from all sorts of different sides. We've spent a lot of time talking about the clinical side of things from people like Chloe Everett and who was the... Alfie Cohen. Alfie Cohen. And their skepticisms and criticisms of ABA and how it's delivered. So we've spent a lot of time talking about that, and I'm sure we'll get back into that.

SPEAKER_00: 4:23

We also had the person with the autism acceptance, and I'm not going to remember their name right now, so I apologize if I can look it up. look back and mention their specific name before the episode is done, I will do so just to give credit where credit is due. Sorry to interrupt, sir.

SPEAKER_02: 4:37

Yeah, no worries. But that's always been kind of like, okay, over there, they're not doing ABA right, but where we're at, we're doing ABA right kind of mentality. And I always kind of wondered why that was. Again, to be candid, we came from a large company that... Yeah, one of the bigger companies around it spent a lot of time focusing on metrics and finances and things like that and maximizing contract hours and authorizations and how we can focus on income. That was kind of my indoctrination into the field. And this team, on the management side, I have dealt with that. But in terms of the BCBAs, that's something we've never really had to talk to. It's always been a pure clinical recommendation.

SPEAKER_00: 5:25

So you're alluding to... the last, what I called my golden age, the last seven years. For me, the last almost 10 years on a particular team. Well, let me interject now because one important thing that I'll say now that I might have to allude to several times throughout this episode is that I can wholeheartedly say that the past seven years on our particular team with our particular parameters are clearly the best years for my clinical practice. Now, I can say that some of that is affected or influenced by my ongoing experience, entering my 27th year. But more than anything, I feel it had to do with our particular fiscal structure. So going from a capitated structure to a fee-for-service where the reimbursement rates were sufficient. Henceforth, I never had to have the discussion about... You're not putting in enough hours because my clients were happy. My clients were making progress. I was exiting my clients over a certain amount of time. Everything clinically was sound, right? But more importantly, we had a very sound reimbursement rate. For

SPEAKER_02: 6:34

sure. And I was one of the contract managers, and also I reviewed all the reports. And let me ask you, Mike, so how many times over those eight years did I review a report and was like, hey, can we give this client a couple more hours?

SPEAKER_00: 6:50

You never said that. You might have asked in terms of a ratio, in terms of, hey, I see that this number of hours is being recommended. This is the program plan. Sure. Are we sure that we're asking for the fair amount of hours, meaning we're not exceeding the number of hours based on the looks of the program plan? And then it could go the other way, right? That's quite a big program plan. Are we sure that those are sufficient hours? So no matter the size, yes, you've always found a good way to balance that out. But never was it just blindly, hey. This client needs more hours. Exactly.

SPEAKER_02: 7:29

And there were certainly times where I would review a report and say, hey, we're asking for this many hours. Do you think we can get a couple more goals in there? And then I even started to change it at the end because we're not running goals. We're running programs. Do you think we can get a few more programs or procedures in there? Or more importantly, can we just figure out a way to document the things that you're doing? Because we would have great discussions about that, right? Because just because you have two goals in a program, let's say you have a two-hour And you only have two goals. Does that mean your RBT runs those two goals and then for the other hour and 40 minutes just sits there and stares at their phone? Well, hopefully not. I've trusted our RBTs are doing something. So the premise being, how do we document what they're already doing, assuming that what they're doing is within the clinical recommendations that you've given?

SPEAKER_00: 8:16

Now, that would imply... that during a session you're not just implementing procedures toward goals, you might be doing other things to gain momentum to actually run those procedures or engage the client in those particular procedures. So again, to your point, the idea that all you can do is run those procedures specific to those goals throughout the entire session is probably not a very accurate way to look at either, right? This is a child, a human child, or a human, you know, a person that you're delivering these services to. the idea that they might deviate well let's see we're in autism treatment the idea that there might be some escalation or there might be some behavior that will interfere well yeah those are all realities right so I think that From a fiscal perspective, we might idealize the idea or the notion of you've got 20 hours a week. You have to have 20 goals. Well, that implies that only those goals are being attended to and that there's no other rapport building, no other enjoyable engagement, something we call reinforcement, which if you're not careful, you might be delivering only on the iPad as you take a break.

SPEAKER_02: 9:28

That's always done separate from the RBT,

SPEAKER_00: 9:30

of course. Right, right. Oh, yeah, because the RBT can't be reinforcing, right, unless they're delivering. It's during break. Break time only. Right. And break time, you can't talk to the client. No. There's no need to engage them there because that's not a socially relevant time, break time. Correct. You can only be– see, again, we're being facetious, but it really drives the point home. So, yeah, we have this notion of if somebody's a full-time BCBA, you're working– you get paid for 40 hours a week, well, that means that you should be seeing clients 40 hours. Right. Well, wait a minute. There's program planning that has to come in here. There's discussions with RBTs. There is certainly discussions with parents, which can be billable or, you know, depending on your funding source. So there's a lot of other work that goes into it. And if we're not careful, we might quantify that so far that then we render the service, the humanity of the service useless. And then maybe we start seeing cookie cutter templated programs, which, of course, we never see in ABA, right? Do this. Never.

SPEAKER_02: 10:29

You never get your box of visuals that we make 10 travel schedules for the next 10 clients, even though we don't know what the next clients are going to be. So now if

SPEAKER_00: 10:37

you've made those ahead of time, that means that you're assuming that every session is going to look the exact same. Wait, is that individualization of treatment? Or again, we've now maybe put cart before the horse. Why? A lot of it is because of revenue, funding sources, reimbursement rates.

SPEAKER_02: 10:54

What if the RBTs or the BCBAs have very minimal time to be able to make those materials, so they have to try to be as efficient as they possibly can during that time, right? So efficiency and individualization are almost diametrically opposed, right?

SPEAKER_00: 11:05

Yep, for sure. Yes, they are, and that's interesting, right? So again, the idea that you can have no planning time or that's not billable, You can't account for planning time. Sure, sure. Again, leaves us with a field that's assuming that this treatment does not require any sort of stimuli, any sort of planning, any sort of discussion or clinical discussion. That just can't be. That can't be the best way to provide this service toward good outcomes. But it is a pressure that people succumb to because of a certain level of reimbursement rates.

