From Ethics to Advocacy

Speaker A: The following is not legal or business advice. This podcast encourages listeners to do their own research prior to making business decisions. Um, welcome to the ABA Healthcare Matters podcast with hosts Rebecca Womack and Dr. Tim Courtney. Enjoy the show.

Speaker B: Welcome to episode five of the ABA Healthcare Matters podcast where we talk about applied behavior analysis in healthcare. My name is Rebecca Wommack and I'm joined by Dr. Tim Courtney, my co host. Today we'll be talking about the importance of ethical clinical practices and how that relates to advocacy in the field of healthcare. I am a behavior analyst, both by education, certification and also licensure. My ability to continue to be a behavior analyst is related to one primary reason and that's the requirement that I keep the Behavior Analyst Certification Board's code of ethics. Some states embed the code into their licensure act and require certification as a BCBA as part of the process of becoming licensed. So there are certainly legal aspects related to maintaining my certification and licensure. Those behavior analysts that work as healthcare professionals have a responsibility to ensure that their clients receive the highest quality possible. I don't think anyone would argue that point. We all want to provide high quality services and sometimes in the process of providing services, it can be easy to lose our way as we try to balance the many varying requirements of health care policies, practices in addition to prioritizing serving our families. Today we're going to talk about advocacy as a behavior analyst and as a healthcare professional, the complex contingencies that impact our advocacy and what that can look like in practice. Tim, glad to be with you today. How's everything going? Awesome.

Speaker C: Uh, I'm super excited to have this conversation again. It's so much fun and invigorating to do these podcasts. So excited to get into it. Last week was so much fun with Dr. Moran. So hopefully people will uh, watch that really soon. Uh, just wow. Lots of great information was shared in that. So that was, that was a really good time.

Speaker B: I enjoyed it as well. And we touched on a lot of things that we can actually pull the thread from for today's conversation. And when I think back to that topic that we shared with him and also how I became really aware of the topic of advocacy in health care, all ah, roads point back to you being one of the people that really is, um, responsible for helping me learn more about this topic and I'll admit like the word advocacy and in healthcare and in this space, I used to think about it in terms of having that conversation as a provider with payers about treatment plans and I was Honestly so intimidated and also impressed, um, when you would talk about how to navigate those conversations based on why you had to have the conversation in the first place, the implications and so on. So I wanted to see if you could share. How did you learn to talk to health plans about those topics that you had to talk to them about, like requesting goals or you know, advocating for hours. How did you learn about that? Who taught you um, how to do that?

Speaker C: Uh, I'd love to say it was a path filled with lots of reinforcement and it was a very easy process. It was, you know, quite the contrary, filled with lots of aversives and you just iterating and iterating and iterating, trying different things, asking more questions that uh, just be. Will be an ongoing theme and something that I continue to strive for is just asking really good questions and from that taking back information and going back and re evaluating your process. And I always uh, something just would always try to do is really look inward. What am I doing that is having an impact on this? Is there something that I could do differently? What overall needs to be achieved? So kind of high level, those are the ongoing things that were happening as I was really learning about how to navigate some of those conversations. And when you have this, this real spirit of being just inquisitive and wanting to understand and wanting to work collaboratively, it, it has always been the best for me and there are definitely times where I just um, am. Can. Can be frustrated that things aren't going really well and really feel as if maybe the process isn't the way it's supposed to go or might be against some of the rules that I understand and that can be very fr. But just taking the time and, and really understanding how, how am I kind of impacting that? What can I take back and do differently? How can I adjust that process and, and through this iterative design thinking strategy of just okay, here's, here's what I need to achieve. Here's the information that needs to be shared. Here is what's really helping push that medical necessity conversation along. Here are potential pitfalls and understanding those pitfalls and how to navigate that really was a lot of the strategy that I went through and just really learning how to navigate some of those conversations and how to always uh, when we're talking about advocacy today and I think there's this powerful way in which we're able to just advocate for those that we provide services for through providing high quality services, through striving for those outcomes, through making sure that we understand this different process. So there's not issues that are going to disrupt care, they're going to slow down care that are going to get in the way of, of some of the outcomes. So, you know, through doing this, I always felt that there was an advocacy component to that. And it's something that, uh, it's nice to see in our ethics and in some of our background as behavior analysts that we have had this real strong advocacy role that we've played for those, uh, with various disabilities, autism, intellectual, developmental disabilities.

Speaker B: I mean all great points. Agree. I think you had some really good insights. And when you think back to, you know, the first time that you had to make that phone call to the health plan, um, can you talk about how you knew what to say? Because I think that's what sounds really intimidating to me or felt intimidating is you're talking to someone you don't see who has every, like every ability to affect your, your life or client's life in a significant way. How did you know what to say and how did you know what not to say?

