Episode 56: A Pediatrician's Perspective with Dr. Steven Merahn

Dr. Merahn is a breath of fresh air! He knows value-based care because he's helped build some of the first Accountable Care Organization's ... and he gets ABA as both a pediatrician and as a visionary for what our future field will look like. He's the kind of guest I love: bold, strongly opinionated about clinical quality, and with the experience to back it up. Enjoy, kind listener!

Resources:

Dr. Steven Merahn online:https://merahn.com/

Steven's artwork! https://www.merahn.net/

Lucile Packard Foundation National Standards for Systems of Care for Children and Youth with Special Health Care Needs : https://www.lpfch.org/publication/standards-systems-care-children-and-youth-special-health-care-need...

Building Better Businesses in ABA is edited and produced by KJ Herodirt Productions

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Transcript

Jonathan: 0:30

My name is Jonathan Mueller. I'm the host of Building Better Businesses in ABA Podcast, and my guest today is Dr. Steve Merahn. Steve, is a MD, an experienced physician executive focused on the care delivery, redesign, system innovation and patient-centered care with a special focus on population health. He's the author of Care Evolution: Essays on Healthcare as a Social Imperative. He's a self-described intellectual adventurer, which I love, Steve. Dr. Merahn was formerly Chief Medical Officer at Centria. He's held executive leadership roles at US Medical Management, which is now part of Centene, Aetna, at the NYC Department of Health and many, many others. And he's the only physician on CASP's Autism Commission on Quality. He also sits on the primary care subcommittee of the American Academy of Pediatric Section on Developmental and Behavioral Pediatrics. Steve, welcome to the pod and tell me what are you doing now?

Dr. Steve Merahn: 1:23

Well, you know, I spent, most of the pandemic, locked down with my family. But when you go into the human services profession, you really like people. So I missed being around people. So as things started to open up a little bit, I, put some feelers out and I was very lucky to have joined, a very exciting nonprofit organization in New York State that, exclusively focuses on, the intellectual and developmentally disabled community. We have two operating groups. We've got a care coordination organization that serves about 30,000, individuals with intellectual developmental disabilities across New York State. About 35% of them have a primary diagnosis of autism. And then we have a very novel health plan. It's actually a demonstration project between CMS, New York State Department of Health, New York City, New York State Office of People with Developmental Disabilities, that is a, managed care organization specifically for people with IDD and their families. And it's unlike any other managed care organization. I mean, as you said, I've worked at that and I've worked at Centene. It's truly focused on whole person care. It's not medical care only, it's behavioral, social, community-based services, spiritual services. So it's really about managed care of the whole person. And I'm super excited to be part of it. I think there's some really, important things for us, and when I say us, I mean all of the professional disciplines that are concerned with individuals with autism in particular, to learn from whole person care. And I will say I'm already advocating internally for behavior analysis actually to be part of our provider network. Above and beyond autism treatment. So because we're a payer, we get to decide who we pay. So we actually may be able to open the door for ABA to be used against a number of other conditions besides just autism for our particular, population.

Jonathan: 3:03

Oh, I love that dissemination word. It sounds like just a phenomenal organization. And you know what, Steve, in the couple conversations that we've had in the past, you are a breath of fresh air in our field helping to bring outside perspectives, that feels important. So this is gonna be a spicy conversation, but I wanna start with something you've written, and I quote,"health is a social imperative and healthcare is a fundamentally human endeavor." What do you mean by that?

Dr. Steve Merahn: 3:29

You know, I'm gonna tie this back to a conversation that's really active in the ABA community right now, which has to do with this word outcomes that people use. Our outcomes, meaning all of us that are concerned with that that that make up the health resource community around any one individual, child or adult. What's our overarching objective for those individuals that we're caring for? And to me, the overarching objective is that they number one, uh, have the capacity to succeed in the world on their own terms. So not have to be forced to meet other people's standards of respectability or other people's standards, uh, of cognitive standards. It's unique to bring your full self to the world and and be able to succeed with your full self. Uh, and this is as true for, the self-advocacy community for autism, but it's also as true for what is variously called severe autism, you know, people who who may not necessarily have, or who require ongoing supports in their lives. the fact is, and I've worked with severely disabled children, they have a presence in the world. They have relationships, and those relationships are rewarding and bring value to everybody who's involved in them Um, So number one, what's our outcome? Our outcome is we want people to be successful for themselves. Number two, can you participate as an active member of family and community? And again, participation may be very personalized. The level of participation or expectations for participation may have to be very personalized. But can we help people participate in the world and bring themselves to the world to share themselves with the world? And it's well established, for healthcare in particular, that quality of health of a community is directly related to the, economic, vitality of that community. And it's not just about work, it's about participation in community. So to me, that health, not healthcare, Is a social imperative, by the way, just like we've decided as a society that education is a social imperative. We have a mandate for K through 12 education in every state of the union. There is consequences if you don't send your child to school. There are options for homeschooling. but the fact of the matter is there's a social imperative, we've decided that there's a value for literacy and numeracy among our citizens. Similarly, we have a social imperative for security as manifested in our systems of law enforcement. Flawed or not flawed, doesn't matter. The fact of the matter is we as a society have committed to a social imperative of security. We have not, by the way, committed to a similar social imperative for health, and I'm an advocate for that. Now, unfortunately, in many ways, the systems of care that have evolved over time are not necessarily organized around meeting the social imperative. And that's where my personal advocacy comes in. It's what the book's all about. To try to figure out what are the organizing principles of systems of care to achieve a social imperative to improve quality of health at the community level,

Jonathan: 6:28

There's a whole separate thread of this conversation around why as a society, we have not made health the social imperative that we have law enforcement, education, everything else. But putting that aside for a moment, like what has to be true, Steve, in order for health to become that social imperative?

