A Fresh Keg of Value-Based Care: Optum's 'Low Hours, High Impact' with Mike and Dan (Part I)

(Part 1 of 2) Grab a seat and pour yourself a cold one! In this episode, Mike and Dan are cracking open the white paper from Optum, titled "Low Hours, High Impact".

For years, the "more is better" 40-hour-a-week model has been the industry standard, but the data is starting to tell a different story. We’re diving deep into the science and the shift toward Value-Based Care, exploring how focused, high-quality interventions can sometimes move the needle further than pure volume.

In this "pour," we’re serving up:

• The 40-Hour Hangover: Why the "intensive" model might not always be the most effective for every learner, especially the little ones.
• Efficiency on Tap: Breaking down Optum’s findings on how lower-intensity, high-precision services can drive meaningful clinical outcomes.
• The Payer’s Perspective: A look at how major payers like Optum are redefining "Medical Necessity" and what that means for your clinic's billing and documentation in 2026.
• Quality over Quantity: How to advocate for the right amount of hours without sacrificing progress or burning out your RBTs.

Whether you're a BCBA navigating authorization battles or a business owner looking at the future of ABA funding, this episode delivers the straight talk you need—minus the boring jargon.

Tune in, drink up, and always analyze responsibly. 

Transcript

SPEAKER_02 0:01

Welcome to ABA on tap. I'm Mike Rebio with Dan Lowry. So without further ado, sit back, relax, and always analyze responsibly. All right, all right, all right. Welcome back to another installment of ABA on tap. I am your ever-grateful co-host, Mike Rubio. To my right, as always, Mr. Dan. Got an easy one today, Mr. Dan. How are you doing?

SPEAKER_00 0:49

Taking it back old school, just you and I, no guests.

SPEAKER_02 0:53

Love having guests, and then looking forward to just being able to kind of sit back and chat. You know, the guests always there's a little extra care and caution. I gotta check out the Zoom, I gotta be doing a little bit of production work and making sure the wave signal looks good. We're not talking too loudly, we're not clipping. Today we just get to chit-chat. Well, I guess later we have a guest of sorts, but it'll be it'll be a little bit easier. We are re-recording this episode, probably an ABA on tap first. We've only had one guest ever say hold off on the publication because they weren't so sure about their appearance, and then they rescinded and they let us publish. And this time around, we we tried this one together, and you came away feeling like maybe we could do better. So I appreciate that. I think it's good to edit ourselves. We do like to do it live and unfiltered here, and we're just saying that batch turned out a little bitter, I guess. The beer wasn't as good, the brew wasn't as good as we wanted it to be. But I'm gonna let you run with this one, man. I think you've put a lot of time and effort into this. Oddly enough, I felt good about our initial recording, but it's because I was riffing, and I think that you're trying to get some of these references, references very precisely quoted, and I appreciate the the work you've done on the front end, sir. But somebody sent you a white paper. Hey, I was I meant to look up the definition, the official definition of a white paper. Sounds a little precarious. But uh, somebody sent you a white paper that was a very interesting publication. As new business owners, it put us right in the throes of you know, themes we talk about day in, day out, in terms of running the logistic and how many hours, who can who's available to be scheduled the so many hours. I know I'm spreading myself pretty thinly these days trying to answer that question.

SPEAKER_00 2:45

Trying to five find a 25th hour in the day for you, man. Oh man. Or a clone so you can be two places at once.

SPEAKER_02 2:50

Well, you know, it's it's interesting. I'm living the life of an RBT as a business owner, right? But it's it is, it's an important question, I think, that this paper presents. Let me pass it to you so you can kind of introduce the full topic for today and we'll go from there.

SPEAKER_00 3:05

Yes. So this is an article from Catalyte entitled Low Hour High Impact: a new framework for sustainable autism interventions. And I think it was sent in kind of correlation with a insurance company that was referencing this article, actually, an insurance company that we now work with. And I think the first reaction by a lot of people when I heard discussions of this article is like, oh, they're trying to take our hours, or you know, that that kind of negativity of like the the motive of the insurance company, which you know makes sense. Probably true.

SPEAKER_02 3:41

Might not be the only motive, is where you're going, but it's probably true. It's probably in there somewhere.

SPEAKER_00 3:46

Not this or that, this and that, right? But it it took us back, I think, full circle from our an inaugural episode, 40 hours. And I think that was the the premise of this entire podcast and why we started was to not just say, look, we're right and everyone else is wrong in the ABA field, and everybody just needs to listen and do what we're saying, but to try to find more of like a nuance, like a middle ground of what is accurate and what's being said, and how as a field can we advance and progress and make sure that we're always being, you know, the philosophic doubt that we attest to that we're we're doing that and not just doing the same thing that we did in 1987 and referencing that study and expecting everyone 30, 40 years later to continue to just give us what we want because that's what happened in 1987. So it seemed like a good opportunity for you and I to rift, but also look at some of the references and the studies and look at our field as a whole, because at the end of the day, at least right now and in the foreseeable future, our field is gonna be funded either by government or medical insurances. Yeah, we don't learn how to work with them and learn how to justify what we want, then our field's gonna go by the wayside.