Speaker C: Uh, to be honest, I had no idea what to say. No idea what not to say. And it was intimidating and scary and there was a lot on the line and I really felt, uh, whenever things weren't going well, it took it very personal. It was, you know, a really difficult and challenging time to navigate those, and navigate those situations. And it was really why I love doing podcasts like this and trying to get information out so that others are more prepared for that, uh, don't have to sit in that chair and feel the way I did, which was, you know, just really hopeless. Felt, you know, powerless as well. Like I, you know, only could, you know, influence things maybe in a negative way. And really the say just like you're saying was really on the payer side and they were, you know, able to, to make these decisions. And at the time there was a lot of adverse determinations. There were a lot of times where services were not getting approved and not getting authorized. And, and so being able to work through that was, was a high pressure time. And it was honestly through just continued uh, talking to the payer and getting this shared kind of understanding. Like I understand that what you want to do and what you want to achieve is this, right? Uh, if I approach it in this way and share this kind of information, is that helpful? Yes. And you one place, one strand that that really was able to put that connection was around DSM criteria and are we addressing those? And, and that was a, uh, real epiphany with the payer was okay, yes, we are uh, in agreement that if we are targeting these areas and working on these things and so that helped really facilitate a conversation. I was fortunate. I was taking, I guess fortunate and unfortunate. I was taking all of the calls and was so I had lots of opportunities working with lots of different insurance companies and different medical necessary reviewers, working with some reviewers multiple times over and over again, which was also very helpful and developed uh, professional relationships where we were able to have you know, really good conversations and could understand where each, each of us were coming from. And you know having a lot of empathy on both sides was, was a, another key strategy that I think helped with a lot of those conversations. But it was, it was a painful process. Uh, and it was really uh, great when I started to access some reinforcement and could really help uh, inform the team that I was working with and then uh, later on being able to inform lots and lots of others. But it was a fun time.

Speaker B: So interesting idea of fun. So that's one thing. But I appreciate you sharing all that because it triggers a lot of other questions that I have about that process. So as an observation, um, looking back to um, when you initially talked about this in the field, from a public platform giving different talks and presentations to now, my observations are that the reasons for advocating or engaging with the payers over time has shifted. So initially the focus seemed to be on unjust denials, unjust restrictions of treatment plans for a variety of reasons, um, and then not, not all of them. I say that very broadly because you know, some of the restrictions, you know, were related to mental health parity violations. But since then I've seen a shift and the conversations more now seem to be around the payers educating providers about work product expectations, policy alignments. Um, what are your thoughts on that and what is your experience with advocacy when it comes to those payer conversations over time?

Speaker C: Yeah, I, I agree there, there definitely has been a change and, and some of that I, I, I, I did uh, appear at times that it was kind of a, a learning process. I mean we were just kind of a newer field. These mandates were kind of new. We were uh, it was a newer process to, to work with us and to understand behavior analysis and to understand what we were trying to achieve with individuals with autism was you know, pretty quick learning curve and a steep learning curve for the payer. So you can see where they were trying to navigate that and have an understanding of, of what we were, what we were achieving in it. And as we've Highlighted before. It's a pretty different service that we do based on the intensity. There's not a real parallel in health care in general. So that was another area that I think led to more challenge for the payer to be able to understand that. And so you can see early on, uh, trying to work through those things and maybe tiptoeing into areas that uh, were like mental health parody violations or weren't necessarily aligned with how uh, the medical necessity review process should go or in line with our contracts or you know, weren't uh, in line with the insurance mandates. And it was all, all learning and all growth and now there is more capacity around that and uh, at times maybe not the capacity on our side as providers. And I have seen, you know, a lot of times when there are a lot of situations that have led to adverse determinations and really working with providers and reviewing products that there were things that we maybe didn't explain correctly or weren't able to really highlight why something should be justified. And, and ultimately uh, at times I've even seen where, you know, just agreeing to maybe a lower intensity of service, uh, just because that's what's likely to get approved and not that, uh, which is an area where I really see that we're advocating for, when we're advocating for the appropriate intensity, what is it really going to take for this client to meet the outcomes that we know we can achieve and we know that they deserve and should have access to. And those are areas where we're, where we're not necessarily really advocating or if we're uh, doing something and just because maybe we don't really understand the process and now it's going to delay services or our services are going to be discontinued or disrupted in some way. That's another area where I see where it's, you know, we're really not advocating for our client by, by doing a lot of those things. So I think that in my experience that's where this shift has occurred, uh, with payers. Uh, but what is, what are your thoughts like? So you're, I mean that's a really powerful insight. And why do, why do you think there's been this shift?

