ABA in Crisis II

Mike and Dan continue to bubble and brew over the challenges in the field of ABA intervention, and specifically the undervalued role of the RBT. They provide impressions and personal tales regarding their own professional transition from possibly the best reimbursement rates in the history of ABA intervention to a new outfit where said rates will be slashed by 60% and now match the rest of the field. Considering the premise that an RBT can make a more consistent and predictable living working at a fast food restaurant, ABA on Tap continues to examine and explore the role of private equity, insurance companies and behavior analysts in creating and sustaining this current crisis.

Sit back, pour heavy, listen closely and always analyze responsibly.

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Transcript

SPEAKER_00: 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_02: 0:53

All right, all right. Welcome back to yet another installment, another brewing session here on ABA on Tap. I am your co-host, Mike Rubio, along with Mr. Daniel Lowry. Dan, how you doing? Good to see you, man. It's been a while. I'm doing very well. It's been a while since we've been in the reptile studio, for sure. We've been super busy with our transition professionally, which fortunately actually gets to fuel our discussion here today. Before we kick into anything too serious here, I do want to send a quick shout-out and acknowledgement to Stephen and April Smith from the ABA Business Leaders page on Facebook and their podcast, 3 Pi Squared. They were gracious enough to invite us onto their podcast recently. I don't think it's been published quite yet, but maybe published over the next couple of weeks. Just for a frame of reference, today's October 22nd. Yes, sir. So maybe in the next two weeks or so, we'll have our guest spot up on the 3 Pi Squared podcast. please do check them out. Stephen and April are doing some amazing things for the ABA services community, making sure that we're staying ethical, and maybe more importantly, making sure that we're being valued at the level we should be, which is something we're going to be talking about today. Now, we went on to their podcast to talk about the idea of medical necessity, which I think is very much related to what we'll speak about today. And what we're talking about today specifically is an extension of our previous episode, part two on ABA in crisis. What do we mean by crisis? A lot of things. I'm going to hand it over to Dan here to explain some of the things that we're looking at in terms of this crisis viewpoint or maybe a little less drastically or dramatically major challenges for our field that we are neck deep in right now, having gone from enjoying, at least for me, better part of seven years, better part of eight years really, you close to a decade, of having worked for a specific payer, a specific medical system here in Southern California, who was providing us reimbursement rates that were a good 40% higher than the rest of the field. Those rates are no longer available to us, so we're seeing the difference in how we are afforded Yep. Yep. Yep. Really, really good things to that, and there's really, really real challenges to that that, again, I know we'll delineate today. So I was going to pass it over to you. I lied. Now, tell us a little bit more about your viewpoint on crisis.

SPEAKER_00: 3:52

Yes. So I think there have been some common themes throughout our podcast over these years. three, four years since we've started. And it all comes from the heart of really enjoying ABA, really working with individuals on the autism spectrum and wanting them to reach their maximum potential. And one of those themes has been the divergence of the ABA that we do with the ABA that we see done or hear about being done from other parents that are coming to us. And then that kind of led us down the the wormhole of getting into the Chloe Everts of the world and the Alfie Coens and kind of the whole anti-ABA movement, which is very real, which led us into kind of where it is now in this ABA being in a crisis. And we've got, on one side of things, we've got clients and people saying ABA was traumatizing to me. You shouldn't use ABA. There's Facebook groups galore that will ban parents if they said that they are using ABA or seeking out ABA. So there's this huge clinical side of things of unhappy clientele. And there's also a lot of ABA entities shutting down. So that is very challenging. And then a lot of people in the ABA field that want to work in the ABA field that are just unable to do so for various reasons. So it seems like the ABA field is getting hit on all three ends. You've got people that are unable to... the ABA field. As a result, the quality of service may be not what we would like to envision, or even the parents that are asking these people to come into their home they would like to envision. And then on the flip side, you've got the outcomes that are maybe not representative of what ABA should be. So ABA is currently getting hit by all three sides, which led us to this ABA in crisis. And we've been able to kind of come out of our utopia into more of the ABA real world and see this a little bit more firsthand and see the challenges on all three ends that an employer is going to face with minimal insurance rates and clients that need a level of service. And if they're being reimbursed at a low level, like you said, 40% less than we were able to do, the challenges that they're going to have to do, especially with... not being reimbursed, non-billable face-to-face time, things like admin or drive time not being reimbursed by the insurance company, so those all being a cost that the company has to take on. And now to moderate that, how service delivery is going to have to be delineated to these clients, which... may or may not be always in the best interest of the client, but hopefully is in the best interest of the client within the confounds and constraints that that provider is able to do within the reimbursement rates that they're being provided. So that's, I think, where we are now. Let me pass it back to you, Mike, before I get on my soapbox even more, and if you have anything to say before we diverge further.

SPEAKER_02: 7:02

Well, I've got a lot to say, and I don't want to slow you down, but what you describe is a very challenging picture. And there are a lot of variables that we'll be able to describe in greater detail within that. A couple things really quickly. We said 40% less. It might be closer to 60.

SPEAKER_01: 7:21

Yeah.

SPEAKER_02: 7:22

Okay. So just think about that. And I think everybody's very ethical about For whatever reason, we're very wise with this unspoken rule of not actually talking the actual numbers. So I'm going to uphold those rules. I think there's an ethic, there's a code there that people don't share that information. But that's to say that we're going to use a hypothetical of$100 in our reimbursement rate for these services. Nice round number. And now we're looking at...$45, maybe even a little bit less than$45. Yep. So, in all fairness to any employer in this field, and again, I'm not using real numbers here,$45, if you want to pay somebody a competitive wage, let's say that maybe that's closer to$60, hypothetically. Okay. You want to pay somebody a competitive wage here in California... How do you do that would be one question. I'm not a business guy. I do know a little bit about business. I've had the pleasure of owning a couple businesses, and that's why I don't anymore, or one of the reasons why I don't. Maybe it's a challenge that we'll face in the future to try to figure this puzzle out a little bit better. Sure. But it makes it very difficult, I think, for a business owner to feel the fruition, the payback of being a business owner. It's almost like you have to be another employee in terms of your profit and pay scale, but you have all the extra work and the responsibility of running the business, which from a capitalist perspective, that doesn't jibe very well, right? Of course. If you're the business owner, you need to be taking a good chunk of that because you're supporting as many people. And right now, that is very difficult in the ABA field, right? Absolutely. Now, it's not to say that The profits aren't there. Otherwise, private equity wouldn't be getting involved. It's not to say that the need isn't there because we've got people waiting up to between six and eight months for services. So there's plenty of work to be done. And what we'll talk more about today is how come people are largely unwilling to do it. Well, the pay is one piece. Yes. Having to use your own car to go to people's homes and sometimes not getting mileage reimbursement. That can be difficult for a young professional, somebody trying to make ends meet here in San Diego, for example. So, yeah, there's a lot of crisis to be deciphered here. Let me let you on that soapbox, sir, and tell us a little bit more about the other variables.

