The Future of ABA: Value-Based Care Explained

In this episode of Acorns to Oaks, we explore the evolving landscape of Applied Behavior Analysis (ABA) and the growing shift toward value-based care. After attending a recent industry conference, we break down what these changes mean for providers, families, and the future of care.

We discuss what ABA is at its core, address common critiques of the field, and examine the potential impact of tying treatment to outcomes rather than time. Most importantly, we ask the critical question: who gets to define “progress” — and what happens when access, resources, and real-life variables are part of the equation?

This is an honest, thoughtful conversation about where ABA has been, where it’s going, and how to ensure care remains compassionate, individualized, and effective for every family.

Transcript

SPEAKER_00 0:05

Hello and welcome to Acorns to Oaks. My name is Sarah, and I'm Christine Dixon, and we're both behavior analysts. And Sarah is also a nurse practitioner. That's right.

SPEAKER_01 0:17

And today we're going to talk about an very important issue that has been on our minds. Yes.

SPEAKER_00 0:22

Well, we we just got back from a PBA conference. Super fun in New Orleans, or Nolans, as they say. We we got a chance to see some remarkable talks. Yes.

SPEAKER_01 0:33

Symposiums. Really great talks. Uh always nice to be plugged into what's going on in the ABA community and see what's changing, what's coming up. Very exciting. Maybe should we start with explaining a little bit about what ABA is in case some people listening in are unaware? Absolutely. So ABA is applied behavior analysis.

SPEAKER_00 0:54

It is a natural science in which we take it all the way back to the scientific method where we identify a problem, we make an observation, we determine a variable that's impacting the problem, and then we change the variables uh to make positive, meaningful progress and meet goals for absolutely.

SPEAKER_01 1:17

So, what that means for most of our clients, we're looking at improving communication skills, improving self-management and social skills, and really helping people to live full, high-quality lives. Which looks different for every person.

SPEAKER_00 1:30

So important, yes. And cultural responsiveness. So, you know, we nurture and nature is a private practice that we have had the pleasure of running for 10 years. And I think one of the keys to success of being in Los Angeles and holding a market share in this highly competitive market has really been how we tailor the programs. Just like a Italian suit is well tailored and made, uh, clinical programs should be very well tailored. And that's taking time to meet your clients and meet the learners and determine what is important for your family and what you want to see. Uh, I remember at the conference, someone was like, we don't take the time to ask that question. And Denise, um, the other owner of the practice, turned to me and she's like, that's the first question we ask. It's like, usually we meet them pro bono to ensure that they're a good fit for us and we're a good fit for them, our methodologies. And um, then we start asking them questions, you know, um, what do you want to see for your child? Um, are there behaviors you want to decrease? Are there behaviors you want to increase? What's important to you? Uh, what is your biggest challenge of the day? Always embedding in self-advocacy and compassion and do no harm. And we've been doing that way before it was popular.

SPEAKER_01 2:52

Absolutely. And I I think that's a really good point because you hear a lot about ABA now. Yeah. And um, some positive things, some not so positive things. It is a science that works. It may not be right for everyone, which I think is really an important part of why we ask these questions at the start to see that we're a good fit, to see that we are going to help this family achieve the goals that they have for their child in their home, which may look very different than my home or your home, and may be something that really needs that individual attention so that it is a very helpful, quick, and effective method of improving lives.

unknown 3:30

Yeah.

SPEAKER_01 3:30

And I think that's what really got us fired up about what we're going to talk about today.

SPEAKER_00 3:34

Yeah. And A B is really based on reinforcement. And I have to say, the critiques of ABA, from what I heard, are very valid. Absolutely. I really don't regularly engage in in the type of activities that are being critiqued. But I can see why um, you know, topics like ableism. Um, it's a good good conversation to have, good discussion. I can see how stereotypes for some can be a coping skill, and uh how we might not necessarily need to treat that every time. So I think the discussion is good.

SPEAKER_01 4:12

I think the discussion is good too, because any science really, any type of human intervention um will grow and change over time.

SPEAKER_00 4:20

Yeah, nothing really stays the same. Yeah, and that and that's why science is dynamic, ever-changing, ever evolving. And I'm just I feel so blessed to be able to take clinicians to the conferences because that's what really keeps the science on the cutting edge. You know, sometimes we interview BCBAs and we always ask, like, what's the last conference you've been to? You know, what associations do you belong to? And what's the last peer-reviewed article you read? Because being in the know is so so vitally important to how you approach people.

