Episode 66: Value Based Care with Dr. Diana Davis-Wilson

Um, and I came down and, um, uh, and I kid you not, I was trying to get gussied up and dressed up all fancily. And I spent an hour in my hotel room trying to get tie, a bow tie, sorry, trying to learn how to tie a bow tie. I had like three different YouTubes going. I was looking in the mirror after an hour. I was so frustrated with myself, like I almost turned around and and just didn't go all together. So I was like super frazzled showing up.

I didn't know anywhere there these earliest days of Ascend and who was there. But you and your husband, some other friends, you were so welcoming and kind and it was such a fun night and an awesome cause. So can I just tell you publicly, like thank you so much for being so welcoming

I remember, I, I remember it vaguely, mostly because I remember trying to wear heels and I had to actually take the shoes off to walk from the parking lot to the event. And then about halfway through the event, I just took my shoes off entirely too. Um, but if anybody knows me, you know, I wear jeans and flip flops and sunglasses. Um, I don't even know what I did with my sunglasses right before this call.

I almost went to go get them, and then I was like, no, I can do it without I, I can do it without. So, um, that was a great, that was a great event and I am so glad that we've been able to connect and, and get to know each other and, uh, you know, work on some projects together. And I know you guys do some incredible work and it's just been, it's been a joy.

You know, you were contracting with the schools or you had, some families that had the ability to pay for services. but for the most part there wasn't a lot of funding streams. and right around the same time that all of that got going, I had my first born and he was diagnosed with autism by 15 months old. So I, had to quickly shift into a parent role and and that was tough cuz as providers, I mean, we have our ways and then all of a sudden I'm, I'm mom.

and I needed to navigate the system and I had been working in Arizona in the system for, gosh, eight years before I had my son. And so we're, you know, approaching 10 years by the time I now need to navigate services for him. And I couldn't do it. And it took a lot of work and a lot of loopholes and calling people that I had built relationships with over the years. And then I just felt kind of gross like that. Here I am, I can make this phone call and get my child whatever they need.

And there are hundreds of families. That just can't access services. So I was looking to do my doctorate in an area that, that would focus on, accessibility of care and, serving, marginalized communities and looking at ways that we can better, take what we know to be just an, an incredible science and apply it outside of that typical, you get a referral from the insurance company and you provide, early intervention services or what have you, and kind of expand, beyond that a bit.

So I decided I was gonna find a degree and it was recommended that I do the doctor to behavior health. And the reason was, is because it was like part clinical at the time. They, it's changed a lot. So, um, I'm gonna date myself. This was before there was a clinical and management track. So there was the clinical piece, and then there was the management leadership, entrepreneurial piece, and then there was the funder relations piece.

And that funder's relations piece was the part that I just knew. that was kind of the ticket into figuring out ways to expand behavior analysis, outside of the realm of restricted autism service coverage that we had. So I, as part of my doctorate, I had to do a practicum and I was very fortunate.

Um, Dr. Robin Blitz at Phoenix Children's Hospital had, right around the same time started talking about her initiatives of wanting to, help some of the primary care practices, the pediatric practices, um, meet their metrics for value-based care. And one of the ways that, she had proposed doing that, cuz in, in primary care, your two largest metrics, uh, three, you have the attendance of your well child visits, and your preventative care.

Then you have tied to that your reduction of, um, hospitalizations, urgent care and ER visits. And then you have, in most of the metrics, a reduction in specialty provider referrals, which I don't know, that that's talked about as much, but that was the piece that we were honing in on.

Um, because what we had found was this very strange phenomena, of pediatricians that would see a child with autism or genetic abnormality or you know, something and they would all of a sudden not know how to treat constipation or all of a sudden not know like basic child ailments. Oh, the child has frequent ear infections, but they also have autism, therefore they must go here or they must see this. And we went out, we had interviewed the specialty providers and they were.