SPEAKER_00: 9:42

Yeah, I feel like it's that meme where everybody's pointing at everybody else because this started... kind of as a combination of two things, of us looking at the anti-ABA movement and then me, maybe like a month and a half ago, going down the wormhole of private equity, which our previous company, Kind of went down, which sent me down that wormhole and saying, oh, well, private equity might be the boogeyman here in ABA. And there's plenty of articles. I'm looking at one right here on Stat News titled Parents and Clinicians Say Private Equity Profit Fixation is Shortchanging Kids with Autism. And the second article here. why the massive investment in ABA companies created a ticking time bomb. So I wanted to look at these articles and say, okay, cool, private equity is the issue. If we could just take out private equity, get that out of the ABA realm, well, then ABA will be better and it will be more back to the utopian. But on the flip side, private equity is still working within the constraints that the reimbursement rates, the insurance companies are providing them. So even if we were to take private equity back and go back to the mom and pop shops, insurance companies still are kind of handcuffing the ability that we are able to provide these services based on the reimbursement rates. But not only that, the other thing I want to highlight is the requirements to obtain those reimbursement rates. So just like from an RBT perspective, having to work more and potentially be compensated less, What the insurance companies that we're finding out at our new gig are requiring us to do more, document more, be more cognizant of what we're doing while concurrently getting reimbursed less. So the question there is going to be, when do we do all this documentation if we don't have the reimbursement rates to eat that up on the company level?

SPEAKER_02: 11:34

Well, surely... I'm going to be a little facetious here. But surely, though, they provide you program development time, right? They're not just reimbursing for FaceTime with the client?

SPEAKER_00: 11:45

That's all that's reimbursed right now.

SPEAKER_02: 11:47

So what insurance companies are essentially saying, and that we're having to work under these constraints, is you don't need to prepare, plan, make materials. None of that. None of that is reimbursed. Because clearly these... Cases don't

SPEAKER_00: 12:03

need any of that, right? Well, if you're lucky, as the BCBA, you will get three hours, maybe four hours every six months to review the data, compile it, and write the report, which itself may take three to four hours. So you might get that on the BCBA level one time per six months. But that's it, on the BCBA level or the RBT level.

SPEAKER_02: 12:23

So I can't tell you the last time my radiologist... did all his analysis in front of me and then told me about it usually he comes in she comes in and they've done the analysis and then they tell me about it which means they had to have time that surely was paid or reimbursed sure to do those things sure so that as professionals they can do the analysis that's necessary medically and then relay it to you the patient, in this case, without jargon, without a nice flow, nice, smooth, pensive, thoughtful flow of information because they've been given the time. But that's not what is being said about ABA. So we're dealing with children, families who are in distress because children are expressing behaviors and or have skill deficits, which can be challenging. Very important work, I would say, from a medical perspective. We know that from our end, the ABA field seems to entail a plethora of different materials and things that i've spoken about here a little facetiously and the two by two square and the lamination and the board maker and all that stuff so we know that that's part of it but none of that to create any of those none of that is reimbursed right now

SPEAKER_00: 13:38

so either for that admin time we're going to have to do one of two things we're going to have to get some sort of uh non-face-to-face billable time or that's going to be taken out by the the company that we're working for, they're going to have to pay for that on their own accord. But the issue is if there's non-billable time and the margins are getting lower and lower and lower, when does that documentation have to happen? Well, it has to happen when you're with the kid because the margins aren't strong enough to sustain paying for that outside of when you're working for the kid on the company dime. And the insurance reimbursement rate isn't allowing you to pay for it on while being reimbursed. So therefore now it's, going to have to get paid for while you're working with the client like you're saying and now we're going to have to cut session short now like you said we're going to have to review analyze and document these things while we're face to face with the client and at the end of the day the only person that's going to suffer from that well everybody's going to suffer from that that but the first person that's going to suffer from that the most is the is the client it's funny and the last thing i'll say to that is i actually saw one of our clients in the um In the waiting room, a client that you work with, a very vocal, I think maybe seven, eight-year-old-ish client in the waiting room at one of our groups the other day, and I was talking with the parent about how things are going, and she was saying the kid still likes to come to the group, but the kid specifically said that he likes the groups a little less because at the end of group, people are having to document instead of playing with him. Okay. And again, is that the company's fault? No. Is that the therapist's fault? No. Where are they supposed to do all this documentation where if it's not done completely correctly, we face an audit and then we're not going to get funding? But at the end of the day, the clients are the ones that are going to pay for that price.

SPEAKER_02: 15:27

Sure, sure. I mean, so the other answer there would be to not... to keep a session, say, directly, the direct face-to-face time of two hours, and then take a hit by doing all the extra documentation that the insurance company is expecting to be part of the service, which doesn't do anything for the patient directly. And so you're right, you're right. So either we take a bigger hit, knowing that the reimbursement rates, pardon my French, suck to begin with, and do the ethical thing, the fully ethical thing, and providing full treatment time based on research now with these 15 hours and these two-hour sessions and all these things that are these so-called standards in ABA, but nobody's upholding them. It's all about limiting reimbursement rates, audits to create exclusions and make sure that providers aren't being paid, that their payment's being withheld, only to jump through all these checklist hoops. You know what the saddest part of that is in terms of who's doing this for insurance companies? It's us. We're doing this to ourselves. It's other BCBAs looking at these things for insurance companies and doing these audits. So we're doing it to ourselves. That's something that, let me make a call out, if any of you are out there, BCBAs working for insurance companies, think about this, please. Think about this. Have a little empathy. Maybe put yourself in our shoes, knowing that you're providing the service, not just looking at a checklist and a report over two screens and simply doing this cross-referencing, this one-to-one correspondence, in order to exclude. Now, I know that you're incented to exclude. That's your job. But let's think about who that affects. The child, the family. Sure. The person that's supposed to be receiving a medically-based service toward their improvement, And I think people do a beautiful job despite all these constraints. It doesn't change the fact that RBTs are getting squeezed. You know, RBTs are no longer even required by most. And again, with all due respect to professionals out there, we don't even have an education requirement. You can do this with a high school diploma. You know, why did we do that? Maybe to lower the value of it, to lower the rates. Right. Sure. You know, again, this is really difficult in terms of. Looking at a young professional who went to school, went to university, studied psychology, did a little bit of learning theory, they come out, oh, I can work with kids and help kids that have autism, but as he's here in California, I'm gonna make a better, more consistent, more predictable wage, Working at Chick-fil-A.

