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

(Part 2 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_00 0:01

Welcome to ABA on tech. I'm Mike Rebio with Dan Lowry. So without further ado, sit back, relax, and always analyze responsively. Welcome back to yet another installment of ABA On Tap. I am your ever-grateful co-host, Mike Rubio, and this is part two of A Low Hours High Impact. Just Dan and me. Enjoy.

SPEAKER_03 0:45

Yeah, that that's such a good point. It it really highlights the discrepancy between ABA and BSD, or more of the experimental side of ABA and behavior service delivery, because we're using human subjects. So we're these these are people's lives at stake. And it kind of goes into, I know when I would teach it to my team about the different experimental designs, and we would talk about withdrawal and reversal designs, and that's kind of what we're reflecting on now. They they're great in theory and they're great in application because they do a good job of showing internal validity and they do a good job of showing and reducing compounds. But the problem is withdrawing a successful treatment or reversing a successful treatment is not necessarily ethical. You're working with a parent and you've found that I don't know, giving them Skittles hypothetically, is being effective to get them off the iPad, then and you say, Okay, parent, you know what, we're gonna stop giving them Skittles for two weeks so that they can bring the tantrums back so we can make sure that it was the Skittles that got them off the iPad. Parents gonna be like, what are you talking about? No, this is working, I'm not gonna change it. And back to the Lovas study, it's it's really, really hard if something has been effective. I don't want my child to be the guinea pig of the next level because what if hypothetically, what if 10 hours isn't effective? But 40 hours was effective, and my child was in the 10 hour group to see if it was effective and it wasn't, but what if they would have gotten the 40 hours, it would have been effective. My child now suffers, and my whole family suffers as a result. It's really, really so hard once something has been shown to be effective with human subjects to get something else to be done because your people's lives are at risk.

SPEAKER_00 2:24

And then to the whole point or one of the points of this article is once something's effective, the notion that more is better always creeps in, right? Whether that's working out or vitamin B12 supplements, or we just have this idea as humans that more has to be better. And when you're dealing with a child and a family, then the idea of 20, 15, 20, 25, 30, 40 hours a week when parents are already working full time, when there's school schedules, when there's speech therapy, when there's OT, a bunch of other therapies that I I wonder how those factor into these studies. Were those other uh were those subjects dropping everything else except for their ABA? Probably not. So there's probably a differential between who was receiving OT or speech, which would inevitably have an effect on some sort of social communication. You know, yeah, that this is hard. This is just hard to do good research, hard to keep participants, it's hard to manage attrition. You might start with 40 subjects and end up with only 20 subjects worth of data. Yeah, this is really difficult to say the least.

SPEAKER_03 3:30

There's so much art with the science. And I know we've always been, at least recently, since we've we've kind of done our own thing the last 10 years running different companies, been of the mindset of can we less is better in the let's let's start with the minimum and go from there. Can I 100% say if the clients we worked with got more services, would they have been better? I can't say without a doubt that they wouldn't have. I don't know. We we we never know, right? And on the flip side, people they get 40 hours a week, can they definitively say if they would have gotten 38, the client would have been worse off? No, like we can't, you can't do two things with one individual at the same time, and that's that's incredibly tricky. It's the people that came to us either lucked out or unlucked out that they got the lower end, and I think they made progress that was justifiable of the hours that they worked. And on the flip side, if it would have gone to a different company, would have gotten a different treatment recommendation, most likely, and a different outcome potentially. Would it have been better or worse? I don't know.

SPEAKER_00 4:33

Yeah, yeah, that's that's difficult, even with the measures we use now outside of our own goals and sort of progressing those, you know. I do I ever see a five-point jump in the violent scores? I don't, you know, it's usually two, three points maybe on the V scale, but that tends to be significant enough to then back to this uh point that the article made earlier. I can say wholeheartedly over these years that we've been involved with several companies that despite those metrics, I know that parent perception has changed. I know that we come away with parents now feeling like they can manage behaviors better. If they can manage behaviors better and their child now express different replacement behaviors, there is a semblance of an ability to learn there, which I know uh really sits well with parents. The idea that I had this child who was misbehaving, who was tantruming, who was always in distress, and now maybe that still happens, but I understand it better behaviorally. I can manage it better for the most part. We can see a change in those metrics. So you know, Johnny's tantrum every day for an hour, now Johnny tantrums every day for 20 minutes. That is a significant difference. I can attest as a parent, you know, forty 40 minutes less of a screaming child every day. That that works out. That works out.

SPEAKER_03 6:01

That's a great segue into the next part of the Catalyte article talks about a better fit for families, reducing the burden of high hour models. So for families, the toll of high hour care is significant. A 30-hour schedule, 30-40 hours of ABA means juggling schoolwork, family, and leaving little time for anything else. A high hour treatment puts parents in a difficult predicament. They must choose between 30 or 40 hours of week a week of treatment that may or may not even be feasible with everything else going on in their life. There's an interesting article here that was referenced. I'm gonna talk about it a little bit and then I'd be interested to get your thoughts, Mike. It says for many, the strain is compounded by the fact that parents with children with autism earn less on average than parents of children without autism. Now let me pull up that article and get you the specifics.

SPEAKER_00 6:56

That's interesting. Right. Um let me find my I'm interested in this metric here because we find my article here. Is that at the start, or is that because they have to modify their work schedule? Right here.

SPEAKER_03 7:08

So this is implications of childhood autism for parental employment and earnings and the results. On average, mothers of children with ASD earn thirty-five percent less than the mothers of children with other health limitations, and 50 so more than even just other health limitations, and 56% less than mothers of children with no health limitations. Oh wow, they are six percent less likely to be employed and work seven hours less per week on average than mothers of children with no health limitations. There were no statistically significant differences in father's labor market outcomes across the three groups. On average, children with ASD are 9% less likely to have both parents working. Family earnings of children with ASD are 21% less than those of children with another health limitation. So it's crazy that I could see it between no limitation and ASD, but it's crazy the difference between ASD and just other health limitations. And so 21% less than other health limitations, 28% less than no limitation. Family weekly hours of work are an average of five hours less than those of other no health limitations. So the conclusion is families of children with ASD face significant economic burden given the substantial health care expenses associated with ASD, the economic impact of having lower income in addition to those expenses. So less income, more expensive is substantial and is essential to develop health care policies around that. Wow. Lot to process there. What are you what are your thoughts there?