Dr. Steve Merahn: 6:45

I think people need to understand that healthcare and quality of health are two different things. That accessing a system that doesn't necessarily support your life course wellbeing is not the same as when the system itself is organized around your wellbeing over the course of your life To look at things more from a developmental perspective, and I don't necessarily mean child development, I mean even as adults, we have developmental phases. You know, I've reached a certain age and I've come to understand that the 20 year old Steven and the 50 year old Steven are completely different people. And that there was a developmental process during that time where I had to learn and grow and change and adapt. And our systems of care can support that developmental process in many ways. It's not just about, treating sickness. It's about kind of redefining what the idea of quality of health is. Again to some extent, and it's, it's particularly relevant for the ABA community, What is the nature of the dynamics in the healthcare ecosystem and how do all of the resources that are, present in that ecosystem, how do they work together around the individuals for which they share the care. and in particular, by the way, and I talk about this often, pediatricians and behavioral analysts who are caring for children with autism are in a shared care model. And so to what extent are both pediatricians and behavioral analysts, actively working to develop a shared care model?

Jonathan: 8:09

Well, I wanna talk a lot about that shared care model and maybe as a precursor to that, I know you recently did a presentation for APBA, and a reminder to our listeners, Dr. Merahn is a, pediatrician, and has been for his career in addition to being an executive. But Steve, I know you're a huge advocate of putting patients first. It's one of the things that you and I like really connected on when we first chatted. But you say in that presentation that even patient-centered care can be done wrong. And I'm curious, how do you see it done wrong in particularly in the ABA field, and most importantly, what do we have to do to get it right?

Dr. Steve Merahn: 8:40

Well, I, I wanna go back because you asked me a question before that I didn't answer, which was the idea of healthcare is fundamentally a human endeavor and those two are related. So being patient-centered and healthcare is a human endeavor, are interconnected. We see a lot right now of fragmentation of care and there's a lot of conversations about the use of digital technologies, to provide healthcare. The fact of the matter is for most of the digital technologies, it's about providing sick care. and for many of the niche companies that are offering preventive services, it unfortunately, can fragment, uh, a continuity of care relationship that's really necessary to to look at that kind of life course, of view, of of improving quality of health. I, think that the human connection, a relationship with someone is really critically important. I think that healthcare professionals should have what I call a level of professional intimacy with the people they care for. and that's, That's a kind of a loaded phrase that I've created. But training when I was, the early part of my career when I practiced medicine, I really wanted to get to know the people I cared for incredibly, incredibly well. And I, I'll tell you a, a quick story about that, about the payoff of it. Mid pandemic, I got a Facebook request from someone I didn't recognize and I was curious, well, you know, who is this person? And they're from Florida and I don't really know anyone in Florida really, other than a couple family members, and so I clicked on the link and, was scrolling through this person's photographs, and then I recognized what it was, and it was the mother of a child I cared for from birth until age three with Down Syndrome. And Elliot at the time now, 30 something years old, I recognized his face and realized it was his mom reaching out to me 30 something years later. So I immediately let her, and by the way, I only let family in my Facebook. I don't do any business or connections. But I let her in and she just proceeded to tell me that the whole family remembers me as singularly important. And the fact that Elliot has lived to now this age and now we're connected, it's as if she's part of my extended family. and I then went back, I had a box in storage and I went back to the box and I actually found some greeting cards that she and her mom, who has since passed away, had given me when I took care of Elliot. I I actually at the time, gave them my home phone number, no cell phones then. Went to their house, to their apartment at times to care for Elliot in the apartment, and got in trouble for that actually in training. But that connection to me was so valuable not just to the relation Elliot's care, but it was valuable to me. And a lot of that humanity, the reciprocity is really important to prevent burnout because when you have relationships with people and you're not taking care of patients piecemeal, you know, piece work, it's energizing, and it changes the equation of the burden of care, which is by the way, on everybody in healthcare, particularly right now, tremendous burden of care. Now patient-centered care. on the healthcare side, we tend to organize ourselves around disciplines. So you've got your doctor discipline, your nursing discipline, your social work discipline, your behavioral discipline, your psychologist discipline. And even when we're doing multidisciplinary care, we tend to think that just because everybody is facing the patient that we're being patient-centered. And that's not true because you need to have mutual agreement on the goals. How do each of those disciplines contribute to the patient-centered goal? So, in my personal case, again, I've got a cardiologist. My cardiologist doesn't talk to my primary care physician. They work for two completely different organizations. So it is perfectly possible that my cardiologist will make a decision that is in conflict with something my primary care doc does and the cardiologist believes that they are in charge of my heart health. So they can operate independently of anybody else's decisions about my overall health. And that's not necessarily in my best interest. Now, I'm in a position to negotiate that because of my skills and experience, but I'm very, very aware that for most of the people we care for, they respect the professions and they give up that level of control to the professions that they trust. And unfortunately, it is perfectly possible that a psychologist will have one point of view on a patient, and a neurologist will have another, and the primary care physician will have another, and a behavior analyst will have another where we really should be saying, okay, what are the goals for an individual? And how can the neurologist, the primary care doctor, behavioral analyst, and the psychologist, all make their disciplinary contribution to the goal? And all work on the same goal at the same time. And even, by the way, let's just say the neurologist has a goal about epilepsy. Well, that's not necessarily the purview of the psychologist or the primary care doc, but the psychologist and the primary care doc can support that goal in many ways. Medication adherence, reminders, encouragement, being open to explaining their point of view on the problem to family members. So there's a collaboration model that's missing, uh, because we tend to think of collaboration as all working on the same person, but not necessarily all working off the same plan.

