Please note that this blog is co-written by members of the ABAI Practice Board. See the ABAI Practice Board website for more information.
In Part 3 of this series, we look at the various efforts respondents reported using to address monetary and nonmonetary barriers to accessing behavior-analytic services. Ninety participants (60.8%) provided qualitative responses in this section. We organized comments into four domains: costs, advocacy, service fit, and service scope.
Many respondents indicated that, as providers, they experienced substantial financial barriers to addressing inequities in service access. The goal of the following section is to describe respondents’ answers within each domain to inform methods supporting better financial strategies to promote access.
Cost-Focused Efforts
Behavior analytic service providers who work in sectors that receive funding through government sponsored insurance, private insurance, or mix of payor coverage noted that accepting multiple sources of insurance coverage was a strategy to improve service access. However, this strategy was not viable for many respondents, noting that some sources of funding were so low that they were unable to cover their costs. Given this, it is important for service providers to understand how to best diversify their sources of funding. Dropp et al (2020) provides a comprehensive overview on various strategies on financing behavioral health systems. There are also various models on how to best optimize payer mix or account for the impact of providing uncompensated care. However, these resources are focused generally on behavioral healthcare and not specific to specialty behavior-analytic services.
Here’s how respondents are addressing barriers related to cost.
- Routinely providing families with support to identify funding sources and navigating insurance when families initiate services or have a change in coverage (e.g., monitoring open enrollment).1
- Obtaining private funding for families with low incomes (scholarships) and having robust fundraising strategies to fund all services via a philanthropic foundation partnership.2
- Using external scholarship sources or overhead funds to support pro bono and sliding scale fee-based services.3
- Using flexible payment plans and strategic service scheduling to reduce a family’s total out-of-pocket costs for copays (e.g., each encounter has a copay, so when appropriate, have fewer but longer encounters).4 This included offering modified services at lower cost to support families with inadequate means for private pay (e.g., training family members to serve as the implementers of treatment plans; limiting treatment plans to most critical needs).
- Continuing services when insurance takes longer than expected to issue authorizations or when there is a gap in service coverage that is likely temporary. This included helping families track authorized care utilization to ensure lapses don’t happen
- Providing no-cost services for therapeutic materials to families (e.g. tablet, skill-promoting materials) or when certain research protocols are applicable
Advocacy-Focused Efforts
Advocacy across levels was another area often referenced to address equity of access. At the individual-level, there were many efforts aimed at coordinating care with other agencies that provide alternative or complementary services. Respondents indicated that either within their agency or via partnerships with others, they connected clients and their families to social work services, education advocacy services, psychological assessment, and case management services. However, some respondents noted that many collaborative efforts do not fit standard billing models, and, therefore, are not used as often as might be beneficial to the family.
One respondent provided a method of advocacy for increasing access at the local-level. They noted that they held open houses so prospective families can see what behavior-analytic services offer. They also shared data with surrounding communities to promote their services.
Many respondents also described engaging in system-level advocacy. Such advocacy spanned the state and national levels, lobbying for care coverage, and ensuring sustainable provider funding. Similarly, respondents noted activities with professional organizations that lobby for adequate service funding and best practice guidelines to support funding levels for appropriate care. Two examples of system-level efforts to address cost and access included:
- One provider noted that by carefully monitoring the effects of treatment, they have been able to advocate for more funds and thus, increase the sustainability and reach of their programming. This was specifically in the context of school-based services through government funding.
- Another respondent noted the importance of negotiating higher reimbursement rates for providing behavior analytic services in geographical areas where it was difficult to staff BCBAs/master’s level clinicians. This was important for recruiting and retaining qualified providers.
Behavior Analysis in Practice has an upcoming special issue specific to public policy advocacy in behavior analysis (see de la Cruz & Brouland (2025)’s forward here). There are 7 articles that address how to improve the access to care through advocacy (see Table 1 in their article).