SPEAKER_00: 17:51

Yep.

SPEAKER_02: 17:51

They're even going to give me a uniform.

SPEAKER_00: 17:53

Guaranteed hours. And

SPEAKER_02: 17:54

they're even going to give me the materials to do the job. I don't have to bring my own chicken in or my own potatoes into Chick-fil-A. These RBTs are sometimes buying their own materials outside of the laminated printing paper, which is also an exorbitant cost to providers in terms of overhead. Sure. Maybe I'm adding to the crisis here, Dan. Help me out. How do we get out of this?

SPEAKER_00: 18:17

Well, what gets you into it and then how to get out of it? We're trying to figure out the part of how to get out

SPEAKER_02: 18:23

of

SPEAKER_00: 18:23

it.

SPEAKER_02: 18:24

What gets you into it? We're very well versed in that

SPEAKER_00: 18:26

one. Yes, yes. And it's why I left my previous company two companies ago is that what I saw as the training side of things is when the field gets devalued and the valuation of a field essentially is set by the reimbursement companies. So the insurance companies are going to be the ones that set the valuation of the field. which is unfortunate because they don't really know what we're doing outside of maybe some of the BCBAs that are reviewing some of the documentation. They're just creating generic rates, and if people are willing to work for them and request more hours, like we talked about earlier, the more hours we request to counteract that, the more that the rates are going to be decreased because we're requesting a lot of hours, and then you get down that circle. But the point being that if the reimbursement rates are so low, the quality of people that we're going to be able to hire become less and less and less. And now we go from requiring people with college degrees, which at our previous company, that's what we required for a long period of time, and we were able to sustain that. because of our reimbursement rates you know people coming out with a bachelor's degree aren't going to be inclined to work for minimum wage that's just not going to resonate for them why did they get that degree to work for minimum wage so either you're going to have people that get a degree come work for a lower rate and then leave because they're like wait this isn't sustainable or you're going to have people that don't have that level of education And one could argue that they get trained on the job, but you're going to have a much higher turnover rate. When you have a much higher turnover rate, what do you have happen? You have people having to build rapport over and over and over and over again with these clients. And that was literally probably the number one We'll be right back. is they're not going to be happy funding building rapport. There has to be skill acquisition being made. So then you run into, well, we're just going to put some random person in your house, this revolving door, and they're just going to come and have to work on skill acquisition. Well, now we get into that unethical issue of parents being really upset and the child not making progress and the field of ABA being devalued as a whole.

SPEAKER_02: 20:52

And then the child doesn't make progress that you can document on said documentation that cuts into the service, and now the insurance funding source is... Auditing you for that lack of progress. Exactly. Oh, get out of this cycle. Exactly. Wow. Wow. I mean, that is a really, really difficult picture there. But the way you're breaking it down, we'd like to talk a big game, and I think it's a really good game to talk about in terms of continuity of care. Given the amount of turnover we're facing, we might be able to do continuity of service. Right? Because you can plug somebody in there. Sure, sure. We've had the RBT person or service discussion. We're plugging somebody in there to do continuity of service, but unless they've got a good rapport or you have somebody really excellent that is good on the spot, you're not providing continuity of care. Of course. You're providing continuity of service. And again, both are very important, but I would argue that care is a whole different level. It's not just somebody, it's not just the phlebotomist who knows how to do my blood draw. It's the one that does it with a gentle touch so it doesn't hurt and I don't bruise and anybody can jab a needle in there and pull blood out. But it takes a very special hand, somebody that knows you, that knows how to do it in a way that's now care, not

SPEAKER_00: 22:06

just service. Exactly right. And it looks at what is the tool that we're implementing here because we're at the medical model. So I've had a lot of medical procedures, hence some of our delays in recording and a lot of surgeries and x-rays and things like that. And when I get an x-ray, I don't really care. I've seen all sorts of different people. Almost every time I go get an x-ray, it's somebody else that does it But the tool is the x-ray machine. They're just pressing a button. Whereas the doctor is the person who I'm really interacting with. And with our field, you're not just pressing a button. It's not like I can just give any individual a book and say, hey, this book, you can get this child to do anything for the book. No, you've got to figure out how to work that book. You've got to figure out that child and what works and what doesn't work for that child. And it's the service delivery person, as you would call it, the continuity of care, that person, who's really working with the child. It's not just like the medical, in the medical field, how you might be able to run, use the technology. In our field, the technology is that person implementing the technology. So I can give four different RBTs the same exact tools, and I might get four different, I will guarantee I will get four different sessions based on how they utilize that tool. Whereas in x-ray tech, presumably I will get the same x-ray with each four different technician.

SPEAKER_02: 23:23

That's really interesting, the way you pitched that, because... So... A radiologist, for example, could be part of the care cycle. But to your point, they're providing service now because we've got a specific machine that's doing things. So the idea of a bedside manner from a medical perspective is a little less on a radiologist than it's going to be, say, on a nurse, than it's going to be, say, on your surgeon, who you're knocked out anyway while they're doing most of the work. But you get my point. There's a certain bedside manner that we're trying to achieve here for RBTs. And we're kind of treating them like radiologists, which is not a bad thing. In terms of not creating these x-ray machines. So now everybody's programming looks the same. Everybody needs a token board. But is that really what's going to get us to the most... to highest level of generality, knowing that as a field, you've had generality? No, of course. That's why it's failing. So you can create a continuity of service in a way that replicates the service in a way that you think you're providing the same care. But to your point, four different people are going to take the same materials and do it in four different ways. The beauty of that is that there's generality that lies in there. Now, we've all come from a discipline many years ago, or from our initial experience professionally, where the answer that that company was putting forth is everybody's x-ray machine looks the same. Well, we're not just taking x-rays here. We're actually trying to incite learning in a developing child. So there's a difference there. And I think that, with all due respect, people have been wholeheartedly trying to figure this out. I know that professionals out there, they have their heart in it. Unfortunately, not all the tools or constructs are afforded to them. to actually provide care a lot of the times, we're just tied up in providing continuity of service such that the solvency is supported, such that the fiscal health is supported because everybody needs a job. So, again, we are being highly critical of this situation. Make no bones about it. It's not to say that we can't empathize or be compassionate about some of the struggles that both the service and care face, right? because of some of the fiscal constraints, and then furthermore, some of the ways that some people are choosing to run these things, right? So I think we can both wholeheartedly say that despite some of the challenges and struggles that we're facing in our current transition, we might be able to say that We are in a better spot knowing some of the other spots around town. Maybe that, yes, we can wholeheartedly say that our employer is trying to figure this out, trying to take care of people, trying to reduce some of the turnover. But at the same time, when you're caught up in the services game and you've taken a service contractor or client and you've got the amount of turnover that the field might be perpetuating in its own, your best bet is to plug somebody back in there, and then you're back into that cycle. So I don't, you know, we don't want to put anybody on the spot as much as the whole situation needs to be analyzed and dissected, knowing that somewhere in this soup, we've got family and child as clients, and then we've got these young professionals that we like to call RBTs. This profession just isn't, It's not cutting it right now. It's not attractive. It doesn't honor the skill set, the heart, the compassion that an RBT has to put forth every day, the endurance, the tolerance, being hit, scratched sometimes, spit on, having to grab slimy items that have been mouthed. Changing diapers. Changing diapers at times, depending on your company's policy. Depending on the setting, are you at home, are you at a school? I had a... Man, I had a doozy of a week this past week now reacclimating to working with school students. And that brand of ABA, which is very far from what I practice during early intervention, as it should be, but certainly a lot tougher for not just myself, certainly the RBT that is expected to be there. for a six-hour school day enduring some high-level behaviors. Do you think schools call us in, Dan, for their best students? Who are they calling us for? The ones that they can't handle. The ones that are en route to some sort of non-public placement, and they need to give us a try to see if we can make any significant difference toward avoiding that more restrictive placement.