Jonathan: 14:12

Hmm. So there's this idea that multidisciplinary care is not integrated care. I think this is a really important point to double click on.

Dr. Steve Merahn: 14:18

Yes, interdisciplinary does not mean integrated. That is absolutely true. Yes, you've got that.

Jonathan: 14:24

I think I've asked you where is this done best in the medical field? And, and you've mentioned cystic fibrosis.

Dr. Steve Merahn: 14:29

Yes,. my earliest experiences with true team-based care was with the cystic fibrosis community. And this was actually back in the nineties, I was working on a special project and I happened to have met a number of health systems that had specialized CF clinics. And you had, a physician and a social worker and a respiratory therapist all involved in care. But they would have these teams, we call'em interdisciplinary teams now, but they would have these teams where they would meet regularly and again, they would all contribute their assessment, to a single source of truth for that child. And then they would distribute responsibility for implementing their decisions among the entire team. And they weren't always physician led teams, by the way. They were often nursing led teams. The physician was obviously there, but the medical hierarchy was kind of flattened out in the cystic fibrosis community because most of the pediatricians recognized that their day-to-day involvement was significantly less than the day-to-day involvement of respiratory therapy or psychology or social work or nursing. There is a active community right now, that, that is very focused on the design of care for what we call children with medical complexity. CF being one of them, but imagine now taking that CF model and expanding it to other children with medical complexity. Meaning multiple chronic conditions, neuropsychological conditions, mental health and physical conditions combined. Kids with disabilities, kids with traumatic brain injury, kids with genetic disorders, you know, all sorts of kids who are truly medically complex, who have dozens and dozens of people involved in their care. And, it's the PCP and the gastroenterologist and neurologist, and the dentist and the speech pathologist and the and the physical therapist and all the, all those various members of resource community for kids who are really complex. And they've really defined in a really wonderful way. This idea of clinical integration. first of all, and I believe this is true, I think that children with autism quote, qualify as being medically complex. And by the way, when we say medically complex, we don't mean medicalizing them, we simply are referring to the complexity part of it. Doctors came up with this, so they call it medically complex, but it's really, they're just complex. So there's four criteria for medical complexity. The first is chronic conditions, autism's a chronic condition. The second is a high level of family service needs. I think we can say for most children with autism, there's a high level of family service needs. There have to be some level of functional limitations, and we know children with autism have functional limitations. And fourth is there's a need for, multiple health resource requirements. And I think given the comorbidities that are commonly associated with autism, generally gastroenterology, primary care and others, are required. Now, we're talking about again, a spectrum of medical complexity ranging from, severely neurologically impaired and technologically dependent, to children with autism, maybe, the other end of the spectrum of medical complexity. And I only raised this because I think there's value in applying the model to children with autism. There's organizations like the Lucile Packard Foundation for Children that have worked very, very hard to come up with models for, collaborative care planning for children with medical complexity that I think have incredible application to the kind of things that the ABA community does for children with autism. And there's a number of other models, shared decision making is a model used in medicine to bring parents in to the decision-making process. Anticipatory guidance is a tool that pediatricians use to say to a family, and by the way, this is not just for disabilities, across the board. Your child is 18 months old, I won't see you for another year, between now and the next visit, here are some things you should expect to happen developmentally. I was fond of saying to parents of like two year olds, I'm gonna see you at the three year visit, that's a whole year from now. Between now and a year from now, it is highly likely that at some point in time your child will do something and you're gonna ask'em about it, and they're gonna deny they did it, right. I didn't do that. you know, something breaks, something falls down, and they'll deny doing it. That is not lying. So this is anticipatory guidance. It's denial, but it's not lying. So don't think you're child's lying, it's really important you understand that's not a lie. Don't try to confront them with it, it's not worth it. They will ultimately learn because again, developmentally, neurologically, they're at a certain place, that's anticipatory guidance. Particularly for children with autism and behavior analysts can use anticipatory guidance in a wonderful way. Here's a great example. There are certain behavior treatment programs that that make things worse, right? So a family may have figured out how to keep things calm by using certain reinforcers that are not necessarily in the child's best interest. So we're gonna remove those reinforcers. We're gonna stop, allowing the child, for example, to eat at the table with their iPad all the time because you just want calm at the table. We actually want them to be fully present at the table, remember full presence and participate in family discussion. But there may be an interim period where it looks like therapy's not working. That's anticipatory guidance. And again, these tools are, they're techniques, they're philosophical in some ways. And again, I mentioned the Lucile Packard Foundation, they've got an amazing framework, on a family centered approach to shared plans of care that we should be using collaboratively. The behavior analyst should be reaching out to pediatricians and saying, I'm doing a shared plan of care based on Lucile Packard Foundation, that will allow the pediatricians to say, oh, you're speaking my language. Happy to contribute. And at the same time, now you've got an engaged pediatrician, you've got the collaboration. And a great example of this is, we know that 35 to 50% of children with autism have medical comorbidities, asthma, epilepsy, gastrointestinal problems. Imagine if behavior analyst now asked, as part of the assessment process, is your child on medication and are there any problems with them taking their medication? Now the behavioral analyst doesn't have to even know what the medication is, because I've heard people say it's outta my scope of practice. It's not outta your scope of practice to ask the question if they're on medication, because now we're gonna go into the behavioral realm. I, as a behavioral analyst, can help the behavior of taking medication and there's all sorts of downstream benefits to family and child by taking a behavioral analytic approach to medication adherence. So again, another place where there's an opportunity for this kind of shared care collaboration.

