The Future of ABA Services with Dr. Darren Sush

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

Speaker B: Welcome back to another episode of ABA Healthcare Matters. I'm your host, Rebecca Wommack, and joining me today is my co host, Dr. Tim Courtney. We are honored to have a distinguished guest with us, Dr. Darren Sesh, who is not only the head of Autism and Psychology for Evernorth, but is also an author, adjunct, uh, professor, clinical psychologist and a BCBA D. In this episode, we have the privilege of exploring Dr. Sush's multifaceted role and learn from his vast knowledge of autism and ABA services healthcare. And we'll even touch on the topic of value based care. Dr. Sush's expertise as a BCBAD adds a unique perspective to our conversation. Whether you're a parent seeking guidance, a healthcare professional, or simply curious about the intersection of autism, ABA services and healthcare, this episode will provide you with valuable insights.

Speaker C: Yeah, I'm super excited about this conversation. I have a lot of fun talking about value based care. But just a reminder, uh, we're going to kind of jump into some topics I know for myself are pretty advanced and, and a little bit, uh, complex. And so if you find yourself getting lost a little bit, Remember in season one, episode four we talked with Dr. Uh, Moran and he went over some of the basics of value based care. So just pointing you back to that. So, Dr. Such, thanks again for joining us. Super excited to have you. Like, wow, what an, what an amazing resume you have. Very impressive. Head of Autism and Psychology Forever North, a clinical psychologist, bcbad. I'm, uh, really jealous of being a clinical psychologist and a BCBA that was, uh, not available. I would have absolutely jumped all over if that would have been an opportunity for me. I think it's a great blend. So kudos to you. Um, this is going to be a really thought provoking conversation. We're going to play, play in this space of hypothetical theoretical, like, what could the world look like? What is this, you know, really understanding that none of us have a crystal ball and things are going to kind of move around all over the place and you know, where, where exactly Value Based Care lands. And I'm confident it's going to land someplace really well. But you know, right now we're in this space, uh, and that's really what we'll be playing today. So before we get started, doctor, can you just talk a little bit about your story and you know, in Particular how you got to ABA and you know, how, what your journey's been like.

Speaker D: Yeah. Well, uh, first I thank you both for having me on the show and appreciate being able to be a part of the podcast. And um, it's always great to get a chance to chat with you too. So thanks, um, I guess a little bit, uh, about myself. So, as you mentioned, I'm a licensed clinical psychologist. Uh, I'm also a BCbad. Uh, I was a psychologist first. Um, and really, uh, as far as kind of finding my way into the world of behavior analysis, um, you know, I can't really say that was something that I intended to find or really looked for, um, when I was pursuing my, uh, education or when I was pursuing potential job opportunities or things along those lines. Um, going into school and undergrad and beyond. My thought was really to be a psychologist, talk to people about what was going on with them, why they were sad, usually why it's one of their parents faults or something along those lines. Just typical, you know, sit down in the office and tell me about your day kind of talk therapy. Um, which I still, I'm still a clinical psychologist, still have very much interest in. Um, and, and I really found the world of behavior analysis because when I was in school I, I wanted to get a job. I wanted to get a job within the field of psychology. I, uh, wanted to gain some experience working while I was also gaining experience in the classroom. And at the time, at least one of the jobs that you could get if you wanted to work in the world of psychology without having a whole bunch of letters after your name, uh, was working with, uh, autistic kids, kids diagnosed with autism, and uh, usually in a behavior analytic capacity. Um, so I got connected with an ABA agency. Uh, I really had very little understanding of what ABA was, uh, had some understanding of, uh, what the diagnosis of autism was. One of the things I've talked about a lot is that most general psychology programs really don't spend a lot of time talking about developmental disabilities, particularly talking about autism, unless you have specific coursework that you have to really seek it out. And then you might have, uh, more of a subject there. But usually it's part of the day's lecture and then you move on to other areas. When I started working for this agency, I really didn't know a lot about what to expect, what I was going to encounter, what was going to, What I was going to be asked to do within the field. Um, but I guess I got, I got lucky in that the families that I Got the chance to work with, especially in those early days, were really awesome. And I was working with kids then mostly, uh, the kids that I got to work with were just really fantastic. Uh, and I just really just love the work so much and love what I got to do and love the experience that it was one of those things I was like, well, this is something I'm going to have to keep going with. This is something I'm going to have to learn more about. But I was really dedicated to being a psychologist, really dedicated to doing talk therapy. And that was really what, you know, I invested a lot of time and still had a lot of great interest in. But then I would find when I would talk to people about behavior analytic concepts or talk to people about the work that I was doing, and you know, outside, uh, the school experience, I would get a little, kind of like a little bounce. And I was like, well, this might be something I have to take a little bit more seriously. This might be something that is actually pulling me in a different direction than maybe what I originally intended. And I probably should be open to that versus just kind of doing what I've always done, but doing what the experience might bring me to and then just sought out the opportunities where they were. So gain more experience, uh, working with individuals with a diagnosis of autism, gain more experience working with families, uh, who have been impacted by the diagnoses, and then, uh, eventually gaining more education in behavior analysis itself.

Speaker B: So I think that's so many things I want to respond to, but I think I just wanted to say that it takes courage to acknowledge, like your path may not evolve into what you think it's going to be, and then also courage to pursue an uncharted path. So I think that's awesome, um, especially because while it's in field of psychology, it's a completely different discipline, um, by its own right. So lots of things that you went through, um, very remarkable. But how did all of that end up at the doors of working for a payer?

