Applied Behavior Analysis
ABA Service Delivery:
Legislation & Regulation
You can do something.
In many states, Applied Behavior Analysis provider rates are not within the control of providers directly. That’s how many providers feel, especially smaller providers. ABA Advocates in Kentucky (KY) is a provider group who worked for a decade lobbying congress for state-level change in legislation. KAPP, ABA Advocates in KY and KYABA worked together to solicit support from legislators that ultimately passed an autism mandate and ABA licensure law in 2010.
Regulatory mandates take collective momentum to change.
Funding for Medicaid is often a primary source of funding for many providers. Regulations and legislation in your state cannot go unnoticed by providers and expect something to work in your favor (especially provider rates or terms). It is what it is… In Kentucky we are fortunate for Medicaid waiver services, for families, clients and students of ABA in the areas of Kentuckiana.
The good, the bad, the ugly here in KY is well above average on the good (thing to work on). One in five citizens of Kentucky access some form of KY Medicaid. This puts strain on state funding, budgets and allocation by state congress. Medicaid is one of the top three budgetary considerations putting it on the radar for cuts at all times! We’ve worked in several states with similar funding environments (Medicaid or Medicaid Waivers). You can read about how state Medicaid programs were created, maintained and operate online. You can begin to see what may work or not, for your state based on a solid understanding of your state’s regulation of ABA services.
Some of you will be surprised that in some provider environments about 15-20% of billable service time is allowed for non-face to face services provided. It varies from one state to the next, either allowing for billable time on graphical analyses/development of individual intervention procedures, assessment review/visual analysis of data during functional assessment, plan development & monitoring of training provided. Yet, you’ll also find other provider funded environments with contradictory or vice-versa allowable service(s) for the same. Many do not allow any time whatsoever for vital parts of the actual behavior analyses, which is important for effective treatment outcomes.
Direct Primary Care Model of Service Delivery.
Community-based service delivery models regardless of discipline present many BIG challenges for various providers. Physician services started adapting in many ways, Direct Primary Care and Concierge type medical services are gaining traction.
Balancing quality service provision with allowable time (CPT codes) and all the necessary components of service provision can be tricky when regulations change or are created for human services. The service provided must be consistent with the disciplines’ professional guidelines. Funders learn if professionals don’t do something about it, then there is no need to rebalance, change or adjust the regulatory mandates (ie, reimbursement rates or service delivery regulation). Not in all instances of course, Kentucky has gained lots of headway for ABA providers but it wasn’t and isn’t easy. It has taken multiple provider advocate groups more than a decade and they still have a long way to go… Being adaptable is key to survivability in the provider environment. If provider policy is too rigid it is considered aversive, complex and barriers are created that reduce the motivation of quality providers to participate in the funder networks leaving patients with limited choices (ie, Medicaid).
Providers may begin looking for alternative avenues to deliver their services. If policy guidelines are not structured enough? Then the provider agencies may not be able to offer all the quality services they intended, critical employee benefits like paid medical/dental/vision/PTO, 401k matching, CEU reimbursement, sufficient “supervision” and many, many other employee benefits could degrade and the services become less and less desirable.
Offering quality services comes with having highly trained providers who need access to important benefits like paid time off (PTO) and other employee assistance (EAP) program(s). It is important for your team to have time to “recharge their batteries” to deliver effective outcomes. Many providers in Kentucky are able to offer benefits because of the advocacy specifically for reimbursement and consistency. There isn’t a plethora of research on regulatory variables that affect ABA providers. It can vary greatly from state to state with very little consistency.
For example, there is a movement in physician provider services towards “direct primary care” (DPC). This model precludes the need for most insurance. Due to over-regulation, which can make it feel impossible to provide quality services. The DPC model was designed based on monthly membership subscriptions for physician care. The monthly service fee model (i.e., you pay about the same you’d pay an insurance company) typically gets you access to the doctor 24/7/365. They’ll provide you with a plethora of services while avoiding your INS company. We’ll see more adaptations like this across disciplines one day, even for ABA providers. It’s a private pay model. Which unfortunately, by design can be exclusive. Ever heard of it?
DPC isn’t perfect for medical providers and it is somewhat of a new “trend” in medical models. Yet it is super interesting and has a lot of provider advantages. DPC has the potential for including sliding fee schedules and for some that’d allow lower income families to participate in the direct primary care model of service delivery. This model evolved from provider adaptations to funder-produced constraints. Illuminating some of the rigid rules of over-regulation. This model moves providers against and away from traditional models of insurance or “fee-for-services” (i.e, which can be a joke in some instances).