SPEAKER_02 4:57

Now, learning to work with them, just uh as a quick point of analysis, from a business perspective. So I know I like to tack the clinical end a lot, but from a business perspective, that means giving them giving the funding sources the greatest value for the best outcomes. That's what they want, right? I mean, uh, you can't complain about that. That makes sense from a business perspective, from an investment public health initiative perspective. And then we go back to the research. What does the research say? Well, and starting in from 1971 to 1987, the only real research out there, we're gonna have to point well, not the only research out there, but Lovas was uh leading that charge. And we know that you know, from that 1987 publication, we were talking about 40 hours. We were talking about treatment being literally a full-time job for a family, for a patient receiving said services, client, maybe. We say patient now with the with the uh medical model. And I guess it's important to consider that I don't think the Lova study was a comparative study. They had a new treatment, it was dealing with a population that you know, at least in the late 60s, early 70s, or before then, we were talking about something like 90% of individuals with autism, or at that point childhood schizophrenia, would end up institutionalized. 1971, that's right after 1964, 67, where there was a lot of government initiative to protect people's civil rights to offer access. I think it was the Down syndrome community at that time that was leading the charge. But I guess my whole point being is there this wasn't a comparative study. It was Lovas essentially saying, and his and his researchers saying, look, these individuals are bound for institutions, they're bound for very restrictive settings. What if we take their full day? At that point, not many, uh, not very many school programs available. Those those were coming around around that time, 64, 67, 71. Uh, again, a lot of government initiatives. So, yeah, the notion that some that that a researcher would say, hey, these kids aren't necessarily going to school. Let's give them an eight-hour program per day that's intervention-based, and then we're going to measure the outcomes and get check it out. Some of this worked. About half of them did pretty well, right? Yeah, actually, even more than that, several of them now lost their presentation of the diagnostic criteria per the article. So, again, not a comparative study. It's just a if we want these individuals to do better, we have to fill their day with this intervention. At least that's my take, right? But now it kind of got stuck. We got stuck there. And if it's a full-time job for a patient or a family receiving services, oh, it's also a full-time job for a professional delivering those services, which makes the logistic nice and clean. Really nice and easy, right? Hey, we got one client, we got one therapist. That's a nice from a business perspective, and maybe that's where we we're still a little bit in a moratorium kind of a holding pattern. Yep. And these days, as business owners, we know that. It's hard to manage, it's hard to give people a consistent livelihood in this industry based on cancellations, recommendations for hours. There's a lot, a lot going on here. But anyway, I'll pass it back to you. I I I I threw a lot at you there, Mr. Dan.

SPEAKER_00 8:33

Yeah, no, that makes sense. And I think one thing that we've been fortunate to dip our feet into is the school side of things, which is nice and does provide RBTs the consistency and the uh the daytime hours, which is great, because so often ABA companies, and including ones that we've worked at, are trying to make their entire living on 2 30 to 6 30 p.m. And that's that's really hard. How do you pay somebody an eight-hour wage when they're only billing four hours? And now the question is, is those four hours that they're billing one client? Or now are they driving to two clients? And now when they're driving, they're not billing. So now are we just gonna have them work four hours with one client because it like you said, it makes more business sense, but now we're gonna justify it clinically. So yeah, like you said, there's a lot of variables in there. The first oh, go ahead.

SPEAKER_02 9:21

No, and then we're off the chart, right? 230 to 630. You can't do 40 hours a week on that. Exactly. So we're shortchanging the client. Oh my goodness. Well, now they need weekends, Mike. Oh, yeah, social groups and all those things that again, not being critical, but that we do to try and provide quality services that evolve over time, that that that follow the patient, the child, if you will, with their progress. And then again, yeah, we always have this question of how much is enough, how much is too much? Uh yes, 40, 30, 20 hours a week, that works really nicely for business. But then what's the individual need? What is the medical necessity, if you will? And then beyond that, what is the ability, the availability of the family, the child from a time perspective, from a finance perspective? Yeah, lots of variables to consider here.

SPEAKER_00 10:14

Yep, lots to uh talk about. The the initial part of this article talks about new research is challenging higher autism treatment. Basically, it said that in the beginning of autism treatment with ABA, the belief was that you needed 30 or 40 hours per week to be successful. And this comes from, excuse me, as I kind of go back and forth. So if there's a little pause, I'm going back and forth from article references. This is from the Lovas article, and this is gonna be kind of our our foundation. I do want to just read this specifically because there's some terminology here that I think is really important and is gonna highlight maybe the the time frame that this article is written. So just the abstract from the Lovas article, which was published in 1987, behavioral treatment and normal educational and intellectual functioning in autistic children. The abstract. Autism is a serious psychological disorder with onset in early childhood. Autistic children show minimal emotional attachment, absent or abnormal speech, retarded IQ, ritualistic behaviors, aggression, and self-injury. The prognosis is very poor, and medical therapies have not proven effective. This article reports the results of behavior modification treatment for two groups of similarly constituted autistic children. Follow-up data from an intensive long-term experimental treatment group, N equals 19, showed that 47% achieved normal intellectual functioning and educational functioning with normal IQ range scores and successful first grade performance in public schools. Another forty percent were mildly retarded and assigned to special classes for language delayed, and only 10% were profoundly retarded and assigned to classes for the autistic slash retarded. In contrast, only two percent of the control group and equals forty achieved normal educational and intellectual functioning. Forty-five percent were mildly retarded and placed in language delayed classes, and fifty-three percent were severely retarded and placed in autistic retarded classes. So first thing that strikes out to me you want you any thoughts on that, Mike?