If a pediatrician sends us one more child with autism, with basic constipation and they've done nothing else to to fix it, we're gonna lose our minds cuz they've got kids that need feeding tubes and kids that have, Crohn's and all these other things and they're seeing primary care visit like services. And so Dr. Blitz had envisioned this training program. where we could actually go out into the community and provide training to the pediatricians on, how to do their jobs.

within the, the compounds of, the special healthcare needs is kind of how, how we worded it. It wasn't limited to just autism, but it was special healthcare needs. so it was kind of like her brainchild and, and it was, um, kind of a spinoff of some work that was done in Ohio. And then I, I'm sure you're aware of the Echo autism. we were very closely connected with the work that they were doing, and she had secured a grant for us to do rural communities in Arizona.

And so we had about 40 practices, which was great. And we got lucky in that most of the practices had some sort of personal connection with autism. So there we didn't have to like they were personally invested, which helped. Cuz sometimes you get a lot of people that kind of drop off after a while cuz of the time commitments and stuff. They're personally invested in it.

And then we had, several individuals that were former students of Dr. Blitz that then went into primary care practice that just wanted to tie in what they had learned into their practice. And at the time, so, you know, we're talking 2014, that was when the big talks of value based contracting were going on and that was when because it, it was following a rendition of the Affordable Care Act that also incentivized federal dollars to go to these value-based programs.

So I was very fortunate that one of the practices that I was assigned to go out and assist with, uh, was in Douglas, Arizona, which is one of our border towns. and this pediatrician had received several value-based contracts and grants and programs to essentially set up health clinics, that would meet larger community initiatives. So not initiatives that were. just specific to, reduction of ER visits, but bigger than that. she did have the metric for, the well child and preventative visits.

but one of her other big projects was to actually reduce the occurrence of teenage pregnancy and the subsequent, health concerns that come with babies having babies. And so, when you think about that and you're like, okay, how does one doctor, in our current healthcare system come up with some way to reduce teenage pregnancy? Seems kind of crazy, right? but she had figured out a really cool program and she had used her money, to, forthright set up, uh, her doctor's office to include a library.

It includes, kind of a study hall. It included a coffee shop, like all of the things that teenagers would want to come in and have for free. she built that within her practice. And then what she started to do, and, and again, it's a border town, and so you've got multi-generation. uh, pregnancies happening even within homes.

She had set up cohorts, for the OB visits because what she realized is that part of why the healthcare, what she hypothesized, was part of why the healthcare metrics for, the teenage moms. Then the pediatrics, so the babies getting access to adequate healthcare was because the teenage moms didn't have transportation. They had, you know, different support systems. They were also going to school.

And so she had came up with a model where they had monthly cohorts, and anybody who is due within that month obviously with HIPAA and consent and all of that signed into being in this cohort. So not only were you seeing this doctor who was a pediatrician by trade, but she had a whole health center, so she was able to have all other types of providers as well.

But her entire goal was to make it so that you weren't going through pregnancy alone, regardless of your age, regardless of your circumstances. And through that, to build systems to where you, you had the community support to get you into the facilities and those sorts of things. And then what she did was she set up patient education systems.

So now it's, Hey, whoever's bringing you in, we're now gonna do an education program to reduce the reoccurrence of the teenage pregnancy with the end goal of getting out and having programs for just high schoolers in general to be able to come in, perhaps get some high school credit and, and go through some patient education to prevent some of that. what's really neat about that and where value-based comes in, Because as we know, it's always the chicken or the egg.

You need the money to purchase the facilities, the facilities to, you know, house the kids and which one comes first and how do you balance that. and rather than like the investor model, she went the federal qualified health center model where she basically would send her metrics into the federal government. And depending on what her, outcomes were, was how much money they would then continue to pay her.

Um, and so her entire model was based on, she did have some grant funding going because, there was some logistics around, immigration status and some things like that that she needed. Um, and then they also actually traveled, I can't remember where, but her husband was also a physician and they also traveled, to underserved communities in other countries and, and did community service.

So she did also have some grant money, but for the most part it was under this value-based system where you no longer had to worry about how much time you were spending with each patient just to be able to, to pay all of your other metrics. Instead, she could actually see the patients in a cohort and she didn't have to worry about concurrent billing or duplications in billing or any of that because she wasn't billing by the hour. She was billing by the outcome.

