Value-Based Care in ABA: What You Need to Know
How moving to a Value-Based Care model could change our field for the better
Today I want to tell you about the Value-Based Care model of service delivery and why I think this model is important and intriguing.
So, what is Value-Based Care?
First, it’s important to understand the way we—as ABA providers—bill and receive reimbursement right now.
ABA providers are reimbursed using a Fee for Service model (FFS). That means that ABA organizations are paid for each service that they provide, oftentimes through an hourly rate. For example, most treatment plans are submitted to insurance every 6 months. Within the treatment plan, a request for treatment hours is made for the following six months. Given the request is accepted, the BCBA and staff are then allotted those treatment hours. They bill for those hours. The organization is then reimbursed for those hours. You know the drill.
Under the FFS model, the ABA provider is almost always going to get paid as long as they provide the service. If a consultation with a client occurred and was billed for, it’s likely they’ll be reimbursed. Getting paid isn’t necessarily contingent on quality outcomes. Instead it’s contingent on delivering the service. If consequences drive behavior, that means that the FFS model might incentivize organizations to deliver and request more services (more unnecessary hours), instead of incentivizing them to deliver quality outcomes.
Value-Based Care is different.
Value-Based Care (VBC) looks to reimburse an ABA company based on performance as opposed to the amount of services delivered. The idea is to incentivize results while keeping treatment costs at a minimum. A provider’s performance would be measured across several different domains that could include clinical effectiveness, cost efficiency, and quality of experience for the family (Cameron et al., 2022).
Your clinic or organization would likely be evaluated on their performance as a whole, across all of their learners (or at least a cohort of clientele in a similar age group, for example). This differs from the case by case approach we use now. Wraparound collaboration with and from physicians, family therapists, and other professionals might become necessary—maybe even required. After all, physiological and environmental concerns (beyond the clinical environment) can impact learner success.
A couple thoughts here…
First, a switch to a VBC model (or similar) could very much happen.
Autism services are darned expensive. The average child with Autism will rack up over $40,000 a year in ABA service costs alone. There are very few medical services as exhaustive and costly.
At some point, insurances and families will want to ensure they are getting as much bang for their buck as they can. They’ll want to take a good hard look at the feasibility of the FFS model. They’ll likely realize a need for a system that incentivizes quality, cost, and outcomes more than it does service volume.
Second, I think this could be a good thing for BCBAs.
Why? VBC and the emphasis it places on clinical performance could require organizations to pivot towards the clinical needs of the organization (as opposed to vast expansion). If getting funding is linked to clinical quality, then an investment in trainings, curricula, day-to-day systems, technology, and general clinical support for BCBAs should become a priority, as well.
A couple of things you can do now:
Check this article out by Dr. Michael Cameron and colleagues. This is a very informative summary on the nuances and merits of the VBC system (citation below).
Become familiar with the BHCOE and ICHOM. If clinical performance and overall quality are going to be measured, then performance standards need to exist. Both of these organizations have begun to set criteria out for outcome measures, performance standards, accreditation, etc..
Hit me back with your thoughts. Would love to get your feedback!
Cameron MJ, et al. Toward a Value-Based Care Model for Children with Autism Spectrum Disorder. OA J Behavioural Sci Psych 2022, 5(1): 180065
So, I get what you are saying, but, on the other hand imagine if other fields and disciplines worked with way? Say, for example, psychiatrists, psychologist, the pharmaceutical field? How many families do we know that go through round and round of drugs before they find something that maybe works a little, or some not at all? Or it works, but it doesn't last...could you imagine the professionals in those fields only billing for outcomes? The same thing for our field, imagine staff giving it their all, trying to work with a family, but only making minimal progress...would you still say that they can only bill for the outcome?
Now yes, I will admit that there are some field in which this has shown to work (lawyers, brokers, etc.) and it seems to work in those fields, but I really don't think it would work in ours...how do you put a price tag on an outcome? How do you operationally define the price equivalency of the outcome of a student? or even the hours needed to be put in for that specific outcome? Teaching one student to brush their teeth might be walk in the park, and for another studen simply getting them to hold the toothbrush is a struggle.
There has to be a balance between the outcomes, the leg work, and even the responsibility. Especially with the way billing works right now, is anyone keeping track of the tons of minutes here and minutes there that you spend extra on each of your students in order to bill? Even if it would be billable anyways with the new reqs.
This is so important! I’m excited to see what BHCOE does with their partnership with Cigna and with Centene.