Master ABA

Navigating the Influence of “Big Business” in Applied Behavior Analysis

The need for ABA services continues to rise and the demand for certified staff is following. This rise is due to a variety of factors including:

  • Increase in the number of children diagnosed with autism
  • All 52 states mandating insurance coverage for autism treatment
  • Increased awareness of the effectiveness of ABA services

Prevalence statistics vary depending on the source and the population included in the statistics. The World Health Organization estimates that 1 in 100 children world wide are autistic and that 1 in 44 in the US are diagnosed with autism annually. This higher prevalence is possibly due to an increased awareness and better access to diagnostics.

In response to this surge of need, states began mandating coverage for treatment for symptoms related to an autism diagnosis. The first law enacted that required coverage for ABA services was the Riley Ward Act, which was established in Alabama in 2012. Since then, all 52 states and the District of Columbia have enacted laws requiring coverage.

According to the CDC, ABA is the most widely accepted and evidence-based treatment for autistic children.

Given these important facts, the rise of “Big Business” entering into the field of ABA, is not surprising. There is a huge need for services and those services are mandated to be covered by insurance. That has huge potential for revenue and leaders in “Big Business” see $$$$. It is imperative that BCBAs understand the impact of large-scale business operations in our field.

The Emergence of “Big Business” in ABA

Firstly, let’s establish what we mean by “Big Business” in the context of ABA. It refers to the involvement of large, often private equity firms, as well as the consolidation of smaller ABA service providers into larger entities. This trend suggests a growing commodification of ABA services. According to a BusinessWire report, the U.S. autism treatment market, which includes ABA services, is projected to reach a valuation of approximately $2.23 billion by 2022 (BusinessWire, 2018).

Some of the largest private equity firms that own ABA companies include:

  • Blackstone
  • Stepping Stones Groups
  • Hopebridge
  • LEARN Behavioral
  • Centria Healthcare
  • BlueSpring
  • Autism Learning Partners
  • Kadiant

The emergence of “Big Business” into the field of ABA is changing the landscape of the field in ways many may not expect. As with nearly everything, the increasing involvement of “Big Business” in ABA presents both opportunities and challenges in the field.

However, this trend could also introduce concerns related to the quality and ethics of ABA services. TAdditionally, the increasing commercialization of ABA services may shift focus towards a more standardized,

The Potential Benefits

The influx of investment from private equity firms can lead to some significant benefits to those working in the field and those receiving services. These include:

  • Scalability: With more considerable capital, providers can extend services to a broader demographic, potentially reducing waiting lists, improving access to care, and addressing unmet needs. It can also present BCBAs with more employment opportunities and resources to better serve their clients
  • Standardization: Large-scale operations may facilitate uniformity in treatment delivery, which can help with the implementation of best practices across different service areas.
  • Research and Development: Increased funding can mean more resources allocated towards innovation, leading to advancements in treatment methodologies that might otherwise be under-resourced.

Addressing the Concerns

However, this rise of “Big Business” brings about legitimate concerns that must be vigilantly monitored:

  • Ethical Dilution: As reported by markets.businessinsider.com, there’s a risk that financial incentives overshadow ethical considerations, potentially compromising client-centered care.
  • Quality versus Quantity: The push for business expansion could prioritize client volume over the quality of services delivered, thereby impacting the efficacy of ABA interventions.
  • Professional Autonomy: A business-driven approach may constrain the clinical judgment of practitioners, as cost efficiency begins to drive therapeutic decisions.
  • Oversaturation: “Big Business” flooding the field with more and more service options could lead to increased competition for clients and possibly affect the sustainability of ABA practices in the long term.
  • Pressure for Profit: The prioritization of profit over client welfare, a potential consequence of “Big Business” involvement, might lead to conflicts of interest and compromises in care quality. BCBAs could face pressures to alter their clinical judgment or therapeutic approaches to align with corporate goals rather than individual client needs.
  • Standardization: In an effort to control quality of services, large ABA companies attempt to create a one-size-fits-all approach, potentially overlooking the nuanced and customized nature of effective ABA therapy.

Not all impacts fall neatly into the pro or con side of the list, as you can see with standardization falling into both the advantages and disadvantages of “Big Business.”