SPEAKER_01 4:54

Absolutely. And I think just the changing nature of science, which you mentioned, I think that's really important to keep in mind as well. Because if you're not staying on that cutting edge, if you're not looking at what is happening in research, what is happening in the industry, you can really be surprised, I think, in a not great way. So it's wonderful to go to these conferences and to spend time with peers and to listen to what's uh new and upcoming and what's working really well and what we can improve upon. Yeah.

SPEAKER_00 5:24

And we've seen this theme, and we we kind of have an inside joke because for the last, I think, four years, we've really heard the theme of do better. Yes. And I like that theme because for me, more is more, and I always want to do better on a daily basis. Um, so I'm always trying to elevate uh what we're doing, the treatments, the outcomes. Um, but at the same regard, I kind of disagree a bit with the do better theme of these conferences. Mainly it started while we were still in the pandemic when we were working so hard, so tremendously hard during the pandemic as healthcare workers, uh, just being in it every day. Nurture and Nature took one day off to restructure how we were gonna do treatment. And then the next day we we went back to work and we worked for four years in Los Angeles under pretty ever-evolving laws and contingencies. And so to go to the conference, I think it was uh Jonathan Tarbux gave the opening speech of do better. And I was like, I have just worked harder than I've ever worked in my entire life. Like, like, you know, a lot of academics come forth with do better. I'm skeptical. And that's one of our scientific attitudes is to be skeptical of new things. And so I think when we went to APBA, we heard a lot about the CASP new guidelines for uh ABA standards. And the guidelines are very important because there are several laws uh both on the federal level and the state level that govern uh these services. Before these laws were put into place, insurers really said horrible things to patients, like, well, you have autism, there's nothing we can do for that.

SPEAKER_01 7:30

You know, you can't expect improvement, you can't expect to see long-term gains. So there's really nothing that we can provide.

SPEAKER_00 7:39

Yeah. And California, um, and I have to give shout out to Gina Green, because Gina Green really pushed the science forward in the laws and through advocacy. Uh, autism speaks, a remarkable Loriumbrum, remarkable advocacy in our field. But in California, we got SB 946. And this was a wonderful law that um demanded that the insurers pay for ABA treatment for autism. And so people that never had access to care started getting this remarkable access to care for those that want it. Absolutely. Now, as you said in the beginning, it's not for everyone. And I understand that completely. And we also have a federal law called the Mental Health Parity Act. And this provides overall federal protections for mental health, which is so vitally important for our country.

SPEAKER_01 8:37

Especially as we see how mental health affects every other part of your life. It affects not only your mental health, but your physical health, your ability to interact with other people, your ability to have jobs and relationships and to live in community in a safe way.

SPEAKER_00 8:53

Yeah.

SPEAKER_01 8:53

So it's really exciting that um so many gains were made. Yeah. Um, as we attended some conferences and um heard sort of the perspective, I don't think that anyone minds being told, hey, let's we can improve. We can do better. We can, we can improve what we do, and it'll be great for our clients to improve what we do. And I love that. What I think can be a little difficult is if we get stuck on, we've done so poorly. When I don't really think that's the truth. I just think that it is an ever-evolving science. We learn, we change, we grow, and that's a great thing. I don't think that there needs to be such a focus on how we could have done better 20 years ago, 30 years ago, 40 years ago. I think take those lessons and build upon them.

SPEAKER_00 9:45

Yeah. Retrospective history looking back, it never works out. You can't apply today's standards to 20 years ago. Um we saw a little bit of that, I think, with like America's Next Talk Model. Do you know that controversy that's going on where they're haven't seen that? Well, they're applying today's standards to um that television show, and it's a bad look, you know, and it's always going to be a bad look, even in medicine, when you apply today's standards to, you know, the Renaissance period. It's a bad look what they're what what medicine was doing back then compared to today's standards. One of the great things about the Mental Health Parity Act is it really stated that industries can make decisions determined on the industry standard. And that is the crucial part is what is the industry standard? Or what are the guidelines of our industry? And we felt so excited when CASP took over the guidelines for ABA because uh, well, Lori and her husband Dan were amazing advocates getting ABA in schools and in homes, and really defining uh several domains in which we could work within. Uh, but at APBA, we were kind of shocked, I guess skeptical, uh to find out that value-based healthcare is being embedded in our industry standard guidelines, um, which are due to be announced, I believe, at the CASP, the Council of Autism Service Providers conference coming up in Vegas. And so at APBA, we CASP uh put forth the repository, I think it is what it's called. And I noticed in the CASP guidelines that are going to be announced um shortly, that um ABA industry standards are turning towards value-based healthcare. Yes. And I am highly skeptical about value-based healthcare.