SPEAKER_02: 11:40

Yep. Yeah, it's like you always use the burger analogy. If I want to be maximally efficient while making burgers, I'm going to have the ingredients that I need, right? The tomatoes and the lettuce and the onion. Those are all going to be right there. But what if a kid wants pickles? Or what if a kid wants something else? Banana pep? Then I have to go leave that area to get something. Each time I'm doing that, I'm becoming more individualized but less efficient.

SPEAKER_00: 12:03

Right, right.

SPEAKER_02: 12:04

So... This has hit us kind of hard personally as well. Like we've talked about these dream rates that we've had for a while. And for whatever reason, we're now going through a transition where those rates are becoming much more like the standardized rates that people are experiencing in the field. And it's very interesting as we make this transition how that's going to affect our ability to deliver services as we know it. With nothing else, the same team, everything else, being the exact same, same office, same team, same management, same whatever. just the rates changing are now going to have a significant impact on the clinical delivery of our service, which is kind of pitting two things against each other or two things concurrently at the same time. You have the clinical service delivery, and then you have the profitability or fiscal survivability of the entity. If your clinical services suck, then that's not going to work. So they have to be reasonably well. But if your fiscal survivability sucks, then you're going to be out of business. So you can to have the best clinical outcomes in the world. But if you're not able to make payment, then nobody's working for free. This isn't a volunteer organization. Then you're also going to be kind of out. So you're kind of pitting these two things against each other. Before I continue to...

SPEAKER_00: 13:25

No, no. I love the way you're pitching this already in terms of the continuum. The idea that if you're only profitable, there's a good chance you don't have enough focus on your service delivery. And if you have only a focus on the best service delivery, you run a risk of not being profitable, in which case that renders your delivery useless over time. If you can't deliver the service because you're not profitable, then that's not going to work. So I like those two extremes, and then we're going to talk about a lot of space in the middle.

SPEAKER_02: 13:55

So let's take the two extremes. So let's talk about profitability first. So in order to maximize profitability, because of the way the funding works, which we'll spend a lot of time talking about, is we only get paid for billable hours right now, outside of the assessment code. Every other code, the direct code, the supervision code, everything like that, I'm sorry, we only get paid for face-to-face time. So everything has to be done face-to-face. There's no paid planning time. There's no data review time, anything like that, all of that has to be done face-to-face with the client. So in order to be maximally profitable, here on the left side taking that extreme, we would want to only pay our staff when they're face-to-face with the client. So you brought up a good analogy earlier. Imagine a doctor only getting paid when they're face-to-face with the client, meaning that they don't really have time to review, to prepare, so they're not going to really be able to read your medical history or anything like that Or if they are going to do it, they're going to do it during your appointment, which is going to be face-to-face, which is now coming out of your time and inconveniencing you. Because instead of you coming to my office as theoretically a doctor, let's say a pediatrician or whatever, and I've already been able to read the background information, now I have to waste your time and sit in front of you and go over the background information, right? So

SPEAKER_00: 15:14

in that sense, really quickly to interject, you're saying the doctor, even in that case, needs time to think, right? It's time to think, to plan, to review, absolutely. Okay, and for us, it's not just time to think. It's a little downtime to then prepare some pictures, put together some toys, whatever it is, beyond thinking, true planning, right? I mean, not taking anything away from doctors, but you've got your stethoscope and your instruments in your office. You don't have to prepare that much. Maybe change the paper on the table. Sure. Right, but for us, that could be not just thinking, planning, analyzing, reviewing, right? but then creating new ideas, generating new ideas toward treatment.

SPEAKER_02: 15:52

Absolutely. Doctors aren't there to entertain us. They're there to run tests, and we're there to do both with our clients. We're there to entertain them and run tests at the same time. Like you said, the only way that that's feasible, if we're talking about fiscally motivated, is to just have cookie-cutter programs and cookie-cutter visuals and supplies. So that's the fiscal side. If we want to be maximally fiscally profitable... the only time that people are going to be compensated is when they're face-to-face with the client because that's the only time the company's being compensated by the insurance company. So that's one extreme.

SPEAKER_00: 16:26

That sometimes even includes report writing. Am I right? Again, I ask only because we've been living in the land of milk and honey. And now, again, to your point, that's going to be changing and we're going to have to contend with some of these new modes of service delivery. Like, it's not just about providing treatment, it's just about the standard that the insurance rates are setting or the conditions they're setting, which is you're going to report on this client's progress, and instead of giving you time to be back at your office thinking about this and analyzing it, we are going– if you want to make it billable, if you will, we're going to make you sit in somebody's living room and do that and somebody's kitchen table and do that. Okay. That's interesting, right?

SPEAKER_02: 17:09

So that's one extreme. The other extreme, maximum clinical efficacy, would be to run a– to our session or however long the session is based on the individual's clinical recommendation, not even take data, be able to video it, go back, watch the session, take data outside of the session, then be able to collaborate with your BCBA or case manager to talk about what you could do differently before you do it next time. So in that situation, we've gone from, in order to justify eight compensated hours, They need to see the client eight hours. This one, maximum clinically, again, I'm taking the far example to say they're getting compensated for eight hours and only two of them are with the client. The rest is planning for what you're going to do next. So clearly there has to be a middle ground. You can't only get compensated when you're working with the client. And you can't expect to have a feasible fiscal program if you're only seeing the client for two hours and the other six hours are unaccounted for.

SPEAKER_00: 18:12

So there is a good intent here, which is to optimize. I don't know that I love that word. It's been used in such funny context in our past. You're trying to get the best treatment for the client while also allowing yourself professionally sufficient time to plan, to analyze, to program. And presumably, the treatment to the client should take the majority of that time, but we can't discount that. the need to sit back, analyze, collaborate, meet, all those things that are important, which currently aren't reimbursable. Those aren't things that... So apparently you're supposed to go right into the client's home and just start providing treatment, take the data, no time to analyze it, unless you're there with the client. So only the face time is billable, and we're saying that the... Or at least insurances are saying inadvertently or indirectly that the rest of the work around... That treatment is not worth anything. Correct. Interesting. Okay.