Speaker D: Yeah, there's not a lot of people who I know who say, I want to work for an insurance company. This is usually you don't you have people who kind of find their path there, I suppose, and are very passionate about the work. And I suppose through, uh, time I've become one of those people who's very interested and invested in how individuals can gain access to services that they need. And that path usually involves whatever that funding source might be. And for a lot of people, that's insurance. Right? That's finding the insurance coverage so that they're able to access the services that they otherwise wouldn't be able to get. Get to the providers they wouldn't otherwise know. But I really wasn't looking to just like I wasn't necessarily looking, uh, initially, uh, to work in the field of behavior analysis. When I found the opportunity to come over to, at the time, cigna, now Evernorth, my goal wasn't necessarily to work with a payer. Um, I had had the experience of being on peer reviews, um, you know, asking for authorizations, asking for funding for the, for the individuals that I had been working with who were under my supervision. Um, those experiences were not very great. Um, I found myself speaking with, quote, unquote, um, peers who had very little knowledge of what it means to provide services based in applied behavior analysis, somewhat, sometimes even less knowledge about the diagnoses of autism. I've said a number of times before is I'd be on a peer review and the person on the other end would say things like, well, can't you just tell them to stop? And I was like, well, it doesn't exactly work that way. Or if you're working with someone for 20, 25 hours per week, when are they supposed to just be a kid? And it's just very much missing the mark of the imperative and valuable work that we do as behavior analysts and servicing this very needed and, uh, deserving population. And it was always a point of frustration, but never, never necessarily like a call to action, if you will. Um, until I was kind of presented with the opportunity to maybe come over to, uh, what was reminded of me on several of my job interviews when I was going for the role of coming over to the dark side. Why do you want to come over to the dark side? Why do you want to work for this funder? Because there's not a lot of warm, uh, and huggable feelings when, that people have when they think about funding sources, especially when you think about insurance. Um, but one of the things I was thinking about is the people who are, or who were generating the policies that are dictating how I work as a professional, dictating how the people I care about are going to receive those services, and essentially what is considered appropriate. If they're not the individuals who do the work or understand the work, we're going to continue to have challenges as a field. Um, and it became very important to me that we have representation on the other side of the table, if only to influence the bigger names on the board to maybe make decisions that would be more beneficial and hopefully then to actually write those decisions and write those determinations and how we work. And I was very fortunate, I feel like I was very lucky to find the company that I work with. They are ridiculously receptive to speaking, uh, about behavior analysis by behavior analysts. Um, they are very open to conversation, very open to making sure that the policy makes sense for providers, making sure that the policy makes sense to the families who are receiving services. And I never found where I've had the position where it's, we have different letters after our name, we have different. And so therefore you don't, you don't get to talk about this because there's, there's a, there's a hierarchy. I've, I've never had that. If anything, I've had the, the quite the opposite where it's, you work in this field, you've worked in this field. We're going to hire people who do the same, who work in this field to get your experiences so that we can make better decisions. So that's been really, really great. And one of the reasons why I continue to, to love what I do and continue to do it, as you

Speaker C: were talking, it was really illuminating for me. So historically I've talked about maybe behavior analysts shouldn't, uh, work on the payer side of the medical necessity review. But you really have changed my mind to hear, I mean, just such a powerful form of advocacy that you were talking about. And you know what? I'm going to go here, I'm going to help change a massive system like that. I mean, we're really, really fortunate to have people like you that are doing that. So I mean, that was um, very powerful. I mean, what are some other myths that you hear about that you'd like to just. About insurance companies in general, or the relationship between insurance companies and ABA services? What are, what are some other myths?

Speaker B: You.

Speaker D: Well, I think one thing I should say is, you know, there's certainly reason to have challenges when it comes to working with a funding source. Challenges when working with insurance companies. Um, that has kind of happened with any big corporation for sure. And I don't want to invalidate the difficult experience that a lot of providers and a lot of families have had in trying to get authorizations approved, in trying to make sure that they secure funding for their family member. Those are very real. And I would be, you know, I'd be kind of unicorn and rainbowing things a little bit too much to say that that's not, that's not true. But, but one of the things that I don't know if it was surprising, but that I've consistently found being on the side of the table I think that I have is that there's consistently attempts to reach over to the other side of the table, meaning we might be the ones who are making the ultimate determination of whether or not we can approve services. Um, speaking of when we get to like the peer review process or when we're writing coverage policy criteria or thinking about, hey, how are we going to determine medical necessity for these services. But at almost every step of a decision where a decision can be made, there's the very active push to speak with the, uh, knowledge source, to speak with the experts, to speak with the impacted people to make sure that we're steering in a correct direction or the most appropriate direction that we can understanding there's going to be other learning points along the way. That's been something that, had I not had the opportunity to kind of be part of those conversations, I would have probably thought there's kind of this big machine that's kind of dictating and then whatever happens on down is the way it's going to be. Um, but I've been really, uh, happy to think to see that that's very much not the case and then been fortunate to be part of those conversations to say, here's the people we need to speak to, here's the people we need to make sure we're listening to and then seeing that that actually is impactful. We're actually making changes, two policies, two procedures to practices because of what we're hearing. I mean, even thinking about, I know a lot of what we'll be speaking about today is value based care. And I mean the majority of the push in relationship to value based care and ABA is in response to the growing interests of the field and families who are talking about what are things that we can do to better access care, treatment and quality services for individuals. Yes, that comes from kind of the funding source in some way, but it's really pushed for, from, from the other side. And I guess the other thing is just, it's just all people, um, you know, it's. We're very conscious about not just kind of seeing things as kind of checks on a board or black and white, if you will, but trying to make sure that we're always looking at the human element when we're reviewing or when we're talking about policy and that we're always tapping into our human element on our end, whether that be clinical expertise, whether that be past experience or whether that be just having some type of, and empathy and understanding, um, that hopefully helps to guide good decision making.

Speaker B: I think it's a great answer and I agree with like your thoughts around just keeping the human element at the forefront of the table. And I also um, want to pull the thread a little bit on value based care, that topic. But before we go there, wanted to get your take on something. So um, I'm curious to get your perspective as a payer who over the course of years has probably seen the shift in, in the landscape of uh, that dynamic between payers and providers for ABA services. Like initially there was a lot of education both ways. Providers are saying here's why ABA is needed, here's the research to back it. And payers are saying yep, we'll listen, we'll take this into consideration. Also we need to tell you a little bit about health care now. I feel like after that education has occurred and both parties have learned there's a shift that has occurred happen where it feels like ABA providers are lagging in some ways behind where the payers are. So payers, I feel like they've caught up. They seem to understand not, not across the board perfectly. But there's a greater understanding. But we're, we seem to be struggling a little bit with um, meeting policy expectations or um, fulfilling our part. But what are your thoughts? Like how do you see the current status of that relationship?