SPEAKER_00: 27:44

We're always going to be the last resort in the school.

SPEAKER_02: 27:46

I shout out to our colleague Manny, who's like, why do you think they call it Ghostbusters? That's what we are in these situations, right? You're going to be facing a very, very tough circumstance. And again, to our credit, we're the ones that are willing to go in there. Well, we're like firefighters in that sense, right? Other people are running away from the fire. They're asking us to run to it. And people do so wholeheartedly. RBT's do so wholeheartedly because it guarantees them hours in terms of their day. But at the same time now, they're facing the highest level, some of the highest level, most complex work that we can be called upon to do so, not with school constraints in terms of not being able to allow kids to move around or walk around for these to explore, but having to really keep them in their seat and help with that, which isn't always easy, and face the consequence of trying to prompt through that, which means kids are They're going to they're going to aggress sometimes. Right. That's why we're getting called in to begin with. So, yes. OK, great. I've got six hours of my day covered as an RBT. I've got myself some good pay. But now I'm having to endure the highest level, most difficult work, you know, with all due respect to everybody who's providing these jobs for sure at a pay rate that is. competitive, but here in California, again, I'm going to keep picking on Chick-fil-A comparable to that wage given the minimum wage standard now for fast food employees.

SPEAKER_00: 29:09

And you can pick on them because they're recording on Sundays and they're not open on Sundays. Oh,

SPEAKER_02: 29:13

then we're picking on them for sure. I would love a chicken sandwich today.

SPEAKER_00: 29:16

And to their credit, they make great chicken, waffle

SPEAKER_02: 29:19

fries, right?

SPEAKER_00: 29:20

I saw a great meme that said Chick-fil-A makes chicken sandwiches out of the chickens that had both parents. I

SPEAKER_02: 29:27

like that one. So point being is, I mean, again, we're not disparaging. Fast food workers should earn a good living right now in comparison to an RBT. We're comparing apples and oranges here. But if I asked anybody off the street, who do you think has a more important job overall, with all due respect, somebody who's providing a medically based service to a child in need or somebody who's making chicken sandwiches? Now, both are very, very necessary, very fruitful, very enjoyable services. But anybody off the street would Probably pick the person helping the child, right? Sure. And maybe that help of the child is getting them a chicken sandwich, too. Point being is nobody went to college to get a bachelor's degree... Yeah. Yeah. That does not sit well with me.

SPEAKER_00: 30:36

Yep. And I think a couple of things just to touch on what you were saying. You were talking about the difficulty of working with some of the school clients or some of the more impacted clients. That's not something we're running away from in the ABA field. We run to it. That's our bag. That's always been our job. We're not saying we shouldn't work with these clients at all. What we're saying is the compensation rate of working with four of these clients to be able to get through your day or working with that client for six hours... where the school teacher would be done after that six hours. And, you know, my wife's a, my girlfriend is a principal of a non-public school who works with very, very challenging kids. And I see her consistently coming home with hair pulled out, scratches, bruises, et cetera. It's challenging. I would not want that job. After those six hours, she's done and she can do her paperwork. She can get her stuff done. With us, after those six hours, it's You got to go see another client for two hours so we can make your two hours to hit that margin so that we can sustain our business so that we can fund you at a rate that's livable, which is extremely challenging. You're either going to not be able to fund that person at a livable rate or burn them out and stress them out to the extent that they're not able to provide the service that's going to be conducive of a field that you want to be representative of what you're trying to do. So I think we're kind of running into that. And also... Specifically, I also want to reiterate that in no way are we coming after the company that we currently work for. In fact, we both believe that they're doing their absolute best to try to find a way to make this work both clinically and financially. I think I'll speak for myself and you as well that this has really given us a a step back to look at the field as a whole, not our specific company, but the field as a whole and say, is this sustainable? And is the quality of service that we can provide within the constraints that we are trying to provide these services with a one hand tied behind our back? Are we able to provide services, or there used to be an ethics code, I think it was like 4.16 or something like that, environmental constraints that confound the implementation of the services, meaning if you're providing ABA services and the environment isn't allowing you to be able to do that in a constructive and effective way, you have to Not provide them. I think, honestly, the reimbursement rates are violating our ethics code. That we are having to look back and be like, are we able to provide these effective services? Because, like you said, our RBTs have to drive places. They have to live. And going back to the x-ray analogy... If that x-ray technician is tired, that x-ray machine is going to perform the same x-ray. If they're hungover, if they're exhausted, if they're stressed, if they're frustrated, maybe they might not get me lined up exactly as they should, but that x-ray machine is going to perform the same thing regardless of their level of mental fortitude and acuity at that time. Whereas the RBT, if they're tired, that session is going to you know, go completely downhill. There's no machine for them to use. Their machine is their brain. And if their brain is stressed, wondering how they're going to pay rent, or they're having to go see an extra client after they got hit and kicked nonstop for six hours, or they're just really, really burnt out and stressed, the quality of service that they're going to be able to provide for that last client is going to be really, really diminished, which is going to diminish the field. And then now we've got these anti-ABA groups, which at the end of the day, like, yeah, the quality of service is not something that I would want to say. I would want to go to a conference of mental health or a conference that autism speaks or whatever and stick my head up there for ABA and be like, yes, this is the best thing of what we've believed in for your last 20 years and my almost 20 years now that I've been so happy about. We're having to really look back and be like, is this a field that's sustainable and something that we want to put our names and podcasts and professional titles on that we can go at the end of the day and look at the end of the day when we go to bed and say, I did the best that I could for this client.