SPEAKER_00 8:56

What's the attribution? Is this this isn't because this isn't characteristic of these families to begin with? What we're saying is it's because of the additional stressors related to autism.

SPEAKER_03 9:10

Or maybe the amount of treatment that they're expected to do. Right.

SPEAKER_00 9:13

So they have to maybe reduce their work hours, leave work, change careers. I mean, that's a lot, man. That's a lot of stress, you know. And and I'm sure people do it gladly because it's their kids. Gladly. That's an interesting term to use here. I'm sure they do it wholeheartedly. Maybe they're not so glad about it, right? But they do it because it's their child. Now let's talk about co-pays. Oh boy. For this treatment. That can be anywhere from five dollars to a hundred and forty-five dollars in our experience, and I don't know how that varies now with different insurance parameters and subsidies not being available. I know that it had an impact on a lot of the folks that we uh have the the the privilege of seeing.

SPEAKER_03 10:01

You know, which is interesting because the $145 copay is is for a family. So the copayes are typically higher, the the lower the insurance premium is. Well, they pay a lower insurance premium, which is still astronomical because they can't afford the higher insurance premium, so then they have higher copays.

SPEAKER_00 10:19

Right. I mean $145, man. That that's okay, so $145 a session. Now let's factor in five sessions a week. That's how do you keep up with that cost? I couldn't be I wouldn't be able to. No. That's that's that would be outside of my budget for I mean, for one child, let alone a family of you know, three with three children and other expenses outside of medical needs that come up. That's really something that I don't know that we factor in. I don't know. Well, I think you and I try to be considerate of that. I don't know that as a field people are thinking about that because you know, we tend to put our blinders on from a business perspective, and the the more the better, right? But then you've got families who may not speak up so quickly. So I know I can't afford this, but my child needs this because you said they need this. Oh that that gives me a that's a little cringy, man.

SPEAKER_03 11:19

That's how much that parent feel, right? They don't know. We're the experts, and we come in and we say, you know what, you're not an adequate parent. Or you that that that that might be accepted. You're not doing everything you could do for your child unless you give them 40 hours a week, which might mean hypothetically you're spending $500 a week in copies.

SPEAKER_00 11:40

What now? I guess on the flip side, if you're paying $145 for the day and you've agreed to one of these 30-hour markers, your kids there for six hours at $140, that's better than $140 for two hours. Okay, so that is maybe that's an argument on that side and saying there's more more value for sure, right?

SPEAKER_03 12:02

Almost replaces daycare at that point.

SPEAKER_00 12:05

Yeah. Oh, that's a whole other episode of ABA. Should you forego preschool services to do ABA? That's a that's uh for another time. I I can't imagine the stress. And I'm sure that that plenty of these parents have bosses who, with all due respect, are probably giving a little bit of heat, a little bit of pressure about having to leave work, about having to do this, about having to do that. And now you've got the expense. Maybe you've got the school calling you because there's behavior concerns. That's just a lot. That's a lot that we factor into that we can certainly do better at if we're if we're considerate.

SPEAKER_03 12:46

Yeah, that's yeah, that's certainly a whether the high hours, I I think that's just something as a field. That that financial piece, that's a lot. They're their expenses are higher, their ability to earn income is less. And now the question is gonna be do we so the the clinic model in some ways is is an answer to that, because then the parents can just drop their kids off and then go to work for six, seven hours or whatever, but now we're losing the the sight of the services. Now it's becoming daycare, and now there's not generalization. And now we've got these services that are lasting for real long periods of time because the kid does great at the the session, but then they go home and it's the same exact environment. And then ABA, if we're saying behavior is a product of the environment, yeah, and the environment at home isn't changing, then it's gonna take a significantly longer time for us to try to change it and replicate it back into that environment.

SPEAKER_00 13:41

Wow. All right, let's let's let's press ahead here. What else does this article throw at us?

SPEAKER_03 13:46

So one more thing on the the parent piece. Effectiveness of parents. So this goes into what you were saying. That I think when I asked you about how do we know if we were successful, you said, Well, I don't know if it would be better than 40 hours a week or whatever, but I know that our parents feel very empowered. Right. So let me highlight the effectiveness of parent-led applied behavior analysis at improving outcomes for parents of all testric children. So the kind of the jig the jig the vibe, I guess, like words are hard, of of this. And basically, what this comes down to is this current study sought to understand the effect of parent-led applied behavior analysis, ABA, which we do in comparison to other practitioner-led applied behavior analysis on parent stress and parent self-efficacy, which is what you are talking about. To do this, we analyzed secondary data from a large behavioral health provider for individuals with ASD. We conducted a regression analysis to understand the relationship between parental stress and parental self-efficacy in a two-way mixed ANOVA to evaluate the differences existed between parent-led and practitioner-led on parental stress and parental self-efficacy. The regression analysis included parents of 2,276 children, so a pretty good amount with ASD, and the comparison analysis of parent-led and practitioner-led applied behavior analysis included 152 children with ASD, with 76 in each group. The analysis found parental self-efficacy predicts 21% of parenting stress with a significant negative relationship. So the more self-efficacy they have, the less stress they would have. The results of the comparison between parent-led and practitioner-led ABA resulted in a significant difference in parental self-efficacy, whereas the parent group exhibited a significant increase in parental self-efficacy, while the practitioner-led group did not. The results further support the efficacy of parent-mediated treatment for children with autism disorder and underscore the importance of significant inclusion of parents in the ABA treatment. What you got, Mike?