Speaker D: Yeah, it's a good question. And I think one of the things that I find myself probably actively having to remind myself is ABA as funded through insurance is not, it's not old. Right. It's a new experience for us as providers. I've been in the field long enough to have insurance generally not fund across almost all states, if not all states, um, uh, authorization requests or services, there was alternative funding sources that were really considered the primary access point. And really within that time there's been that paradigm shift of um. Because of the advocacy and because of the work that families and advocates have done, insurance has really become probably the primary source for funding for ABA services. But with that there's a learning curve that happens I think across both providers, families and then I think also for funders about how what that's going to look like and how that continues to need to evolve as the field progresses, as the field changes, as the number of individuals who have a diagnosis of autism progress, as the science of behavior analysis demonstrates more and more effectiveness working across populations. So thinking about, you know, continuing that conversation, it's always going to be a learning curve I think for everyone. But there needs to be. If you're not, if you're not asking questions and you just assume you have all the answers, you're probably not doing a good job. Um, so being open to kind of learning more and, and, and doing better is, is going to be uh, an important goal I think across, across everybody.

Speaker C: As um, you know I started to dive into VBC and you know looking at, and common strategy that suggested is really trying to improve the relationship between providers and payers. It's, it's almost seen as an, as an essential piece really if we're going to have any possible success with this. So I'm, I'm curious at, at the different levels, like if I'm a single bcba, I'm in a medical necessity review all the way up like throughout the field. I mean what are ways that you could see strategies from your vantage being inside where we could really improve relationships between providers and payers?

Speaker D: Yeah. And I guess maybe this is a good point for me to I guess make the disclaimer or the statement is, you know, I can speak for, I work for Evernorth, right. So I'm head of Autism Psychology at Evernorth. Uh, I can speak to my experiences within that company. Um, I would assume there's a lot of similarities across the other funders. Um, but there's also differences, right? Different funders might have different priorities, they might have different expectations. Um, so if, if you happen to be you know, listening to this and um, you know, working with multiple funding sources or a funding source that's not, not Evernorth, I would encourage you to, to make sure that you're reading up on who you are working with. If they're ideally, you know, there's not a lot of differences because I know how frustrating that could be as a provider to have to kind of shift things depending on, on who you're working with. Hopefully those differences make sense. But I know that could be a challenge of you know, trying to kind of cater to the different people that, and the different companies that you're working with. I think some of the things that, that we prioritize when we're thinking about kind of moving into the value based care space is, is what does this mean for behavior analysis? Um, you know there's models of value based care across other fields. There's um, and across other services. And uh, one of the things I find myself saying a lot is ABA is different. Right. While we can use those other, um, those other fields or those other Ways, uh, of doing things kind of as a guide or as a model. We don't necessarily have to, you know, start from scratch, but we also need to understand that the populations that are being served by those different types of services, uh, are very different and vastly different and the expectations might be different and the type of services are very different. So for example, if we're thinking of substance use, right, and we're thinking of creating some type of value based care arrangement for, uh, substance use, uh, treatment, uh, um, oftentimes those individuals are within services for, at different levels of care for shorter periods of time than what we can expect someone to participate in ABA services. And one of the things that you might look for as a potential determinant of quality is recidivism rate. So is the individual seeking services, uh, at this, at this provider, with this provider and then is discharged and then comes back. That might tell us a little bit about either that individual circumstances or maybe uh, the company or the agency as a whole. We don't necessarily see a lot of that in the ABA field. Uh, certainly there are people who come back after being graduated or discharged from services. But that means something usually a little bit different than when we're thinking about it for other types of care or other conditions. But one of the things I think is most important to think about when we start to even have the conversation of uh, value based care is how do we even distinguish, differentiate, identify quality ABA service provision? Like what does it even mean to be a quote unquote good ABA service provider? Um, and I think that's not only important for providers to try to have this kind of ideal standard to hold themselves to and to try to make sure that they're including within their training not only important for funders to help to distinguish those providers, but for families as well. Because a lot of times the way families are finding ABA services are, you know, through word of mouth. They're maybe calling to see who's in network, they're calling around to see who they have. But there's not necessarily a great or effective way of knowing is the ABA service provider that you found the one that you really want to be going to? Usually it's kind of by word of mouth. Um, maybe, maybe you have the opportunity to speak to some people about the services that are being provided. But a lot of times it's also just a wait list, right? They can take me, they can take my family. They have an open spot for uh, for the person I care about. And because of that, that's, that's why I'll go with this particular agency. And there's not necessarily a way of helping to distinguish, you know, the quality of service being delivered by one versus the other provider.

Speaker B: Oh, uh, such good points. And I, I know that like the value. The topic of value based care within ABA Services certainly brings to the table more questions than answers. Like that's just a given. And you know, for our listeners who are like, what are you talking about? Again, just want to refer you back to season four because we want to really take the opportunity to pick Darren's brain around this topic and get his input. Um, so when you think about just value based care as, you know, something that occurs within health care and you compare that to, um, the current fee for service model, what would that look like in terms of a relationship with a payer and how would that compare and contrast in the context of ABA services?