SPEAKER_02: 34:47

Man, so many pieces to unpack there in what you said. The first thing I want to talk about is, so you're doing an extremely difficult job, an extremely important job as an RBT. And to make it viable, sustainable for yourself as well as your employer, we're looking at eight hours worth of reimbursement services. If you're at a school site for six hours and then drive to a client for two hours, that's one thing.

SPEAKER_00: 35:14

And that eight hours of reimbursement services is probably going to be necessary because of the margins and you have to have a biller. You have to have people like that to make sure that you're not missing any of those words and you're billing out money. everything correctly. These are all people that are unpaid that are paid for by the people that are working with the client at such low reimbursement rates. They're going to have to blood, sweat and tears for eight hours to make sure that the people that send the billing to the insurance company don't miss anything because the insurance companies are just waiting there to deny services like you've talked about.

SPEAKER_02: 35:45

So that's one thing. If you know, again, you're, you have the six hours at the school, you're having a tough time. It's a challenge. It's a challenging case for sure. That's why we're there. Then you have a break driving to the next case, right? So we're talking about making it a full-time, just like Chick-fil-A, you're on with a 30-minute break at some point, right? So that's one thing. But now the idea that to do the same thing, if you don't have a school case now, you have four home cases, which would be driving in between, which now takes your eight-hour day and surely makes it a nine-hour day. hour day, maybe even more with just the driving. Now your half hour break somewhere in there by law. So now we're looking at a nine and a half or ten hour day which you're away from home. Now, yes, you may not be working the entire time. It doesn't mean that you're not tied up. with work matters, transportation, to and from, or whatever the case may be. You can't be advancing your personal life. You can't be cleaning your house or apartment. You can't be buying groceries. You're stuck at work. You're not resting. So now we've got a 10-hour

SPEAKER_00: 36:47

day. Not collaborating with your professionals on how you can do your job better.

SPEAKER_02: 36:51

Back to that. So if you're working four hours back-to-back, when are you going to talk to your supervisor?

SPEAKER_00: 36:55

When they come out to the session at the expense of the child services.

SPEAKER_02: 36:59

Exactly. And now they would say, oh, well, then do it at the same time together. Okay, if we're doing a two-to-one, now we've changed. the ratio, so we're actually not doing a better service or a less restrictive service. So yes, we do all these patches to make this solvent, because we are all very passionate about what we do, and at the end of the day, the simple fix would be, hey, insurance company, oh wait, they're hurting financially. No, they're not. Come on, man. Give a livable wage. These are medical professionals. The way they treat RBTs is as if you were in the hospital, right, and you press that call button, and they're going to have to go find the nurse to hire to respond to that call button. That's not the way it works. There's always a nurse available at that hospital, and right now there's actually shortages, which is why healthcare is being affected, the quality of it. But that's the way RBTs are treated, right? We can't... hire you or give you pay or work until the call button rings. And then it's going to take us a couple of hours, patient, don't worry, actually a couple of weeks to get that call button responded to. And then if you choose that you don't want the call button anymore, the nurse doesn't get paid.

SPEAKER_00: 37:59

And while the nurse is walking up to you to deliver the services, you don't

SPEAKER_02: 38:03

cancel the call button. That's it.

SPEAKER_00: 38:04

Yep. That's it. And you don't get, the nurse does not get reimbursed while they're walking to you. They only get reimbursed while they're actively addressing whatever your concern is. And then they get called to a different floor and they're And while they walk to that client, they're not getting reimbursed.

SPEAKER_02: 38:18

Or in a way to make it sustainable because, say, paying mileage per mile might be difficult, but now your minimum wage, your fast food minimum wage, which makes it a competitive wage usually, we might bring down to the actual minimum wage as you drive to the hospital. Absolutely. You think nurses would keep those jobs? Absolutely. I mean, nurses are getting paid decently well, and even with that, we've got a shortage. So there's no surprise that we've got people waiting six to eight months for services that can't be as high quality as they could be if these reimbursement rates were just fair. And again, we can pick on business owners, you know, but the idea is, like I said earlier, as a business owner, you have a certain expectation to be compensated, to be able to compensate yourself for in a way that's a little bit higher than the rest of your employees. That is for you to organize and take on the full responsibility, accountability, and liability of being a business owner. The only way I see it right now is that you're going to be getting paid the same salary as the rest of your employees. You just have the prestige of being an owner, which, okay, maybe that's not so bad, but again, it's not a business model that anybody else would sustain in any other field. So why would we be expected to do the same thing with a medically-based service? It should be comparable to nursing or a doctor's We're doing something that's very important, developmentally speaking. And we're taking on much more rigor in terms of having to drive there. Now, lastly, the other option you have is to bring somebody into the office, right? That's where you were going. Yep. Bring somebody into the office. Great idea. With one caveat, right? At least one caveat, which is now you're not working in the home, which is where the parent is having most of the struggle. Yeah. Can that be generalized? Maybe it can. Could it affect generality? Of course it can. We're not in the same environment.

SPEAKER_00: 40:11

Yeah. Regional Center used to fund all of our services, right? And they would give us the four contracts, the three, the three, six, the four, and the four, six-year-old. Because by the time of five, because it was all funded by the state, they would say because they're in the school system. We're working through the school. They don't need in-home services anymore. So now with medical insurance, our focus is we're going to supplement the school with in-home services. Why? Because that's where these kids are having struggles, going to eating at home or going to the bathroom at home or interacting with their sibling in home. But as a result, like you said, we've got a couple options. One is they do a fourth two-hour session in the day. That can be very challenging.

UNKNOWN: 40:53

Right.

SPEAKER_00: 40:54

And that also runs into a lot of logistical issues of how are we going to reimburse that staff from going from one case to another case. So an easier suggestion would be instead of doing four two-hour sessions, let's do two four-hour sessions. Well, now we're running into the issue of two issues, one being respite, now we're just being babysitting, because being around a client for four hours... A lot of times, honestly, does become more respite-y. Or you do it at the office, but now that's basically school part two. So... And you're losing that seventh dimension of ABA, that generality. If you're at the office, the parent's not there delivering the instructions. At the end of the day, our goal is designed obsolescence. We don't want the kids listening to us. We want them listening to the parents and interacting with their siblings. So now we're foregoing clinical priority for the logistical convenience of having a longer session or a clinic-based session. But we're losing some of our clinical integrity at that time. But we might have to do it because... The reimbursement rates. So you know what I think the answer is, Mike? I think the answer is we need to get some magic mind, and then we can figure out what the solution is, because we've thoroughly identified the problem. All right.