Speaker B: Um, so I think that as providers who are going out into the field, we curated a way of setting up the payer's learning history. So there's this kind of give and take back and forth over the years. The payers would say, no, we're going to reduce or deny, um, these aspects of your treatment request. And in response we would respond with research that was kind of the typical cadence for a while. You can't do that because research says, and um, a lot of times the payers were gracious in accepting that or there was some give and take. But what was not discussed is the credibility and or veracity of the work product on the table as a standalone document. Justifying okay, so even though research says that, does this document align with the payer policy number one. But um, establishing the need, the medically necessary need in the first place and creating a clinical roadmap based on the assessment results under the umbrella of medical necessity for ameliorating the impact of symptoms. And I feel like over time payers started to pay closer attention to the work products themselves which unfortunately um, didn't always stand up to that level or that requirement. That's one part of it. The other part is the accountability piece. So providers were submitting work products that maybe met that, those requirements in terms of content but didn't have or speak to um, the implementing of care or showing stewardship over the care. So what I mean by that. So let's say in the initial treatment Plan Someone requests 30 hours per week for services and has you know, x amount of goals and then during the next authorization period, um, they request the same amount without speaking to the fact that the family, for scheduling reasons or Covid or moving or whatever were only able to utilize 50% of their services. And speaking to the progress made under the 50% utilization and just discussing it from a clinical perspective and payers then saying well look, you made this amount of progress in this amount of time, we're not going to give you the same amount of services when the child is doing well under a lesser intense model of treatment because you don't have any reason for that. Uh, and so what that did in my opinion is highlight over time a variety of opportunities for providers to really pause and think about well why am I asking for 30 hours when the family only used half of it made progress with their goals? What is my clinical justification for not changing that requirement and what's my plan to account for those discrepancies and, and payers rightly so, um, you know, have, have, have the right to ask those questions. It's them showing stewardship over their member base or their consumer base.

Speaker C: Yeah, a lot of interesting things that you discuss there and the one that you highlight, there were just a couple that I'd love to touch on. But the one in regards to this justification, uh, being solely research, uh, so you know, I don't Know, if, have you ever encountered this? So you're, you. You would have really solid evidence supporting from a, you know, you're able to pull a lot of studies and you submit that uh, with your, uh, maybe your appeal or maybe it was in your initial request and then the response from the, from the payer or the insurance company is equal justification based on research for their determination. Have you encountered that?

Speaker B: Um, yes, I have. And I think this is where, you know, just my opinion, I might have to go into hiding after I share this, just as a caveat. But I think this is how I think about that process. Both are true and both are right. And like as a de facto, the American Medical association accepting the eight CPT codes into the category one set, um, means that the interventions that were approved associated with those CPT codes are widely accepted by the medical healthcare profession. That speaks to the, to the credibility of the research under a model of medical necessity. So we know that the research says a lot of things about what we do and where we do it. The point is to show through your assessment work the level of issue or challenge, um, in that environment that the client is experiencing due to their diagnosis, both objectively and subjectively, and what your plan is to address that in a way that is germane to the service given the environment. So in a school setting, just because, you know, the literature shows that we can be effective, we can achieve outcomes and we can make change in behavior in a school setting doesn't mean that that's the only reason why we get to provide services there. It's our job to set up treatment in that environment in consideration of all the variables that impact services. So we're considering the school, we're thinking about idea, we're thinking about the client's IEP or 504 plan, the family's values, all of those things contribute to the case for medical necessity. Um, to me, it's not just about research. We're not there to talk about research. We're there to advocate for the services that we have deemed, um, that our client needs as being medically necessary.

Speaker C: I've often thought about that as clinical judgment. And what are your. I mean, would you kind of agree and you know, so you have like this, like. I love how uh, just like what you said, like it's already been accepted. Everyone knows we have strong evidence and support for our interventions. If you, as long as you're conceptually systematic and your interventions are in fact behavioral analytic. If they're not, that's another problem. Something you definitely should be looking at and addressing for a lot of reasons. Right. So it's always an assumption. It's behavior analytic. So, you know, using your clinical judgment to be able to support, uh, and be able to, uh, justify why you're asking for X intensity or X dosage of service or, you know, you want to target these specific areas.