SPEAKER_02 12:35

Was that a hard R? Oh no, it's a hard D, I think. Oh, we're getting a little dicey here on ABA on tap. I mean, that's the first thing that stuck out to me. I I and I'll say it from a social connotation, just because that word has such a a rough feel to it. It's always been used rather disparagingly, I think, even even when it was acceptable in scientific circles, it just has a real rough ring to it. And what we're talking about there, then, what I'm gathering from the abstract reminds me of early days of discrete trial, right? So we're looking at milestones, specifically drawing a straight line between the presented the deficits being presented and some milestone, like say identifying your colors, for example, for a preschool kid. Now, by achieving that, now you're retesting this child with an IQ test of some sort, developmental scale, if you will. And because you've taught those items, they have a better chance at getting those answers, right? Which then improves the scores. Not necessarily an illogical or erroneous approach, but it's we're we're kind of treat treating to the test. We're talking about teaching to the test, right? Teachers know about that. Here we're sort of providing treatment to the test. So the main the main measure here would be the IQ score. Did that have an impact in how these kids interacted with their siblings, how they were on the playground? I don't know. But these are questions that I think become of greater import, of greater importance for us these days, not just the scores. However, if you're doing any sort of progress report every six months, we're still reaching for some sort of statistical measure. Which again, we I don't know that you can get away from it, but it doesn't always mean everything we think it means. The idea of normalizing is something that's become a bit of a controversial topic, I guess. But yeah, I mean that's what they're doing here, is they're saying, hey, if if you score above 70, I guess, or maybe 85 is a better measure, then we're good. We're good. You you're no longer intellectually disabled, so therefore everything's okay. And that that perspective may have changed in modern day. I don't know.

SPEAKER_00 14:59

Test scores are interesting both in the ABA side of things and just in general. I remember speaking to a friend of mine last week, actually, and he has some kids that I think are in middle school, and he was saying that he wanted to look to go to a different school because the other school was better or performed better, and I said, based on what? And test scores. Said test scores. I was like, Well, is that really the metric of success of a school? That is a metric that could be a success, but there's so much more than that, and there could be various reasons that somebody would want somebody in a school versus another school, but I think when we look at if you were to just pull up a list of best schools in San Diego County, it would be quantified via test scores. It's like, is that the best metric? Which gets me to the question with ABA, and I think something that we've really struggled with and continue to still struggle with. What is our metric of success that we can go to insurance companies? Is it the vinyland scores or whatever standardized assessment? Is it getting that closer? Is it an IQ score? Is it a number of mastered goals? I think we've really struggled both with the general education but also ABA in figuring out what the metric of success is so that we can go to these medical insurances and say this is the discharge. When they reach this level, they will be discharged. Because even for us, like you can always write more goals and they're going to be relevant. We could write goals for your neurotypical daughter. Yeah, I'm sure there's things that she could work on, so it's it's tricky, which also then gets into the medical necessity question, which throws another kind of wrench into it as well.

SPEAKER_02 16:37

But go ahead. It depends on who you talk to. So some folks are gonna take our vinyl and scores to use that specific example, and they realize that scores nine and below maybe present greater need, maybe, and then you've got this sort of haphazard criteria of well, when they get from nine to eleven, is that when we discharge them? Right? And then you talk to other funding sources, and they're saying, well, it's got a it it has everything to do with the traits of autism spectrum disorder, for example. Core deficits, thank you. I was I was losing that particular phrasing. But the core deficits, right? So now that's gonna be more particular, knowing that those funding sources also ask us to use something like the violent, but now we're those two measures have nothing to do with each other because the violin doesn't necessarily address core deficits or list them. It lists developmental delays per no particular diagnosis, right? So I mean I don't know if that makes a difference, but again, we're sort of now dealing with two different lists of criteria. And and I'm I when I say that I'm not being I you know I love to talk trash about insurance companies.

SPEAKER_00 18:00

Careful. One that we've been working with, it's been turning things around in like a day. So Okay, I'm very sorry.