SPEAKER_02: 19:14

Yeah, which I think ABA doesn't do itself any great favors because we don't really have that. Because we're not licensed in many states, including the one that we work in, we don't have a lot of leverage and a lot of lobbyists and a lot of people to really understand ABA. At a higher level, assemblymen, representatives, people that can really pass bills. I know the, what is it, SB, the bill that the medical insurance...

SPEAKER_00: 19:44

946 here.

SPEAKER_02: 19:44

SB 946. That was the big one that opened up all of the funding sources to us. But since then... It doesn't seem like the field has had a what's good for you is good for me mentality. It's been a very cutthroat field where if I can undercut you by a dollar, I'll get all of the insurance company's clients. And the insurance company is like, heck yeah, because there's no real standardized practice. There's not a lobbied licensure group going and saying this is what it looks like with ABA. This is what we need. It's basically coming down on the business side of, hey, company B will do it$1 cheaper an hour than company A. Let's do it for them.

SPEAKER_00: 20:27

So we've done this to ourselves in many ways, you're saying. And I remember 11 years ago now, as SB946 here in California was passing, I remember seeing the scramble. Yep. And I remember saying to myself, whatever the incidence rate was back then, going, aren't there enough clients to go around? Are we sure this is what we want to do? Which is devalue. The unit price... the unit cost of our services just to get more clients. So the volume of clients, right, a volume of services, a high volume, is in fact part of the problem that we'll talk about a little bit later with regard to larger ABA companies with a great deal of turnover, which clearly won't be able to deliver continuity of service or continuity of care, now leading the charge, requesting lots of hours to maintain that volume, and then maybe Making insurance companies think, well, those are plenty of hours. That unit rate, that rate cost needs to be a little lower because of the number of hours they're giving. And then we've got all the research that says, our inaugural episode saying 40 hours. We've scaled that down to 25 hours. Now there's talk about 10 to 15 hours. That's good. We're scaling back. What that tells us is that ABA works better. Sure. Right? level of monetary value, I think you're right. A lot of this, we did to ourselves. 10, 11 years ago, with SB 9-4-6, at least here in California, we weren't the first state to have an insurance mandate, but I suspect that everybody else did it the same way. And now we're sitting in sort of a crisis, to use your words. The reimbursement rates are hard to deal with, and in fact, are low enough that they might be perpetuating some of the problems that we've talked about here on this podcast.

SPEAKER_02: 22:24

Definitely. So without getting too much into the clinical, which I'm sure we'll spend a lot of time just talking about the fiscal, talking about both the individual company and then the reimburser. So if the individual company is if a lot of them are trying to undercut, which they obviously are, and then, you know, rates have kind of been standardized as a result of that. Once they've undercut, then the margin is smaller. So then they have to figure out how they're going to manage that margin, right? Because it's now smaller. So how do we continue the same level of service with less reimbursement rate, which at some point becomes not feasible, i.e., our program is worth switching as well. You just can't do it after a certain period of time. So on the individual employer and those who are undercutting and working for lower rates, then it's like, okay, so where do we... How do we get a reasonable reimbursement enough that we can pay our staff and maintain our margins and pay all of our executives and higher-ups and things like that at a lower reimbursement rate? And that then comes into things like cutting travel time, cutting collaboration time, cutting all of the non-billable things, right? You just look back and you say, well, what's billable when I'm face-to-face with the client? Everything else we're going to have to really cut on or cut out because that's not being compensated for anymore. The issue being the more that you start cutting those things, you're now increasing turnover because it's not sustainable, especially in an area like Southern California where we live, where rent is insanely expensive. You're decreasing the quality of individuals that are going to work in that field.

SPEAKER_00: 24:05

Inevitably.

SPEAKER_02: 24:06

Inevitably, right? It's no longer sustainable. Now these individuals might have to have second or third jobs, and now they're coming to this job tired, which is going to be very challenging to work in this job not tired, much less tired. And you're running into a lot of these situations where the individual is being squeezed that much harder to do the same level of work. Now your quality is going to be decreasing.

SPEAKER_00: 24:31

Yeah, that's really challenging. I want to give a somewhat hypothetical example of what you're talking about. And I say someone's hypothetical because, again, we're going through a similar process right now. And let me just talk about my circumstances as a case manager, as somebody that I get to do program coordination and development, which I'm very grateful for. But, again, now that stands to be at risk because of a need to do more client time. So let's say that, hypothetically, I'm carrying a caseload of about 20 clients. And people might say, wow, that's really high. Well, it's actually well above the recommended number of clients to supervise, as stated by the board. So let me admit that. First of all, wait, am I being unethical? Or am I being subdued here or subverted to an unethical practice by having that many clients? Well, let me explain. A lot of those clients are fading. So they have a low... Number of service hours per week because of that. And they might actually then have just a consult model, which means I'm only dealing, talking with the parents once in a while, looking at the client as well. These all things that are reimbursable under our current situation that could be changing. We're not sure how that's going to change as we take on other payers. So that means that I'm able to deliver quality service and supervision to all 20 of those clients based on a certain level of service. Okay, now those same clients and that same quality service I've been delivering, now somebody tells me the rate that you get reimbursed for those services, we're going to cut by two-thirds. Okay, now in order to survive that, I have at least one of two choices, and there's probably other choices, options we can come up with here. But one thing is going to say, well, then we've got to deliver more service hours to those 20 clients. But wait, we haven't asked one question about medical necessity or need in that equation. All we said is they might need more hours to cover the bottom line. Now, the other answer to that same question is, get more clients. Now, until you get more clients in order to deliver what you deem clinically is medically necessary to then see how that contributes to that fiscal need, you might still be facing the same problem all the while. Sure. Right? Now, in a capitalist society where we all like to make money, I get that, the idea of profitability or your percentage of profitability is Usually fixed, right? Any given smart business plan is going to say, we are seeing a 20% to 30% profit margin here. And what we're saying based on this model is that might have to slide a little bit. You might have to be okay with 10%, sometimes 18%, sometimes 25%. But the idea that you are going to somehow maintain a 20% profitability rate no matter how many clients you have, That's a little sus, as the kids say these days, isn't it?

SPEAKER_02: 27:36

Well, somebody's going to have to pay, right? It's either the company or the client.