Speaker B: I think that that is everything, to be honest. But I think it's what I wasn't necessarily taught because when I was in school, this wasn't a thing. Right. Like, um, this was starting to happen on a national landscape, but it wasn't where it is now. So I think it has everything to do with exercising clinical judgment and demonstrating the, the process of that decision making in their treatment plan as justification. Because the other thing too is that, you know, as practitioners, we have to remove our bias. Just because someone comes to us with a diagnosis of ASD or whatever is covered by the health plan doesn't mean that they automatically warrant ABA services because of the diagnosis. We still have to be an investigator to, uh, evaluate what is going on, what our findings are, and what that means in terms of our recommendations. I think over the course of time, there has only been one client who had a referral sent in for ABA services. After my assessment. I didn't recommend, um, what I would typically recommend, which is, you know, treatment for a couple of years, but I think it was just a focused model of care for six months and that was it, um, which was a little bit different than what the family was recommending, but actually ended up working out. So I think it's what is absolutely needed. But I don't think that we as a field are mentoring our future healthcare providers under that, um, kind of mindset or that way of thinking. Yeah.

Speaker C: Um, when we think about, like, our education around these areas, and I, we've talked about it a little bit before, but I equally, you know, just really trained as a generalist. I went to the, to graduate school at FIT and worked under Dr. Jose, uh, Martinez Diaz, which was amazing. And in hindsight, I can really see where he taught me a lot about advocacy, not in coursework. I never got anything about being able to navigate, uh, medical necessity or. But I was taught a lot about these are our concepts, these are our principles, these are, you know, our interventions. And this is the empathy we should be showing for our clients and compassion. And, you know, he. Dr. Martinez would get very emotional in a lot of presentations. And it was that emotion that was often around, uh, areas that were, uh, where, you know, maybe for some Reason services were, were not able to get access or wasn't able to achieve certain outcomes. And you know, just this longing to be able to help, which was, you know, just. I'm so grateful that he passed that along to me. And it's just been an ongoing think area that I. Helps me and being able to advocate and be able to navigate some of this medical necessity was, you know, just really, uh, knowing that I'm gonna. I have solid judgment for this. Everything that, that I'm asking for, all the amount of hours I'm asking for, everything is this is why I think that's, um, important. This is why I think this is going to be necessary. And I truly feel in my heart that this is the right thing to do for this client. Uh, when I've seen situations where it's kind of clear maybe a behavior analyst or is not feeling that way or is, you know, maybe feeling a little bit differently and not fully, uh, able to have this, uh, backing, you know, which makes clinical judgment very easy and honestly makes ethics easy, makes navigating a lot of this very easy, is when, you know, like, this is. This is why I need to do this. You know, when you think about your coursework, uh, and do you. Can you see areas where you were maybe taught about advocacy and about clinical judgment?

Speaker B: Yeah, actually I, I can. I'm thinking back to a few professors that I, um, really appreciated learning that from, both on the behavioral side and on the clinical side. So one of the professors, um, that I learned how to write assessments from did a great job of teaching, uh, not only taking the assessment and performing it with fidelity and the importance of all that, but what it means to take the results and translate that into information that is usable not for you as a practitioner only, but also the family or the person who the assessments are about. And that is an area where I think our field, um, still is a lot of room to grow in because we, um, sometimes we just submit the graphs or charts or the reports, but we don't translate the implications of that. And that's the key to making a case for medical necessity is taking that data and talking about it in terms of the findings and the application to the client's life. Um, and on the behavioral side, you know, I'm thinking of Dr. Miltenberger, who has a fantastic way of pulling from the literature, packaging it and, and sharing it in ways that are digestible, applicable and understandable, which, ah, is not easy to do, um, because there's a. We have a. We have a lot of fancy Language in our field that take a lot to, you know, you have to use like a fork and a knife to kind of dive into some of those conversations. Um, but I think those, those two kinds of schooling certainly helped contribute to clinical thinking now. But it's all the other things that, you know, came after my experience in grad school that I also think need to now be incorporated into our grad programs.

Speaker C: Yeah, I just really hope that in coursework now I, uh, I would love to learn more about you. Just haven't been in a graduate program in quite a while and so it would be nice to know what is being taught and what is being shared around the medical necessity process or how to advocate, how to show clinical judgment and what that means. But ultimately I still really hope people are leaving their programs, whether it's an online program or it's a brick and mortar program, but they're leaving truly believing in the science, believing in what we do and you know, ready to carry on that torch. Uh, is, you know, just a very important part to being a behavior analyst. And it's, it's tricky to me at times when I, when I've encountered that where I just am not really feeling that. It always was just a shared thing. Like we always, like when I was a monks behaviorist there were you just this where the science is amazing and we can achieve amazing things, we just have to apply it. And there are other things practically that would get in the way, uh, that I was. And that's what I've really loved about operations is moving that stuff out of the way so you can just focus on being awesome. But if you're lacking some of this belief in the science, you know, have you, have you encountered, you know, just where, where maybe there was some question