SPEAKER_00 15:59

Ah, that's that's uh music to my ears, man. That sounds exactly right. I think that's part of the answer here in terms of arriving at an adequate recommendation of ours is okay, you're gonna drop them off at the clinic. Great. How many hours do I get with you, mom and or dad, knowing that if I'm in your home after work between 230 and 630 after school after work, then we're gonna get the more bang for everybody's buck. Is that right? Yep. I think that I mean that makes perfect sense, and I think that's the answer here. It may not be the most attractive answer from a fiscal perspective or a or a business perspective. It doesn't address or ameliorate the scheduling constraints, but it does speak to the most effective way to do this, I think. And when when we say parent-led, I remember in the old days, you know, we're gonna teach parents to do discrete trial. I don't think that's what we're talking about here, right? The idea is is how am I going to teach you these basic uh concepts at ABA? And then how do those translate into your daily parenting practice, knowing that a couple times a week I come and sit with you? And I like the way you put it these days, and we're gonna meet you where you're at, meaning, oh, you've got a session with us from four to six now. That doesn't mean you drop everything at home. It means you keep things going at home and we fit into your routine. And yes, we certainly might change, adapt, modify some of these routines in the future, given our behavioral recommendations, but the the days of you have to stop and drop everything to come and do this session and do these oddly, you know, oddly toned prompts and our good jobs and all that stuff, that's not necessarily what we're talking about. We're gonna we're saying do what you do and then add these things, pepper in these things, these ABA things into what you're doing, and let's see what happens. I like that. I think that's that's part of the answer there, along with us being more conscientious of our recommendations and our definition of medical necessity and what they think, what we think they really need to address it. Probably the the next question is how many of those hours, if not all, can you, mom, dad, brother, sister, grandma, grandpa, be around? Even if you're just listening to what we're doing, we need you present.

SPEAKER_03 18:22

Yeah. And I and I honestly I wonder where that came from. It probably came from the Lovas study because they needed practitioners to implement something a very specific way. The initial Lovas methodology, it was brand new. So nobody knew how to do it. In fact, I remember one of the parents here in San Diego, one of the first people to receive ABA in San Diego, had people from UCLA, her and like four parents combined to basically bring people down from UCLA a couple times a month to work with their kids because it was so special specialized. Parents couldn't do it then, and that makes a lot of sense. But now that we know what we're doing, it's it is a very interesting model of it's you know, going from the direct both the BCBA level, which wasn't BCBA at the time, but now the BCBA level and the parent level, to going down to creating these RBTs and having so much be done in the direct service model. And these RBTs are not theoretically trained, even though they are at our company, to really incorporate the parents, involve the parents, train the parents. That's not within their scope and their certification. So when they're there, they're just running trials, and the parents aren't really involved. So it's really interesting how the field has progressed into that or never progressed away from that, might be the better way to say it.

SPEAKER_00 19:43

That's a great point. I I think it that's exactly where it started, right? The idea that I mean, just imagine like you know, your neurosurgeon being like, hey, we're gonna teach you how to cut your head open. And no, never. But these parents, these family members, that's exactly what we're asking them to do. And and you know, in the old days, I remember asking people to do some very unnatural things, some some really weird things in terms of even just basic blanket ignoring extinction, which was erroneously applied for many years, even by me. It was weird things that we're asking parents to do that are outside of their scope, outside of their understanding. And a lot of times it was just a lot easier for us to we're trained in this discrete trial methodology, we'll just do it. In fact, it's so specialized that we need that separate room in your house so that we can close the door and that way your child can't elope or run away. Yikes! Even saying that now is gives me chills. But yeah, I mean that's that's that's just it is we're expecting them to basically understand and then apply a medical treatment, you know, as it were, in order to get their child better. And what we're saying is, yeah, that's the way it has to be. It's it's a little bit like physical therapy, right? You you gotta go through it. You can't just sit around and we're saying you have to go through it with the patient, with your child. So if they do this exercise, you gotta be right there with us. And yeah, I mean, that makes sense. It improves the entire environment. It actually makes total sense because from an ABA per from a behavioral perspective, it can't just be the child that we're applying this to. We have to apply it to the whole environment for the behavior to actually change.

unknown 21:21

Yep.

SPEAKER_00 21:21

So that that's a that's really good point. I like I like the way that resonates.

SPEAKER_03 21:24

Yeah, I love the medical analogy that the neurosurgeon or even like the blood draw or things like that.

SPEAKER_00 21:30

Imagine that, even that easy thing, right? Okay, uh, please uh here, go to the lab. Here are the tubes, here's the the tie. Go ahead and tie yourself off. And can you draw seven vials for us, please, Mr. Rubia?

SPEAKER_03 21:41

On the flip side though, like I remember when I was on blood thinners, they would have me like do do they would teach me how to do it myself, right? So I remember there was one I would have to go in and they would they would draw it. But if you're doing something this frequently, like it's kind of interesting to have this lower level professional, let's call them like the medical. Assistant constantly drawing your blood. Like at some point, it's like, why don't we teach you? So you don't have to drop everything you're doing, come to the doctor's office, work around our schedule. Let me teach you how to do it, and then you can give me the numbers I need as the doctor, the neurosurgeon, to let you know if this medication is effective or not.

SPEAKER_00 22:17

Yeah. That that I mean, I've always had that analogy between autism treatment and say like diabetes. I think it's it rings true here again that that we have to teach the patient and their family to do certain things on their own. And that's going to constitute the most effective treatment because it's consistent, it's daily, and it doesn't require us to have to be there other than to do maybe that maybe to your point, that's where more generality comes in. One more person coming in with which to practice this behavior.

SPEAKER_03 22:47

Yep.

SPEAKER_00 22:48

Okay. Okay. How are we doing here?