Speaker D: Yeah, so it's a good question. So I think one of the things to remember within the fee for service model, it's not necessarily like it's a broken system. It's certainly, it's a very workable system. It's a good system. It's a system that served us for many years so far. And frankly, it's why we even have funded ABA services for autistic individuals in the first place. Because we were able to put these types of practices into place, we were able to put this funding into place. And it's important to make sure that we acknowledge the important developments that's resulted from the fee for service model. And there's a lot of providers and families and probably funders too, who likely prefer that model. Um, they found that it works for them and that they can continue to practice under that perspective. Um, so I don't necessarily think, think thinking about that. I don't necessarily think it's like if it ain't broke, don't fix it kind of situation because even though the fee for service model isn't exactly broken, that doesn't mean that there aren't opportunities for improvement. So some of the challenges with fee for service model is that it doesn't help to really distinguish providers and, and who are um, demonstrating those higher quality care activities that lead to better outcomes, to better prognosis, to better services for their clientele. In fact, it might actually counterbalance that because a lot of those things that providers do in order to make sure that the services they're providing are top notch, are the best that they can provide, are getting to the best prognosis for the individuals they're working with, sometimes they're not able to specifically bill for those services. Um, and the fee for service model is really just a one for one. You provide the intervention, you bill for that intervention, hopefully you get the funding received back for that intervention. Um, and unfortunately what can happen with that is it promotes kind of the continuation of more and more services that may or may not necessarily be appropriate for that individual. A value based care model, in essence, essentially, um, providers will hopefully have the opportunity to earn potentially preferred contractual arrangements with funding sources by meeting specific performance and quality measures that have been found to be connected with um, better long term outcomes for their clients. So rather than focusing on exactly how much intervention you provided from an intensity perspective, it's focused on whether the interventions that were provided were effective for the individual. So thinking before about, well, how do we identify, well, what constitutes good care, what items are necessary, what actions are necessary to implement to get to quality care, to be considered a quality provider. Um, in the field itself there's not necessarily standardized metrics for that or standardized ways of benchmarking those metrics. Um, that's one of the reasons why we did partner uh, about a year ago with the Behavioral Health center of Excellence BHCOE to try to look at what does the research tell us, what does the field tell us? Uh, uh, we create a provider work group to get feedback from providers themselves, uh, family work group to get feedback from family members, uh, and autistic individuals themselves to try to. And also just looking at the data, our shared data between us, uh, Evernorth and Bacoe to see can we start to better identify the specific metrics that help to lead to quality service provision, uh, in ABA so that we can use that database decision making in thinking about value based care.

Speaker C: Just stepping back just for a second. So uh, when you, you know, you talked about, in your history, you know, delivering ABA services and so if you could step back into your, you know, just thinking about what it was like to be a behavior analyst and working with families and you know, providing high quality services. So for that person who's providing services, what, what is it? How would it look different for them under a value based contract versus a fee for service model? Like just really diving into the day to day.

Speaker D: Yeah. Um, I think the nitty gritty of it all, like the boots on the ground aspect of providing ABA services would likely be fairly similar. Right. Hopefully we're making sound clinical decisions that are conceptually systematic. Follow the get a cab of it all. Making sure that the work that you're doing is relevant to that individual, that the goals included within your treatment plan are important for that person. Uh, that there's data informing those goals and informing your treatment decisions based on appropriate observations and assessments based on appropriate plans of care. I think all of that would likely or hopefully should likely be fairly similar especially when you start getting to the, from at the one to one level, the direct, the direct instruction level with, with the individuals receiving services. I think the things that would be uh, slightly different is there with potential value based care arrangements. And again this is something that we're thinking of. So it's not necessarily things that are established but we want to try to think of what things could look like so that we can plan accordingly and make make good informed decisions. Right now with fee for service you really have to start thinking about your, your intensity of services requests based on what's going to be funded. Um, but with a value based care there might be opportunity to look at okay, how are we going to provide uh, a treatment package for this individual that's really individualized without thinking about that CPT code versus funding versus reimbursement type of, type of uh, circumstance. Um and how do we make sure that we're providing the quality interventions for this individual on a more global scale. Um and then making sure that we have ah, ah a better arrangement with our funding source in order to, to do that. Um, you know there's, there's a lot of uh, bureaucracy that goes into needed bureaucracy that goes into the review process and the authorization process. At this point providers are conducting their assessments, putting together their treatment plan, submitting the request if it requires preauthorization, um, that request is then reviewed and more often than not it's approved for usually something like a six month basis. And uh, then it's come back and the cycle kind of repeats itself as we continue to look at how services are assisting that individual. The potential for value based care is that perhaps there's an opportunity to kind of not have to have that exact one to one circumstance each time M and it saves time for the provider so that they have more uh, consistency, they have more predictability in what they're going to be uh, funded for, who they're going to be working with and how they can work with them. Uh, and uh, less of that kind of every single person gets that single eye, uh, which is time consuming and sometimes problematic especially for providers.

Speaker C: From your, like from your van. Just a little follow up question. So I mean would you see it as a more efficient system? I mean do you Think it's going to lead to more effective services. I mean it sounds like very similar and kind of a little bit freeing. Like it's just do good behavior analytic work, which has always been really the premise. You do good behavior analytic work. A lot of this stuff is easy. But I mean as far as the overall system, do you see it as a more efficient system?

Speaker D: That's the plan, I think. You know, right, right now the fee for service system is, is efficient in that you're requesting essentially the funding for each CBT code or each 15 minute increment that you're providing services with. So if you're looking at it from just kind of like a checks and balances type of system, it's it, it's not necessarily inefficient until you start putting it into practice in the real world and you start putting real lives into those numbers. Right. And you about this is, this is intervention that's affecting an individual, affecting a family, implemented by a person who has clinical expertise, reviewed by another individual who has their own clinical expertise. So once you start complicating those, those just simple, those simple checks, it does become a less and less efficient process to continue the fee for service model. The idea that the, the value based care arrangements might have is that it expands the model so that it hopefully will remove some of those um, inefficiencies and allow providers to kind of do the work that they do not necessarily with less oversight, but with, for lack of a better term, proved oversight. Right, Oversight based on the work that they've done. If you're doing great work with the individuals that uh, you're serving, then you probably don't need as much oversight as maybe other individuals. Now there likely will be the opportunity, a lot of providers, like I said, really like the fee for service model, there will likely be the opportunity for them to continue to stay within that realm if that, if they so choose. Uh, and then there'll be providers who maybe are in there with some education, they're still doing a fee for service model, they're still doing kind of the standard contracting because maybe they need some additional support, guidance to get them to kind of that those preferred opportunities.

Speaker B: So there's a point to everything you're saying like the efficiencies and the model of care leads ideally to better outcomes. Right. And so like, and the way that they, we know that is because outcomes would be targeted. So from your perspective, and this is such a question right now, I think it's a question of the year for our field um, what do you think would be outcomes for organizations to start looking at or targeting to prepare for delivering services under uh, Valley based care model?