And so it was, a pretty incredible, incredible, system to watch her build out. Um, and I do need to follow back up with her because it's been a couple of years and I'm sure it is incredible.

for us and for what we were trying to build now, we, we were a little bit fortunate for her in the fact that she had already envisioned her and her husband had already envisioned a value-based program, and had already envisioned what if it wasn't about the dollar and the hour and it was about the outcomes. so they came to this with that where our other sites wanted to access the federal money. So they were hoping that we could give them solutions.

Um, and I think that the biggest, the, the two largest hiccups that we ran into in all the rural areas was connectivity to internet. because that even makes access to specialty providers hard. I mean, it was just, there was just a lot of issues there. And then transportation, that generally speaking, the reason why folks weren't following up with medical care was because they didn't have means of getting there.

And, you know, if you have a child on spectrum here in Arizona, um, and that is the concern, um, there are transportation services, but they're, they're limited. They're limited just like many others in workforce and funding and safety. so many of them will say like, you will transport your child but not a nonverbal child. Or, we'll transport your child, but you need to have a behavior tech with you. And so there's all these like logistics around transportation.

But in their system, they didn't have that because they chose to do the cohorts. So, without outwardly saying like, Hey, you're gonna give each other rides. It was organically building community relationships. And so, when we first started with them, they were in a small facility. Um, I say small, it was rather large, until, they were able to secure the funding to then buy out an old school building. And they redid the entire school building. They, I, they did a theater room.

That's when they did the, the, the coffee shop. They redid the entire outside playground. So again, trying to get everybody to come and see, and, I had gone to lunch with her a couple of times. the doctor. And it was incredible driving through a neighborhood where everybody knew her and waved, and the kids all hugged her.

And so she brought so much of a human element that, based on how much they've grown into, um, gosh, they're in three other towns now, so Douglass is one of them, but they're also in Bisbee and in, uh, one other, they might be even, even in four now, based on their growth, I'm going to venture to say that, that the outcomes are quite well as far as the, the producing the outcomes in order for the federal government to continue to increase what they're paying out to them.

as far as the study on the teenage pregnancy, I think that's going to, you know, be a, a multi-year study. She was just getting it started. I think their average. I don't remember the numbers, but they were kind of crazy. by the time, individuals were 15, 16 in high school, they were, I think they were at about, 70, 80% of their females, were pregnant or had been pregnant. It was very, very, very large number. and so yeah, I need to circle back with her and see kind of what her current data is.

But given the nature of this study, those individuals. The impact probably isn't seen quite yet, but, um, I would imagine over time. But that brings me to a great point. Value-based isn't about outcomes. Always today health plans are looking at long-term ROI and per capita changes.

And so even if she didn't move the needle in the last six years, if she's got a system that still leads her to a hypothesis that's going to move that needle, that's still, salvageable with the health plans and her federal contracts because they're not looking at the solution for, okay, how do we make sure that 16 year old, Jill gets her four month in for shots.

They're looking at how do we make sure that that four month olds at 16 doesn't have these comorbid medical or mental health issues or these other things as a result to this today. So it is more of a a longitudinal long-term study.

And, I wonder, Diana, are there metrics you think for ABA providers that you know you can start measuring right now, if you're not already thinking about clinical quality and ways of communicating back to payers, your clinical quality.

They do it different. We kind of are quite dismissive of, other healthcare literature. and I think that if we were to start to tie into the other healthcare literature, starting with what is literature telling us now? is impacting health outcomes in adults 20 years from now. Because what I see in the field is we're looking at, okay, how do I get, you know, maybe a four year old with autism, integrated with their, peers in the mainstream classroom in first grade.

Health insurance doesn't care about that. I mean that very nicely but they don't. Now there's a component of that that matters because what we know in social determinants of health is that, the less of access to an appropriate education, the lower, amount of, or quality of, of opportunities to engage in the education system are indeed long-term healthcare costs metrics.

and so it's almost like we just stopped there and we're missing that bigger piece of what makes the academic performance important to health plans. And it's not that they're getting along with their peers or they're mainstreamed or they can read or write.