Jonathan: 21:12

I love that these models already exist, right? It's not like we're having to reinvent the wheel. We're bringing what we've seen work elsewhere in other parts of healthcare to autism services. But I wanna talk about an elephant in the room here, especially as it comes to collaborative care planning, shared decision making with other providers. Um, there are hierarchies, amongst medical providers. You, alluded to it earlier, right? And some care teams are run by nurses and, but then you've got PhD level and, how important or how much of a barrier are these different levels or perceptions of levels between, say, master's levels, BCBAs versus pediatricians versus other surgeons, et cetera? How much is that potentially getting in the way and what do we do about that in our field?

Dr. Steve Merahn: 21:52

First of all, it's not insurmountable. The problem is, and you know my apologies to everyone listening right now, is the behavior analytic community has continued to protect itself in a walled garden. So, I don't see an active movement to define behavior analysis as a healthcare discipline, and that's problematic for the discipline because then people don't know how to categorize you. If behavior analysis took the time to, to really define themselves, to create an identity within the healthcare ecosystem, they would find that they will find their place. I mean, there was a time when nurses were subordinate to doctors and nurses wrestled control of their professional identity from doctors, and now have an independent professional identity and an independent nature of practice. And I think that, behavior analysts could do the same, but they have to be willing to come out of their niche and work in that system to define their identity. Problem number one, is most of the medical community doesn't know what behavioral analysis is. There are geneticists who are not clinicians who inform my understanding of genetics. There are microbiologists who inform my understanding of infectious disease. I don't understand why behavior analysis doesn't inform my understanding of behavior. And that's not even on the clinician side. That's as a basic science. So the fact that there is a basic science. The second part is because of the way autism has dominated the identity of behavior analysis most, of the healthcare community, less so pediatricians who are getting more and more familiar, but most the healthcare community sees behavior analysis as autism treatment, and they don't understand the bodies of literature, the bodies of literature that demonstrate the value of behavior analysis for feeding, challenging behaviors, Downs Syndrome. The study that was most exciting to me, there's a genetic condition called Prader Willi Syndrome, in which children have insatiable appetites, to the point where families have to put locks on the refrigerator and hide food. Well there's actual studies that show behavioral analysis can be used to manage prader willi syndrome, this is remarkable. And, again, I said, medication adherence and even things like hygiene, sleep, dental health, substance abuse, seatbelt use, toothbrushing, all that stuff, all those health related behaviors in addition to health conditions are all amenable to different forms of behavior analytic interventions. That's stuff you all should be standing up and shouting and spouting and being proud of. You know, at the same time, keep in mind that it is an ecosystem and there's gonna be competition. You talk about the hierarchy, I look at it as competition for identities. But for example, in 2016, there was a report, out of the Institute of Medicine on workforce development to affect the cognitive and behavioral health of children. Okay. Institute of Medicine report. Behavioral analysis wasn't mentioned. A report on workforce development on the behavioral health of children, behavioral analysis is not mentioned. I can't tell you why, other than the fact that the lead author doesn't believe that behavioral analysis is an actual discipline. Why? Because it may be lumped in their mind with education or psychology, or it doesn't have that independent identity as a clinical discipline. Or it may just be, oh, that's just an autism treatment. I'm, fond of showing this graphic to people, but there's a, document called the Standards of Care for Children and Youth with Special Healthcare Needs, put out by the Association for Maternal Child Health Programs, the public health people. There's, three dozen professional members on that team. No behavior analysis, standards of care for children with special healthcare needs, no behavior analysis. So you're not present if you're not present, you're not gonna get the identity or the recognition, that honestly, I believe you deserve. Now, the other thing is there are, I have to say, other approaches to behavioral health than ABA. So, you can't be exclusive. You gotta be able to, play in the ecosystem well. And the tensions that I see between, for example, speech and language pathology and ABA have gotta be neutralized. There's gotta be respect for both disciplines because, by the way, I think that there's a place for everyone to contribute if appropriate. And I'll, I'll give you an example from my own experience with working in an ABA provider. Um, you're working with a five-year-old, on, graphic, work, right? I don't know any discipline that understands the fine motor coordination of the hand than occupational therapists. And I don't believe, unless there's OTs that are also BCBAs, I'm not sure that part of behavioral analytic training is really understanding that neuromuscular development and anatomy of the hand, right? Well, okay, let's get an occupational therapist and a behavioral analyst together to figure out the behavioral treatment program that is developmentally responsible, understands the neuromuscular development of the hand and allows us to achieve the, you know, the, the graphical expression that we're looking for. That's not, necessarily talking about the occupational therapist treating core autism symptoms. It's the occupational therapist's expertise is in some areas and behavioral analysts are in others. And by the way, the issue of the occupational therapist's perspective on autism and the behavioral analyst perspective on autism, we've gotta figure out a way to resolve those issues because every discipline may have its own point of view. Read an article today about the use of hyperbaric therapy, uh, in children with autism. I Again, this will hit the news and then the world will have to figure out where this fits in the broader treatment plan. But there's always these new stuff and you can't draw a hard boundary around your particular disciplines approach. Because if we're gonna be child-centered, we have to actually do the research to, the comparative effectiveness research. But if we're not working together, we can't compare.