Service Fit-Focused Efforts
Respondents indicated several efforts to improve the fit of services to the needs of those being served. The most common was flexible hours, flexible scheduling, or both. This included after-school hours, weekends, evenings, fewer longer sessions (vs. frequent shorter sessions), and offering alternative days when a session needs to be rescheduled. The second most common was issues of location. Many providers either provide transportation to and from services or work with a third party transportation service. Other providers noted that they brought services to the clients directly by either traveling to their school, home, or providing telehealth services.
Image by Twinster Photo from Pixabay
Different types of service locations were noted to have different benefits for individuals and families.
- School-based services occur within established educational routines/hours and do not require any additional transportation or resources. In places with year-round schooling, these benefits are more consistently realized throughout the year.
- Clinic-based services may double as respite services for family members, given the flexibility it gives when the client is receiving services. Some providers noted that providing childcare services was an important determinant of care access in that childcare or respite services are often necessary due to family work schedules and other competing commitments that would otherwise interfere with the ability to access care.
- While home-based services require the presence of a guardian, they do relieve the family from transportation-based barriers. One of the most innovative services noted by a respondent involved the provision of home organization assistance to help families establish an appropriate service space in the home when home-based services are provided. Some non-US-based providers who did not provide home-based services noted that making home visits was a useful way to help identify additional family support needs. Other non-US providers indicated they extended their services to other daycare settings and nursery programs.
- Several providers noted that they used telehealth to improve access to services but none of these respondents provided any additional details regarding the benefits of this format. This includes individuals working in schools who provide hybrid education experiences (higher education context).
The onboarding process for services can often involve a lot of time and paperwork. It can be a significant burden for families to organize the anticipated information needed and bring them to an office for processing. Digital forms were mentioned as tools for decreasing paperwork burdens. One respondent noted also providing virtual support to aid families in completing their onboarding process for their services from home. Another respondent noted that a clinic representative would meet families wherever they needed to facilitate completion of onboarding paperwork.
Service Scope-Related Efforts
A few respondents noted efforts to hire staff to increase their capacity to provide services as well as the range of services provided. This also included interpreters or bilingual providers to increase the accessibility of services to clients and families. Similarly, a few noted efforts to hire a diverse workforce that reflects the communities they serve.
Several providers indicated that they provide caregiver training and support as a means of increasing access to quality care via the family providing better continuation of care and skills maintenance. A few respondents indicated that they provide wrap-around services or write comprehensive treatment plans reflecting the 24-7 needs of clients and their families so they can proactively address needs that can negatively impact care access. One respondent noted that individuals on their waitlist receive some level of support.
Call to Action
After reviewing these barriers to equity of services and how respondents attempted to address them, there is a clear gap in the literature to support these efforts. While we were able to identify some central themes for success, no respondent referenced any established methods that guided them. Advocacy is one area receiving more attention (see Behavior Analysis in Practice Special Issue or Perspectives on Behavior Science Special Section). However, there is still a need for specific recommendations on how to address service inequity through advocacy.
Furthermore, recommendations are nonexistent on how to combat behavior analytic service inequity when cost prohibits it. This includes methods to diversify reimbursement (e.g., payer mixture, portfolio management) as well as accessing additional funding sources (e.g., grants, scholarships, sliding scales). The practice board is issuing a call to action for recommendations, strategies, and models from those knowledgeable in this sector to consider sharing their lessons learned and effective practices with the field. We welcome any submissions to the committee for a blog post or a proposal for a webinar.