SPEAKER_02 18:06

I apologize. We might have to retract that. It's the they're an easy target. Uh there's lots of money flowing through their coffers, they're an easy target, and then you I don't envy their position in trying to work with individuals like us to figure out how to do this, right? Because we talk about standards of care, which is I think you know, this article alludes to a little bit. Well, that's hard. It's not like you know, if if a kid goes into the doctor, they're a certain age, a certain weight, they're looking, they're displaying symptoms of ADHD, the idea that 30 milligrams of this, that, or the other might work. And we can't necessarily quantify ABA treatment that's specifically outside of the hours of treatment that we provide. And then there's a lot of discussion about we're we're back full circle. How many hours? And then what does that look like? How restrictive is it? How adult directed is it? What are the parameters? What are the needs? So it's really hard to standardize treatment. You know, what what again? I don't envy their position.

SPEAKER_00 19:10

So going back to Lovas, a couple of the things that really stood out to me. One was the amount of times they used the word retarded in that article, which I think is not necessarily a reflection of Lovas being not politically correct or not exactly, or being disrespectful. While it seems that way right now, I think that is a sign of the times, which shows that this article that we're constantly referencing while relevant is 40 years old and a lot of things change over 40 years. 40 years old. I just think forty years.

SPEAKER_02 19:43

For all intents and purposes, that's four decades.

SPEAKER_00 19:46

Yeah. Wow. So a lot of use of the word R, which highlights how old the article is. With that, it also said the prognosis is very poor and medical therapies have not proven to be effective. Which also I think gives credibility and going back to the times of well, maybe today if we're doing it the same way he did it, is not the best way compared to what was available to them based on the results that they had, seems pretty effective. Yeah. Now the question is on us, can we continue to develop that methodology and those programs to stay up with the times? Because if we're just citing an article in 1987, we're not really staying up to the times, and we're basically using the retarded word when I obviously if we were to use that word, that would that would not be okay as as it shouldn't be. So we're kind of taking both ends of the coin here. We're we're using an article that says that word a whole lot of times, but not but just using what's in the article, like we're saying take this article as truth, but now we can't use some of the words. So the point being we need to kind of progress through that.

SPEAKER_02 21:00

And the last thing are you suggesting that people are referencing this article to to to recommend a high number of hours, Mr. Dim?

SPEAKER_00 21:08

Is that what you're if you're gonna say that Lovos said that the reason we need our 40 hours is because of this article, then what you're basically also saying is that it's okay to call these people retarded. That's that's what I'm trying to do.

SPEAKER_02 21:22

No, no, I but I you know I think that somewhere in there, yeah. People in this day and age, colleagues of ours, would still cite this article as a reason to recommend high hours. And I like your point. It's not to say that the research isn't valuable. No, the research is very valuable. In fact, we've built our whole industry pretty much on this particular article, I would say. And then you're saying if you read through the article, well, it's pretty antiquated too. You know, so if you're still using this as your justification for recommending thirty hours a week, you might you might approach this with greater caution.

SPEAKER_00 21:57

There you go. Very well said. The last thing that stood out to Me was in this article, 47% in the treatment group achieved normal intellectual functioning, where only two percent in the control group did. So, in this article, those are pretty strong results. That's a pretty significant, pretty similar in the mild level, and then obviously in the profoundly again, what he called retarded at the time, only 10% of the treatment group versus 53% of the control group, which again shows the lack of treatments outside of this that were effective at the time. Because if you weren't doing this, you had an over 50% chance that if your child was diagnosed with autism, that you were going to be in a profoundly retarded classroom.

SPEAKER_02 22:43

Man, this is this care this captures 16 years of this project, right? No less, right? 71 to 87. So these are pretty robust numbers. I mean, I I would say that that's a good amount of time to get through all the protocols, to crunch the numbers, to compile. I mean, think about the amount of changes that he must have seen too, even just in the educational system from 71 to 87.

SPEAKER_00 23:11

Yep. So he did a really good, you know, component analysis, looking at different treatment packages. But the question is, let's look at the parametric piece and let's kind of expand on that. The hardest thing to do is come up with the initial study. After that, then it's easy to iterate on that and look at the limitations and address those limitations and future research. So the next part of uh, or anything on the Lovos article. No, no, okay. We're good. The next part of the Catalyte article talks about recent large-scale scale studies and analysis are telling a different story. Maybe there isn't a consistent link between more hours and better outcomes. Some studies are showing that just 20 10 to 20 hours a week are providing meaningful outcomes. So let me reference two of the studies that they had talked about. One is determining associations between intervention amount and outcomes for young autistic children, a meta-analysis. And again, without boring you all, please feel free to check out the full articles. I just want to have some highlights so we can keep it moving and keep people engaged. It's hard enough for me to read through these articles. Nobody wants to listen to me talk about them. But the objective of this article was to examine whether different metrics of intervention amount are associated with intervention effects on the development domain for young children. So it was a meta-analysis of basically 9,038 children. Wow. And none of the meta and the results, none of the meta-regression models evidenced a significant positive association between any index of intervention amount and intervention effect size when considered within the intervention type, leading to the conclusion that the findings of this meta-analysis do not support the assertion that intervention effects increase with increasing amounts of intervention. Health professionals recommending intervention should be advised that there is little robust evidence supporting the provision of intensive intervention. One other study that was referenced, and then I will pass it to you to get your thoughts, is autism intervention data, a meta-analysis of early childhood intervention studies, project AIM. And this is actually published in 2023. Okay. A couple of highlights that I want to mention, and then I'll pass it to you. Again, the objective is to take the meta-analysis, so the current research and past research, to summarize the breadth and quality of evidence supporting commonly recommended early childhood intervention, autism interventions, and their estimated effect on developmental outcomes. It was a meta-analysis. The conclusion and results. Again, there's a lot of like actual numbers that I'm not going to bore people with here in the results, but there were 289 reports of 252 studies representing 13,134 participants. The conclusion here, the available evidence on interventions to support young autistic children has approximately doubled in four years. That's great. Some evidence from randomized controlled studies trials show behavior interventions improved caregiver perception of challenging behavior and child's social emotional functioning, and that technology-based interventions support proximal improvements in specific social communication and social emotional skills. Evidence also shows that developmental intervention, your specialty, improves social communication interactions with caregivers, and naturalistic development behavioral interventions improve core challenges associated with autism. Particularly difficulties with social communication. However, potential benefits of these interventions cannot be weighed against potential adverse effects. What are your thoughts now?