SPEAKER_03 22:50

Are we getting through this? Next part. Moving from the parents, I'm gonna throw some numbers at you. All right. I know we like numbers, and let's see what we're gonna do with them. So the next part of the article is relief for a stress system. Fewer hours, more capacity. So we already talked about how more people are needing the services. There are more people that are getting certified. That being stated, there are in 2025 there are 77,415 BCBAs in the United States. In 1999, there was 28. So there is a lot more people to provide the services. Interesting that there's so much of a wait list. So here are some of the numbers. The prevalence of autism currently is listed at 1 in 31 individuals are diagnosed with ASD. It occurs in all racial, ethnic, and socioeconomic groups. It's over three times more likely in boys than girls. And it's just interesting looking at these numbers. So in 2000, it was about one in 150, 2006, 1 in 110, 2016, 1 in 54, now to 1 in 31. Actually, it hasn't increased as rapidly as I thought it would, but now one in 31. I do want to briefly say where this number comes from because it was always interesting to me. It's not like they know every child in the country and every child that has autism. So the report data includes data from the expansion of the ADDM network, which is 16 communities across the United States, including Arizona, Arkansas, California, Georgia, Indiana, Maryland, Minnesota, Missouri, New Jersey, Pennsylvania, Puerto Rico, Tennessee, and two parts of Texas, Utah and Wisconsin, individuals ages four and eight years old, which basically come from the the to identify the children with ASD, the site personnel requested and linked medical records as well as educational records. So that's just where it comes from. But my question to you is, or my numbers to you are it's one in 31. So that's one number. 84% of US counties lack adequate evaluation resources. Oh jeez. So that's an interesting statistic. One in twenty, so one in thirty-one across the United States, one in twenty-two in California. I don't know if that makes us better or worse, but we're definitely different. It's an average of sixty thousand dollars annual care for autism for somebody that has autism. Now, in addition to the LOVAS study, it's been updated to a call it saves about three point six million dollars. The lifetime cost of somebody with autism cost about three point six million dollars in terms of social costs, treatment costs, and lost productivity. So yeah, what uh what you got with those numbers?

SPEAKER_00 26:02

Well I'm not even sure where to start. Lacking adequate diagnostic resources, yet the incidence rate is this high. That's a pretty interesting juxtaposition. I don't know if I'm missing something there. But that's that's remarkable.

SPEAKER_03 26:22

I guess it makes me I'm gonna throw a little bit of a So maybe the diagnosis uh is clustered around more urban areas and there's a lot more undiagnostics are like.

SPEAKER_00 26:35

One in twenty two in twenty-two as opposed to one in thirty one. I'm gonna say something, and it may not be very popular.

SPEAKER_04 26:44

Yeah.

SPEAKER_00 26:44

Well, I think I've said it before. I how much does diagnostic substitution play in here? Given that there, you know, so there's there's basically two routes you can go with your child with behavior issues these days. You're gonna go the medication route, riddle in the stimulants, so then then you're gonna have ADHD, or you're gonna have ASD and get ABA. But what other options do parents have? And how does that factor in here? What would those numbers look like if we were looking at children under the age of 12 who are on stimulant medication for some sort of hyperkinetic behavior? Would they compare? I bet they would. Yep. I bet they're even higher, right? I bet more kids are on medication than are diagnosed with uh and diagnosed with ADHD than are diagnosed with autism, I would say. I don't know if RFK Jr. would agree with that right now. Uh oh, I I better. I'm gonna avoid that pathway. But to my to your point or to your question, I guess that's what I'm wondering is how much does the diagnostic substitution, how much is this benevolence on the behalf of on behalf of some diagnostician who's like, man, these working with this kid here in the office, and these parents seem stressed and look at this collateral and they've already had a bunch of other issues. Let's get this kid this label, because then they get those ABA folks who, you know, thank you for the I'm flattered. Thank you for the uh opportunity. But I wonder, I wonder how much diagnostic substitution fits in here.

SPEAKER_03 28:17

Yeah, that's that's a great question. You have a child that's struggling, and you got two answers, right? Medication or ABA. Medication or ABA, yeah, that's that's a great point.

SPEAKER_00 28:27

I don't know what else the medical field offers for for that stuff. You know, they used to do talk therapy, but depending on your child's communication abilities or skills, that may or may not be accessible.

SPEAKER_03 28:40

That's a great point. I mean, there's probably a lot of non-insurance approved people saying that they do behavioral skills on or with children. So you can probably find a lot of quote unquote off-label stuff. You go, I'm sure there's a lot of TikTok advice on on how to parent your child. That's an option. But in order for like the evidence-based, yeah, that that's a great point, Mike. You've got medication, and again, a lot of the medication is gonna be used off label, so the evidence base is is there, but maybe not how it's being used, or the behavioral side of things, yeah.

SPEAKER_00 29:14

That's so I mean, I think that's got something to do with it. There's such a variety, there's such a I guess, variability in the presentation of ASD. So again, it could be you know, something very, very mild in terms of deficits, but that's impacting a child or family's life in a notable enough way. A lot of this is gonna be self-report, right? So parents, and I'm not being critical of this, but I think parents can advocate for it, whether it's at school for qualifying for an IEP or with their doctor and saying, look, you just I need help, you know. And as a doctor or diagnostician, what are you gonna say no? Right? Okay, no, let's I can I can see where this maybe smacks of a little bit of ASD, let's get you this help, you know. Now, what about the self-fulfilling part on the other end? Right? So now as a parent, you've confirmed your suspicions. Now you either lean into the treatment or you lean into the diagnostic traits or both, which can have a tremendous effect on outcomes, I think. That's one of the things that I try to caution parents about. Like, that's is this is this really the autism that your child's displaying, or is this just a seven-year-old boy who would otherwise do that, you know, if they didn't have the autism?

SPEAKER_02 30:30

Yep.

SPEAKER_00 30:30

That incidence rate is is tremendously high, though, man. I I'm back from the I think it was Mandy Ralston we had on recently. She was talking about the one in 10,000 days. I remember that.

SPEAKER_02 30:39

Yep.

SPEAKER_00 30:40

I remember that. Yeah, I mean, that was probably if I grab my old abnormal psych book, that's probably what it says.

SPEAKER_03 30:45

That's why I was surprised that it was so high in uh 20. Let me pull up the numbers here. In 2000, it was one in one fifty. I started in like 2006 with about one in one ten. So it's certainly increased. I mean, it's one in one fifty is fivefold since since then one in one ten, you know, it's three a little over almost fourfold. So it's increased, but I do remember like the one in ten thousand. Yeah. So I I think certainly as awareness has increased, it has not been a linear increase, it's been an exponential increase. Almost on the reverse.