SPEAKER_02: 42:09

Thank you, sir, for reminding us about that. We're chatting about human behavior. We're chatting about fatigue, about our daily efforts to get the day started well, to boost our performance, to energize, to stay alert. I know that a lot of our colleagues... We're always looking to the coffee. Always looking to the coffee, a little pick-me-up to start the day, to keep it going later in the afternoon. I certainly love my coffee. You see my cup right now. But what you also see is that little bottle with that green elixir. No longer the green elixir in there because I've taken it. And that's what I'm talking about here. What you're referencing is magic mind. No doubt coffee works. Sometimes I need a little bit extra. Sometimes that coffee in the afternoon doesn't make my stomach feel so good. Okay? So I need not just energy or wakefulness, but true mind-boosting, brain-surging action. This is where Magic Mind does the trick. Especially when preparing for the podcast, Magic Mind is what I keep on tap. The secret, Dan? Three days in a row at least. All right.

UNKNOWN: 43:10

Okay?

SPEAKER_02: 43:10

And more is better. But three days prior to our recordings, I start my magic mind routine, nice and cold, deliciously invigorating, little green shot, paired with my coffee right before we hit the record button. I feel it kick right in, fresh and earthy, mild and cool in my stomach, and a noticeable increase in my mental acuity. And I know that I'm getting better. Good ingredients, good, wholesome, basic ingredients. We're talking about adaptogens, herbs, roots, and other plant substances like mushrooms that help our bodies manage stress and restore balance after stressful situations. We've got nootropics, substances that can enhance brain performance or focus. What we're talking about here specifically is L-theanine, naturally occurring non-protein amino acid that promotes relaxation by reducing stress and anxiety levels. On the flip side, it can also boost your energy during the workday while also promoting calm and improving sleep quality by promoting a more relaxed state later in the day. We're talking about vitamin D3, strengthens bones, the immune system, improves brain function, boosts your mood, helps lower your blood pressure, fights inflammation, strengthens oral health, a bunch of good stuff in D3, and then a nice little kick from the agave sweetness. Some energy drinks on the market include up to nine cubes of sugar in each serving. magic mind uses three fourths of one cube of sugar per shot and this is not refined sugar but derived from agave this means delightful sweetness with less than 10% of the sugar found in most energy drinks so if you want to boost your brain performance your memory your mental acuity your alertness you need that pick me up in the afternoon after six hours of sessions and you've got one left Please try Magic Mind today and use the following link found in our episode description. Thank you, sir, for that opportunity to share that. Let's kick right back in.

SPEAKER_00: 45:31

Absolutely. Good thing you took your magic mind so that you could express the benefits of it because that one's a doozy.

SPEAKER_02: 45:37

I needed it today, for sure, as we contemplate the crisis that our field is in. And, you know, when we were first talking about this, I remember saying that crisis maybe felt like a little too strong a word, and now I don't. I don't think it is. I think it feels a little dramatic at first. Whoa, crisis. But when you look at all the variables that we're trying to figure out, and I love the way this conversation has gone for us because we've really boiled it down to two variables or two elements that are the most important. Number one is going to be the RBT. We can't have this field without the RBT. And we both agree that this circumstance certainly is not honoring the value of those professionals.

SPEAKER_00: 46:16

Can't have this field without the RBT in the current model. If we go parent training, then maybe we can, but the way it's currently

SPEAKER_02: 46:21

delivered. And then most importantly in this equation is going to be the client, the patient. Yep. They are the ones that are being affected most by this model, knowing that in order to do our best work, it needs to be sustainable. And what we're saying right now is that this is... likely very unsustainable for most RBTs, and the ones that are doing it, can they keep doing it at this breakneck pace?

SPEAKER_00: 46:46

Which is unfortunate because people don't get into this field for the money. You could make comparable money working at a fast food restaurant or working at a business or whatever. People get in this field because they want to see people progress. They have a general desire to help people. But if you're not able to pay rent, you've got to figure out how to help yourself. If your gas tank's empty, you've got to figure out how to help yourself before you can help people.

SPEAKER_02: 47:13

How can you argue with that? You know what I'm saying? How can you help others if you are in a compromised state? And fortunately, throughout this transition, that has been one of the very clear difficulties that for our transitioning staff of RBTs. To their credit and to the employer that took us in, their staff has learned how to adapt to this situation. They understand the flow. They understand the endurance.

SPEAKER_00: 47:44

I'll be with much higher turnover.

SPEAKER_02: 47:45

Yes, that is something else we're saying that is important to note. I mean, again, I think I've said it on this podcast before. This goes back a few years, but I can count on one hand... the people that left us before 2020, and having started to work with the company in 2016, four years, I think maybe there were four people that left, three of those left to pursue other opportunities like school or moved because of family circumstance to a different part of the country. I believe one of those we terminated. One termination in four years, why? Because people could afford to have a career, a true preserved livelihood, right? And again, certainly want to shout out the vigor, the impetus of our current employer. Very grateful that they were able to take us in. These questions are near impossible to answer in a good way. Yes, that's what we're finding.

SPEAKER_00: 48:44

Yeah. And with those previous reimbursement rates, we were able to collaborate, which is a big one, right? When we talk about the job duties of the RBT and the BCBA, where the BCBA's job duties are to create and develop these plans and the RBT's job duties are to implement them and provide feedback for the BCBA. I'm not exactly sure when insurance companies are expecting this interaction to happen of the BCBA to explain it to the RBT and the RBT to give the feedback back to the BCBA because it's not billable unless it's in the house. Then if it's in the house, you're running one of two issues. Like you said, you can't take data and run a program at the same time or interact with the kid at the same time. You can't talk with your RBT and BCBA while interacting with the kid at the same time. Or... And you're going to run the issue of dignity of talking about progress of the kid and talking about the kid while the kid's right there. So you're running into these issues. Well,

SPEAKER_02: 49:40

I'm saying it works out. It's very logical, right? So you have to have an RBT do eight hours of service in order to arrive at solvency. That, by default, says there is no... other time other than the time you're in session with the client. Now, to answer your question, I think most of these funders would expect us to do these things out of the kindness of our own heart. On company time. But when do you have the time if you have eight hours worth of clients? Well, then now you're going to go into overtime for your employees, so now you're making them work longer hours, having to drive in between clients, go to and fro, not to mention gas prices right now. We haven't even touched that. Inflation, cost of living adjustments, things that this field is not keeping up with. So, yeah, I think to answer your question, these funding sources are expecting us to do this for free, so to speak, paying atrocious rates to begin with, rates that require or necessitate an RBT to be scheduled Eight hours a day. which immediately by default removes any of the program development or time to discuss the case, but yet they want to make sure that you're doing that so that you can promote progress, otherwise the progress isn't indicated and then now your services are compromised. It's unbelievable. I mean, it's an inescapable cycle of foolishness. And why does it keep perpetuating? Because a lot of good people like the work they do, don't want to do anything else, like the interaction, maybe weren't trained for anything else, don't want to switch careers, but might be forced to.