SPEAKER_02 27:03

Oh man. So it's an interesting comparison. So it's hard to say given the we'll call it the heterogeneity of autism traits and its manifestation. It would be fair to say that some of those kids in the meta in this meta-analysis, had they not been receiving a higher amount of services, may not have achieved the outcomes they achieved, right? That still doesn't get answered.

SPEAKER_01 27:41

Yep.

SPEAKER_02 27:42

And I'm not in any way promoting the idea of more is better. In fact, I think we go the other way in practice.

SPEAKER_01 27:49

Yep.

SPEAKER_02 27:49

So just to put that out there. But yeah, I mean, I think that that's one compound here is that we don't know that the kids in this study that didn't receive, that received more, would have hit the outcomes that they presented with had they received less. I like that they talk about detriment because I think it's easier to say that if the kiddos that received good outcomes in this meta-analysis with fewer hours had been receiving more, now we are posing a matter of restriction. Right? Because you're you're putting a child in a situation that they don't need to be in, where they could be out playing, you know, little league with their peers or whatever the case may be. Sure. Whatever the else they want to do, we we start talking about a matter of restriction. And then there's something else you said, or that the article stated, uh, that I really like to talk about, a little bit of a tangent. We won't spend too much time on this now, I don't think. But how does this affect parent perception of need and behavior? I think that's a really key component. So if all of a sudden you're telling a parent, hey, your child, we think they need 40 hours a week, oh my goodness, well, is that that severe? As opposed to, hey, to come to our clinic, you have to commit to 30 hours a week. Well, wait a minute, my kid doesn't need 30 hours a week. So parent perception, right? Versus, you know, maybe the risk we run, which is, hey, we think your kid might benefit from 10 hours a week, you're available for. So we're gonna have to do whatever we can do in those four hours, knowing that we can also meet that availability with our logistic. And now, you know, are we shortchanging? What what what is it this whole you know article is saying in terms of hours versus quality of service versus type of treatment? So they're this is a monster. This is quite a beast that they're dealing with here in this white paper with all the variables, and it makes sense. I don't think they're trying to identif to interpret all of those things, but again, there's just a lot of confounds here that leave questions unanswered.

SPEAKER_00 29:51

So let me add one more article that they reference on the first page. It's a multi-s multi-site randomized controlled trial comparing the effects of intervention intensity and intervention styles on outcomes for young children with autism. Basically, what they did in this study was they took 87 children with autism, mean age about two years old. They were assigned to either naturalistic developmental behavioral training or discrete trial teaching, each delivered for either 15 or 20 hour, 15 or 25 hours per week for one year. Children were assessed at four time points. Examiners and coders were native, naive, excuse me, to the treatment assignment. And the conclusion, again, without getting too deep into the results, neither treatment style nor intensity had overall effect on the child outcome in the four domains examined. Excuse me, initial severity did not predict better response to one intervention style than to another. We found very limited initial severe very limited evidence that initial severity predicted better response to 25 versus 15 hours per week. So that's interesting because I think historically people have said the more severe somebody is, they need more hours. And you've kind of always thought maybe the opposite, or at least it's not that that cut and dry. You're blaming me, I'm gonna blame you.

SPEAKER_02 31:14

Um I think you and I had a really good discussion about this 10 years ago now. And I guess it was one particular factor that you and I were considering and thinking that maybe more impacted patients were often going to resist that's the word I want to use treatment more, meaning that we might spend more time trying to actually gain the instructional treatment, not accessible to the children and the momentum. So the idea that you're doing that ad nauseum for four hours a day, five days a week, it seemed a little bit counterproductive to us. So the notion that we would spend just enough time doing much more parent or family guidance, I like that, I like that phrase that we use now, to see how treatment might occur on a daily basis in a naturalistic day-to-day living fashion, as opposed to having to be one of us that is there that whole time. Uh so yeah, I mean, I I think that we had a good conversation about that. The idea is as as the child begins to show engagement and improvement, then maybe we can increase the hours as opposed to saying, hey, their IQ score, their standard score is really low, and the only way to address that deficit is to pack up the hours. I mean that's it, that's you know, that's worth discussing there, right? Like if you're not responding to the treatment, then how is more better?