Image by Cheska Poon from Pixabay
- Magnabusco (2006), Powell et al. (2016), Scudder et al. (2017) ↩︎
- Jaramillo et al. (2018), Jones et al. (2014), Magnabusco (2006), Stroul et al. (2009) ↩︎
- Armstrong (2012); Jaramillo et al. (2018); Jones et al. (2014); Nagle & Usry (2016); Rieckmann et al. (2015) ↩︎
- Miller et al. (2016), Velott et al. (2016) ↩︎
References
Armstrong M. I., Milch H., Curtis P., & Endress P. (2012). A business model for managing system change through strategic financing and performance indicators: A case study. American Journal of Community Psychology, 49, 517–525. https://doi.org/10.1007/s10464-012-9512-z
Dopp, A. R., Narcisse, M.-R., Mundey, P., Silovsky, J. F., Smith, A. B., Mandell, D., Funderburk, B. W., Powell, B. J., Schmidt, S., Edwards, D., Luke, D., & Mendel, P. (2020). A scoping review of strategies for financing the implementation of evidence-based practices in behavioral health systems: State of the literature and future directions. Implementation Research and Practice, 1. https://doi.org/10.1177/2633489520939980
Jaramillo E. T., Willging C. E., Green A. E., Gunderson L. M., Fettes D. L., & Aarons G. A. (2018). “Creative financing”: Funding evidence-based interventions in human service systems. Journal of Behavioral Health Services Research, 46, 366–383. https://doi.org/10.1007/s11414-018-9644-5
Jones A. M., Bond G. R., Peterson A. E., Drake R. E., McHugo G. J., & Williams J. R. (2014). Role of state mental health leaders in supporting evidence-based practices over time. Journal of Behavioral Health Services Research, 41(3), 347–355. https://doi.org/10.1007/s11414-013-9358-7
Magnabosco J. L. (2006). Innovations in mental health services implementation: A report on state-level data from the U.S. Evidence-Based Practices Project. Implementation Science, 1, 13. https://doi.org/10.1186/1748-5908-1-13
Miller N. A., Merryman M. B., Eskow K. G., Chasson G. S. (2016). State design and use of Medicaid 1915(c) waivers and related benefits to provide services to children and youth with autism spectrum disorder. American Journal on Intellectual and Developmental Disabilities, 121(4), 295–311. https://doi.org/10.1352/1944-7558-121.4.295
Nagle G. A., Usry L. R. (2016). Using public health strategies to shape early childhood policy. American Journal of Orthopsychiatry, 86(2), 171–178. https://doi.org/10.1037/ort0000088
Powell B. J., Beidas R. S., Rubin R. M., Stewart R. E., Wolk C. B., Matlin S. L., Weaver S., Hurford M. O., Evans A. C., Hadley T. R., Mandell D. S. (2016). Applying the policy ecology framework to Philadelphia’s behavioral health transformation efforts. Administration and Policy in Mental Health and Mental Health Services Research, 43, 909–926. https://doi.org/10.1007/s10488-016-0733-6
Rieckmann T., Abraham A., Zwick J., Rasplica C., & McCarty D. (2015). A longitudinal study of state strategies and policies to accelerate evidence-based practices in the context of systems transformation. Health Services Research, 50(4), 1125–1145. https://doi.org/10.1111/1475-6773.12273
Scudder A. T., Taber-Thomas S. M., Schaffner K., Pemberton J. R., Hunter L., & Herschell A. D. (2017). A mixed-methods study of system-level sustainability of evidence-based practices in 12 large-scale implementation initiatives. Health Research Policy & Systems, 15, 102. https://doi.org/10.1186/s12961-017-0230-8
Velott D. L., Agbese E., Mandell D., Stein B. D., Dick A. W., Yu H., Leslie D. L. (2016). Medicaid 1915(c) home and community based services waivers for children with autism spectrum disorder. Autism, 20(4), 473–482. https://doi.org/10.1177/1362361315590806
This is an impressive series of posts so far. I commend the ABAI Practice Board for confronting a problem that challenges our “save the world” conception of our selves and that results from big-picture factors that probably nobody can directly alter. Yet calling it like it is, rather than pretending that all is well, is essential to forging a better discipline. That is to say, we have to hold ourselves to high standards, even when the sort term outcome is to highlight that there’s plenty of work to be done. That’s the only chance we have of MEETING high standards. I hope this important conversation about equitable access to ABA services continues long beyond the run of this series of posts.