SPEAKER_00: 27:40

So it's a matter of ethics here, and that's what we're talking about. And again, let's make clear, and I know that you've been very good about this in our personal discussions, and I'm sure you'll bring it up again during our discussion here. We're not putting anybody on the spot. We are honestly and candidly talking about the challenge we're currently facing in trying to answer a lot of these questions. We want everybody out there who's doing this good work to be profitable, to be successful, to pay their staff well, to do innovative work. that pushes the bar up, that makes us better at what we do, that makes us more humanitarian at what we do, that makes us really bring the idea of accessibility up to include everybody and not necessarily pinpoint or rule anybody out or push them to a margin. The idea is that we really want good service with good outcomes and everybody to be served well And we also want our professionals to be able to put food on the table and stay with their jobs to provide a continuity of care. That's a lot to take care of. So we're certainly not singling anybody out. We're not pointing the finger as much as looking at our current circumstance and saying, hey, this is really hard. But at the end of the day, either you distinguish yourself by, you know... recommending the appropriate level, clinically appropriate level per your expertise number of hours first, and then looking at the margin second. And in this really competitive market with rates that are looking pretty atrocious these days, I think it's very hard for people not to put the cart before the horse. So suddenly we're looking at how much is going to make us money. Let's recommend that number of hours. And I hate to use this word, but But I believe that would be unethical practice.

SPEAKER_02: 29:35

And like you said, at that point, you're indistinguishable for the insurance company, right?

SPEAKER_00: 29:39

You're like every other rat in the race. And I say that using that word very specifically. We don't want to be a rat in this race, right? We want to be a... an animal with a better reputation. Sure,

SPEAKER_02: 29:55

sure. So what happened maybe, I don't know, a month ago as we were starting to go through this transition, then I got the quite harsh realization of what industry standard rates are because, like I said, we've had these amazing rates for the last almost 10 years, seven, eight years.

SPEAKER_00: 30:11

I'm going to stop you for a second, and I'm going to do this often. I'm sorry if I'm breaking your train of thought. But in regards to our situation, I've heard... Amazing is a better word. I've even heard the word unrealistic, right? And what I want to say is our rates were what they're supposed to be. That's a good point. And that's something that I want everybody that's listening to this, everybody that we'll be working with over the next few months as we make this transition, I'm going to be correcting people on that. No, no, no, those aren't unrealistic rates. Those are the real rates. And by accepting anything below that, We're choosing to run in this race, and unless we distinguish ourselves with our clinical practice and the number of hours we recommend, then we're either addressing the problem or we're part of the problem.

SPEAKER_02: 30:56

That's a great point. Thank you for doing that. That's a great point because those rates are what allowed us to get out of that proverbial rat race and out of the... All of our case manager meetings are just going to be talking about how we maximize contract hours and templated schedules and things like that. I

SPEAKER_00: 31:13

mean, to come up with or not to come up with, but to adopt joint attention procedures for us, which have been very successful to talk about things like reciprocal limitation without that time to plan and program and study. afforded by the correct rates, I would not have been able to do that. Sure.

SPEAKER_02: 31:30

And I would venture to guess, talking about my original company, that the vast majority of case manager discussions with higher-ups are focused around billing and efficiency and how to increase billable hours compared to at our current company, it was much more focused on how do we improve the clinical quality. Let's chat about the clinical quality. And somewhere in the middle is probably the sweet spot there when we're talking about the rate situation, but it was very nice to Have a lot of discussions that at no point where we're like, you need to be more efficient or build more hours. Let's talk about what's best for the kid. Because like you said earlier, and I also agreed with, somebody has to pay. Somebody has to pay the piper. It's either going to be the company or the client. Someone has to pay for these rates. And so often the companies throw it on the clients and say, well, you just need to do more hours. You need to do them at times that don't work for you because we can't afford to take this hit. You need to take the hit as the company.

SPEAKER_00: 32:29

That's, I mean, again, that's interesting. So you need to take the hit as a client. Yeah, and access our particular schedule of services versus us adopting your availability. That's a really tough continuum to handle, man. And again, we're not putting anybody on the spot as much as saying that's tough. That's really hard. If you are to only provide services in certain blocks of time, that's going to make it more convenient for your logistic. At the same time, you are losing some clients who don't fit into that. Or you're... making clients fit into that to the level that perhaps it makes ABA a bit of a burden as a treatment, right? And we don't want that. If something's a burden for you to receive treatment, then I would suspect that it would affect your treatment outcomes.

SPEAKER_02: 33:11

Yep. Yeah. You're either going to have to pay in terms of convenience because we're no longer fitting into your schedule in terms of quality of care because now you're getting a new staff every three weeks because it's not a sustainable model, because we're trying to squeeze the margins however we can. At some point, somebody's going to have to pay. And right now, it does seem like... For the most part, the clients are the ones that have to pay because of the poor insurance rates or the way that the models are delivered.

SPEAKER_00: 33:41

For us, maybe continuity of service is what's important. taking the hit, right? In terms of RBT turnover, things like that. Exactly, yeah. So the client still pays, to your point. Yeah,

SPEAKER_02: 33:52

and currently, we can collaborate. You can chat with your case manager if you're in RBT. But most companies, that's not how it works. They can only chat at the client's house. And like you said, how weird would that be if the nurse and the doctor and all of the technicians are chatting in front of the patient about what their findings are? There's a lot of concessions that have to be made because of the margins and or because of the way things are run. So that put me down to a wormhole or rabbit hole about a month ago where I found a couple interesting articles on the website STAT, and these were investigations. The first one was by Tara Banow, and it talked about how parents and clinicians say private equity's profit fixation is shortchanging kids with autism. So again, we've got the clinical and the financial issues sides of the coin. But the issue that you've talked about is if we're always starting with the financial, if we're always starting with how can you be more efficient before we're ever saying how can we be better clinically, then we run the real risk of running unethical services because now we're increasing session length without caring about the clinical need. We're telling people to come to the office instead of doing home services because it's fiscally more beneficial. Again, not saying that that's not the best option, but if that's always our starting point of how we can be better fiscally before how we can be better clinically, because that's what private equity cares about. Again, we're coming from a company that bought us out that was backed by significant private equity and is actually letting us go a year after they bought us out because the private equity realized how challenging the ABA field is with those profit margins. It can be a very difficult situation.