SPEAKER_00 32:42

Exactly, exactly right. I I just really appreciated that discussion. I I thought that was really interesting because everything is a cost-benefit analysis, and whether we're talking about physical costs, we're talking about time, we're talking about parents' energy, there's a cost to any level of ABA services. And if we're saying that instead of six hours a week, you need 40 hours a week because your child is so impacted that in order for me to get, and I'm just gonna use 10 trials, and you know that's kind of antiquated, but I know a lot of people have to hit their 10 trials. In order for me to make get let me figure out how to create an environment so that this individual is accessible and attentive to my 10 trials, I need 34 more hours a week versus somebody who may be a little bit less impacted. The question I think then becomes is that worth is the cost now worth the benefit on everyone's end? Kind of seems a little bit extreme when you look at it like that.

SPEAKER_02 33:42

It does, it does. I mean, and especially given these outcomes, right? There's there's no difference, there's no significant difference between 15 or 25 or the type of treatment being delivered. Yeah. Um again, we don't know a whole lot about the the actual subjects in the study, meaning there could have been a wide range of of severity or impactedness, but again, that you know, we don't have to worry about that now. I think the point gets made pretty cleanly.

SPEAKER_00 34:09

So I think there's a couple things, some kind of take-home points or some questions that I have that that these studies kind of bring up. Number one, so it did show in Lovas' study that the high intensity, the 30-40 hours of treatment were substantially and clinically significantly more effective than the other. Now, one of the rebuttals to Lovas' article was that he had a small sample size. But let me ask you this why do you think that in his time that might have been true? What are the variables that existed there? When now we're saying maybe it's less true or maybe even untrue that somebody would need that level of treatment?

SPEAKER_02 34:58

I'm gonna have to go to school programming. I think that's the biggest difference, especially if we're talking about 1971. Now, I'm not sure you know how many years this data was being collected versus being crunched. But I would say that in 1971, having a child enroll in this treatment and this young autism project probably made a lot of sense because there wasn't much else for those kids to do. I think that's maybe four years from the initial Individuals with Disabilities Education Act. I think 67 was the first iteration of that. So four years after that, now 20 years after that in 87, I'm gonna say there was probably a lot more school-based programming where now these kids could receive treatment all day along with peers in a more comprehensive setting, and then come home to a little bit of individualized, more specialized treatment, perhaps. But that's what I would go with.

SPEAKER_00 35:59

Yeah, I think I would go with efficiency. I would like to think that we are more efficient, we're more knowledgeable. Yeah, I think about it like you know, the the model A or the Model T, like those old cars back in the day, they were they were seminal. Without those cars, we wouldn't have here. Yeah. But if somebody came up and was like, you a Model T is appropriate or like you know, fast enough and safe enough and efficient enough compared to normal cars, compared to cars today, we we would laugh at them. And I I think that's kind of the the thing I look at is I think that we should be able to back in the day, they'd have these big, you know, 12-liter engines that produce like 100 horsepower, and now you can get that out of a one-liter engine. Like we're so much more efficient and knowledgeable and iterated on that. And I would like to think that, like you said, school I think is a huge input. Also, the way that we do our sessions with joint attention and focusing on things like that. I would I would hope, and I would really challenge everyone to say that if you're saying that because of the Lovas article, you need 40 hours a week, what that's saying is you're doing things the way that Lovas did them in 1971 through 1987. And that's I think that's a cause for concern. We should be way more efficient and way better and more knowledgeable with the services that we're delivering. And if we're not, we have no right to jump to the insurances and blame them for anything. Wow.

SPEAKER_02 37:25

Sticking up for the insurance companies. Dan, you've come full circle here. Don't go, don't go too far now, man. Don't go rogue on me.

SPEAKER_00 37:32

Wait till next week till I'm talking to them.

SPEAKER_02 37:35

You're on the you're on the uh you're on hold for four hours so you can run through two claims and then hang up and call back. Yep. Anyway, that that never happens. I I I like the point you make. Efficiency technology, maybe the advancement. It's funny because you can say that we're using the same technologies that Lovos did. We're just applying them differently, right? The the I for me, the idea of a discrete trial is much more dynamic than when I first entered this field, where it was pretty forceful. You know, I've got 10 trials to show you. I'm going to prompt you through just about every aspect of this trial because apparently I need you to sit down in this chair across from me at this table, and then we've got all sorts of iterations of errorless learning or things that that were now procedurally very sound, and then maybe not very compassionate, perhaps not very humanitarian. I don't know what the word is, but yeah, we've gotten we've gotten wiser, we've gotten better at the way we apply our technologies, and certainly I don't I don't know if we're up to the to the ABA electric vehicle uh phase quite yet, but we're certainly you know running a split eight, you know. We're yeah, I don't know how much more efficient that is, it's faster though.