No matter what changes continue to happen, the landscape of employment for BCBAs has begun to shift, with more BCBAs moving into new roles within larger organizations. This could impact their autonomy in practice, the client-therapist ratio, and the overall dynamic of ABA services delivery, but it provides them with a potential platform to make a broader impact for a larger number of staff and clients. BCBAs must be equipped to make some hard choices about their careers.

Is “Big Business” Actually the Problem?

A tale of 2 ABA companies

In 2019, I moved from New Hampshire to Florida to be with family and enjoy the amazing Florida weather. I had heard the rumors of the unethical practices happening in FL, especially the unethical billing practices. I anxiously researched every company I considered applying to, nervous about finding a company that was ethical.

I applied for several positions with both large and small companies. Through phone interviews and ongoing research, I narrowed my options down to just 3 possible positions that I would interview for in person when I traveled to FL, 2 with smaller companies, and 1 with a very large ABA company.

For a variety of reasons, I ended up choosing the position with the large ABA company and within a matter of 2 weeks began regretting my decision. Here are some of the things that I saw when working for this company:

  • Directing funds away from front-line staff
    • I received a relocation bonus when I accepted the position
    • The company paid for me to spend my first week in a hotel to do training at their main offices. They spent days training me to use their online data collection system.
    • There were a very large number of people working for the company who brought no revenue into the company including:
      • Entire “C-suite”-CEO, CFO, CIO, etc.
      • IT department
      • Credentialing department
      • Recruiting department
      • Intake department
      • Billing department
      • A lawyer
      • 2 BCBAs per region to oversee the clinical and financial operations of all the clinics
      • Operations manager for each clinic
      • Receptionists
      • Etc.
  • Standardization
    • The BCBA who oversaw much of the clinical work in our region was working to develop a set of Standard Operating Procedures to be used throughout the company. These included procedures for:
      • Feeding
      • Toilet training
      • Other sensitive topics that should be individualized
      • Nearly every detail of the clinic. I couldn’t even order a step stool for our clinic without referencing the “style guide.”
  • Required Meetings
    • Regularly scheduled weekly, monthly and quarterly meetings regardless of need
  • Focus on revenue
    • Monthly report that detailed revenue from each client based on
      • Rate from insurance
      • Number of direct service hours
      • Concurrent billing availability
      • Etc.

After 6 months of this backwards thinking, I had to find a different position. In fairness to this company, I had only worked for nonprofit companies since 1997 so I had a very different mindset. I acknowledged that this was not a bad company, it was just not a good fit for me.

I took a part-time position with a nonprofit company I found about an hour from my house, further with traffic. It was refreshing to work in a nonprofit again, having my values align with those I was working with. But 6 months after I accepted the position, the director told me that the nonprofit sold the ABA portion of the business to a for-profit company that was owned by an occupational therapist. We were told that nothing would change.

Here’s what I saw:

  • Weak or nonexistent training/onboarding for new staff, especially RBTs
  • No support for BCBAs
  • No quality oversight for services
  • Limiting supervision for clients whose companies don’t allow for concurrent billing
  • Focus on revenue (see the quote below)
“Our profit margin for the ABA department is currently not sustainable to stay in business with the way we are currently running this part of our business…the real cost of paying a BCBA is much more than their hourly rate or their salary. There has to be a certain number of RBT hours billed just to pay the BCBAs salary.”

This is an actual quote from a very long email sent by the company owner to ALL the ABA staff, including RBTs. He went into details about the cost of staff training, salary and benefits. He told staff that he would stop paying for overtime, admin time, PTO, and benefits.

So where is the real problem? It’s obviously not just with “Big Business.” I wish I could say that these are companies that are exceptions, but this attitude has become common.

Our Path Forward

In balancing the scales between business growth (be it “Big Business” or small companies) and ethical practice, we must engage in continuous dialogue, education, and advocacy. As BCBAs, we have a responsibility to navigate this complex environment with transparency, integrity, and unwavering commitment to our clients’ wellbeing.

Our role is to synthesize these developments, assessing the organizational ethos of the companies we engage with or work for, and ensuring that client outcomes remain at the heart of all service delivery. This can be difficult to do when we rely on these companies to pay our bills. After all the hard work of becoming certified, our futures are far from guaranteed.

Protect Yourself and Your Career

When working for any company, large or small, it’s critical to put things in motion that protect yourself and your career. Diversifying your income is a vital step in this process.