Speaker B: around that belief that's so interesting. So I would say not necessarily a belief in the science as much as not like there's a disconnect in how to take the science and apply it to the real world. Um, so a lot my experience has been with, uh, especially a younger behavior analyst is that when they get their certificate they jump right into a position usually with a company that's providing ABA services and they feel very lost, like they don't know how to take the academia, um, the rigor that is taught there and adapt it to a child that's 10 minutes late or who has a fever, or there's those real life variables that affect the picture of services and also how to advocate for themselves so that they're operating, um, under their own scope. Their own capacity that they're not getting overwhelmed in how to have those conversations, um, with their, their employers about hey, you know, um, unfortunately I can't. I don't feel comfortable starting out with a caseload of 20 people. I just you know, got my certificate yesterday. Can you help me with this, that kind of thing. Um, but so tell me a little bit more about that if you don't mind. So when you say like you're not seeing as much of a belief in the science, like what does that look like in practice?

Speaker C: I've just situations where maybe uh, there is a, you could have a. Where I would not really just justifying the intensity of hours and not feeling comfortable in the amount of hours. And ultimately at times it really feels like. Because I don't think I can achieve these outcomes and I don't think we'll get to those outcomes and I don't truly believe that we can get there. And, and there is a uh, portion of where it's capacity and I think there are you know, at times trying to even like oh, I want instead to have this other uh, profession take over. And you know, I'm trying to be a little bit generic here and um. But it's at the root though it always. And I think it was, you know, you know we're, we're going to talk a little bit later about like pet peeves. But this was something that for me personally was. It has been hard to get past at times with, within and in younger behavior analysts is where. But I've also seen it in more senior people that have, have been around for a while and are still just not fully maybe have not encountered uh, being able to achieve amazing outcomes and not been. Not even encountered a really comprehensive program. You mentioned earlier focus programs. We have a lot of history in doing this focused work coming in doing functional analysis, functional assessment, identifying why problem behavior is happening, fixing that whatever setting it's at. We're at home, we're in school, we're in. And we're amazing at doing that right. And there tends to be very little questions. But on the acceleration side, that's where I've seen. Or the amelioration side where we're addressing symptoms and being able to really understand the diagnosis and know that yeah, we can maybe we won't get vocal verbal behavior here, but there is other communication that we can get, whether it's selective or being able to augment it in some way, but we can definitely get communication. We can get social skills, we can get uh, adaptive skills. There's a range of areas that. That we can and can be effective in. But you're just having still this fairly narrow focus and uh, other, you know, not really have. Have encountered. I think those contingencies is where. Where I've encountered, you know, some of this that. That's just really felt to me like it, it. It might be a belief issue. And truly believing is where I've, I've housed it. And it's something that, you know, my leadership personally want to be able to inspire and help, uh, behavior analysts be able to get to that. And you, you mentioned an interesting point that gets there. I mean it is such a cliff that you jump off when you finish your graduate program. And you know, the board has done a lot to try to make sure fieldwork experience is helping to make that a little bit smoother. But I, I just a shameless plug. There was an article I did with Dr. Hartley and colleagues and where we uh, talked about an apprenticeship model and some behavior analysis in practice there. I think there's a revision even that's coming out really soon or has come out. But it's a, um, that model of just being able to. To take field work experience pretty seriously. And, and it's just such a great moment when you have uh, when this really passionate person excited about the field doesn't have a lot of these, uh, caseload requirements and a lot of that pressure. And you can truly develop a lot of this belief and get them to contact a lot of the reinforcement around having. And achieving amazing outcomes and being responsible for that. But hopefully fieldwork experience is. Is building a lot of this. But also in coursework, it's not just concepts, concepts boot camp. But also there's a piece to it that is. Is getting at. At a lot of this that we can really have. Have this new field of behavior is coming out really, really inspired and, and I see a lot of it still happening. So I mean it's. That's always very exciting and, and rewarding to see it, uh, continuing to happen.

Speaker B: Yeah, I agree with your thoughts. And I think that what um happens is, you know, depending on who is heading up the organization, if you know they're obesity or not, um, it's more about them understanding or accounting for educating newly certified behavior analysts about the healthcare space. Um, because I think there's this assumption that you're certified and therefore you know how to navigate a caseload over CRBTs, manage all of that within, um, a feasible work week and not burn out. And I just, you know, I haven't seen that yet, like, as something that is naturally occurring. And that's where I think a lot of our younger professionals are probably leaving the field because of burnout and not having supports in place, um, to help hone those skills in them as, you know, provider who is practicing services in health care. And then also the other part of it is that an unfortunate consequence of our field expanding quickly and, um, all 50 states are green states now, is health plans are not always capturing or there's not always an occasion for, for people who are not maybe doing things the right way for that to be caught by a health plan. And so then they have this learning history that, oh, I can, I can manage or do these things when in actuality it's not the right way. But you build up a long learning history and then you're teaching other people who are teaching other people, and there's this ripple effect. Um, and so that's where I really try to remain anchored in not my own thinking about things, but what is fixed. Like our code of ethics, the different, um, resources out there in the field about our CPT codes and the practice guidelines that are generally accepted standards of care. Um, if I can point my knowledge base to that that I know is what has, what has stood the test of time and is tried and true. But my thinking can get kind of wonky.