SPEAKER_00 31:25

Is there an age cap on these numbers? Are they saying 18 and under, or is it just open-ended individuals in general? Because the other thing we could cite is 2015. I think the DSM five probably had an effect. I think a lot of adults came back and were diagnosed, you know. So you had because the criteria opened up, it was no longer age limited, if I understand correctly.

SPEAKER_03 31:48

So the age this is eight-year-olds. Okay. Eight-year-olds. And then they're extrapolating that.

SPEAKER_00 31:54

So this is the information that recently our our beloved government was using, right? They were talking about eight-year-olds, weren't they? I think.

SPEAKER_03 32:01

I don't remember. I think they're trying to take out it.

SPEAKER_00 32:04

Okay, I mean you know, at least they were they were using legitimate stats. We should have gotten Tylenol to uh to uh sponsor this episode. I'm getting in trouble today, Dan. What's wrong with me? Why am I trying to stir up trouble? All right, so what what does this article take us next here?

SPEAKER_03 32:23

So for payers, this mismatch between rising autism prevalence and clinician supply creates a direct challenge in meeting network adequacy requirements. So there's two things happening at once. The clinician supply is not congruent with the autism rate. So there is going to be a kind of a difference there. There's going to be people on wait lists, but it seems like the clinician supply, like if you look here, I'll show you the graph. It's not going to do y'all much as listeners. But there are a lot of areas in the country that are really, really impacted. And again, mostly the rural areas. So that kind of goes back to our question there about BCBAs in different areas. And certain areas, people really being on long wait lists, because you might only have, I think they were saying New Mexico, West Virginia, some places like that. I can find you the man.

SPEAKER_00 33:15

What's up with those red sectors there? So, like, just kind of call out. I mean, like the Texas panhandle. Yeah. That's not very urban at all, right? That's that's pretty rural all up. South Texas, too. That's pretty small city, pretty rural farm country. Yep.

SPEAKER_03 33:32

So that's that's a a trick that I think that insurances are also kind of you know wrestling with. I I do think it's interesting, and this is spoken from experience, that we applied, you know, when we started our our company, we applied to a lot of different insurances, and most of them we got in network with, but I remember a couple of them specifically saying that there is no network need when I know that there is. So the question there being, do they just not want to go through the credentialing process? Which is probably a pain in the butt for them, to be honest with you. Now they have to manage another provider, it can be easier to kind of streamline your thing. So the insurances are citing a problem which is true, but they are not completely absolvent of responsibility in this problem. They are with the cost that they're charging parents, that can be, and then also the the credentialing side of things, they are not without blame in this situation.

SPEAKER_00 34:29

I mean, there's a lot of complexity to the transaction that occurs. I I like the point you make. I remember it was almost ironic how many calls we got all of a sudden from prospective consumers from those funding sources who we were told, you know, no, we don't need any more providers, and then inevitably that week, you know, somebody would call and well, we're on an eight-month waiting list. Who are you with with that funding source? And it's like, oh, really? So this kind of brings us this is a nice segue. I'm not sure how close we are to wrapping this article up, but I think that's kind of the main point, benevolent point this article's trying to make, and I'll give them the benefit of the doubt. They're saying is if you've got your service providers tied up with more with higher rec higher hours in terms of recommendations, then that's taking the time away from other kiddos who are waiting. So the idea being that if we were to reduce our recommendations, we could and and provide fewer hours, then we could serve more clients, which is a very true point.

SPEAKER_03 35:41

That's what it says here at the bottom of this page paragraph. By adopting lower hour and parent-mediated treatment models, pairs can expand service capacity without having to increase their provider networks.

SPEAKER_00 35:53

Interesting.

SPEAKER_03 35:54

Yeah, so that's that's the thought. Same providers seeing more patients. But as we mentioned earlier, that may be less cost effective for them. And especially as private equity and ABA starts to you know spread its wings and people are more aware of it and it gets more business oriented. I have to imagine, I'll say this not as a guarantee, but I'll say I have to imagine that the majority of discussions, and I know people have come on this podcast and said that private equity wants good clinical services because it helps their reputation. Okay, fair. I still would venture to guess that the majority of discussions are based around efficiency and how can we bill out more hours. If you are not, if you are a provider and you're not providing adequate, or let's say you're not providing exceptional clinical services, your higher up probably isn't gonna know about that unless it gets to the point of a complaint. Then that becomes an issue. But if you're in that that area, but if you're not billing enough hours, there's probably only a month or two that that's gonna slide, if that before that rings a bell and you're gonna be getting a talking to.

SPEAKER_00 37:03

Interesting. That's very interesting. And and I mean, it's hard to talk about quality of service. They allude to different treatment types here, along with the variability and the amount of hours being recommended. But yeah, some sort of the experience level of the clinicians delivering the service. I wonder if that's a variable that could be looked at given the high turnover because of the stress and logistical complexity of being an RBT, for example, not to mention the competitive or not competitive rate of pay if you live in a place like San Diego. Yep. It's not cheap to live here. And you know, I've I've talked about the Chick-fil-A problem. You got you can go work at Chick-fil-A or you can work as an RBT and probably make the same amount of money an hour, except if somebody cancels their order at Chick-fil-A, you don't lose out on that two hours of pay.

SPEAKER_02 38:00

Yep.

SPEAKER_00 38:01

Man, there's just so many variables. I I I know that we had considered these individually, but as we talk to about them all at once, it it's you know, it's overwhelming, man. This is I don't know what the answers are, other than despite their motives, I have to agree with this article. I think less is more anyway.

SPEAKER_03 38:20

So the the kind of how they wrap it up, and the last kind of parts to chat about here are aligning with value-based care. That's their hypothesis. And I appreciate the fact that they came up with a hypothesis.

SPEAKER_00 38:31

That makes sense.