Speaker D: Yeah, and one thing I will say before kind of answering that question right, because my answer is going to be a little bit of a non answer because we're still in the development of this process. We're still looking to make sure that we enter into this responsibly and sometimes that maybe takes a little bit more time. That's uncomfortable. But I think from my perspective and from kind of the greater royal we's perspective, it's better to kind of make sure that you're entering into something informed and responsible so that if we, when we do start to put into place these types of contracts, we're doing so uh, in a way that's actually going to be effective and beneficial versus kind of just putting something into place and then having to correct and correct which could cause harm especially for this at risk population. But I uh, think for providers and I've gotten a lot of feedback from providers, organizations both large and small saying we want this now. When can we do this? How do we start getting this going? Um, which, which is great. And that's again that's really what the impetus has been for kind of looking, looking into these types of contracting arrangements. Um, it's, it's, it's, it comes down to a very simple answer of data. Let your data be your advocacy. Let your data be your guide. And our field is so data driven. We, we, we always are. We're constantly talking about database decision making within the work that we do, within the treatment plans that we develop, within the types of care that we provide for the individuals and outcomes. And quality is like the one area within behavior analysis that we have yet uh, to put our full dedication to utilizing the data to our advantage. There are definitely people who are doing it and I don't want to discount that, but it's probably our biggest area where we could use our data to inform our decisions that we're still in the quote unquote in the process of doing so versus kind of uh, having already made those steps. So what are we collecting data on? Well, are we, we're collecting data on the data, the data from our, the assessment instruments that we utilize. We're taking data on master targets that we implement within the goals and treatment providing. We're taking data on the populations that we serve. How long does it take to get someone into treatment? When we first started our look at them, are we making them wait for three Months on our waitlist or are we trying to get them into services as quickly as possible? How are we making our staff decisions when it comes to families that we're saying we can help and support? Those are important things uh, that we can be looking at as a field and we likely have the data on. What do our families feel about, how do they think about the services that are being provided, what supervision is being provided? These aren't things that are really novel to think about. These are all kind of again go in that category of good aba. Um, but we can quantify that and learn something from those data points to see is this actually impactful for the people that we want to support. Now there's a caution, right? There's a caution when it comes to value based care. There's about a million cautions when it comes to value based care. Um, but one of the main kind of worry points that, that, that we've had as we even started this journey is that once you start putting the term outcome when you start thinking about this population and when you start thinking about ABA services is might this then negatively impact uh, uh, populations that are already disadvantaged and already disenfranchised with ABA services or with the medical model in general? So when you start thinking about outcomes and you think about the autistic population, individuals who tend to show or demonstrate uh, uh, less positive prognosis might be those who enter services later in life. We know based on the research that earlier intervention is ideal. Earlier intervention leads to better outcomes. But what about the individuals who for whatever reason were not able to access services earlier on? Well what populations are those black and brown individuals, individuals from minorities, individuals from lower socioeconomic classes, individuals who live in service deserts? Those are individuals for a number of reasons might have uh, challenged uh, outcomes. And if we just say we're looking at positive outcomes as a means of being able to have access to value based care contracting, might that mean that provider organizations are less likely to accept those clients? Might it mean that they'll be less likely to accept individuals with really severe and significant challenging behaviors, dangerous behaviors, uh, individuals who are older, just in general, who maybe have received services for a while, but are just, but are, but uh, are falling off of that service cliff, if you will. And uh, we want to make sure that if we're going to put anything into place that we're not contributing to the already lack of available services for those populations. So in as we develop what it means to provide quality services and what those metrics might be and how to measure Them. We also are thinking about how do we measure the provider groups that are actively working with those populations and making sure that essentially we're practicing what we preach as a field of behavior analysts that are serving those populations to a degree that they deserve to be served.

Speaker B: So I have a follow up question to that. In primary care with value based care contracts, one of the hallmarks of that model is the emphasis on preventative care. So your showing signs of prediabetes or you have a history of heart conditions or cancer. So your, your care team is going to do a lot of things to help reduce that risk and the cost of care, um, over your lifetime. Do you, do you see? So drawing on that like parallel model within the field of ABA and the VBC model of care, are there things that we could be doing from the standpoint of not necessarily preventative care because the diagnosis has been assigned, but again, still to better position, especially the groups that you mentioned. I appreciate you bringing that to the forefront because I think that's something that can get lost in the uh, hustle and bustle of trying to get this all figured out.

Speaker D: Yeah. And I think there's two sides to thinking. There's probably more than two sides, but two clearer sides of thinking about that. And I'll break it up into one from kind of the provider perspective and one from the funding sources perspective because I think it would be really irresponsible for the funding sources to continue to say, here's what we need from you providers, here's what you need to do, here's what you need to change, and here's what we're now going to be measuring you on. If we're not also doing things ourselves to ease access to, uh, engaging in those quality, uh, those quality activities or those activities that lead to better prognosis, things that providers can likely be doing or even just the field of behavior analysis. Right. Um, are we expanding our expertise, Are we expanding our networking activities and not just kind of speaking to ourselves as behavior analysts? Um, you know, oftentimes we go to ABA conferences and they're really fantastic and we get to see people that we haven't seen in a long time and share stories and talk and hear some really, and hear some really fantastic and amazing research and information and. But one of the challenges with that is we're oftentimes speaking to ourselves. Right. Um, so there's, number one, there's the potential for groupthink in a way in that we continue to confirm the things that we already hope to confirm, but we're also potentially limiting our opportunity to hear this perspective of other fields or even similar fields who work with populations that we would like to be working with or work even with the autistic population. So going and attending conferences, reaching out, networking individuals who are outside the ABA world is not only important to help disseminate what we can do as behavior analysts, but also make sure that we're sharing information on that Rolodex of connections. Right? So when a, uh, primary care provider is saying, okay, I'm meeting with this family who do I think could be helpful for them, they know to think of a behavior analyst if that's who they can appropriately be linked to, and that that connection is there. I, um, think the field does a really great job at that to some extent. But as a field, we probably continue to need to work in those areas, I think from the funder's perspective. So one of, there's a couple initiatives that we've taken to help to not only, uh, ease providers access to providing quality care, but also to help to better ensure that families will have access to quality care as early as possible. So one of the really cool things, uh, that we have in place right now is the autism early identification process. So, uh, based on information that we have available, we're able to hopefully reach out to families who potentially may meet criteria for an autism diagnosis, whoever member who may potentially meet criteria for an autism diagnosis. And we can reach out to them before they even start to access those services or think about those services. And it's not some creepy, hey, we've been monitoring X, Y and Z and now we know all about you type of thing. Um, which would be pretty interesting if that technology existed, I suppose, but is more so. Hey, we've noticed that you're interested in the, you have these types of questions. Maybe we can help point you in the right direction. Have you looked into speaking with a developmental, uh, pediatrician? Have you looked into these types of assessments? Have you spoken with a speech and language pathologist? Have you looked into ABA services? Are you interested in reviewing any type of diet, getting better clarity regarding diagnosis, uh, for your child or your family member? And one of the things that comes of that is families are more informed of their opportunities for services, even if it's not behavior analysis, but just services in general much earlier. And if we're able to get them some type of appropriate and helpful service earlier, not just in aba, but it's often better.