Speaker C: So, yeah. And, uh, uh, for me, a great place to calibrate a lot of that has been at conferences, has been being around other colleagues, being able to hear how other things are interpreted, and being able to really nerd out in a lot of language and get around others that are really kind of passionate about that. And I know you've had some recent conferences that you've been at, so can you kind of highlight some of your recent conference experiences?

Speaker B: Yeah. So, um, just around the topic of advocacy, um, one of the reasons why I went to the um, business or, um, Behavioral Health Business value conference in D.C. was to learn from other healthcare disciplines within behavioral health care and how they're responding to, um, just being in the health care space, whether they're an insurance company or they're a healthcare provider or they're a vendor who, you know, collaborates with both of those groups. And it was interesting to see that there are a lot of parallel pain points, um, broadly speaking, being experienced that are similar to what we're going through, um, trying to solve for challenges ahead of time to support moving a pipeline of clients, trying to address, you know, the topic of medical necessity and what that looks like and how to deliver sustainable services. And what I've learned, that is no matter. One of the takeaway points for me was that no matter your role, it's so important. Whether you're the healthcare organization or you're the provider or you know, you're the vendor, you understand that role and you understand the parameters well and you're accountable for it. Because when you're not, when you, when you kind of like maybe step down from accountability, not step down, but maybe you're not as accountable or knowledgeable as you should be, that affects everything, affects services, affects the relationship, it affects the family most importantly. And then from there things can unravel somewhat quickly.

Speaker C: Just looping back to Even when we started the conversation today, we had highlighted this shift in the medical necessity review process. Would you see something similar as a move from fee for service to value based care, uh, that there could be some similar growing pains and then it evolves into different kinds of challenges?

Speaker B: Oh absolutely. I mean I think part of the challenge with talking about value based care within ABA services is that I don't think our current clinical infrastructure, our model of delivering care is set up actually to implement value based care services. Um, according to a traditional model, um, we from the get go, you know, should be learning how to provide services alongside other healthcare disciplines, how to integrate care, how to coordinate care, um, beyond. I will talk to them maybe once this treatment period and we'll share goals like in order to. And uh, I don't need to be insulting in that way by any means but Valley based care requires you know, sort of this lock arm or lockstep approach to um, serving the client. And it's not just the client because the family is also affected by the client's diagnosis. Whether it's um, you know, dealing with concerns about um, mental health. Maybe pre existing conditions are exacerbated by the stress that is related to um, the child's diagnosis, money constraints which could also affect health. And I was just having a conversation with a colleague just before our podcast today who discussed, you know, a family member that had a broken femur from their child, um, who is diagnosed with autism. When we think about value based care, the focus isn't just on the cadence of six month authorization cycles projecting out titrating services, but it's about the cost of care to the family as an effect of the diagnosis and how to work with all those different health plan or health discipline touch points with the client to move the needle, um, in the direction collectively which has implications for documentation, service delivery. All of it, it just the whole picture of services would change completely under a value based care model.

Speaker C: Yeah. And when we were like just thinking about the painful time of working through some of the medical necessity challenges and you know through that phase of bringing our field into this healthcare space, uh, one, one thing that in just in hindsight and just kind of occurred to me as we were talking was vision and, and seeing that wow, this is so important for the field. Like this is so amazing this that we're going to be able to fund this intensity of service and you know, be able to, to make this kind of impact. And so I had you know, vision really helped continue to move through there and as you're talking through value based care and uh, I just continue to have this vision of that being really an amazing evolution this next kind of phase for us that still supporting, I find very little that's going to be contrary. I mean I can't think of anything again that's going to be really contrary to effective behavior analytic services. It just seems like it's going to be so much more amazing, so much more support, so much, such a larger impact. I mean is that, is my vision off here? I mean do you share that or do you have a different vision of our uh, moving to value based care?