Jonathan: 28:34

I like how you've made this now really practical around, for example, the importance of, neutralizing, dissonance between, occupational therapists or SLPs and ABA. If you were to put on your pediatrician hat, what is something that any ABA organization or providers, BCBAs could go out and do to start to break down these walls with pediatric practices?

Dr. Steve Merahn: 28:57

So I have to give first credit to two organizations. A tremendous thank you, to Gina Green at APBA. I know Gina's stepping down as CEO I reached out to her a couple years ago around these very issues. She welcomed me with open arms into the organization, not officially, but unofficially. She and I actually organized a conference that was unfortunately, attenuated by Covid, called Bridges to Behavioral Health. It was jointly sponsored by a nonprofit I work with and APBA. The idea was to bring pediatricians and behavioral analysts together to share knowledge. We had a number of very prominent behavioral analysts come, Wayne Fisher, Hank Roane, came and presented. I'm sadly, I'm not gonna be able to name all the names, but it was an amazing group as well as some amazing pediatricians, Dr. Catherine Zuckerman, who's on the American and Canada Pediatrics Autism Subcommittee up in Oregon presented as well. It was online covid at one of the worst parts of the pandemic, and we just didn't really have the outcome. But that was, that was the beginning. And, and I think we need to look at doing that kind of thing again, probably with a little bit more collaboration from the Pediatric Professional Association who wasn't involved at the time. The second shout out I want to give is to the group at CASP, who has, again, welcomed me in with open arms, has, listened carefully to some of these ideas. Occasionally rapped me on the nose with a rolled up newspaper and told me to sit, stay for a minute. But, the fact of the matter is, Judy Ursitti and CASP and I have been actually reaching out to the American Academy Pediatrics. I can tell you that the, pediatric subcommittee, for the section on Developmental Behavior Pediatrics is now actively exploring, creating a relationship with CASP. We'll see if that comes to fruition. I think those kinds of things will really help. I think the next thing that can happen is for local chapters of CASP and for your listeners, viewers, now, this is really critically important, to reach out to the state level chapters of the American Academy of Pediatrics and simply say, we're here as a resource for you. If any of your members at the state level have issues with children with autism, please reach out to us. We are happy to serve as a resource to find, services for your patients to help you understand what behavior analysis is, we are happy to come and do lunch and learns, with your staff, those kinds of things because honestly, it's, it has to happen at those multiple levels. It has to happen at the national level, but also we've gotta really bring it down to the local level. And then, you know, as I said the Lucile Packard Foundation model of, shared plans of care, you can download that from the Lucile Packard Foundation for Children's Health website. I mean, honestly, Jonathan, you wanna make it available, to the viewers, we can, get them the.pdf and then start to say, okay, how can we begin to apply this in our practice? The other thing is, knowing the pediatrician of every child you care for and reaching out to the pediatrician of every child you care for, and by the way, don't send them your behavioral treatment plan. That's not what they're looking for. They're looking for a one page note that simply says, oh, by the way, we're sharing the care of this particular child and family. Here's what we're focused on doing a little bit, love to hear from you if you've got any treatment goals that you'd like to see us work on from a behavioral perspective. And at least let them know you're there and you're involved in their patient's care. And the more you're able to do that, over time you'll find the ones that are interested in working with you. Once a year send them a note saying, here's a status report of where we are. And that establishes the identity of what a behavior analyst can do and contribute.

Jonathan: 32:36

And these are the kinds of outreaches that pediatricians would welcome, I'd imagine. I mean, you gotta think a pediatrician for most other medical conditions in a kiddo developmental or otherwise, they serve as almost a hub and spoke and they're referring out right to different resources. Do pediatricians welcome that kind of outreach?

Dr. Steve Merahn: 32:50

If you are not making a demand on them and you're adding to their knowledge base and you're offering them the opportunity to contribute what they see as autism related goals to treatment plans. There's no loss in that. And by the way, they may choose not to respond the first, the second, the third time. The other thing I would encourage, again, if you are gonna send a note like that, please encourage our shared family member, to reach out if there's any issues with therapy. Because sometimes they'll say something to the pediatrician that they won't say to the behavior analyst, or, by the way, they'll just disappear from your behavior analytic caseload because something came up and they'll never tell you, but the pediatrician may know about it. So again, you're opening the door to say, if there's ever an issue that comes up in your relationship with the work we're doing, please, feel free to reach out or encourage the family to reach out to us. That is again, being part of that kind of human fabric that we're cloaking the families in.