SPEAKER_00: 35:38

So that's to say that given our current rate, which will be changing, unfortunately, everything else paled in comparison. Yes. So the idea that this national outfit was going to be able to grow our division anywhere else in the country or anywhere else in our city, given the other rates compared to our current rate, seemed an impossibility. Sure. And yet people are doing it somehow. Yep. And doing good work. Yes, that's true. Some are also doing less than good work, in my humble opinion, but there are certainly people out there doing good work, preserving clinical integrity. That's what we want to try to get to.

SPEAKER_02: 36:12

And the issue with private equity, that's why we're now transitioning to another smaller company, is a lot of people have to get paid. The private equity has to get paid. All of the management has to get paid. That's all coming out of non-billable... That's all paying for non-billable people being paid for by... people billing at very small margins. That's very challenging. So you can imagine, even if that RBT or that BCBA does become more efficient, it's not to their benefit. It's to the people above their benefit to pay for their salaries or to pay for the private equity. The private equity is not investing in it to be nice. They don't care about the clinical outcomes. They care about making money, their short-term profits. So at some point, those people have to get paid. The second article that I read, and again, we'll go into these in a lot more depth. I look forward to this being a very much multi-part series.

SPEAKER_00: 37:04

I think we're coming back to this one at least once.

SPEAKER_02: 37:06

Yes. It was titled, Why the Massive Investment in Autism Companies Created a Ticking Time Bomb. And this was by Chris Larson. Again, talking about how there's a lot of private equity, a lot of investment in autism. But as we do that, We're then more concerned with the profit margins. So then things become templated. Then things become standardized. Then it's a primary focus on the billable hour over everything else. And it creates a ticking time bomb because we're no longer in a nice medium between fiscal solvency and clinical outcomes. We're far more focused on fiscal solvency, which works for a short period of time, which private equity really cares about because they're just going to sell the company. They don't care about it after that. But after that, you've devalued the field so far that the outcomes aren't good, and now the insurance rates want to pay less.

SPEAKER_00: 37:58

And from a clinical perspective, that type of distress is going to lead to the things we've talked about here. So now you don't have time to plan? Well, that's okay because we've pre-made this vertical schedule here, which may or may not apply to your client, but we don't care because... That gives you materials to work with, which now fits into our templated treatment model, which now is not individualized, but we will all claim it is because we want to feel better about the dissonance that we're experiencing, knowing that we've got to keep our jobs. We do care about our clients. We do care about their progress. People do amazing work with some of those templated models, but it's not the best we can offer. And to your point, this is being affected. This is trickling down. This is truly trickle-down economics, right? Truly. And it's the The trickle that's left at the bottom here for a lot of the workhorses, the people that are at the front line doing this actual intervention in people's homes, there's not a lot left over there.

SPEAKER_02: 38:56

There's not. And I do want to spout some statistics from this article. But before I do that, maybe we should all get our mind right and talk a little bit about how you can get your brain in the best optimum state to internalize these statistics I'm about to spell

SPEAKER_00: 39:13

out. Even when you're working under pressure at these reimbursement rates that we're very concerned about. So what we're talking about here is productivity, and you need mental clarity. I'm always looking to do more to be more efficient. And when I hit that point of mental fatigue, I start yawning. Or maybe the baby had a couple of wakings during the night that it I've traditionally looked to coffee. Somehow that extra dose of caffeine, the second wind in the late afternoon, is what people are always, always after. I love coffee. I've got my cup right here. You can see it. But it doesn't quite hit the mark for me outside of wakefulness. I need alertness, increased acuity, a surge to increase my mental endurance, and more of it on the spot. Or as we like to say around here, I need this stuff on tap. Magic Mind is the perfect brew to have on tap for you. for my mental clarity and acuity. Now, don't get me wrong. It has not replaced my morning coffee. Dan, you can attest. It's right next to my coffee cup right here. Yep. But it has assured that I can keep it to one cup of Joe and still have all the mental performance power and alertness that I need. Now, I find that when I can get magic mind in me for about three days in a row, that's when things really start to kick in. However, I have also discovered its power on the spot, like in the late afternoon when I've not when I've not paired it with my morning coffee, but instead have it replace the afternoon cup of coffee, which never delivers for me beyond stomach uneasiness and jitters. Again, at least for me. Even when you're doing your best to concentrate on creating content, developing programming for clients, managing the family routine and transportation schedule, trying to get a little exercise into the mix, you're not always 100% focused. You're not always getting everything done as quickly and efficiently as you'd like. Again, we're talking about efficiency today. Efficiency with minimal margins here. Maybe they should

SPEAKER_02: 41:03

just invest in MagicMind for employees. You

SPEAKER_00: 41:06

know what I'm saying? That's not a bad idea. That's what

SPEAKER_02: 41:07

Google

SPEAKER_00: 41:08

does. I like it. Yes, they do. Again, I found the perfect solution, just like Google. And in fact, I'm lucky enough to say that Magic Mind found me. And now it's my go-to before recording ABA on tap or simply managing the daily grind. It truly is a little shot of brain-boosting magic. Consistently creating new content isn't easy, and it requires a lot of focus and energy. Being a parent takes a lot. Since I've started using Magic Mind, I'm able to keep my energy while not overloading on coffee and getting that uneasiness in my stomach. In fact, my family has witnessed such an improvement in my mental performance and overall that my teenagers have begun to enjoy the benefits of Magic Mind as well. And I feel good knowing they're consuming good stuff. Some matcha, some agave, and a whole lot of magic in the form of adaptogens, nootropics, and mushroom-based ingredients. So, if you want to boost your brain performance, memory, mental acuity, alertness, try Magic Mind today. Please use the following link found in our episode description. That's www.magicmind.co slash ABA on tap. That's ABA on tap in all caps, www.magicmind.co slash ABA on tap and use the discount code ABA on tap to receive 20% off your purchase. Thank you, sir.

SPEAKER_02: 42:33

Good thing you had your magic mind ready for that one.