Speaker B: No, I 100% agree. I think it will be far better. And the method of measurement in a value based care model is like our sciences, love language, it's about performance and outcomes as opposed to that fee for service contact which really works well in a business model because you're able to project and forecast and anticipate and scale accordingly. But with value based care that type of measurement is, it's not on the table, it's very obtuse and you have to shift your thinking from um, services, you know, and dates and times to what matters to the health plan in terms of impacting the cost of care and thinking somewhat along the lines of innovation. What are other ways outside of just data driven outcomes that we can look at to evaluate progress over time? For example, if a client who has autism and whatever other comorbid conditions because of those diagnoses, has 10er visits a year, um, a ton of different medications, sees X number of specialists. Those are also markers for the health plan that they can look at over time to see the impact of ABA services and how that can reduce the intensity, improve um, the condition. But in order to get at that, the behavior analyst has to be really prepared to um, work in concert with them in real time to make those effects in treatment, it's just it, I think it will be tremendous and life changing and I think this, the brilliance of what we do will have a broader reach but it will take a bit of work to get there.

Speaker C: Yeah, and I still this belief because even as you're talking about and describing that profile of client, you know, I just know we could be amazing with that and can really help reduce ER visits and be able to improve overall quality of health. I, I know the science can achieve that and it's really going to be important that everyone can believe that and we can just get away from are we covering X amount of sessions or X amount of intensity of or this number of hours but out it's fully outcome focused and so it's a, I, I, I remain very, very excited about that uh, that change and I know it's going to be very complicated and again there'll be steps and so it's great that you're and, and, and I see that's another form of advocacy that we didn't really tap into is staying ahead of these things. Being aware I know so much, we, we're just diving into how do we keep our business afloat or how do we keep making sure that we can provide and deliver services as providers. And there's so many pressures and contingencies that are making that very challenging. But being able to peek above that and look out at a different vantage and have or uh, maybe you're fortunate enough that your company's large enough to be able to have somebody that's looking at this, this higher vantage and can see what's on the horizon and kind of help navigate and make sure that you're, you're pointing in those, in those areas because it's a, uh, it's going to be a uh, a very interesting process.

Speaker B: Yeah, I agree and I think like I'm a fan of forward thinking, thinking 10 steps ahead. That's something that my husband, who has a military background has done a great job of teaching me about. But it's going to be critical for us to adapt our thinking to that mindset as providers because part of the value based care model is the timing of intervention and the shift of intervention and intervening is more on an antecedent, um, approach as opposed to reactive. Um, so you know, someone goes in, they're not feeling well, they're sick, they're um, having all these symptoms and the doctor says hey, um, thanks for coming in. Based in response to these symptoms, looks like you have diabetes, here's some insulin. Send you Anyway, right. And maybe consultation with a diabetic or with a nurse. But a value based care model, um, in part incorporates innovating sooner so investing preventative, um, care into investing into preventative care so that you're not getting to the point where you're needing more costly intervention. So when we think about the diagnosis of autism, you know, we have to remember clients come to us when they're diagnosed so there's no heading off a diagnosis. We're responding to the diagnosis. But what we can do is still intervene on things that compound their current condition or exacerbate um, their symptomology. So what that could look like is, you know, um, working together with their other specialists to help get them off medication that's causing a lot of different side effects, that's interacting with their behavior, um, ways to just essentially reduce the need for continuous intervention over time to support their independence and quality of life.

Speaker C: Yeah. And the, and that's. I, uh, love the notion of being 10 steps ahead because even thinking about programming, looking out like what are some potential impacts, what are some other symptoms or other impairment areas and it, you know, just trying to get away from this narrow focus that we were uh, highlighting earlier. But I, I see that again as just another powerful way of advocating is to just make sure that you're really looking at how can we have this amazing uh, outcome for this individual that

Speaker B: we're serving, you know, and that to me. So your comment about powerful advocacy, that speaks to my mindset on how I've changed my thinking around advocacy. Um, it used to be, you know, looking at the need for engaging with payers, um, pleading for services that you think the client needs based on your assessment, but turning that and trying to use the 10 step ahead approach by advocating in real time through what you're doing with your clients. So writing a treatment plan that follows the payer policy incorporates all those elements. So you're making sure that that's not a roadblock to timely access to care, that you're following our field's generally accepted standards of care when you're developing your services and that your case for medical necessity and you're um, always accounting for if you're mid services, uh, explaining or justifying or clarifying why things didn't go the way you thought they would go and what your plan is to counteract that going forward and that over time, like a steadiness in that type of work will help establish credibility with the payer far greater than a con, a reactive conversation. Hey, why didn't you approve these goals or these hours because the payer sees this person knows what they're doing. They are accounting for all the missteps or the things that, you know, were not in the plan. And they're really, um, consistent in their reporting, um, for the clients that they're serving.

Speaker C: For us now you're speaking my love language.

Speaker B: Perfect.

Speaker C: That is definitely so key. It's, you know, just always maintaining professionalism. Always just making sure that you're leads, uh, to that confidence when you know you're doing things right. You understand this is why you feel like you're doing things right. This is how you know it's going to help the client that you're serving. Uh, you know, those are, you know, just ways. I think it makes, makes advocacy very, very simple in a lot of ways.