Jonathan: 33:55

I love that, the human fabric we're cloaking the families in which comes back to this idea of this is what true patient-centered care I'm learning really is. Well, I wanna pivot to a topic that could probably be its entire own episode, but value-based care. And I know you've got some really, really specific thoughts on this, but what has to be true for value-based care to thrive in autism services?

Dr. Steve Merahn: 34:19

Well first of all, you have to be very clear about what value means, and unfortunately, right now, value is predominantly defined by payers. Which means that the anchor, the foundational metric of value becomes economic. There's this concept in healthcare called the triple aim, sometimes called the quadruple aim, but the triple aim. The triple aim is, highest quality of care for the individual, improving quality of health of the community and managing costs. Notice I didn't say reducing costs, I say managing costs. We want the cost arm of the triple aim is about efficiency, not savings. But what happens is it gets interpreted as savings, or it gets interpreted as cost reduction. By the way, I happen to think the behavioral analysis can contribute to that as well. Back to my medication adherence question. We know that children with autism are admitted to the hospitals at significantly higher rates than children without autism. If we can ensure medication adherence for epilepsy and asthma and reduce admissions for epilepsy and asthma, then behavior analysts are actually in the value chain for reducing preventable utilization of inpatient services, which is a big point of value-based care for payers. But by and large, the anchor, as I said, the foundational element is economic, and it's a balance of what they call quality and economics. And by the way, most of the quality measures in medicine in particular, most of the quality measures are population based metrics with known health economic value. So a great example of this is, everyone with diabetes should have an annual eye exam. Okay? Why? All because diabetes affects your blood vessels, it makes them stiff and sticky, and that can cause retinal disease. All right. We wanna get early into retinal disease. Why do we wanna get early in retinal disease? Well, because late retinal disease is devastating, blindness is devastating. It's also more expensive for payers. So the earlier you can intervene, the less downstream costs at a population level. So I'm not saying it's a bad thing to get eye exams, I'm simply saying the choice of the measures often are this balance between the economic value of the measure and the actual measure itself. Well, I think there's other ways to look at quality, and I think quality of life. Remember back to my social imperative conversation, quality of life, functional capacity is a quality issue. My capacity to move through the world, whether it's at the very basic level of activities of daily living, sleeping, toileting, eating, personal hygiene. Whether it's the capacity to have independent living skills, even by the way, if you're living in a residential facility, you can still have certain amount of independent living skills, communication skills, or functional capacity. Your ability to go into a store and purchase things on your own without having to have someone there for you. But by the way, if you're using, augmented communication tools, the community has to be willing to accept, remember, succeed on your own terms. My own terms are, I use augmented communication. So the world has to be willing to accept the fact that I have augmented communication and not dismiss me or marginalize me or freak out because I'm asking you to work with me through my augmented communication skills. But, you know, functional capacity to me is as a huge value proposition. Again, back to the way the systems are organized for publicly funded programs, Medicare, Medicaid programs, state level funded autism programs. There's a real value to them to consider these more functional metrics because, we're really now looking at whole child economics over time. You are looking at an investment in autism services, ABA and others, but let's just say autism services between two years of age and five years of age, that could potentially reduce the need for special services and supports in school that could reduce the need for, social services, vocational services, housing services, and others between 18 and age 65. So, for commercial health plans that are only in the medical space and are under mandate to pay for ABA, they are just looking at this from the medical model. But the states can actually look at this from a whole child model. And I personally think if we can create a legislative mandate for commercial payers, to offer ABA, we can also, create the similar mandate for the extent of services to have a bigger ROI at the state level. Because again, ultimately if you've got a child who's, uh, with a commercial payer, and I'm gonna medicalize their plan, and I'm sure the behavioral analysts here have had the experience of a commercial health plan saying, I don't pay for, ADLs, I don't pay for, what they consider academic services. Well, you know, there's symbol recognition and there's learning to read. And to me, symbol recognition is a functional capacity. Learning to read is an academic thing, they're related, but to me, I really want people to be able to do symbol recognition and if that ultimately gets them to learn to read, great. But the fact is even commercial payers, should understand the ROI at the social level. And that's again, where some of these more functional approaches to the value proposition. A great example of this is simply kindergarten readiness. We know about the diagnostic delay issue is a significant problem, it results in treatment opportunity loss. We know that, many children are diagnosed later because of all sorts of issues with screening in the community. But if we really invested significant dollars in getting kids actively diagnosed by, two and a half or three, or even earlier, given some of the new tools that are coming out, and got them the levels of comprehensive integrated services before kindergarten and came up by the way, with a metric of kindergarten readiness because it's not academic, it's functional. If we could have a real functional definition of kindergarten readiness, now we've got a kid who's gonna kindergarten who really will not necessarily need as many special service and supports. They may, because one of the things that we forget about because of that course of life challenge, that developmental challenge, is just because we are able to provide very effective outcomes oriented treatment to a child at age five, there's all sorts of developmental sequences that occur next, and they may have to go back into therapy, get other treatment along the way because of changes in their developmental status. Uh, and I'll give you one great example of this, high school, requires a multi-channel capacity that middle school doesn't. So middle school things remain linear. You may go from classroom to classroom, but by and large, the work in each classroom is linear and the classes have a linear relationship to each other. In high school you've got a multi-channel at the same time you're moving between classes in a different way. You've got assignments coming at you in different ways. And your executive function skills, which may have been appropriate in middle school are challenged in high school. Well, a lot of neurotypical high school kids struggle with this, but certainly, children with autism are really gonna struggle with that. And they may need not formal intensive intervention. They may need some coaching. And to me, again, ABA is a wonderful coaching tool around some of these behavioral issues. And by the way, I also think it's probably appropriate for some kids with ADHD as they get older as well.