It's that we have data that says that by having those specific skills, you are actually going to drastically change your overall access to healthcare, healthcare, equality, uh, the frequency, and then the prevention of other healthcare and disease. And so usually when I'm talking about medical necessity or value-based care, I know that the, the literature says disease, and I know that that's, not necessarily like what I would go out and say, Hey, I'm treating this disease.

I don't mean it like that, but I, I wanna tie it back to how important it is that as behavioral analysts we are able to crosswalk what some of those things mean. And when you look at the health plan, a health plan, or, the insurance companies, the industry in general, their job is to incentivize, uh, reduced cost to the government, and yes, we, yes, there's a lot of other pieces to it.

Like we want people to be, well, we want people to be healthy and we want them to strive and do good and contribute to society. And yes, there's all of those pieces, but every single one of those kind of go back to that one metric of like, it still has to be at a reduced cost to the government.

Um, and so I, I think that for us, what we have to start measuring is that bigger picture back to the social determinants of what is the other healthcare literature saying about, an individual that can't access a gen ed classroom. It doesn't mean that they need to be in a gen ed classroom.

It just means that we need to go in and we need to say, okay, what does the literature say when, you know individuals are limited in this access, oh, it says they're at a greater increased risk of heart disease. They're at a greater increased risk of obesity. Those are gonna be the metrics that, that we have to start thinking about, talking about running numbers on. Um, you know, and, and kind of looking at that.

And, and I would say in behavior analysis we have that added piece of, so often by the time our individuals are 8, 9, 10, I used to say 14, 15, 16, but it's down 7, 8, 9, 10, they're being treated with psychotropic medications. Um, and so again, we're talking. what are the side effects? What are the increased cost to a health plan? And how can behavior analysis reduce the need for psychotropic medications? And don't get me wrong, it, it doesn't eliminate it for everybody.

And there's research out there that supports some co-treat and stuff, but, but how do we reduce that thinking about not thinking about like, Hey, we can solve this with behavior analysis and you know, maybe kids should or shouldn't be on medication, whatever. But thinking about, wow, this medication, if you are on it for the next 20 years, makes you susceptible to all of these high cost comorbid diagnoses. And all of that's literature available to us. It's just in other healthcare realms.

Um, the other one I'll touch on just real quick is family health. Especially in a value-based system, oftentimes they're looking for a holistic, in fact, in value-based systems and in, medical necessity, criteria. The family is a component of that because by not treating the, the individual holistically, sometimes what will, inadvertently happen is that we create other high cost healthcare needs for the families. And so we have to cover that piece too.

So definitely the metrics for family, uh, family care, one area that I have been very, very interested in we have a couple of other professionals out here in Arizona is again, that kind of preventative care for siblings. because again, these are high stress, research shows that many siblings of individuals with, uh, developmental disabilities may also have co coexisting or, or co-morbid or develop a, mental health, concern at a later date.

And so how do we start to take that in and start to incorporate that into our treatment and then turn that around to the health plans and say like, Hey, we hear you. our colleagues in these other fields are saying, guys, what's going on? We keep getting this influx of these other disorders. And we hear that. And so now how do we make that a part of our plan, from a perspective of preventative health that then the health plan can say like, okay, yes.

Cuz what you're doing isn't just helping little, Jose, make it into first grade. You are now helping Jose's family, reduce, those costs. And again, health plans do everything off of per capita, which is very strange for us cuz we're very individualized. They can't be because they're serving hundreds of thousands of people. And so they have to, they have to look at it from a, a different lens.

And sure, there's all the logistics and coordination involved in the financial end, but even more importantly, like the blow to someone's psyche and mindset of getting laid off, of having to switch and, and potentially making a decision not to continue to access ABA right? Like a, a child is a part of their environment. And if we neglect thinking about family support systems and siblings, we're missing the boat as a field on what's best for kiddos and families.