Speaker B: Absolutely. And I, you know, I know this all might also sound a little bit ivory tower. Ish. You know, if you're listening, you're like, yeah, but my work schedule or my caseload or my, my employment. Employment situation doesn't allow me to do it that way. And so take what you can in chunks that are achievable for you. You don't have to completely become, um, perfect in one day, but do what you can in a way that makes sense and that is feasible for your workflow. Um, and then gradually add in things as you feel more confident and competent in what you're doing and that will, that will take the task of becoming a provider who delivers excellent work products, which, you know, we all want and it's a given, but I think it's a little bit harder to achieve than we realize. Far more, um, doable than just saying, well, I'm going to do that starting now, because that's a lot.

Speaker C: You're always so good at closing us up. Like, you have these just profound insights right at the, right at the end. I think you just, just always do such a great job of, of closing up our, our session.

Speaker B: Well, thanks so much for the chat today, Tim. I appreciate it. And, um, you know, before we go, I do want to put you under the hotspot a little bit. I have a couple of questions for you that I feel like, um, I want to know the answers to number one, but also I think it'd be great if our listeners get to know you a little bit better. So, um, when it comes to you, um, as just Dr. Tim Courtney, what would you say is your biggest pet peeve?

Speaker C: You know, I. Hyperbole is one area that I really continue to, to struggle with. You know, so uh, you'll have a, an incident or a situation that may happen that's, that's very isolated and then it gets extrapolated and you have a very large response. And so one thing that I love about our science is it's data driven. So let's, let's monitor that, let's observe for that. Let's see if there requires a response and not this. And even you know there could be really tough things that might happen and that uh, but it just doesn't often require this really uh, reactive response and major system changes uh because of a small kind of thing. So that, that tends to be a pet peeve for me personally.

Speaker B: So what time of day do you get your best work done?

Speaker C: Oh definitely in the morning. Like I have a uh, the. So I like to, to work my day in a lot in a different kind of way. So I like to do deeper work things that are going to require a heavier cognitive load earlier in the day, uh, later in the day. It's really one of those just monotonous tasks. That's where email will get checked or filing things in my uh, my computer just you know, just the more stuff that doesn't require a heavier cognitive load. Um, but mornings, I love mornings.

Speaker B: What was your favorite subject in let's say high school?

Speaker C: High school? Yeah. I uh, to be very honest I did not love a lot when I was going through school. Like I didn't, didn't have the best experience. Wasn't super excited about much in high school outside I was. I really enjoyed most of the social opportunities and to be honest probably maybe even the physical education class or uh, an art class might have been something I, that I enjoyed the most.

Speaker B: I laugh because I think that is so funny. Like I hear you maybe as younger Tim to your parents being like I'm m really not getting the class as much mom and dad, but I really like you know, my friends and hanging out with them which is a very high school, I think normal response and I think a lot of people could identify with that.

Speaker C: I was truly the class clown. Like I really enjoyed getting people laughing and uh, it spent, had had way too much fun with that.

Speaker B: Fantastic. And last question. If you could live anywhere in the world, where would it be?

Speaker C: Uh, it would be Aruba. I Aruba.

Speaker B: Interesting.

Speaker C: Love Aruba. I go there all the time. I'm actually getting ready to go in uh, in a couple of weeks and, and just can't wait. It's just my space where you know, just looking at beautiful space you just can breathe better. You can, you know, meditation gets easier. Like it's a. Ah. I, um, it clears up, just reinvigorates. So if I would really encourage people just to get in touch with nature, get in touch with places where you can, can really be able to let a lot of all the stuff that's going on privately. Can just kind of let it, let it calm a little bit.

Speaker B: I feel like we should probably do a podcast there, so.

Speaker C: Oh, yes, we should.

Speaker B: Let's look into that. And thank you so much for sharing. Love those answers and as always, love connecting with you. Um, appreciate everybody's time today and hopefully, you know, I'll close with this thought. When you think about advocacy, whether it's conversations with payers or you're working on a work product and you're trying to improve from your last effort, your advocacy is taking what is and making it into what it should be. And so if you can do that, whatever you're doing, you're advocating and we're here cheering you on. Thanks, everyone.

Speaker A: Thank you for listening to the ABA Healthcare Matters podcast. This podcast is created and hosted by Rebecca Womack and Tim Courtney and produced by Will Courtney. For more from the show, you can follow us on Instagram @abahealthcarematters, Rebecca on LinkedIn and Tim on LinkedIn and Instagram. RTIMCourtney socials are also available in today's show Notes. If you like the content of today's episode, please make sure you remember rate and review on Spotify or Apple Podcasts. Thank you for listening and as always, keep fighting the good fight.