The DPC provider model is growing. It hits home with regards quality of services, giving all the time necessary to provide the best attention and expertise to the problems being addressed. See the link if unfamiliar – prediction indicates that this model will generalize to other disciplines on a larger scale for the reason you are starting to discuss which go well beyond just constraints on billable time – there is a plethora of issues providers face as a result of over-regulation, restriction and in some cases, the “requirements” actually go against the licensure law as well as ethical guidelines – providers can’t always foot the bill, philanthropically just because the funder designed an ill-thought out foundation of which you are suppose to provide services, yet only by how they define the service, and only within the boundaries they outline for you… It’s incredible. Anyone interested in this topic with comments or insight, contact me directly – even though this state (imo) has some features that are “provider-friendly”, it wasn’t by design, and usually it was a result of some design-flaw itself that serendipitously ended up working in our favor, if you will… without taking my ranted, tangent on this, too much further, it’s flat out mind-numbing in some cases. So in light of these flaws… we sometimes might find ourselves fighting the funder (against changing it) because the change would be less provider-favorable and thus, we are then in a weird position advocating for the circumstantial “flawed-funder-design” in service delivery, because the initial flaw in design can be adapted to work best for the client and for the clinicians ability to deliver the highest quality service. Entities or gov. funders that out-right don’t allow or understand the nature of quality ABA service delivery models, like the BACB consumer guidelines (ie, we’re not exact to other prominent and useful disciplines in terms of service delivery), these are based on the INS plan offerings and often contradict our professional guidelines or licensure mandates… as a result, some entities eliminate any and ALL “non-billable service time” (ie, say in Medicaid Waivers) or with funders like some INS companies. Anyway, many instances of this can end of being so confusing that it might takes years for providers to begin understanding – how things “got this way” ie, when the funder’s service regulations appear not only irrelevant to the discipline’s core values but, also blatantly counter to how they are trained, how they can ethically even provide the service at all. For example, I’m aware of one funder’s set of regulation(s) for “behavior-services” that mandates the provider NOT see the client AT ALL after the assessment and behavior plan are written, trained and paid for by the funder… Yup, wow?!@&# and this is as real as the sky is blue folks, it’s in place today.
I get it too, funders and providers are looking to save money and seek fiscal responsibility. That is a good thing! There are so many ways service delivery models can be designed to provide quality services while prevention fiscal irresponsibility. Which seems more likely with designs that are made to cut corners or that implement service models that are grossly insufficient and counterintuitive to the disciplines professional guidelines.
Lastly, without an advocate group in your state to put up legitimate barriers against these huge provider challenges, it’ll be nearly impossible to make broad changes in that state. Topics like billable services, face-to-face vs. non face-to-face billable time, what is included in the service description, who can be at the session, what should or should not be in the assessment or plan… it’s hard for new providers to understand all these broad and sometimes counter productive rules and regulations, for good reason too, sometimes they make absolutely no sense at all. Yet, you have to understand the evolution and history of ABA (or other services) in your state or region, to begin putting the puzzle together, before you can effectively produce meaningful changes in those rules & regulations.
Unfortunately, in some instances, the lack of rules or the abstractness of them may be more favorable, but this ambiguity can also have downfalls later…
Finally, to gain more control of these issues its ideal to begin working through your regional state association like here in Kentucky with KYABA, where we have made some slow but promising progress. If you don’t have a regional association create one, if the one you have doesn’t want to work on these huge provider issues, go ahead and develop a local or state private provider/advocate group with structured by-laws. Organize your state or regional providers first and then, together begin breaking down ever rule and regulation affecting your services, employees and clients. All the funder regs. you are engaged with should be guiding most all of your agency policies ie, if you are being paid by them to provide a service…
The bottom line for providers!
You have to gain a full understand of not only the rules themselves but also their history/evolution, ask questions like “why are they designed this way”, “who made them”, “what are they based on” and “what makes them justifiable”.
Compare them against the BACB, ABAI & APBA professional guidelines and your state licensure law… always place primary emphasis on the needs of your clients and employees or practitioners, and then find funds to solicit a lobbyist or hire one immediately by combining efforts with as many local providers as possible. Ask around, go to your local congressman or woman, find out where lobbyists are located. Typically lobbyists outnumber taxpayer funded congress-women and men by a ratio of 52:1. Throw a rubber stone directly at your congressional building and you’ll hit one! Some lobbyists are linked specifically and only to stakeholder issues regarding healthcare, that’s their formal lobbying expertise. You’ll likely need to make an impact on legislative before anyone will listen to you, then you can start doing something about it!
Resources for behavior service providers from Clinical Behavior Analysis
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