SPEAKER_00 38:51

If we get stronger AI and the ABA maybe will be in the electric vehicle.

SPEAKER_02 38:57

No, but I I think that's true. It it's you know I've said it many times, Lovas would turn his grave if he saw what some of us are still doing that really mimics what he's doing. And I think that this article begins to make that point. We need this Lovas information because without it a whole population, a whole demographic of people was written off. Yep, right? And then now as the treatment evolves, as the outcomes evolve, as a society we evolve, knowing that our perceptions of certain populations have changed, given the success of this treatment, it behooves us to move right along with it.

SPEAKER_00 39:37

Yep. The last and paragraph on the first page poses an interesting question. So it says for the broader healthcare system, lower our models, free up scarcer provider capacity, and help sure shorten long wait lists. So there's an interesting, as I think you would call it, juxtaposition or almost like irony in the in the field here is that we're requesting more and more hours per patient as we have less and less providers to serve more and more patients. Why do you think that is?

unknown 40:09

Wow.

SPEAKER_02 40:10

I mean, I I think it comes down to logistics, right? I think it comes down to filling filling time and schedules. I you know, and I I hate to put it that way, because I don't think I don't know that anybody has that soul intent in mind, right? But then when it comes down to the nitty-gritty and you're looking at your staff and you're looking at your client list, you you start filling up those hours, you start filling up those time blocks in a way that makes sense from a business perspective, but then walks us right back into this quandary of how many hours is is uh sufficient, how many hours constitute the medical necessity, right? And I think that's what what you and I have been arguing, debating, trying to avoid in our own business practice is saying, Yeah, it'd be great to get this kid to fill in this Monday, Wednesday, Friday slot for this particular therapist, but guess what? I don't think they need that time, or maybe you know, it's easier for us than saying, oh, that doesn't really match up with the time frame anyway, the blocks, and I don't think they need it. But there's always this question of logistics and scheduling that's looming in the back of our minds, which is completely contradictory to the idea of necessity, right? That's the tricky part in our services and the delivery of this medical service is if you're a pediatrician, that that that patient and that parent drop everything to come to you to get your help. In this case, we are trying to make sure that we fit into you know, so you don't call the pediatric office and they go, Oh, so when are they done with school? You think it'd be okay if they came to our office at this time? No. They tell you when, how, and how long exactly, so that they can run a good workflow, right? And get to see many patients. And for us, it's different. We as we should, we're catering to the patient and their availability, and again, it walks us right back into the quandary of sometimes we might want to recommend more hours because we think they're warranted, but the the patient simply isn't available for it. So lots to consider, man. So lots to consider here.

SPEAKER_00 42:14

Yeah, I'd agree. I think a lot of it comes down to the you know the business versus the clinical, the logistical aspect of it. Yeah, predominantly ABA is done in the home. Yeah, and when you're going from home to home, there is a transportation time to get from one home to another home. And when you're doing that, you're not getting compensated as a company. In San Diego, because we're pretty urban, sometimes that's pretty close, and we're pretty fortunate with that. But then you have traffic, or we talk to people like you know, Jennifer Stevens, who somebody might be an hour or two away, and now you're driving non-compensated an hour and two each way to see this client. Now the question is from a business of fiscal perspective, how much, how long do I need to be able to bill for this client to even make up the unpaid time and drive time that I've done? So that's a big challenge because it's not like, to my understanding, and I'll say this for San Diego, it's not like insurances or any funder is gonna say, Oh, you have to drive an hour versus 10 minutes to go see this person, we're gonna pay you more. So that just all comes out of the company coffers and then creates a discrepancy, which actually there's an article that I'll reference in a little while that talks about that rural services versus urban services. So the other option is that places do a lot of clinic-based services now. So they extend the hours to justify the drive time, or they do clinical services, which again makes sense business wise. That's a great that now we're at the pediatrician model. They come to us, no drive time. That's great. There's a lot of benefits for that, and could potentially, if you have multiple clients, create a pure dynamic and environment, and and that's a wonderful, wonderful thing. Take now the the flip side of that is now we're losing the generalization. How are parents? Parents actively involved in this process, our parents actively involved. When when we ran the social groups at our company, we would run parent groups concurrently and the parents would come, but that's not how it is a lot of places. A lot of times it's drop-off and respite, which parents greatly appreciate. But then we don't have the generalization. So then we have these services going on forever. And the question is, are we asking them to come to the office because it's better for the client or better for the company? And I understand without the company, you don't have a service. If you're not profitable, you can't stay in business. So one could argue if it's better for the company, it's potentially better for the client because then they will get no services, but that can create a pretty dangerous rabbit hole now to where you're justifying all sorts of clinical concessions to make bit to meet business outcomes.