SPEAKER_00: 51:12

Yeah, yeah, absolutely. And again, being so outcome-oriented as well, they want us to have these outcomes of success and graduation, for lack of a better term, from ABA while hitting all of those constraints that you just talked about. I mean, you're going to hit one of two roadblocks here. Either we're collaborating, like you said, off of the clock, and then we're running into that issue where it seems like Over the last eight years, I was able to avoid. But previously, I was not. And most people I talked to in the field also are not able to, where the company says, don't work when you're not on the clock. But they're giving you all of these things off of the clock. It's kind of inferred, but not explicitly stated. You need to work when you're off of the clock. So you're doing it out of the kindness of your heart when you're already having to scramble to get hours and stressed out by the end of the day. So you're doing it on your end as the employee, Or the company's going to take it on. Again, shout out to our current employer who is allowing for a level of admin and collaboration time. But now the company takes that on. And then within the margins of that, that's why a lot of these other bigger companies are going out. So either the company has to pay for it or the person has to pay for it. And at the end of the day, that's a really, really challenging thing. Those are two people who are working on such thin margins, that person working on such thin mental margins by the end of the day, or the company working on such thin reimbursement margins that it creates a huge challenge. Now,

SPEAKER_02: 52:44

the good thing of all this here, one good thing of all this, is that clearly this model directly supports and promotes Individualization of services. Oh, wait, no, it doesn't. Sorry, I had to correct myself there. No, again, if we went to an insurance funder and said, hey, great, we're going to take your reimbursement rates, and guess what? We're going to make sure that every child has the exact same program, and we have to go ahead and recommend the 25 hours which are empirically validated, which, of course, you guys are not using as the excuse because it's a high level of hours to reduce the reimbursement rate, but don't worry. We're going to make sure that every program looks the same because that's what you guys want, right? Well, no, we want individualization of services. Well, then support it with the business model. Something's got to give,

SPEAKER_00: 53:33

right? What if eight of those 25 hours are either spent documenting the services you did or trying to figure out how you're going to provide those services?

SPEAKER_02: 53:43

There you go. I mean, again, something's got to give at some place. And then... Moreover, you have a professional whose rent isn't based on how many hours or cancellations they didn't suffer that pay period, right? Their rent is the same fixed monthly rent every month, like it is for anybody else, or a mortgage, right? Your mortgage company isn't going to adjust your mortgage because you got four cancellations and your pay was less, but that's what we're expecting RBTs to sustain, to live through. Again... If I'm going to fault anybody here, it's going to be the reimbursement rates.

SPEAKER_00: 54:18

Exactly. As well as, when are these RBTs supposed to plan for session? If they've got the four two-hour sessions during their drive time, they're supposed to plan it for the next session, or if they have the two four-hour sessions when they're driving from one client to the other, or during their lunch time, they're supposed to plan, then you're going to run into unplanned or sessions that don't have a lot of thought and are very cookie-cutter, like in this article this about halfway through they said you can't just walk in and hand people a book and say this is what we're doing for the week because you're totally going to miss the point of what this individual child and parents need said eric larson executive director for the lovas institute midwest a private aba provider that's not private equity owned these but these people working in the industry say private equity in an effort to save money on time-intensive assessments often uses cookie-cutter treatment plans that are simply copy and pasted from one client to the next, which they said runs counter to how the therapy is intended to work. So if these people aren't being provided with time to plan, you're either going to get crappy clinical time or these people are going to be really, really stressed out at the end of the day. Again, it's not like, again... Please, if somebody's in the medical field, come on and correct me for these statements. But I assume if an x-ray technician gets a work order that says, you know, four-part humeral fracture, take an x-ray, every four-part humeral fracture, you know what x-rays you have to do. Every child with autism, you're going to have to do something totally, totally different, and it requires thought. I can't just give you a script to say, do this. And then you do it. You're going to have to take a lot of thought and planning and materials and things like that. What are you going to bring to session? Does that come out of your own pocket? What mental acuity are you going to have in session? Do you even have any left after your third client of the day going to your fourth one? Or even if you only have two clients... Again, I don't want to get harped on the number of clients. I want to focus more on the number of hours. So let's say you have two clients. You have a six-hour session and then a two-hour session. After that six-hour session, when are you going to come up with a plan for that two-hour session? Do you even have energy left to do that? At the end of the day, these kids are the ones that are getting squeezed, then the staff.

SPEAKER_02: 56:36

The logistics says, in your example, the logistics says, yeah, you have time. like you said, while you're driving. Yep. That's it. And the

SPEAKER_00: 56:44

insurance companies would say, you figure it out.

SPEAKER_02: 56:47

Yeah, and if a tree falls in the woods and nobody hears it, did it really fall, right? Well, this is the way we're treating drive time in the profession for RBTs is the drive time doesn't exist because we're not reimbursing you for it necessarily, but you have to get to the client to do the work, which then gets paid at a certain rate, which we're saying is largely unsustainable. So it's these vicious cycles that we keep... Going back to, and we have the answer. We had the utopia. We lived it. We experienced it. Again, when we say the answer is higher reimbursement rates, we mean it. We mean it. We've been there. We've seen it. And it would need to be significantly higher, right? Or if it's going to be, say, somebody that's competitive in this current market, and I'll name them directly like a TRICARE, well, then make sure that the services can be individualized. Don't be so scrutinizing and so rigid about the way you're doing service is that everybody is afraid to work with you that everybody's complaining about working with you thanks for leading the field right with the demo model and everything that they did to bring it up to speed sure but then why do all that and then not honor the field and allow people to actually clinically do their work you know

SPEAKER_00: 57:55

well what's that what's going to happen with a documentation system that is so specific is you're going to have to have a staff member that their job is to look over the notes and make sure that it has all of the criterion in fear of an audit that person's not built So that's going to come out of those margins for the RBTs, which is going to then affect their ability to be compensated for the non-billable time. Because now you have somebody, their only job is to make sure that you're fulfilling all of those TRICARE requirements. The session is going to look the same one way or another, but the documentation might look a little bit different. And God forbid it looks different and then we get... you know, audited, and then there's an issue.