SPEAKER_00: 42:36

That's a lot to say. You're right. I couldn't do it without the magic mind.

SPEAKER_02: 42:39

So I want to talk about some highlights of this article. So the first thing they said in this, again, why the massive investment in autism companies created a ticking time bomb by Chris Larson, found it on STAT. It's also in behavioral health business.

SPEAKER_00: 42:58

That's statnews.com, right? I believe that's the website.

SPEAKER_02: 43:03

I believe so. Yes, statnews.com. Exactly right. So he starts off saying the autism therapy space got a shock to the system with hundreds of layoffs to major operators. So we can just... Talk a little bit about that. In our area, in our demographic area, some of the biggest ones, CARD was one of the biggest autism providers around this place.

SPEAKER_00: 43:26

They were international for a little while, I believe. I mean, certainly a national outfit and now gone,

SPEAKER_02: 43:31

right? LME, Invo, a lot of these companies that were some of the biggest players in the game, gone. Why would they be gone? Well, are people with autism... Are there less people with autism?

SPEAKER_00: 43:46

The incidence rate went down. No. It keeps going up, I'm pretty sure. Okay.

SPEAKER_02: 43:52

That's actually the interesting point. And what they talk about in this article, they say the demand of services is growing significantly.

SPEAKER_00: 44:01

Everybody's got a waiting list right now. I

SPEAKER_02: 44:02

mean, I'm

SPEAKER_00: 44:02

hearing six months, eight months waiting list. There's a demand for services for sure. So why

SPEAKER_02: 44:08

are these major players, both a lot of the small ones in this area... And even the big ones are going out of business. Why is that? When the incidence rate, as it talks about here, the incidence rate of autism in 2005, according to this article, was 166 children or 443,000 people a year. The latest estimates suggest 1 in 32 or 1 in 29 or 2.3 to 2.6 American children have autism. 2.6 million? Million, sorry. 2.3 to 2.6 million American children have autism. So if these companies are having wait lists and the incidence rate is going up, why are these companies going out of business?

UNKNOWN: 44:54

Right.

SPEAKER_00: 44:54

So they must not be able to deliver service because nobody's taking the RBT position? Is that part of it? What else?

SPEAKER_02: 45:02

Yes, that's a big one. So they talk about here, they say, with the demand of services growing, investors and operators have seen the autism space as a golden investment opportunity.

SPEAKER_00: 45:13

So that means there is money to be made. Yes. Just not to be paid out to RBTs.

SPEAKER_02: 45:17

The very next sentence, the rash of layoffs reveal that there are some deep-seated challenges. So there's a huge supply and demand issue. The issue being that as these margins get cut smaller and smaller, the people actually delivering the service are less and less compensated. So the supply goes way down, the demand goes way up. And now we're wondering, now instead of taking a macro look at the situation, companies are like, well, let's pay them less. We're not able to... So everything has to work on scale, right? If I make 30% of... A$50 an hour rate, right? That's$15 an hour. That's nothing. But if I can scale that across 100 clients or something like that, now we're talking about making some significant income. The issue being that if there's not enough RBTs... Well, what can we do? We can make the ones that are working now work more efficiently and with more client hours. Eventually, they're going to get burnt out. So they're going to drop off. And now it becomes this revolving door that has less incoming as it has outgoing. And now you run into a situation where you're no longer solvent because of that. So that's one of the big issues that they talk about here. They talk about at the same time, autism... services, specifically ABA, grew in popularity. So between 2005 and currently, this was written in 2022, so last year, you had that huge increase in prevalence. ABA providers increased a lot. People saw it as a really, really good opportunity. The BRAF group data shows that the number of private equity investments per year tripled or quadrupled from 2018 to 2021 compared to 2015. So a lot of private equity saw this as a really good opportunity to get in the field and really start focusing on the fiscal part of ABA. What happened? The people that actually delivered the service got squeezed too much And now the model wasn't sustainable because you didn't have enough staff to maintain the scale that kept this feasible at the margins that they were working in.

SPEAKER_00: 47:42

So then again, to go back to the problems that this perpetuates is, and I think you're going to talk about this from this article, the idea that you start a company, an ABA services delivery company, right? And you look at the rate of reimbursement of your single payer or however many payers you've got on your panel. And based on those rates, you very wisely go, now I have to make sure that my RBTs deliver this X number of hours each. of service per day. And it means that my BCBAs have to deliver this number of hours of supervision. And this is well before you have any idea what your clients need. Yep. In

SPEAKER_02: 48:32

fact, just to say that, one of the companies that was kind of a competing company to our current company mandated that clients sign up for a minimum of 25 hours per week. Doesn't matter the client, the need. for them to take them.

SPEAKER_00: 48:49

That's what research says, right? Research says that... Every client. Right. Which makes me wonder then...

SPEAKER_02: 48:54

Even if you have an adult who's working at Microsoft and maybe just needs a couple social skills.

SPEAKER_00: 48:58

So does that mean that those clients then get faded? So you go from 25 hours and you get faded to zero because that's what the model says? That makes no sense, right? Again, being very facetious, I get very passionate about this. And I understand the numbers. I know multiplication. I know how to add. I can do long division. I know how to run a spreadsheet. What I know better... is ABA services and delivery and programming. And I can empathize, right? So the idea that, of course, you're a smart businessman. There's a difference, at least two options here. I've set my quota for my RBTs and my BCBAs. I can do this at least one of two ways. I can say, we're going to ensure you hit that quota based on this volume of clients, okay? That's option A. I would deem that immediately unethical, right? The idea that you don't know what these clients need, but you've already determined what they need based on your bottom line. Or the better answer, in my humble opinion, is you have these clients. You have this level of service based on their need. That's a little below the quota we need towards solvency. What's the answer there? More clients. More clients. And we have a waiting list for most people. And we've got an increase in ABA services and prevalence over the last year, but we're having trouble finding more clients? How is that?

SPEAKER_02: 50:21

So one of the issues that you do run into is that more clients means more travel. And now you're talking about an expense that's not reimbursed by insurance companies. ABA companies barely even reimburse it. So it'd be much easier to put the one RBT with the same client for four hours to avoid having to compensate for travel than it would be to have them see a new client for two hours in addition to the current two-hour session.