Speaker B: Excellent points.

Speaker C: Yeah, it's so awesome. There's so many pearls of wisdom that you're passing along, I mean really, really great stuff. I want to back up to one thing because I was just actually reading today, uh, encouraging us to attend other kind of conferences and you know the uh, and there was a reference to like payer conferences. Are you familiar with some payer conferences we should be thinking about attending and also like what would that be like? I mean I'm really curious like what, what would it be like to like what are the kinds of talks and the things that we would anticipate at a payer conference?

Speaker D: Yeah, so, so specific. I probably can't name for you like specific conferences to say hey here's the exact one that you that that's wor are going to attend. But I do think it's worth uh, I mean even forgetting kind of my role as a representative of a payer. But just speaking as a behavior analyst, I think having behavior uh, analysts who work with the autistic population attending these conferences and ideally even presenting at these conferences helps to make sure that the people who are in the room making determinations related to coverage policies, making determinations regarding funding, making determinations regarding coverage that they're hearing from the individuals who do this work and they're coming from a more informed perspective either by saying hey we need to reach out and get more information or they're saying this is something that we need to continue to look into. And I think that's what a lot of the advocates who uh, who eventually got funding in the first place were doing is they were reaching out to those, the decision makers from at the funding sources to say this is why you need to pay attention to this. This is what, this is effective, this is research based, it's evidence based, it's empirically, empirically validated and, and, and this population is not getting the services because the funding isn't available to them. What can we do as a team to make sure this is going to happen? So because of that great work, maybe you don't that that conversation doesn't need to be as dire but it still needs to be focused.

Speaker C: If you had the opportunity now to talk to um, an owner of a, of an ABA company and, or uh, you know, and they have the potential to change some of the infrastructure. Like what are some things you would. And again just some of your own personal thoughts like an ideas of things that they should be thinking about as maybe infrastructure changes going from fee for service to a value based model.

Speaker D: Yeah, well I, I think one of the things that would likely be beneficial and it's probably easier to create than to re. Redo. Right. But that doesn't mean that there's not opportunities for, to look into current practices if you're already, you know, running your agency. But one of the things that I like to think about is kind of thinking about the micro and the macro. So the micro work that we do if we're working at an ABA agency, is what's specifically happening with this individual client. And you can get probably even more micro than that saying in this particular learning area or at this particular goal. And if you think about looking at that small scale, you might say, well, what's the progress at this particular goal? Why do I think this person is making progress here? Why do I think they're not? Are there any barriers? Is there anything that I can do about these barriers? What's the function of behavior? And you kind of going from there. And we can use that simple behavior analytic thought process as we get more and more macro. Start thinking about the individual at uh, the whole. Start thinking about the person in their entire caseload. Start making comparisons. If you have multiple BCBAs on staff to, if you have multiple offices and you're a larger chain organization where you might have offices across different states, if you're taking the data based on um, the work that you're doing, what does the assessment date information tell you? Are individuals actually conducting assessments? Are they engaging in supervisory practices? Are you fulfilling your, your clinical recommendation of the services that you think need to be provided for that individual? And then how did you make that decision in the first place? If you start to think about that from the micro onto the macro, then you can start making, uh, making thoughts of, well, this person seems to be struggling a little bit as a, as, as one of my employees as a bcba, what are some of the things that they might benefit from to help support them in doing work that is better representative of my name as a, as a company owner or ah, as an, as an agency, do we need to have more clinical education? Do we need to have more, you know, supervisory oversight? Um, is it the clientele that they happen to be working with just happens to be a little bit more of a difficult clientele? And if so, how can we support them with that? It's of course easier said than done. It's very easy for me to kind of from over here say, here's all these things that you should do. But starting from that scale and then building up the antecedent behavior consequence of it all is fairly similar. It just gets larger as you start thinking about it, but it can be applied across the different agencies.

Speaker C: Yeah, I hear just an ongoing theme, just good behavior analytic work. We just do good work. You know, uh, all everything else will just solve itself almost. It's just. But you know, really focusing on that

Speaker D: and that's one of the things thinking about, you know, right now. Again, the fee for service model isn't, isn't broken, but it can be improved and it's probably important to improve and make, and make more efficient. And that's where preferred provider opportunities, value based care opportunities. It helps to essentially reinforce the behaviors that we hope to, that we would hope to continue. Right. So just basic principles of, of reinforcement. If these are the behaviors that, that we hope that agencies are going to do, then how do we make it so that number one, the opportunity to engage in that behavior is that much easier? Right. And then how do we reinforce that behavior so it's more likely to happen again? Right now it's harder to engage in the behaviors that we think uh, of as quality because the, the amount of work that's required in order to do so is sometimes so, so limiting because it's so challenging and there's so many other competing expectations and the reinforcement for those quality activities is, is either lackluster or inconsistent. So if we can create consistency and value to those behaviors, then they'll likely, then they'll likely occur.