Can you, Diana, Clarify for listeners what you mean when you say social determinants of health.

And so, uh, again, healthcare literature for many, many years has been looking into the effects of, not just, again, do you have access to a peer, but also what is the, the quality of that peer access and what does that mean for long term, supports. they look at, education and, just all of the things that, we may not think about when we're thinking of, I have a toothache or I have a broken leg.

You know, we're not thinking about all of these other things, and I'll be quite honest, um, where most people understand social determinants of health and where the literature lies and I think needs to be better highlighted is again, these marginalized communities. Because the problem that I think that we have and that I think, you know, insurers have is we're trying to create systems that are, one size fits all because it reduces cost to us.

But as we do that, we continue to push aside these marginalized communities. And one of the things that the social determinants of health can do, if you're looking at those outcomes, you can start to look at again, the impact that access to food and not just any food. Again, we're talking social determinants of health are about quality. It's not about like quantity and acceptance. You can have access to ramen. That's not what they're talking about. Do you have access to fresh vegetables?

Do you have access, you know, these things. And in the primary care practices over the last, two years, and I don't know if you've seen it with your kids, my kids have gone to a pediatrician that I actually, worked with in the training cohort. and every single appointment we get asked do you have transportation to your appointment? Transportation is one of those social determinants of health.

If you do not have adequate transportation, your healthcare metrics are going to be significantly, worse than somebody who does. And so I, I, it's looking at kind of those pieces again, and we run into this in our DCS system, and different things where people are like, well, but you have food. Well, yes, but if all you have access to is ramen and mac and cheese cups, that doesn't solve the issue. You need access to fruits and vegetables.

And my doctor asks every single appointment for my kids, do you have fresh vegetables? Do you need help accessing, um, clean water? Like things that I mean for many of us, we may take for granted. but those sorts of things, in healthcare matter at, in preventative health at such an early stage. and again, we can't look at it as like, oh, well this family has access to these things. Well, no, we're working with individuals who their ability by the nature of some of, you know, some of the.

strengths that they have in, in some of the areas that they need. they have opportunities for growth. When you're looking at those pieces, it, it isn't the same quality. So yes, mom and dad may be able to transport, but if they can't safely transport him when he's 21 because he's unable to safely stay in a seatbelt, well that's gonna be a problem. And again, I don't know that we're thinking that far ahead.

I don't know that we're looking at all of those pieces that make access to healthcare, and I think that's very evident in our group homes. we have failed to generalize across time our own programming. And when you look in group homes, oftentimes these individuals had families that had access to all of the, you know, the similar, social determinants of health that would yield to positive outcomes.

However, that individual may not have, or that individual's access to it may have been, restricted because of the nature of, you know, their needs. so social determinants of health is looking at kind of those things that start at a very young age, but they impact long-term health outcomes.

I think, um, there are a couple authors, Wilkinson, maybe and Marmot who published a book called Social Determinants of Health that said and presented evidence among many other things that differences in health between populations can be due to different characteristics in society, not just differences in healthcare. And that, that was a really powerful concept, right? in our field, you don't hear people talking about SDOH right, but who's talking about it?

I mean, families are living it every day clearly. Funders, insurance companies are talking about it. Cause they've, they understand this and they get this. pediatricians talk about it, other parts of the healthcare system talk about it. So I think it's really important that we bring this into our lexicon and think about how we contribute. Even if what we're doing, um, can be interpreted narrowly as aba, it fits into this context of an environment of broader social determinants of health.

That's critical.

Um, because, when we're doing appeals, we again, go right back into ABA and what the research for ABA says, and yada y. Well, what if I'm doing an appeal on an individual who historically, had a reduced access to, for whatever reason, whether it's they individually did, or I have the healthcare literature that says this particular population for a myriad of reasons is going to have a later diagnosis or have later access to care or later social validity and family, you know, treatment

acceptability,. That's all data, even though it's not in our literature. That's all data that I could be using in appeals specific to that individual, that has nothing to do with me and my treatment plan. It has to do with, at this point, all of the same reasons that you are denying these services. All of these same reasons and other healthcare literature are already addressed. So let me bring that literature in and show you.