Jonathan: 42:11

So powerful. But I really like this idea of the simplicity of an outcome or a quality outcome is simply like kindergarten readiness. As opposed to picking HEDIS measures or like, I don't know, any number of other things that are more economically rooted.

Dr. Steve Merahn: 42:24

So there's two other things I just wanna kind of layer on that. Number one, a higher order outcome measure does not preclude the need for evaluation of treatment effect. But, again, and I'm a little controversial here, changes in your Vineland score are not an outcome. Changes in your Vineland score are an indication of treatment effect. What we really wanna do is say, okay, how are the skills you've acquired gonna help you with that? Again, I'm gonna come back to my social imperative, succeeding in the world on your own terms and, being an active, productive member of family and community. And so, we really need two tiers of metrics. Let's not call'em outcomes, let's call'em metrics. We have treatment effect metrics and outcome metrics, and they're related to each other. And also by the way, by having those two together, you can start to do some regression analysis to determine which treatment effects are actually having the best, roll up into that longer term outcome. I've actually told this story to parents. I often would ask a parent, what are your goals for therapy? What are your goals for treatment? What are your hopes and aspirations for your child? By the way, inevitably in that conversation, it will come out that they're worried about what will happen when they're not around anymore. And again, this is a gap in behavioral analytic training because being a clinician means having a relationship. Back to the humanism, having a relationship with the people that you're caring for and understanding where they are and, whether it's, I'm gonna say psychologically, I can also say where they are in terms of their inner verbal behavior. But the fact of the matter is there's inner dialogue going on in their heads all the time. And Skinner would call that intraverbal behavior. So let's get that out in the world so we can understand what's going on there, and then perhaps affect it. But I would say to families, what are your goals? And I would have mom say to me, I just wanna go to the movies. I just wanna go to the movies. I wanna go to the mall I wanna be able to not have to worry about a meltdown. I wanna be able to give my other child some attention without always having to toggle. And I would say, okay, that's our goal too. That's our goal too. But here's the path we need to take to get that to happen. Step number one, your child needs to respond to their name. That's step number one. Step number two is there's this concept called joint attention, and we need to ensure that your child has mastered joint attention. Well, now, again, outcome mall, treatment goal, joint attention. I've connected joint attention with the mall, and now the family's like, okay, I get it. Now I understand why we're doing these little things in six month cycles. But if we don't acknowledge and align the bigger treatment roadmap around these more life course outcome related goals, then we're not serving the families and the children.

Jonathan: 45:32

Hmm. So powerful connecting outcome or differentiating between outcome metrics versus treatment effectiveness metrics and how you tie them. Well, I'm gonna ask you, and I think you've already answered this in multiple different ways, but if you had to put a fine point on this question, Steve, what's one thing ABA practice owners should start doing and one thing to stop doing? How would you answer that?

Dr. Steve Merahn: 46:00

I am gonna go back to my, outreach to the pediatric community as the one thing I'd really love them to do. I think that developing a responsible professional identity among the broader child health community. To be present to, find out when the annual meeting of your state AP chapter is and showing up. Those kinds of things really, really make a difference. And again, your expectations have to be low. These are very, very, very busy people who have incredible demands. I was talking yesterday to a colleague of mine who's at a large medical center in, in New York, and she said to me, their emergency room is backed up for 12 to 18 hours at a time right now. So the healthcare system's overwhelmed. So you just wanna be present, you know, it's like, hi, I'm, just letting you know we share the care of this child. Just letting you know, if anything comes up, let me know. if you know of a behavioral challenge with your child, let us know we can put it on a treatment plan and we'll let you know how it's going. There's two things I would stop doing. The first is, I would stop relying on formalized assessments for treatment plans. You can't do a treatment plan from the VB MAPP. You can't say this child scored X on the VB MAPP so my treatment plan's gonna be to get them to the next box on the grid. That's not a treatment plan. Treatment planning should be done around child-centered domains, and the more that we can begin to think in terms of developmentally appropriate practice, but also around this idea of child-centered domains, there's real value again in terms of being part of the broader child health ecosystem. And when I say child-centered domains, I'm talking about things like, okay, the three big ones for autism, communication, social interaction and behavior. But there's also, executive function and health and life transitions and perceptual sensory issues and activities of daily living. So you use tools like the VB MAPP to say, okay, of all the things I've discovered here, what are the individual and group social issues that I can identify from this? But you shouldn't anchor your treatment plan in the assessment. The assessment should inform the treatment plan. And the second thing I would stop doing is being so rigid about scope of practice. Again, you can ask about medications you're not analyzing what the drug does. You're not prescribing it, but you can know whether a child's on medications or not. You can know what chronic conditions they may have, you can ask about that. But the other part of it, in terms of rigidity, scope of practices, yeah, you're a behavior analyst, but you're also a person. And the relationship you have with your clients has to be at the person level. And then you bring your behavioral analytic framework to the person. And that personalizes you, it also personalizes ABA, and reduces some of the formality. Now this is a training issue. We've minted a boatload, of behavioral analysts in the last five years or seven years, depending on how long you've been around. And a lot of those training programs are limited in terms of the core clinical skills. For me it was seven years of training, four years of medical school, three years of residency. And, then I spent the next seven years working in public health, and I can tell you three of those seven years were basically an extension of my apprenticeship because I was a junior doctor. And despite the fact that I was a medical school graduate and I finished three years of pediatric residency, I still in many minds was early career and treated as if I was early career. I did not have the same levels of responsibility as more senior physicians. And, we're taking people who are finishing their, master's degree and I don't even know with 15 or 1700 hours of practicum, and we're putting them in the world and there's no, hierarchy, in terms of, your early career. No. You're early career, you need to be seasoned. You need supervision, I needed it, by the way, to this day, I need it. I went and got some special training a couple years ago in, in mental health. And when I was, in that training I had a senior psychiatrist I reported to on a weekly basis. Even though I was, a fully blown grown up who had run healthcare business. So there's a certain humility that has to come with being a clinician in the world. And there's still a developmental sequence you go through, as a clinician and as you learn over time. And supervision is really critical and it's gotta be supervision from someone who's significantly more seasoned than you. It's supervision of you in terms of your career path.