SPEAKER_00: 50:48

Now, if that client needs those four hours a day, right, and we haven't just invented goals to cover those four hours or use a templated program or a cookie cutter to fill those four hours, okay, that's fine. but I don't think that's what this article is saying. I don't think that's what the field is putting out. The idea is that we're putting the cart before the horse. We're determining the quota and the service delivery needed to maintain solvency, if not profitability in this case. Forget solvency. That's a pariah in capitalism, right? You don't want to just be solvent. You want to be profitable. So the idea is you see these numbers, you see these reimbursement rates, you determine what this client needs, what the medical necessity is, not based on medical necessity, but based on profit margins. Yeah,

SPEAKER_02: 51:33

it's money in versus money out, right? And where's the money in? The direct billing. Where's the money out? When they're not direct billing and when they're driving. So we've got to minimize that, and we've got to minimize the driving. So that's where we're going to start. We're going to start, how can you see that one client more, because then you don't have to drive.

SPEAKER_00: 51:47

Now, private equity still saw this model as profitable.

SPEAKER_02: 51:52

They did.

SPEAKER_00: 51:53

Which is interesting.

SPEAKER_02: 51:54

This is kind of to the next point. So as... The prevalence of autism increases. It says currently for every BCBA, there are about 41 children with autism. What did you say the BCBA recommended caseload is?

SPEAKER_00: 52:09

Twelve.

SPEAKER_02: 52:10

Twelve. So we should be great.

SPEAKER_00: 52:12

Well, I'm running about half of that.

SPEAKER_02: 52:13

Yeah.

SPEAKER_00: 52:14

And guess what? I'll be asking for more clients instead of trying to pad my current clients' hours. Because, again, at some point... You know, you come in as this private equity firm. Now you're telling me I need a certain amount of hours without knowing any of my clients. That dog don't hunt.

SPEAKER_02: 52:29

Yep. So 41 children with autism per BCBA. And like it says here, you actually didn't see this part, but it says an average caseload of 12. That would mean the current workplace would be able to serve about 684,000 out of that 2.3 million children that have autism. And that's just children. So there's clearly a huge need, a huge need. The RBT and the BCBA position is highly coveted. So what happens? So in a market where you've got a lot of players coming into the field, a lot of private equity, right? You've got a lot of demand for BCBAs. What is that going to do to their salary if the supply is down and the demand's up?

SPEAKER_00: 53:16

Sorry, I kind of missed that a little bit. So you're saying...

SPEAKER_02: 53:18

So if the supply of something is down and the demand is up, what's that going to do to the salary? Increase it. Increase it, right? Increase the unit cost, right. That's going to increase it. And I need to now make my position... more appealing than the other position, right? Because we're saying the market is now being saturated by companies coming in, but the supply of BCBAs is low. So I need to make my position more appealing. So what does that do to the salaries? Like you said, that goes up. What's the issue with that? The margins of the insurance rates. So what this is talking about is how salaries both for RBTs, but more so BCBAs have been going up. probably not mine specifically, but have been going up. Well, the margins have not been going up. So what happens? You go out of business, right? And it talks about, it says, we've watched salaries elevate over the last 10 years. What happens when salaries elevate? People jump ship because the market's saturated. There's always another company trying to pay you a dollar more or something like that. to get you to come to them. So salaries elevate. But again, you're only working with a certain amount of margins. So you have to do one of two things. You're either going to go out of business. You have to find a way to efficiently manage that or you fraudulently bill. Again, I don't. I haven't experienced that at my companies, but I know it's very pervasive from a lot of the CEUs that we do. But a lot of these companies are having no choices. They're having to pay elevated salaries on reimbursement rates that don't even cover the salaries, much less the overhead and all of the profit margins and things like that. That's where you get into really trying to tell these people they need to work hourly. They need to bill every hour that they're being compensated for, or even worse, fraudulently bill.

SPEAKER_00: 55:09

And then somewhere in there, again, not to sound like a broken record... don't individualize your treatment. Let's just pretend we individualize your treatment, but you have to do it this way because you have no planning time, you've got no time to meet with your RBTs, and all that gets cut out of the equation, you become that road warrior that's always out, you know, the road warrior always out delivering services, feeling very isolated, maybe working for a reasonable wage, but now you're on the road the whole time, your mileage isn't being compensated in some cases, certainly not getting Gas prices keep going up. On continuity of care, given somebody that might be a good service provider but now needs to go work a different job because they don't feel well compensated or it's too stressful. We all know this, everybody listening here, whether you're a parent or a professional in the field, a teacher. This work is hard. This is not easy work.

SPEAKER_02: 56:22

They mentioned that here. This is not a job you can just pull somebody off the street to do. And they talk about the RBT situation. They say this in turn collides with the stagnating insurance rates for ABA, which they reference an article here called Time Has Run Out. Senate Committee Sends Strong Message About Mental Health Parity Enforcement. 2022 and 2023, they're actually meeting with Senate committees to discuss Basically fix these stagnated insurance rates because why would insurance companies increase the reimbursement rates if, number one, people are willing to work for that rate, as you mentioned, is the ABA company. Do you just do it and kind of join the dark side? Or do you say that you're different but take the fiscal hit? So because ABA companies are willing to work for these rates, why are insurance companies going to change them? Additionally, because ABA companies are requesting so many hours because of the rates being terrible, insurance companies are going to say, Why are we going to pay you more? In fact, we've heard that directly from insurance people off the record that have said, yeah, y'all request way too many hours. We're not going to pay you more per capita or per hour because you're requesting way so many hours.

SPEAKER_00: 57:37

And in order to maintain that bottom line, your recommendation doesn't seem to be going down. It's likely staying the same. So now the notion that your stuff works when your recommended hours stays the same, That doesn't jibe, right? It makes us look bad.

SPEAKER_02: 57:55

It does. It does. So we've talked about why the insurance rates need to increase. We've talked about what the field is currently dealing with right now in terms of the BCBA and the much greater demand than supply. But that's constrained with we run at a cap with the rates. So you can only compensate so much before you become insolvent. or start to become fraudulent, one or the other. And the last thing I'll talk about here, and it can be a segue into another episode.