And I think the more that we can have conversations with health plans where health plans understand, that perspective. and it's hard cuz a part of me is like, I want health plans to understand behavior analysis. I don't think that, it's not that they understand or aren't striving to understand, it's that they're trying to figure out how we serve that bigger mission of reduced per capita healthcare costs. How do we prevent illness and disease? and we don't think about our services that way.

We don't think about our services as I'm providing ABA and I, I say this to families all the time. I actually just did an, an intake, uh, for a nine year old who is not toilet trained. That is a preventative health issue. Me toilet training him is no longer a Hey, I wanna make sure that you, are good to be able to get into this preschool program. No, I'm needing to run a, a toileting program because this is a healthcare issue if it's not addressed long-term.

And that's what the health plans don't hear enough from us on. They just see like, Hey, here's this plan and we're gonna work on these goals. And then in peer reviews, when they ask why, they get a lot of like, well, I ran the VB MAPP or I ran the ABILS and this is what they said. Or the parent said, this is the concern. And I think we have to shift that and say, well, here's why.

Because we've got an increased risk of being, denied social access, which is again, let me show you the literature that shows that that long-term is going to create higher cost health for you. Uh, urinary tract infections, frequent urinary tract infections, and now urinary tract infections of maybe somebody who's non-verbal and unable to tell you. So they don't just manifest as just an infection.

They actually manifest as a behavioral emergency, and I can tell you in the group homes, I work in a medical condition like that could take a year or two before they can actually resolve it because it's masked by all of these behavior issues. And these behavior issues are getting different strategies tossed at 'em and medications tossed at 'em. And at the end of the day, it's like, who thought to just do a basic medical review? Who ran the blood work?

Who looked at, hey, this individual may not be independently toilet trained or who did all of that? And oftentimes the behavior analyst in behavior analysis, we don't, our new ethics code does call for us to consider the medical piece. But for years, that wasn't always the first go-to it was what are the four functions of behavior and let's run an FA and, and kind of, um, miss that piece. But that piece is so important because that's where our communication to the health plan comes in.

I'm going to justify my treatment because I know that if this is not remediated here are all the other high cost procedures you're gonna be faced against feeding therapy. Same thing. A four year old who only eats Oreos is subject to based on other literature, heart disease, obesity, all these other things. So I'm not treating this food selectivity because mom and dad targeted it, or it showed up on one of my questionnaires.

I'm treating it because it's medically necessary to prevent other high cost health, and I just don't think that's the way that, I don't think that's the way that we're advertising and communicating about our service.

and you're on the behavior analyst committee, which is extraordinary. Tell me, what are the most important things you've learned in your, tenure?

and we were also a part of the original, writing of the bill back in 2009. It went into effect in 2010. Uh, we didn't get behavior analysis representation on that board until 2017. and so between 2010 and 2017, uh, Dr. Davey, myself, Kyle Leininger, several of us would just show up at meetings, uh, because we're like, Hey, we wanna be a part of this and we wanna grow and we wanna learn.

and then we finally, with the help of Kyle and his team, we were finally able to pull the trigger and get some legislative. Laws passed that allowed for us to be on there. and I've learned quite a bit between that and my doctorate as far as, um, you, you know, I think as a field everybody means well, but I think we misinterpret a lot of intentions. for example, the RBT credential, this is an easy one, right? The RBT credential.

A lot of people are like, well, the BACB says you need 40 hours of training and then you're good to go and you just need this supervision. 5% of your hours every month. Yes, that's what the BACB says, but it's one part. our ethics code also says that you must be meeting, they must be meeting fidelity. You can only delegate things to them that you know that they have competently met.

Um, and so I think what has happened is cuz everybody's kind of just honed into like, okay, I'm gonna make you an RBT and I'm gonna set you up with a insurance company. What has happened is, the assumption that the BACB is the regulatory body in all of that, um, has created a lot of confusion for behavior analysts. And in that you've got your Department of insurance and your federal laws guiding insurance and you've got your regulatory processes like licensure, and they actually trump the BACB.