SPEAKER_01 11:51

Um yeah, so our understanding, and we may be wrong, as this is a new concept for us, is that value-based healthcare will determine what is reimbursed for results over time spent. So that sounds great, right? Better results is what we're looking for. Well, we don't live in a world where everyone is the same.

SPEAKER_00 12:16

Yeah. And the equation behind it. Yes. So the concept came from Michael Porter, uh, who is a Harvard business professor and um economist, yes, business consultant. And I believe the equation for value value-based healthcare is value equals clinical outcomes over cost, correct? With cost being the denominator and clinical outcomes being the numerator in terms of value. Yes.

SPEAKER_01 12:49

Yes. So ways that this has been um applied in medicine include um weight loss drugs. Yes. You may be prescribed a weight loss drug, and within one month, you are expected to lose 12% of your weight, um, or you will no longer have insurance coverage for that medication. That is my understanding of how that works in a medical setting. Um, so you too are skeptical.

SPEAKER_00 13:17

I this is gonna be a ginormous change.

SPEAKER_01 13:22

Absolutely.

SPEAKER_00 13:22

Yeah. And it's going to affect a lot of people. Um, I'm highly skeptical about value-based care, um, mainly because it is the language of the insurance companies. Um, and it's interesting because just two years ago, the industry was really pushing towards, and I also heavily push towards cultural responsiveness. Uh, this is a very great concept. It's an important concept towards autonomy, how we create goals and cultural responsiveness and working with so many different families really comes to build meaningful goals because who's determining what's of value and what's meaningful? Is it the family or is it the insurer? Correct. And it seems like if CASP goes ahead and announces these guidelines, that it really is going to be the insurer. And there's a lot of criticism, and we should be skeptical, you know. And you're seeing it in the medical model as a nurse practitioner. Yes.

SPEAKER_01 14:32

So uh during my preceptorship, I did see that in the clinic space. Um, and I think what that illustrates for me, it's very cut and dry when you're looking at a medication, right? I give you a medication, I see an outcome. But when that medication also requires behavioral change, there are a lot of factors, as we know, that affect behavioral change. And just giving a drug is not going to affect behavioral change. Um, when we are looking at our clients and we are taking into consideration not only cultural responsiveness, but also the socio-ecological model of all of the factors that interact with the child, the family, the community. All of these factors are going to affect behavior.

SPEAKER_00 15:17

Yeah, and that's really interesting because, and maybe we're wrong, and this is our opinion, but you know, I really see a lot of systemic racism, right? Racism built into systems. Um this seems to me that this is going to be another system where um we're going to reward the people with the most resources and give the people with the most resources the best health care. Absolutely. And the people that uh have real disadvantages and and systemic disadvantages um are going to be cut off from treatment based on you're not getting the clinical outcomes. Absolutely. And in the value-based care model, one of the most upsetting points about it is that the provider's pay is going to be determined by the clinical outcomes.

SPEAKER_01 16:22

Yes. And I think this is interesting in terms of how will we define what those outcomes are. And how are we measuring client success? Because if you think about it, if you have two families, you have one that has a lot of socioeconomic benefits. They maybe have money for child care, they have money for enrichments, they have uh health care, they have a nice home in a safe neighborhood, they have green spaces that they can exercise in, they have access to healthy food. Those people are going to have very different outcomes than someone who does not have all of those benefits and access to all of those enriching activities and locations and resources. So what we see and what we are concerned about, and this is our opinion, we don't know for sure, but what we see is a contingency that as behavior analysts we are seeing possibly lay out in front of us. And that is the comparison between progress that's made when someone has access to all of those wonderful things, versus progress that's made when someone does not have that access.