Speaker B: I just want to note that like what's just listening to you both and listening to how you eloquently described the trajectory of uh, how to execute and carry out with success what you're talking about. I think that as behavior analysts we can get really hyper, um, focused on the specifics of our science, which is true and necessary, but miss out on being parsimonious in the process. And so then we create these webs of systems that look brilliant in design but in actuality are just too burdensome to execute. So I think having parsimony at play through the whole way will help safeguard things. I felt like that was a Dr.

Speaker D: Seuss page out of a book you reminded me of. I had a supervisor when I was on practicum for my psychologist doctorate and not a behavior analyst before I even probably again before I even knew about all that kind of stuff. Um, and he talked about uh, behavior in terms of train tracks and it so applies to behavior analytic work, especially ABA as, as applied to the autistic population. And what he said was when, when you're writing I'm going to do this, so hopefully everyone m can see I'm Making my hands look like a train track. If you're, if you're listening to this. Visuals are really great for a, for a podcast, I've learned. Um, but, but one of the things he talked about is that when a train is, is, is on the train tracks and there needs to be a shift or a turn to a different direction, there's a, there's a shift or a lever that's pulled that switches the rails and that, that shift is really like 2 or 3 inches, right? Probably, I'm not a conductor. Um, but we'll just say it's 2 to 3 inches just for ease of this, of this analogy. But what that does is it shifts the train to go onto a different track and get to an entirely different, uh, destination. So that small little shift can mean something completely, you know, can, can lead to a whole different change. Um, and when we're thinking about behavior analytic work, sometimes these small changes that really are impactful for the individual and the work that we do, especially on the individual basis, is often small and slow. But if you think about what those small and slow changes mean in the greater span of the life of that person, it can be really impactful. So just as the train could end up in New York versus Florida, this individual that we're working with can end up in a completely different direction because of these small little changes that we're putting into place and consistently assisting them with, uh, or working with them with, or learning them, learning about them from, um, and the same can be true on an organizational level. So if we start collecting, you know, be parsimonious, collect, collect what bit of data you can collect on the individuals that are working with you or for you and use that as your starting point and then grow from there.

Speaker B: All great points.

Speaker C: Really, really wonderful when you, um. So if putting your psychologist hat on, right, so you have a, a behavior analyst or an organization that's really anxious about this. I mean, what would be some tips that you would kind of help, uh, to just if you're anxious or uncertain about moving. And what's this going to mean for the, for the future? You know, what, what would be some, some ideas you would give to them?

Speaker D: Um, yeah, I think, I think there's a lot to be nervous about only because change can be nerve wracking. Right. Um, and, and there, there could be or might be that pressure from particular funding sources that this is just the way things are going to be. I, um, think, you know, I could say at least for the, for the time there's there's. This is still something that we're developing within, on our end. Um, and they'll likely be the providers who business as usual will continue to occur and what they're used to and uh, what they're comfortable with will, uh, will be monitored in a similar way. But one of the things that I would suggest to do is if there are questions or concerns, then raise them. Raise those questions and concerns and raise those questions and concerns with the informed individuals. So by speaking with people like myself or people who have similar positions to me at other funding sources, engaging in conversation and being receptive to that conversation, that can often be the most helpful versus kind of internally worrying because usually those worries just spun out of control, spin out of control and aren't, aren't really solved or supported. Um, so asking those questions, looking for the things that, the information that might be, that might have gaps in it, um, and then growing from there is probably some of the best help from a, from anxiety perspective and also from a company growth perspective.

Speaker B: All really good points. And I think about this conversation and I'm internally wondering, do you have like the next two hours to keep talking about this? Because there's so many things truly. And I was like trying to take notes as you were talking on some of this stuff about this, this topic in general. And I appreciate your expertise and I know that Tim does as well. But we also have a segment, um, during our interview where we like to get to know the guests a little bit more. And we call that Guest Matters. And so we just wanted to throw a couple questions at your way just to understand a little bit more about you. So when you think about all the pet peeves in the world that you could have, I have a lot of them. What would you say is your biggest pet peeve?

Speaker C: We can maybe do some counseling on that part, actually.

Speaker D: Yeah, exactly. Uh, so like personal pet peeves. Not, not industry based pet peeves.

Speaker C: Oh.

Speaker B: I mean, I think one personal, one industry. I mean, take the opportunity, have it.

Speaker D: Uh, so I have no pet. No. Um, so personal pet peeves. Uh, two. So one is when people don't return the shopping cart. But there's an issue with that. Right. Because you never know somebody's story. Right. You don't know why someone is doing that. I think you're allowed to at least have the initial reaction. Right. Um, you shouldn't judge without knowing, without me to do judgmental in that. And it's very easy to judge, especially when it comes to shopping carts. But that might be one the other and probably the one that I find more salient for me is, you know, when you go into like a. Let's say you go to like a coffee shop, Starbucks, whatnot, and like, you hold the door open for someone and they walk through and then they get in line in front of you. Yeah, that bugs me.

Speaker B: Yeah.

Speaker C: Oh, yeah,

Speaker D: that would be my. So I think what, uh, you know, I think again, you don't know anybody's personal story. You don't know why they. If they're in a rush or why they might be in a rush or what they're trying to get to. But the thank you and then the switch back in line to say, you held the door open for me. You would have been before me in line. But, uh, but pet peeves don't have to follow logic. And they're. They're the things that. That bother you deep down in your soul than in the dark places. So, uh, that probably my big one.

Speaker B: Before you go to your professional one, I have to tell you something to support your pet peeve about the shopping carts. I remember listening to a podcast on leadership ones, and I don't remember anything else about that episode other than the person speaking said, the hallmark of a leader is someone who puts the shopping cart back. And I was like, oh, oh, my. Oh, my. Okay. And so in my head, that voice pops up when I have my shopping cart.

Speaker C: I'm like, I'm a leader.

Speaker B: Let me go put this stupid thing back. So.