So when you just come and say, well, the BACB says we only need 5%, and I call it a misinterpretation because I don't think that what we're asking for, what the health plans are asking for or expecting is different than what the BACB is saying. or, uh, look at the, the, now it's the CASP um, healthcare guidelines, right?

It's not that they're different, it's that we're honing in on one piece to just dot Is and cross Ts, and we're not actually looking at the purpose and the reason and what that means to the end user, what that outcome is.

And I think that since I've been in the regulatory role, I see that a lot is that there's a lot of colleagues, a lot of behavior analysts that just come out and are like, but the BACB said, and it's like, Yeah, there's one place that they say that, but it's also in addition to all these other standards.

And, and I'm glad that the BACB transitioned the health plan standards to CASP because I think that also muddied it a little bit, where then people were like, well, the BACB said, and it's like, no, no, the BACB isn't just an autism provider and all these things, so now CASP can really take ownership over this is standards of care for this population.

And as we continue to grow as a field, we'll have standards of care that other professional organizations will be able to set forth and, communicate that with the health plans. I think in regulation, that's been my biggest thing, is that we are missing the mark in really focusing on the outcomes. and instead we're so busy trying to just make sure we're dotting is, crossing ts and that's it.

and then I think the other thing that I've learned, part of it in regulation, I think part of it in other work that I do is that not only is value-based care an important initiative for us to go to, but I think that we have to start to think about that in how we pay our employees.

And so often we have so many bonus structures and stuff that are set straight to just hours that are either not attainable because the tasks that are required, like let's say of a BCBA to do for case management isn't always billable. So when we have these billable quotas, people are overworking without it actually having meaning.

Has meaning to many of the organizations because their direct care hours are the ones that they're looking at, but it doesn't have meaning to that tech meeting, the competencies to be able to meet the outcomes for the child. And I think that's where we start to kind of lose that.

And again, in the regulatory side, that's a lot of what I see We have a lot of conversations around budget and legislation and legislative sessions and how these things all go together and, and I think it gives me a little bit of a different perspective than most when it comes to what health plans are experiencing. because many of them, especially the access plans, they have to stay within that cycle and they have to play those politics and they have to do all of that.

and in Arizona, we have an incredible, incredible stakeholders at all of our health plans that are high level and they, they believe in us and they believe in what we do and they support our services. but they still are working within a system and we have to understand that system and that system is within, more of a larger legislative piece. So I think, yeah, I think healthcare is politics and that is probably the biggest thing that I've learned.

And, and I think as a field, we need to do a much better job in outcome measures and making sure that we are creating systems that are ethical, so that we can meet that. and I think value-based care is, I think the avenue that's needed. I do think the fee for service creates a burden. it's almost a hindrance that kind of just bottles everybody into this area, and I think value-based care could open that up.

And then regulation come in and make sure that people are actually meeting those outcomes and support and training our colleagues into not just being stuck in that bottleneck.

Um, and it's, you know, dozen or so managed Medicaid plans, um, to make sure that, that we're moving in the right direction. Well, Diana, what's one thing every ABA business owner should start doing and one thing they should stop doing?

Um, I think it's those bigger long-term outcomes where we start thinking about how we're gonna generalize these skills. across time for these individuals. Um, I, I really think that that should be a thing. And honestly, I think that although value-based contracts aren't, they're there and not necessarily for ABA where we want them to be. Um, they exist in other realms and we know that to be true in hospital and, and rural community centers. We know value-based contracting exists.

Even without that existing though, I do think that we can set up infrastructures to be more, intentional about applying behavior analysis to our systems. And so again, how we pay our employees, um, you know, you look at, various balanced scorecards and things like that as opposed to incentivizing the hour cuz we know that the health plans are incentivizing the hour and it's causing it to be very difficult for us to operate. Um, and so apply that then to your employees.