SPEAKER_03 38:33

I think it's easy to you know poo-poo everything and say, well, there are problems, and there are problems. This is a solution. I don't know if this is the best solution, but this is a solution. And they cite the fact that it autism care is costly and annual pediatric expenses topping sixty thousand dollars per child, lifetime cost reaching three point six billion, that's cost to society. Sorry, three point six million, that's cost to society, which is also an interesting per individual. Per individual, the lifetime cost. There's an interesting stat here, too, that cumulatively the lifetime social cost to date of individuals with autism, meaning how much it's physically cost society, but also in terms of reduced productivity, is estimated to be 7 trillion, the equivalent of about two years of total feb federal revenue for the United States. And by 29, if the prevalence remains the same, it will be 11.5 trillion growing to 15 trillion. So clearly there is an need here. Clearly there is a need. It is expensive. So one thing that funders are looking at is value-based care. How can you show us that you'll be successful and we will pay you accordingly to the success? And I think that goes back to maybe the question I asked earlier is I love the idea of value-based care. The question is, what metrics are we gonna use to base our success and our value? What defines value in ABA?

SPEAKER_00 40:05

Well, we know what defines value for the insurance company. Yep, it's all about the numbers.

SPEAKER_02 40:11

Yep.

SPEAKER_00 40:11

Well, knowing that our metrics are hard, so if we're basing it just on our goals and goal mastery, that's easy to fudge, right? So that's not gonna that may not give us the truest measure. We talked about parent perception, so maybe participation, maybe consistency of service delivery outside of illness is one way to look at that. So it's almost like, again, going back to physical therapy, that's kind of how they measure that, right? Like, have you been consistent about your treatment? And then what do the outcomes look like? What are you reporting in terms of your you know, new ability or of your mobility or whatever, you know, your flexibility, whatever they're measuring?

SPEAKER_04 40:47

Yep.

SPEAKER_00 40:47

Because the idea for value for them is going to be less expense, fewer hours of treatment, better outcomes, right? I mean, that's basically what it translates into. So I think that this is where I have a couple of ideas.

SPEAKER_03 41:01

Yeah.

SPEAKER_00 41:03

And that there's gonna be interagency problems here, but one of the answers would be to collaborate, coordinate between schools and insurance companies such that treatment could be delivered during the school day, for example. Okay. Now schools might take that on, but that's gonna look different than say actual BCBAs going in there and providing that treatment. So that's that's one way to sort of consider it.

SPEAKER_03 41:33

And that'll be another good discussion for another episode because BCBAs sometimes aren't well trained to work in the dynamics of schools, right?

SPEAKER_00 41:40

So we're good at the one-to-one, not so well-versed all the time into the group contingencies, although it's part of our content. It's part of our should be within our content expertise or within range. And I said I was gonna say two things, and I've completely forgotten about the second one. I lost my train of thought. Oh, sorry, I interrupted. No, that's okay. No, you didn't. It wasn't, it wasn't you. It was me getting into the schools and I guess the other oh, what I was gonna say is how come insurance companies don't survey consumers more about the quality of these services? They're always asking us and sort of grilling us, what about a quick call to the consumer? Hey, how's it going? How's the attendance? How's the how are you feeling about the services? Do you feel like your child is improving? Do you feel more competent in addressing behavior challenges? That might be another way, another variable to integrate here in terms of the value. Because value is very easy to put a monetary connotation on it. And and I'm sure it's part of that definition here, too. But then for a parent, it's values maybe the ratio of time and and fiscal investment now in comparison to the out or or along with the outcomes, the improvement in my child's behavior, the improvement in the quality of life. We get to go to restaurants now, we can go to the movies, you know. Johnny's playing T ball. I don't know. That that's valuable too, right? So that's what I would say is given the constraints of the day, how is there more collaboration between schools and and private private treatment per insurance? And then where does the parent get to speak up, not just the clinician, and saying, Hey, yeah, no, they they come and they're here, they're consistent, they give us a consistent treatment. That might you know open up the doors for improved rates, yeah. Improved rates of reimbursement, which I know would certainly be a welcome change. We'd be okay with it, our employees would be okay with it. We'd it would give us um a little bit more leeway in terms of the scheduling strain and those things that get very difficult that then lead to people wanting to fill in the time blocks by recommending more hours.

SPEAKER_03 43:51

Which is interesting because if we're saying that our rates need adjustments, but we're saying we do the same services that we did forty years ago, yeah then If the insurance company says, Okay, well, cool, we'll pay you the forty year old rates, right. We really don't have a lot of ability to go and say we deserve more than that. Unless we can say we can do it better than we did 40 years ago.

SPEAKER_00 44:12

Yeah. Yep.

SPEAKER_03 44:14

So there's a couple just final articles that they reference. One is the initial psychometric properties of the Catalyte family well-being scale. And the results of this analysis revealed very strong internal reliability and a three-factor structure, valid validity analyses. Revealed a moderate positive relationship with parental self-efficacy and a moderate negative relationship with parental stress. So I think part of the you're saying part of the value needs to be from the parent side of things. Literally, how are things going? Like, like you said, could be maybe there's a one to five Likert scale. One thing that's one of our new insurance companies does that is both a positive and a negative, is we have to kind of re-upload all of our reports and recommendations on their portal. But one of the questions is how involved are the parents? And they have them label it and they have them label like the barriers to the parent involvement. And I think that's as we're talking about values, not just making it a two-way street between the provider and the insurance company determining the value, but somehow including the parent in that.

SPEAKER_00 45:24

Yeah, no, I think that's very important. And again, this is where there's all sorts of privacy matters that that come up here. But again, what is the teacher thinking about that child? How would there be more of because for any child that's school age, it's going to be that triangle, right? It's going to be our opinion versus the parent's opinion of improvement versus the teacher's opinion of improvement. So if they could bring those parties closer together in terms of defining value or or outcomes, that would I think that would mean a lot. This would it would remove the focus on standardized measures being used for unorthodox situations. So we're using a vineland which is was not designed to capture what we want to capture, but it is a relevant scale. I mean, we want to see improvement towards towards some sort of normalization. I know that's not a popular way to think about this right now, but at the end of the day, that's still what leads a diagnostic, right? Hey, that looks abnormal, so to speak. And I know that there's a you know plenty of controversy to discuss there. But you know, yeah, that that might be that might bring it closer together in terms of a child's environments, the generalization of certain skills from home to school to community, we could sort of work as a liaison in that triangle there.