Speaker D: Well, it's like the completely altruistic activity, right? Because in essence, you're why you can leave the shopping cart there and go about your life, but you're putting it back so that the next person's able to access or I always think about the person whose job it is to have to kind of collect that. And, um, you know, it's one less thing for. Have to. For them to have to clean up of me while they're. While they're there. Um, so that's. That's what I always try to think about. Plus, then I always like to ride the shopping cart, you know, down the scooter.

Speaker B: I can somehow see that. What about your professional pet peeves? Do you have one?

Speaker D: Or so I. One of the things that's really one of the things I love about my job, is really cool about my job, especially when I'm doing reviews, is I get to see treatment plans from providers all over the country. I see how, uh, you know, hundreds, if not thousands of people are implementing behavior analytics services or how are conducting ABA services Um, so I get to read a whole bunch of treatment plans and kind of see kind of what works, hopefully what doesn't. One of the things that challenges me the most is when I don't see a date treatment plan. Um, so that's, it's a, it's a pet peeve. Sometimes it matters more than it doesn't. Um, but, uh, having a date there, so I know when it was written and when the data was collected, when I don't see that sometimes that, uh, beyond. Beyond it being an aspect of our coverage policy. But that's, that's sometimes frustrating because then it's like, well, I'm not there with you. I don't know you.

Speaker C: You.

Speaker D: I know you know this, but I need to know too. Can you please help me? Um, so that, uh. And usually it's just, it's just, it's not like a malicious thing. Usually providers just sometimes don't. Don't, you know, they forget or it's like an easier kind of thing to leave out. So that sometimes gets a little, a little frustrating because I know it's something that could be done.

Speaker C: Attention to detail. It's a key aspect of treatment planning, for sure. When you think about your, your personal workflow, and I think this is really something, initially I didn't think much of, like, oh, I'm kind of work, work okay most of the time. But I've seen more and more that there are definitely times a day where I'm pretty optimal. Have you noticed for yourself personally, like, there are times a day where you can get the most deep work done.

Speaker D: I don't know if there's a time. I don't know if I've ever had that time where, you know, how some people are like, oh, I'm, um, in the mornings, I am on point and I can, yeah, I could focus so much better in the mornings. Or some people, they feel like they could focus so much better at night. I don't know if I've ever been like that, where I've had a time where I said, this is the time that's really going to be my golden hour for work. Um, I have kids. Um, so the time where I'm able to work is the time where, you know, I don't have that competing. So if they're at school, it certainly becomes a lot easier. Um, when they go to bed, it becomes a lot easier. Um, so. So those will probably be the times where I'm, uh, able to get my things done, uh, more effectively and more efficiently.

Speaker B: So when you Think about just back in the day when you were not Darren, Dr. Darren Sesh, head of, um, all things psychology, ABA at Evernorth, um, and you were going to school to prepare yourself to become the person that you are now. What would you say is your favorite subject at that time?

Speaker D: Oh, yeah. Good. Um, so it wasn't ethics. So I book that I have is on ethics in aba. Um, and I did not like my Ethics in ABA course at all. That's actually one of the reasons why, uh, we wrote the book is because I didn't. I didn't like the courses that I had taken. Nothing against the professors that I worked with, um, but they just. I didn't find them to be the most interesting of courses. Um, but I. I don't know. I. I always like the. The. The, uh, conceptual courses. So, you know, thinking from like, the ABA perspective, constants and principles, obviously, is just, you know, it's an interesting one because where you start to really get to dive into, um, you know, what it. What it means to be doing the work that we're doing. Um, and one of the reasons I really like that course too is I had been working in the field at. To the point at that time, so making the connection with the work that I was doing and then the background to why I was doing what I was doing and the terminology behind it and kind of putting a lot of context to it and meaning behind. Behind everything and getting that deeper grasp and understanding. I really enjoyed. You know, if we go back to high school psychology and social studies classes.

Speaker B: I liked basket weaving was mine.

Speaker C: Do you have a favorite place in the world?

Speaker D: You know, I don't. I don't know. Uh, I don't know if I have a favorite place in the world. It's. That's tough too, because one of the things we, my family and I, my wife and I and our kids, we do like to kind of travel to, uh, different places and try to see as much as we. As we can, which has been. We've been fortunate to be able to do that. One of the things that's tough with that is when you find a place you really love, once you leave, you want. You want to go back there, but there's so many other places to see. So then the question becomes, do you go back to this place, the tried and true, uh, or do you try to see, uh, some of those landscapes that you haven't had the chance to see just yet? So, uh, that's the battle. But, uh, yeah, I've been fortunate enough to Be able to kind of check out some really amazing places.

Speaker C: Awesome.

Speaker B: That is awesome. It's great to be able to travel with little ones and to be able to spend time with your family too, because I think sometimes it can be easy with how encompassing working in this field is that you are your job instead of you are a person who has a job. So, um, I love that you go back and visit favorite spots. I think that's important. Um, I just want to say thank you so much for your time and your expertise today. It has been a true pleasure. I always learn something when I listen to you present or on all the other podcasts that you've been on. Um, you really are a true expert on many topics, but also, we just appreciate the gift of your time. It's been great.

Speaker C: Thank you. I really want to thank you for your advocacy and it's just come through and so many things you said, like how, I mean, you're jumping in and trying to really do this tough job. And, you know, and it's, um, and even like, in your recommendations for us, you can just feel this like, uh, advocacy that's just. It just comes out. And then honestly, like, I just really, really appreciate it. Appreciate what you're doing for the field. We're very lucky to have you. So thanks again for all of your amazing work that you're doing.

Speaker D: Thank you. Thank you both so much.

Speaker B: Well, thanks everyone for tuning in. Until next time, take care of yourselves and we'll look forward to talking to you soon. Bye, everyone.

Speaker C: Bye.

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 at @abahealthcare matters. Rebecca on LinkedIn and Tim on LinkedIn and Instagram. Dr. TimCourtney. Socials are also available in today's show. Notes. If you like the content of today's episode, please make sure you rate and review on Spotify or Apple Podcasts. Thank you for listening and as always, keep fighting the good fight.