Jonathan: 50:44

So much wisdom in that the idea of the humility of, being early stage career and developing over time. Well, before we get to our hot take, I'm gonna put you on the spot, what is the over under year by which you think a majority of ABA providers will have a chief medical officer, whether full-time or sort of the external.

Dr. Steve Merahn: 51:01

I don't see it happening. I was lucky and grateful at Centria, it was early in the company's life cycle. However, you have to understand, Centria had at the same time a very, very significant home healthcare business that took care of home bound, medically complex children. So when I joined Centria, the home care business, ventilator dependent, medically complex kids, home care respiratory therapy, nursing, rehab, the home care business was bigger than the autism services business. And that's how I ended up there. So while I was there, we grew the autism business. The home care business remained one state. The autism services business grew multi-state. But I personally, I would love to see some of the, ABA providers. ABA services companies, bring on a pediatrician, because it would significantly help, the presence and identity of behavioral analysts.

Jonathan: 52:01

Well, Steve, where can people find you online?

Dr. Steve Merahn: 52:04

Oh, boy. Um, that's a good question. LinkedIn probably the best place. I don't do a lot of social media, and I'm really actually pondering taking my limited Twitter presence away completely. Um, but LinkedIn's probably the best place to find me. I'm always open to invites, particularly from the behavioral analytic community, happy to connect. For my book, I do have a website, merahn.com. But it's just for the book. there's a contact, page there as well.

Jonathan: 52:35

Terrific. I'll drop those in the show notes along with the link to your current organization. All right. Are you ready for the hot take questions? All right, here we go. Rapid fire, you're on your deathbed. What's the one thing you wanna be remembered for?

Dr. Steve Merahn: 52:47

My kids

Jonathan: 52:49

What's your most important self-care practice?

Dr. Steve Merahn: 52:51

Art, I make art,

Jonathan: 52:54

Hmm? What type of art?

Dr. Steve Merahn: 52:55

Right now sculpture. But I've had a long standing art practice. It's so funny. So I just started to go public with this. I've been making art since medical school. I actually have, drawings I've made in the neonatal icu, they are anonymized obviously, but I've been doing that for a really long time. I never told anybody. It was really just my way of kind of getting away from the day-to-day, pressures and burdens of being in the human services business. But merahn.net is actually my art site.

Jonathan: 53:21

I'm gonna drop a link to that as well. You heard it here first.

Dr. Steve Merahn: 53:24

It's brand new. I just put it up. It's, literally days old

Jonathan: 53:29

Fantastic. Uh, what's your favorite song?

Dr. Steve Merahn: 53:33

Oh boy. Um, Cloudburst by Lambert, Hendricks and Ross.

Jonathan: 53:42

Nice deep cuts. Uh, if you could give your 18 year old self one piece of advice, what would it?

Dr. Steve Merahn: 53:50

Uh, go for it. I only say that because I actually went to medical school kind of by accident. I was a lost soul. I was not a particularly successful high school student. As a result, my parents said I couldn't go away to college. I went to community college for a year to kind of prove myself to them. Got into the state university system in New York, transferred twice, dropped out once, and was very fortunate enough to have met a mentor. One of my professors took me under his wing and somewhere along the line, this idea of going to medical school came to me. I think if I had had better advice at 18, I probably would be an artist.

Jonathan: 54:31

Wow. Wow. Oh, powerful. Well, last question. If you could only wear one style of footwear, which would it be?

Dr. Steve Merahn: 54:44

You know, there's these weird slip on things I wear now. They're not leather, they're kind of woven cloth and I can't describe them, but it's comfortable slip-ons.

Jonathan: 55:00

Right on. Hey Steve, thank you so much for sharing your wisdom and coming on the podcast. This has been a ton of fun.

Dr. Steve Merahn: 55:07

Thank you so much, and again, feel free to reach out. I'm, I'm open.