SPEAKER_03 46:38

So maybe um maybe having the insurance take an active involvement in the treatment plan. If if right now they're relying on us, which we're happy to do, but if you're gonna ask us for our expertise and then say we're wrong, then you may want to have an active involvement in that treatment planning. That's a it's kind of an interesting thing to say, well, you're the expert. I see this a lot on the medical side of things, right? The my doctor will say, Well, I think this migraine medication is the best for you, but insurance will deny it.

SPEAKER_00 47:07

No, you have to try something before you try something else.

SPEAKER_03 47:15

Okay, well, let's make it a conversation between all of the people so we can be on the same plan rather than doing this smoke in mirror show where I'm gonna ask you what's the best, but then if it doesn't jive with what I think is the best, it's it's almost setting up somebody for failure. I know it's the best, I'm gonna ask you, and if it doesn't jive, then I'm gonna deny it.

SPEAKER_00 47:35

And my motive to begin with anyway was to save us money as the multi-million dollar insurance company. Maybe. Maybe. I'm sorry, I got ahead of myself there. I actually like that quite a bit. I'll even do you one better, right? We got plenty of BCBAs working on the insurance side. We'll feed you the profile, you take the collateral from the diagnostics that you asked us. Based on what's written in there, you come up with an initial treatment plan, and then we'll tell you how it fits in real life here. Sure no. You you tell us what you think, and then we'll scale that down or add some things based on the reality on the ground floor, and then we go from there. Again, you know, we would still face the idea of fiscal pressures to do less from one side and more on the other, which is you know, highlights this controversy or this battle of more or less from a fiscal perspective for both sides, right? One one multimillion dollar side wants to spend less, small business owners like ourselves would love to do better fiscally, but not at the risk or the compromise of ethics and integrity, which is what makes it difficult to do well.

SPEAKER_03 48:46

And and I say this coming from a company that we rarely get pushback from from our treatment plan. Right, be fair. But but we know a lot of people do, and when we do it, it can be frustrating. It kind of feels like you know the cop coming and pulling you over and saying, Do you know why I pulled you over? Like a setup, right? Like you can only answer wrong. It's like, well, why don't you just tell me why you pulled me over, right? Why don't just tell me what you want as the insurance company, like you're saying? And if you know what you want better than we do, tell us what you want and let us let us provide that.

SPEAKER_00 49:16

New law, by the way, they have to tell you. They can't ask you that question anymore, at least in California. I don't know how that pertains to other states, but if you get pulled over, they have to tell you why. There's no longer this, do you know why I pulled you over? No, tell me why, buddy.

SPEAKER_03 49:29

So maybe a collaboration. I I think at the end of the day, it is a, you know, we we badmouth insurance not we, as in you and me, but I think the field, you know, looks at us as insur enemies like you know, the other side is we're working against each other. We gotta we gotta work together. Yeah. There's one last article that I want to reference that's referenced in the Catalyte article, and I just want to highlight some some pieces here and get your thoughts, Mike. In the conclusion, and this article is the Applied Behavior Analysis in Children and Youth with Autism Spectrum Disorder, a scoping review. And the part that I thought was most relevant, according to the US Department of Health and Human Services, 1999, just a little older, ABA is the gold standard of treatment for ASD and is funded almost exclusively across North America. The current scoping review spanning 770 study records showed positive and beneficial effects of ABA for children with ASD across seven outcome measures. However, only 4% assessed ABA impact had a comparison group and did not rely on a mastery of specific marks skills to mark improvement. So we kind of talked about both of those, about the challenges of having a comparison group when you're trying to ethically do studies on human individuals, and specific skills as improvement. Without ongoing research and development of a standard of care, governments and policymakers will have the not have the most up-to-date information that reflects ABA-based and other interventions in terms of the ever-changing landscape of diagnoses, modern technological advancements, changes within the intervention implementation, and the measurement tools of treatment efficacy. We still don't necessarily have the best measurement tools of treatment efficacy. One such example is the measure of subject quality of life, which is made evident by the scoping review, was not measured in any study record recorded, but is of utmost importance to truly indicate the overall long-term impact of ABA. I thought that was interesting. You alluded to that earlier, talking about treatment planning not based on a vinyl score, but quality of life. Again, one of the things that the insurance company that I've been referring to does on their portal is has the question of what sort of things can the client do now based on the ABA treatment that they couldn't do. Quality of life. We can get so caught up in the minutiae and trying to, you know, progressive violence score trying to do one goal per hour or something like that, that we totally and this is us as a field, this is not the insurance company being culpable of this, that we totally lose sight of the the reason and the quality of life. Are we is the success this violence score? Is the success increasing someone's quality of life? And how can we do it? What are your thoughts?

SPEAKER_00 52:23

How are those things related, right? So, what what does the vinylin tell me that then informs me as to why certain difficulties are occurring, now knowing that it's also an environmental parameter, right? So there's certain things happening in this environment as a result to of certain traits that are being expressed by this child and responses from their environment and vice versa. You know, how does that how do those things inform one another? I think you make a great point. You may not have specified this, but but those things aren't informing one another, right? And and any given funding source is going to be looking at a violin score as their main reference. None of them are gonna be calling the parent. Some of them, to your point, are now saying, hey, as you rewrite your report to upload it into our portal, tell us some of these important things. And I'll actually commend them for that. I think that's we need more of that. We need more of, hey, tell us how you think it's going, and then we're gonna call the consumer and see what they think. Because at the end of the day, we do need to answer this question of wow man, you're recommending 20 hours a week? That's quite a bit. That means you're there four hours a day if it's not weekends. Okay, that is a restriction to somebody's quality of life to have somebody non-family, non-related, in their home with them in the community four hours a day, that could be a detriment. So let me call the consumer, let me see what the provider is saying, let me look at these violent scores. How does it all fit together?