SPEAKER_02: 58:34

And what we're seeing is the documentation has to look exactly the same. Yep. So where is the individualization there, right? It's really hard to individualize because, to your point, there's a nervousness about what we're going to put on those pages. Now, it's not about my clinical integrity as to how I think, you know, given my training and very expansive experience as to how I think this needs to be managed. I need to worry about how somebody else who has no idea about the situation, not even any physical presence in the moment in that circumstance, I have to worry about what they're going to think based on their checklist, or we're right back to the same problem, which is something gets kicked back, payment gets withheld, now the RBT is affected yet again, and worse, the service continuity is affected. Forget the care, which is already secondary in most of these mindsets. We're right back to the same

SPEAKER_00: 59:23

cycle. The cookie cutter, right?

SPEAKER_02: 59:24

Yeah. If you have no time to make materials... Why would you make new materials? You make the same old junk. Sure. And we call it do this.

SPEAKER_00: 59:33

Or even on the BCBA level, the cookie cutter, right? Because you have to fulfill that TRICARE note and that BCBA, who likely hasn't been in the field for a long time because they've been reviewing reports, you have to generate or you have to create your programming around what you think they're going to approve, which makes sense within... Within reason, we shouldn't be just recommending everything willy-nilly, but you're now having to make all of your sessions based on what that person's going to approve, that person who has never met the client.

SPEAKER_02: 1:00:02

Ever.

SPEAKER_00: 1:00:02

And also, may not be an active BCBA in the field. So... And what I mean active, they might have a certification, but they probably aren't seeing any clients anymore. They're probably just looking at, when I was a BCBA, this is what worked, or these are the things that my insurance provider is saying needs to get checked, these checkboxes. That's it. Do you have a certain number of goals? Do you have maladaptive behaviors for decrease? Are you targeting this behavior with this goal? Well, maybe there's a better way to do it, but we're not going to allow that because that doesn't hit our criteria. So now you're getting into that cookie-cutter model from the BCBA as well.

SPEAKER_02: 1:00:35

And one of my favorite regulations thus far. you have to have two behaviors for decrease. That's interesting to me. I mean, again, maybe it's a safe assumption given the demographic that we provide services to. Sure. But I still think it's wrong. How do you know there's going to be at least two behaviors for decrease? How do you know that as a clinician that has my constant expertise, I even want to track those or work on those? Maybe I'd like to focus on the... Why would I waste time measuring something I want to go away? Why not waste my time? the undesired behavior will also be reducing.

SPEAKER_00: 1:01:27

But let's say you are going to focus on those replacement behaviors and they allow for that, which they all do. You have to do it in the exact way that they want you to do it. They

SPEAKER_02: 1:01:35

demand it. They don't just allow it. They demand it.

SPEAKER_00: 1:01:37

Even though you're the professional with a certification that is at least equivalent to theirs. So the BCBA is universal. So we'll say, because a lot of times it's not even BCBAs that review things, but let's say it is a BCBA that reviews it. So a certification that's equivalent to theirs with more relevant experience because you're actually working with kids now where they're not, but most importantly, you know the client. They don't. But at the end of the day, that replacement behavior that you choose has to be approved by somebody who isn't as active and doesn't know that client.

SPEAKER_02: 1:02:14

I like the way you said it. We're getting close to time to wrap up here. Actually, it's time to wrap up, but I like the way you say it. We're not opposed to the oversight. We understand the necessity of it. What we're saying is the way it's being implemented is a constraint, and it doesn't. It's not to benefit the program, the divergence of programming to benefit the client. It is primarily and almost solely to find exclusions, which then affects the continuity of service, which of course then dilutes the care. Yes.

SPEAKER_00: 1:02:46

I guess my final words, with more oversight, and what I mean by that is more documentation and less compensation... Something's got to give. And that's why ABA is in crisis right now because it's getting hit by all ends. And we don't know. When you have a field where we have a plethora of clientele, I mean, ABA has gone from, I think, 1 in 10,000 when I first started to now 1 in 33. You've got companies with massive wait lists. That just doesn't seem to make sense. We have more clients and less people willing to do the work.

SPEAKER_02: 1:03:20

My final thoughts here with regard to private equity, for example. So if you know there's money to be made, then how is it that you're not able to honor the professionals making the money by doing the service delivery in a way that is ethical, in a way that is respectful? How, as a private equity, are you so smart in business to see an opportunity from a business perspective for profit and then fail like you are? The only answer has to be greed in my mind. Because you wouldn't have seen, you're so good at your numbers, you wouldn't have seen the opportunity if it wasn't there. The only reason the opportunity doesn't exist in those situations of those players that have fallen by the wayside is because somebody ran away with the majority of the loot And people like RBTs are now out of a job. And service continuity is disrupted. Again, there is no care if there is no continuity of service. Can't have care without service. And if the service isn't provided, then the care can't be developed or implemented. I'm going to say it's greed here. I'm going to really make a call out to any of you in private equity or who are business owners in this line of work. And insurance companies. Insurance companies, please. Yeah, reimbursement rates. Let's start treating these medical professionals, these RBTs, with the due respect. Let's start treating these patients who need help. There's wait lists. People are waiting for this help. As medical providers, we should be jumping at that opportunity. Boy, aren't we? It's not viable. It's not sustainable. It's not an attractive line of work. Even if you've got the biggest heart known to man and you want to help kids, I think a lot of people, their endurance gets tested.

SPEAKER_00: 1:05:01

Can't help kids while you're living out of your car because all the toys are in your car.

SPEAKER_02: 1:05:05

And then you're buying those toys, too, so hard to pay rent when you're having to buy those materials. Again... I would say something's got to give. We've got to do better. We have to do better.

SPEAKER_00: 1:05:13

I think at the end of the day, yes, this is a scientifically validated procedure in the lab. We're trying to move it to the living room, and there are a ton of roadblocks into getting this service into the living room and try to keep this ABA as valuable as we know it can be and give some... Debunking to some of the detractors gets harder and harder when insurance companies are making us do our services with one hand behind our back.

SPEAKER_02: 1:05:43

All right. Well, all of you out there, stay hopeful. Keep your passion. Keep your compassion. Keep doing God's work, to use that phrase specifically. We know you're out there. We see it every day in our surroundings. We put forth our perfect effort every day, and this is hard, very, very hard, challenging work, but we also think it's very valuable. So insurance companies out there, let's raise those rates. To the rest of us, always analyze responsibly. Cheers. 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.