SPEAKER_00: 58:27

Yeah, we're hitting our hour mark, which we like to be very faithful to, but we've got a lot more to talk about. So we'll run over time a little bit and maybe find a good stopping point here.

SPEAKER_02: 58:37

I hear the outro music playing in my proverbial headset. It said, Yikes. That's insane. So again, we're in one of those situations where the demand is much higher than the supply, and the supply that we have is getting knocked out because of the compensation and the reimbursement rates. So now the little supply that we do have is becoming less and less, and the demand is becoming more and more. And like this article said, and you said, you can't just take somebody off the street and... have them be an rbt and work with a client and have a reasonable level of clinical outcomes unless you're trying to do a cookie cutter template model where you just give them the visuals and say go work with the client but when that happens now you've devalued the whole field which brings us back to the clinical concerns that we've talked about that alfie cohen's talked about that a lot of these facebook groups have talked about not getting good clinical services with their with their staff which we've talked about some of that being accurate, some of them maybe not being accurate, but a lot of times it is because the reimbursement

SPEAKER_00: 59:49

rates are so low. So can you imagine, I'm trying to find a good comparison here, but can you imagine, I mean, we both were involved in PT recently, right? So the idea that I go to my PT outfit, just to use that statistic and try to extrapolate it, and for every 10 sessions I have, I'm going to see seven different physical therapists. Can you imagine... our team, which is solid and it sees very little turnover, every year seven out of ten people are gone and there's new people. What does that do to continuity of care? What does that do to professional development? What does that do to team morale? What does that do? I mean, again, the client loses.

SPEAKER_02: 1:00:29

That means every time you see that new therapist, you have to explain your situation all over

SPEAKER_00: 1:00:33

again. Which, again, works to then now pad my supervision hours because I'm going to have to, you know, the client will benefit from that. That is billable, but But, you know, again, now I'm changing the ratio in those sessions. It's not one to one. It's two to one if I'm not careful about it. There's a lot of setbacks to be had when you don't have that continuity of care, especially now when it's based on fiscal pressures because we're unable to retain good people only because we can't pay them enough because we're not being reimbursed enough. So it's quite a cycle, quite a vicious cycle.

SPEAKER_02: 1:01:08

Yes. And I guess in conclusion, as we will continue this, I look forward to having a couple of guest speakers who have expressed interest in this topic as well. You know, it's one of those situations. It's like, are the criticisms of ABA correct? Is it the individual company of the ABA? Is it the field of the ABA? Or are they misunderstanding? And I think whenever I give you a multiple choice answer or which one is it, what

SPEAKER_00: 1:01:34

do you always say? Well, in this case, you gave me three. So I usually say both because you give me two options. Now I'm going to say... All of them. Or yes, right? Yes, correct, Dan, correct. So we've covered a lot of ground here, sir. Sorry, go ahead.

SPEAKER_02: 1:01:46

So when we talk about the rates, do the insurance companies need to increase the rates? Yes. Or... Do we understand why they don't? Do we need to also, as an ABA field, change our service delivery model, right? Because yes, they need to increase their rates, but it's a tough sell if the increased rates, we're going to keep doing the same amount of hours. Or with private equity firms, again, that increased rates isn't going to go to the staff that's providing the service. That's going to go to the higher ups. So there's a lot of, again, like you would call it multivariate, there's a lot of things here, just like trying to schedule out an eight-hour RBT day when you only have two There's a lot of variables in here that on surface level seem like they could be solved easily. But when you really dig down into it, you can understand why insurance companies pay less. What we need to do as an ABA field to demand that they pay more and show them that they should pay more rather than demand that they need to.

SPEAKER_00: 1:02:42

That's a really good point. point to end on. I do want to allude back to what you said. Yes, I do think that we've got a multivariate problem here with a lot of univariate solutions being applied. And the only way you're going to solve a multivariate problem is by addressing more of those variables. And again, it's either, and then people, we vacillate between just addressing the fiscal health or just addressing the clinical integrity. And in either of those situations, you're going to run into big problems. So the answer that we'll discuss next time is somewhere in the middle. Give us our closing comments here.

SPEAKER_02: 1:03:19

With a long-term outcome, like you said, right? Maybe one month we don't get our 20% profit margin, but what we're not going to do is create new protocols because one month Yeah.

SPEAKER_00: 1:03:54

Magical. It's amazing.

SPEAKER_02: 1:03:55

And that's not the tree they're willing to knock down.

SPEAKER_00: 1:03:59

No, no, no. I mean, the idea here is profits, right? Again, with all due respect to private equity, they don't care about the widget. They care about the profits the widget makes. So we have to understand what they need, and it behooves us as clinicians to then work within that model, but more importantly, to your point, work within that model to the level which then we can go back to private equity or insurance companies and say, hey... You want us to keep doing this good work? You have to adjust for cost of living. Our RBTs are in San Diego, California, the third most expensive rental market in the country.

SPEAKER_02: 1:04:34

I saw it was first, actually. It passed San Francisco, but whatever. I think Boston and New York might

SPEAKER_00: 1:04:39

still be ahead of us. But, I mean, we're splitting hairs here. The idea is that a$20-something an hour wage... And you're using your own car, paying for your own gas, not being paid mileage. Not guaranteed hours. Not guaranteed hours. So if your client cancels, now you're out of that wage. That's just not going to provide for continuity of care, which means that the service suffers. Again. With all due respect, does private equity care about that when they're looking at their profitability margin or not? They don't.

SPEAKER_02: 1:05:09

And then we have to come on ABA on tap and say, it's not the ABA that's faulty, it's the delivery of the ABA

SPEAKER_00: 1:05:16

that's faulty. With all these factors involved. Sir, we've covered a lot of ground. We're certainly going to come back for a round two on this.

SPEAKER_02: 1:05:23

And

SPEAKER_00: 1:05:23

three or four. And maybe three or four. We're going to bring some business owners in on this, which I have been, but not in the current climate. You are privileged to manage some of these. situations, so we know a lot about it, but we're not in the direct situation. Again, covered a lot of ground. Keep analyzing responsibly out there, please, despite these profit margins, these minimal margins. Cheers. Cheers, brother. ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.