Starting an information or consultation business as a side hustle can be an empowering and fulfilling choice for BCBAs. It not only provides alternative income but also offers opportunities to take a stand against unethical practices that some employers may engage in. Here are some positive aspects to consider:

  1. Independence and Autonomy: By starting your own business, you gain the freedom to set your own schedule, choose your clients, and decide on the services you offer. This level of independence allows you to align your business with your ethical values and prioritize the well-being of your clients.
  2. Making a Positive Impact: As a BCBA running your own business, you have the opportunity to make a direct and meaningful impact on the lives of individuals with autism and their families. You can provide personalized and evidence-based services that truly meet their unique needs.
  3. Advocacy and Ethical Practice: Having your own business gives you the platform to advocate for ethical practices in the field of ABA. You can ensure that your services are delivered with integrity, adhering to the highest ethical standards and prioritizing the well-being of your clients.
  4. Flexibility and Work-Life Balance: Running a side hustle allows you to have more control over your time and achieve a better work-life balance. You can choose to take on clients and projects that align with your availability and personal commitments.
  5. Professional Growth and Development: Starting your own business provides opportunities for continuous professional growth. You can invest in your own learning, attend conferences, and collaborate with other professionals to expand your knowledge and skills in the field of ABA.
  6. Financial Security and Diversification: Having a side hustle can provide an additional stream of income, offering financial security and stability. It allows you to diversify your income sources and reduce reliance on a single employer.

By starting your own information or consultation business as a side hustle, you can create a positive and ethical impact in the field of ABA while enjoying the benefits of independence, flexibility, and professional growth. It empowers you to stand up against unethical practices and prioritize the well-being of your clients, all while building a rewarding and fulfilling career.

The emergence of “Big Business” in ABA is a multifaceted trend with substantial potential impacts. While acknowledging the potential enhancements to service accessibility and innovation, we must remain steadfast in our ethical obligations. Let us continue to share insights, uphold the highest standards of practice, and collaborate towards a future where growth aligns with the core values of our profession.

We are not just BCBAs. We are stewards of behavior change, committed to the betterment of those we serve. Let’s journey together toward an ethically sound and effective ABA practice amidst the everchanging business tides.

Next Steps

Learn more about ethical decision making practices. We offer a CEU course called The Moral Tightrope: Why Good People Sometimes Choose the Wrong Path. This course is currently only available in our membership, the Dojo at the Master ABA Academy or in the BCBA Toolbox.

Through Master ABA we Empower Advocate and Transform BCBAs by helping them develop confidence in their skills. Join The Balanced BCBA to learn the framework we created to build Master ABA. Take control of your career today!

Through The Balanced BCBA you will learn how to create a meaningful impact and connect with your ideal customers. We walk you step-by-step through the process of starting your own information or consulting business. Finally, you can create an income that doesn’t rely on insurance-funded or school-based services! Click here to learn how!

References

Autism acceptance: 15 stats on Autism Spectrum Disorder. (n.d.). Cigna Healthcare Newsroom. https://newsroom.cigna.com/autism-spectrum-disorder-stats

Autism and insurance coverage state laws. (2024, April 26). https://www.ncsl.org/health/autism-and-insurance-coverage-state-laws

Kogan, M. D., Vladutiu, C. J., Schieve, L. A., Ghandour, R. M., Blumberg, S. J., Zablotsky, B., … & Lu, M. C. (2018). The prevalence of parent-reported autism spectrum disorder among US children. Pediatrics142(6).

Larson, C., & Larson, C. (2022, July 30). Why the Massive Investment in Autism Companies Created a ‘Ticking Timebomb’ Behavioral Health Business. https://bhbusiness.com/2022/07/22/why-the-massive-investment-in-autism-companies-created-a-ticking-timebomb/

The U.S. Autism Treatment Market is Expected to Reach $2.23 Billion by 2022 – ResearchAndMarkets.com. (2018, May 1). BusinessWire. Retrieved April 29, 2024, from https://www.businesswire.com/news/home/20180501005785/en/The-U.S.-Autism-Treatment-Market-is-Expected-to-Reach-2.23-Billion-by-2022—ResearchAndMarkets.com

Treatment and intervention services for autism spectrum disorder. (2022, March 9). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/autism/treatment.html#:~:text=Behavioral%20approaches%20have%20the%20most,Applied%20Behavior%20Analysis%20(ABA).

World Health Organization: WHO. (2023, November 15). Autism. https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders

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