SPEAKER_02 44:48

Well, and it could I mean you you keep saying generalization, right? It comes down to environments. If the parent isn't there and we're not in the environment where the troubles are being expressed, you we're we're missing a little bit, you know. Not to say that it can't work. It certainly can work to receive services in a clinic and have that new skill or new replacement behavior generalized to the parent at home. But there's certainly a barrier that exists there as opposed to us going to their home and working in that setting where these troubles are otherwise being expressed, right? It's almost like we give them a new setting, the clinic, to now express behaviors that are of concern. Yep. So the generality works against us in that sense. Yep. Uh, they're generalizing the undesired behaviors.

SPEAKER_01 45:37

Yep. Yeah.

SPEAKER_02 45:38

Man, it it it's tricky. It's tricky because you're right. You know, maybe one of the answers here is having insurance companies account for travel time, knowing that that is part of the service. We can't deliver the service in home. And and and a lot of insurances will put parameters around community-based work. They want you to have community-specific goals, although I don't know that they do so much for the clinic-based goals, those seem to kind of mimic what would be home-based goals. Again, there's just a lot of a lot of pastiche here, a lot of patchwork to work through, and a lot of it is probably because we're chasing the most solvent model from a business perspective. It it doesn't necessarily go back to the uh need there to the patient. Yeah.

SPEAKER_00 46:26

And I know for a fact a lot of companies, their clinic services are basically like home sessions moved to the clinic, so there isn't interaction and things like that. They're going into rooms which are highly designed, which kind of take me back to older school ABA where we had the room in the house with the IKEA table and the things like that. Which now the question is, what's the benefit of doing it there versus at home? I think you just answered it. So you go the next page gets into a couple of questions about the Lovas article and its uh credibility a little bit. Credibility is not the maybe some challenges on the limitations.

SPEAKER_01 47:05

Yeah.

SPEAKER_00 47:06

And this is early intervention project. Can its claims be substantiated and its effects be replicated? And I just want to highlight a couple highlights here. See what I did there? Highlight some highlights. Nice. And they talk about how experts, some of the questions now over the 40 years that we've had a chance to look at the study, are that the study only had 38 children. Half of those, so 19, were in this experimental group. So we're now extrapolating big findings over less than 40 individuals. Also, the questions about how much treatment is needed and whether the dosage type should vary by individual, were never addressed. So it's tricky, right? Because in ABA we do single subject research where we just take one person and follow them on across the duration of their life, which is great, but we don't have any control. We can't do two treatments at once, so we can only see the treatment that we're giving that individual. On the flip side, Lovas, who had the control group, so did the between subjects design, he wasn't able to alter it within that one individual, right? So the hope is that you get a big enough sample size that you can account for all of those treatment effects. But the question is with less than 40 people, was he able to do that or not? And yeah, so there have been some other questions, basically focusing on those two things, the treatment size and the lack of giving multiple individuals different types of treatments that have suggested that while that's a great article, maybe there's some limitations that hopefully within the last 40 years would have been addressed and could be addressed to make our use of that research that much more profound. What are your thoughts there?

SPEAKER_02 48:51

I mean, that's interesting. I think that's getting so that's a good point. And then I would also argue that for a seminal study that's a little bit nitpicky, right? The idea that you would identify a certain even 38 individuals with autism when the word autism wasn't even in the DSM is interesting. And I would also say that most recently, I think that even early star Denver model research has been lauded because it's got an N of 30 or more. Now, 30 being sort of this magical statistical number, that's a good sample size. And then to support the argument this white paper is making about the the criticism about the Lovos article, they took their sample size of 38 and cut it in half. So 19 is, unfortunately, a small sample size. And then we're talking as behavior analysts who love the single subject. So the idea that we've got 18 more of those in this particular study, then you know, also says something. I I I think it's a fair confound to be pointing out, and then I would also argue that I don't think modern day research has done any better in terms of inferential statistics and large sample sizes.

SPEAKER_00 50:03

So that's yeah, and I agree with you. I don't think it's so much a attack on the Lovas article. I think it's more of a reference of why have we not continued to do why haven't we continued?

SPEAKER_02 50:16

I think there's a lot of variability in the sample sizes, in the diagnosis itself. I think it's hard to create coherent groups for participation. Yep. I think it's hard for families to participate in this research when you're already receiving 20 to 40 hours of ABA a week. I don't know. I mean, you know, to go now do an additional now. There's insurance-based studies, right? So the idea that you might pull your kid out of their insurance-based treatment to then put them into a study, you know, that's also tricky, right? So I think that it's very difficult to do this. It's difficult to do clean research in in general. And now when you've got patients, if you will, that are being served at home versus you know, cancer patients who are coming to a cancer treatment center to get their chemo, it's probably a lot harder to get those participants to stick and to participate consistently and therefore to end up with consistent or or viable numbers. Hence the meta-analysis all over this white paper. And I'll stop myself there as this concludes part one of our discussion on the optimum white paper. Low hours, high impact. Please return for part two and always analyze responsibly. 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.