SPEAKER_00 17:33

And we we really have had the clinical experience. Absolutely. We've been in the most posh privileged homes in Beverly Hills in Los Angeles, and we've also been in the poorest communities. And the differences in resources really impact overall treatment outcomes. And here's how it does that. One, they're gonna hire an advocate like myself to get them better services at the IEP, because pushback in the IEP means better services for the child, right? Two, they're gonna be able to uh pay for uh private speech, private OT. Those things make a difference, especially when we have phenomenal continuity of care and the goals that we write speech is working on, the goals that OT has, we are also working on, because then you have many providers, both in school and at home, working on the same goals. Collaborating. Yeah. Versus uh a disenfranchised or marginalized community like the Latino population, um, where the parents might be working all day. And uh the child uh goes to school. Um, they don't have the education. Sometimes, sometimes they do. And Denise Renseria Gonzalez became an advocate for that population uh in Los Angeles and has done a phenomenal job. You know, they might be working, both parents working, like my parents did until six o'clock. The children might be in after-school programs uh where services may or may not be able to take place. And in terms of private speech and OT and play dates and birthday parties and social groups, and they might not have the money to do those things because those things do take money. They do, they do. It's very difficult.

SPEAKER_01 19:31

Not everyone has the same access.

SPEAKER_00 19:33

Yeah. We also see this in food, right? Absolutely we know that good food um helps development, right? It does. There's the omega-3s are recommended and fish oils for brain health during development.

SPEAKER_01 19:45

Basic vitamins and nutrition and what you get out of a basic healthy diet really impacts development in your brain and your muscles and your bones throughout your body. So if you're unable to access healthy foods, if you're unable to access after-school enrichment and athletic programs and private speech and OT, you're not going to have the same outcomes. So if what we're looking at here is outcome over cost and who is paying that cost as what equals value, as what equals value, and what equals what will be funded, um, we see a long-term reduction in care being offered to the most vulnerable of our clients and families.

SPEAKER_00 20:33

Um and it's heartbreaking. It's really is. It's a it's a system that's going to lead to, in my opinion, many, many, many problems. And the other thing is that behavior analysts use evidence-based practices and empiricism, right? We want to use things have that have been studied, replicated with valid data before we use them on our um clients. And here we're rolling into a model of value-based healthcare, which we don't know if that's going to produce the best clinical results, because we've never really used that equation. You know, that cost as the denominator is concerning.

SPEAKER_01 21:21

I agree. It is concerning. And I think as behavior analysts, we look at contingencies. And what contingency does this set up for the business owner? If you are going to be reimbursed based on progress over cost, as someone looking to stay in business, you may not be able to serve the clients that we would like to serve, which is everyone. And I think it sets up a really dangerous precedent in which people who have the highest needs will not be offered the service because the cost variable is the what we're focusing on. As a funding source is going to determine what is outcome that is beneficial or not. So I think I have a lot of questions. I'm interested to see how this was developed. You know, if you look at a policy cycle, you'll start with here's the problem. You should be including community, so the people who will be affected by whatever you're looking to implement and setting up this uh plan to improve services and reduce costs, if that's what we're looking at. Um, and then roll out something that you're going to implement, right? It shouldn't go straight from, well, the cost is too high and the service isn't as good as we think it should be. So let's just cut this the funding. I don't think that's going to lead to excellent services. I think it's going to lead to exclusion.

SPEAKER_00 22:48

I do too. Because as providers, when you look at there's confounding variables to treatment, taking it all the way back to the scientific method. We are a natural science. We are not a social science. Um, but taking it all the way back, there's confounding and extraneous variables that impact treatment. And in this case, with the most vulnerable population, there are so many variables like comorbidity. Yes.

SPEAKER_01 23:15

Yes. So if you have a genetic disorder in addition, if you have pediatric feeding disorder in addition, if you have any sort of comorbidity that could affect your behaviors, you're going to need more service.

SPEAKER_00 23:29

And what is going to be the scientific method to evaluate the insurance company's value? Like, how are they going to take into account all these variables? Absolutely.

SPEAKER_01 23:42

And who is defining what this progress is? So are we paying a specific amount for being able to uh ask for things, demand and and to understand our environment? Are we paying a certain amount for being able to use the restroom? How is this going to be broken down? I'm really not understanding. And I wish someone would reach out. Yes, please help us.

