A CASE FOR / AGAINST CLIENT SELECTION (EIBI vs. CHALLENGING BEHAVIORS)

I wanted to share this exchange I’m having with a BCBA on Reddit…

FROM BCBA (IN RESPONSE TO OUTCOMES-BASED REIMBURSEMENT MODEL / CLIENT SELECTION)

Part of the reason for the tiered model is that the bulk of direct work in an EIBI program takes very little skill. I can train someone to implement one of my programs to high-fidelity in an afternoon. I’ve been practicing for over a decade and sometimes parents or new techs are genuinely better at direct services than I am. In terms of learning outcomes, the actual difference between an excellent tech and an average tech is pretty low.

It’s difficult to measure outcomes, they can be easily fudged, and reimbursement linked to outcomes would only encourage client pre-selection.

Also, client pre-selection and “cookie cutter” approaches is typically good for the field and the consumer. If a standard cookie is what 80% of your clients need you can pump out standard cookies and have a separate kitchen/refer out the other 20% for bespoke cookies.

MY RESPONSE

Certainly, for any business, standardization is the goal because it drives efficiency, which reduces costs. But in our field, when we’re dealing with people, how do we make sure that the outliers – i.e. difficult cases – are also getting services when the profitability model clearly favors standardization?

You mention referring out. Maybe that’s the model that the field needs to move to – agencies that specialize in difficult cases, reimbursed at higher rates to compensate for the greater degree of specialization. Similar to the medical model.

But since our field isn’t currently set up this way, how do we make sure that the “difficult cases” are not being passed over for the easier EIBI cases? Incidentally, this seems to be the trend, especially in many large agencies.

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QUESTION… Do you think it’s unethical for a business to cherry-pick cases? In any other industry, it’s the prerogative of a business to decide to whom they want to provide services.

But in the field of ABA, with an existing system with ABA organizations that were previously set up to treat all levels of challenges across the board, what impact will this bias towards EIBI cases (i.e. cherry picking) have on the lives of clients who fall outside the norm?

Whose responsibility is it to ensure that consumers with challenging cases are getting access to services they need in a timely manner, without being discriminated against when the economics of the business clearly favor standardization?