And when we incentivize the hours, you know, and you're like, Hey, you gotta bill 30 hours a week or, or what have you not, that's the only metric that we're kind of looking at. I think that it. inadvertently creates an issue with those outcomes because the BCBA are just trying to, to meet their metrics or have access to a bonus because they, they need the money or what have you. And, and it's at the expense of not having the precision that our field actually brings to the table.

Um, and so for me it would be even without the value-based contracts, starting to look at getting the field used to conversations like, here's your base pay and here's your, your potential scorecard. And getting people to, to start looking at some of that discretionary effort and looking at, ways that we can incentivize that aren't just that billable hour, because I think that's gonna make it very difficult to.

Articulate the value-based care, um, but then also meet those metrics when, when it is afforded to us. I think a lot of health plans are gonna come back and be like, you guys don't really know what you're doing, but that's because we've done so much adding bonuses and pay raises. And if you bill 30 hours a week, you get x bonus.

If you bill 35 hours a week, you get this bonus, and now all of a sudden we're gonna be like, It's not what you bill, it's how we move kids through the system that matters. Um, I think that's gonna be a little bit of a different shift for us, which is surprising because, you know, scorecards and value-based systems by the heart of it, are behavior analytic But we've, we've all just been taught under this fee for schedule and we just do it.

But if we can start to envision how we make our systems operate more behavior analytic, then I think that, um, that transition will go much better.

Diana, so tell me, are you ready for the hot take questions?

I can't make it perfect, but I do. Um, that's how I got started here when I realized that I had a lot of privilege and still couldn't navigate the system for my son, and that was when I knew I needed to shift from the clinical realm and get into the advocacy realm and do that work.

And then I have a toddler, so it's very, very bizarre. Um, and I know it sounds really cliche and really odd but having these conversations are really, really grounding for me. they don't take work. I don't think of them as work. Um, so I really do enjoy, um, being a visionary and times that I can do that, whether it's in my car driving, I do a lot of that where I will just say, you know, I'm just gonna drive the long way this time. Um, just so that I, you know, and I, and that's what I do.

I just process like all of these, things. I also do a lot of self-reflection, and I teach this in my classes is, you know, after this call, I'll spend the next hour, like, you know, and then I'll listen to it and be like, I should have used this terminology, or maybe I could have said this difference. And I do a lot of, self-reflection because I, I like to grow as a professional, um, and, and personally. And I find that, that has to start within myself.

and so I do a lot of self-reflecting and kind of visionary work.

Anyway, it came out when he was on Nashville Star, again, I'm a country music nerd. when he won the championship, the rendition that he sang of that was just like, it still gives me chills. So that's probably, you know, kind of my go-to like, Hey, I wanna listen to this song. But again, it's kinda out there. not a lot of people know it, but that, Nora Jones is another one.

I normally listen to Country, but you put on some Nora Jones and I am, I know that's not a song, but, um, I'm not really good at remembering songs. I could sing it to you, but nobody wants to hear me sing. But

Um, I'll bend a couple of rules if I know that I have the documentation to kind of support why it's necessary for this particular circumstance. So I'm a little bit of a risk taker, but in life in general, I'm actually risk averse. And so, I spent most of my childhood and early adulthood just, you know, living everything by like, you're supposed to do this and it's supposed to look like this. So, we talked before this call that I've never gone skiing, um, or snowboarding.

Well, because there's risks associated with it. I don't swim because there's risks associated it with it. Believe it or not, I didn't fly in a plane until I had to start traveling for conferences because there's risks associated with it. Um, I don't let my husband drive. Because there's risks. I don't know why my drive, I think my driving is better. I don't know.

but yeah, I'm very risk adverse and I wish that I, I wish that I would've spent some time at 18 kind of just exploring different things because now everybody is like, Hey, so I'm way past those days and I'm like, I don't even know what you're talking about. Like, I, you know, those weren't even a thing. So I think just living a little, maybe taking some, some time to, explore the teenage world. learning to swim, maybe learning to snowboard something

But um, I think other people get a little bit thrown off on my jeans and t-shirt when I present at conferences.