SPEAKER_00 24:05

Please help us understand. We don't understand. We need we do need help. And we and we hope and we want engagement, you know. Um, but I am very concerned that the most complex cases, which are the cases that I like to take on, you know, I'm the one of the oldest behavior analysts in our practice, so I do try to take on the most complex cases. Um, those cases sometimes do not produce the best clinical progress. So is value-based healthcare going to make providers not want to take on those highly complex, severe behavioral cases?

SPEAKER_01 24:47

How are they going to quantify what is progress for an individual with those variables in mind? Are we looking at age? Are we looking at development? Are we looking at um where they live, how much uh resources that they have access to? Are we considering comorbidities? I think there's a lot of questions in terms of how we're going to determine what was a high-quality health outcome when we are not necessarily looking at individuals, but perhaps a bell curve. Right.

SPEAKER_00 25:20

Yeah. So let's talk about a lot of those variables that impact treatment that are very real to people. And that would be someone passes away. Absolutely. During a during a progress reporting period, which the insurance company would say is at the six-month mark, right? Yes. So the family dynamic can completely change. Um, parents get divorced, uh, parents get evicted, uh, parents lose their home. Um, parents move, you know, they're in a new town. Family dynamics change all the time. The sibling has a severe uh, you know, medical condition, uh, a parent has cancer, all these variables are going to severely impact treatment and cancellations. Um, you know, sometimes kids have highly uh compromised immune systems. Absolutely, absolutely.

SPEAKER_01 26:16

So uh if we look at it through a socio-ecological model where we start with by looking at the child, the child may have comorbidities, medical problems, they may be in and out of the hospital for periods of time, they may be unwell for periods of time. If we were to look at the progress of that client versus someone that does not have those same challenges, they're going to be very different. So, will that be considered through this value-based model? Um, if you move on from what is affecting the child specifically, but what is affecting the family, as you mentioned. There are changes with the family, there are changes with the parents, there uh are a lot of political things happening right now that might change where people want to live, that might change how healthy and safe they feel in the community. Um then if you move into the community itself, right? We have uh economic problems that occur. We have um industries changing, maybe people lose their job, maybe they have to move to a completely new place, have a completely new school, and all completely new um therapists and speech and OT and medical providers as well. So I I think there are so many variables that touch a child in terms of their behaviors and how they are supported within this model, which does affect so much more than just one interaction between one provider and one child. I think that we really need to have evidence that shows us how this is going to improve quality of care.

SPEAKER_00 27:47

Yeah, because that is the cell line from the insurance companies, right? Is that it's improving quality of care. Well, I'm all about improving quality of care. And I think that happens with providers at education level and taking your company and teams to conferences, seeing the academics' research, which is so vital to drive our science, behaviorism, that whole science behind the academics driving what's the most efficient, dynamic treatment, um, but using that empiricism and replication of studies. You know, ABA does a wonderful job graphing, right? Behavior analysts show progress through graphs, right? That's one of the things that was on my board exam. Um, we do within single subject research design, meaning we're gonna track all the frequencies of the maladaptive behaviors, and we're going to track all of the replacement behaviors that we want to teach. And we're going to graph that either in terms of percentage of opportunity or rate or um, you know, standard celebration. Uh, and so that's how we always traditionally demonstrated progress is we took baseline, we changed variables, we proved functional control, like hey, we changed this one thing, and then this happened and the behavior started going down. Um, it's just I don't see how we're going to get there, but help us, help us understand. Maybe we're missing something very big.

SPEAKER_01 29:22

Yes, and I'm open to that. I am as well. You know, I I think our concerns, though, are valid because we care deeply about our clients from all levels of socioeconomic access, uh, from all levels of baseline functioning and different diagnoses.

SPEAKER_00 29:40

Um and it stands against our values, which are compassionate care, individualized treatment, cultural responsiveness, you know, diversity, equity, and inclusion. Um, those things are important to us. So, but please help us understand. Uh, this is just a brief conversation. We're just two behavior analysts, um, kind of talking about things we care about. Uh, but yeah, thank you so much for for coming to our the podcast, Acorn to Oaks. And uh still so much more to discuss about value based healthcare. Yeah, we have a lot of questions. So many questions. Please reach out.