SPEAKER_03 53:48

Which is tricky because let's say I I know with this provider, if you ask for more than 10% you know, supervision, then you have to put a justification. So it's interesting because now and and I'm not saying that's wrong, because without justifications, we know that there's a lot of fraud in all medical fields, including ABA. So people will ask for a lot of hours. So then it becomes the the clinician's justification that's writing the report versus the reviewer's justification. The reviewer's justification trumps it if they want. Right. So it does create an uh an interesting kind of dichotomy there.

SPEAKER_00 54:27

And again, the reviewer, with all due respect, I know the reviewer isn't sitting there going, Oh, this is too much, these are too many hours for this kid, it's too restrictive. Their motive is to save their employer money. Like that's you know, so if there's a way to get around that, I think that that is something else to consider. And I'm not being critical, but that's what it bro, that's what it boils down to. When they come to review or audit you, they're looking for one thing recoupment.

SPEAKER_02 54:54

Yep.

SPEAKER_00 54:55

Right? They're not again, not calling the consumer to say, hey, are these good services? Is it going okay? No. We see a mistake in your note, you misspelled the last name, we're gonna deny that claim because we want to recoup money or deny you payment of something. Again, not being critical, those are the facts. But until we can get around that mindset, you know, we might keep hitting these obstacles over and over again.

SPEAKER_03 55:19

So I think we shoot ourselves in the foot as a field too with we our s some of our standards of practice. Again, that's what medical insurance runs on, medical industry runs on, are are not great. It's five percent of ours supervised by RBT. That's the the the kind of BACB requirement, is five percent. And if insurances can reference that, I mean, that's we put that on ourselves. They didn't they didn't put that on us. We put that on ourselves. And now let's say you're that may make sense if you're working 40 hours a week because well, that's still only two hours a week, right? That's that seems absurd. But let's say you're only seeing a client like we do, maybe two hours a week. Five percent is gonna be like every few months we get out there, and then you get parents that only see their supervisors every few months, and they're unhappy with ABA because of a practice that we put in that, but insurance is now enforcing it because they're saying, well, you know, you can't you can't do more because this is what your field is saying, and now we're kind of running into a situation where I don't know who caused it, but there is certainly a problem there because we've had RBTs come to our company specifically saying they never saw their supervisor.

SPEAKER_00 56:31

Yeah, that's interesting. I never thought about it that way. It's it's it's set up, the system is set up that way. I mean, it's our own board saying five percent, which is minuscule. I think most insurances cap us at twenty percent of the actual hours delivered, right?

SPEAKER_03 56:45

And I don't think our board specifically says five percent. It's a minimum. It's a minimum. Yeah, I think they say it's a minimum and it's case by case specific, but you know, without having a a number, insurances are gonna reference whatever the number is that we have, and that's the number that appears there.

SPEAKER_00 57:00

Interesting. So it's almost better to consider the client, the idea that you're supervising the client and the RBT as opposed to supervising a percentage of the amount of hours. Okay.

SPEAKER_03 57:12

You've talked a lot about hours. I guess the last question that I will ask to you is your thoughts of so when we're talking about hours, and we've talked about, as did this article, about lower hours potentially being better. Or there in recent studies haven't been substantiated research to show that significant 30 to 40 hours is better than 10 to 20 hours. Let's say an individual is being in unsuccessful with a lower rate of service. What is the what is the reason and what is the the solution? Is it change the are the procedures not and I I mean it's probably all of them, are the procedures being done in session not effective? Is the clinician not effective? Do they need more hours? Do they need a different service? It's really tricky when it's not being effective. It's like medication, right? Uh a lot of our people that we work with, our clients are on medication and the medication's not working. So they go to their psychiatrist, and then it's like, well, let's up the dose. Well, is that correct? If it's not working, is more of something that's not working better? Maybe. Should we change the medication? What what are your thoughts there when it comes to the hours piece? Because I feel like a lot of times what the field does is just ask for more. And insurance is does the opposite, ask for less.

SPEAKER_00 58:29

Yeah, I mean, that is tricky. I think we have the answer, right? I think you you start with it's almost like weightlifting, I guess, right? Like you as you get stronger, you add more weight. You don't start with 250 on the bench. You start with what you can lift. And then as you get stronger, you add more if you choose to, you do more reps if you choose to, you add more time and weight if you choose to. But we actually go the other direction, right? And we go the other direction maybe based on developmental time frames. So the notion that we are more plastic earlier than later, which is also a notion that stands to be challenged with modern neuroscience. We used to think of more critical periods of plasticity or maybe greater plasticity, brain plasticity, younger in age. I don't know that that's necessarily the premise anymore. I think that it we consider learning and plasticity more of a lifelong parameter now. Yeah, that's interesting.

SPEAKER_03 59:23

That's funny you mentioned that. There's a quote here that I don't necessarily agree with, but it goes along with what you're saying. It said, I can't think of another medical service where the provide where they provide the highest dosage of intervention first. Usually you start with a dosage and then the medication be it a medication or physical therapy to get where you need to be and then titrate from there.

SPEAKER_00 59:44

Yeah. No, that's a good point. I mean, then they do titrate up and down, right? With any medication.

unknown 59:49

Mr.

SPEAKER_00 59:49

Dan, we've covered a lot of ground, sir. I'm I'm exhausted.

SPEAKER_03 59:53

I was a lot. But I think we're all on the same page of who needs to change, probably all of us, and as a field, we're the insurance isn't going to change for us. We need to change for them.

SPEAKER_00 1:00:04

All right, man. Let's get some closing points here. So I would say, you know, maybe upgrade to a V8 or a V12 from your Model T.

SPEAKER_03 1:00:12

Yeah, yeah, yeah. Lower hours, maybe just or has proven recently to be just as effective as more hours. Better quality doesn't necessarily mean more quantity.

SPEAKER_00 1:00:24

Include your parents. Make consider parent-led parent highly parent involved, high parent involvement, and focus on quality of life and always analyze responsibly. Cheers, brother. Thanks.

SPEAKER_03 1:00:37

Always analyze responsibly.

SPEAKER_01 1:00:41

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.