3 Pie Squared and ABA Business Leaders

ABA on Tap is proud to present a very special, super tasty, full-bodied brew for this episode. It is our honor to host Stephen and April Smith from the 3 Pie Squared--ABA Business Leaders podcast. Dan and Mike were extremely grateful to have appeared as guests on their podcast in November of 2023. Stephen and April cover a variety of topics all under the umbrella of ethically and fiscally sound ABA practice. Their courses and consultation services have proven instrumental to hundreds, if not thousands, of ABA professionals across North America.

You can pour this one over several times for sure. It's cold, a bit bitter, certainly sweet with a lot of clarity. It packs a punch--sip, relax and always analyze responsibly.

All ABA on Tap brews pair well with cerebration. SO--if you are ready to enjoy the benefits of Magic Mind and boost your brain performance, please use the following link and use the discount code AOT to receive 20% off your purchase, and 56% off a subscription.
https://www.magicmind.com/aot  

Transcript

SPEAKER_02: 0:00

Welcome to ABA on Tap, where our goal is to find the best recipe to brew the smoothest, coldest, and best tasting ABA around. I'm Dan Lowry with Mike Rubio, and join us on our journey as we look back into the ingredients to form the best concoction of ABA on tap. In this podcast, we will talk about the history of the ABA brew, how much to consume to achieve the optimum buzz while not getting too drunk, and the recommended pairings to bring to the table. So without further ado, sit back, relax, and always analyze responsibly.

SPEAKER_01: 0:54

All right, all right. And welcome yet again to another installment of ABA on Tap. I am your co-host, Mike Rubio, along with Daniel Lowry. Mr. Dan, how you doing? Doing great. Very excited for today's episode. I am super excited for today's episode. We are very, very honored to have Stephen and April Smith as guests on today's podcast. How you guys doing, Stephen and April?

SPEAKER_04: 1:21

We're great. Doing good? Thanks for

SPEAKER_01: 1:24

having us. Thank you. Thank you for your time. Thank you for accommodating our Sunday recording schedule that just seems to work best for us and our activity. So we were honored to be guests on your podcast. I think it was back in October, November of 2023, and that turned out well. So thank you for returning the favor. We have a million questions to ask you guys. We'll try to keep it to about 500,000. I think we have time for that many, right? You were saying. Both of you and 3Pi Squared and the ABA business leaders courses have really been instrumental in helping us plan for our future, so we're very appreciative.

SPEAKER_04: 2:31

Wow, so glad to hear that.

SPEAKER_01: 2:33

All right, well, Mr. Dan, you want to kick us off? I guess the first thing's first. Let's just hear the origin story. Again, you guys have certainly become heroes to us in our current quest. So tell us how you got started. I know that you were in more direct practice, and now maybe you spend most of your time with consulting. Give us a little synopsis here on the origin story.

SPEAKER_04: 2:58

Yeah, definitely. I would be happy to. Yeah, so I have been in the ABA field since, I don't know, the early 90s, back before all of the BCBA and insurance. Back before it was cool, yeah. So, yeah, so I've been in the field as a tech, you know, back then we called it behavioral therapist. Yep. But anyway, ABA line therapist, you know, back in the early... I think my first training was in Lovaas Training. So I've come quite a long way and seen the industry change and grow over this last bit. But I guess to bring us to when we started together is we were living in Virginia. We had just moved to Virginia from South Carolina, and I was looking for a job in the ABA industry. And There was nothing. And I thought for sure, we were outside of DC. We would have like a lot of opportunities much greater than South Carolina, but it just really didn't work out. And so we were on a walk in our neighborhood and we, Steven said, there's gotta be kids on the spectrum who need services here. Because at that point we were just enough out in the suburbs that DC people who worked in DC wouldn't come quite as far. So that's when we decided we would start our own ABA agency. And so we started all self-pay.

SPEAKER_03: 4:31

That was in 2012, I think, right? Yeah. 2011.

SPEAKER_02: 4:36

Oh, wow. Okay. So fairly recently. Okay. About 10-ish years ago, a little

SPEAKER_04: 4:41

more? Yeah. So I did the clinical end, and this was there again before insurance came. And then I hired my first tech, and she was like, admin tech, and we were just really winging it. Like, we were just... Well,

SPEAKER_02: 4:58

you can do that when it's self-pay, right? You can wing it a little bit more.

SPEAKER_04: 5:01

Well, I mean, and this was before insurance mandates. This was before, you know, like, you know, there were no licensures yet. Like, this was really still the beginning of a lot of it. Maybe there were some in Florida. Maybe Florida had already.

SPEAKER_01: 5:15

It had just started probably, right? So 2012 was when California kicked in, and we weren't necessarily early to that game. So, yeah, you guys were right at the start of everything.

SPEAKER_04: 5:24

So, yeah, so we, you know, we did a couple of years and then it started to take off and, you know, we started to get, you know, wind up the insurances and things were really getting like real. Right. And so Stephen decided he was he had a full time job as an engineer, completely different than the ABA field. And and he had been helping engineers.

SPEAKER_03: 5:49

Research, right? Well, I did the website. I started her QuickBooks account so that she could actually get paid because you do it for free. And so I was kind of like that back-end guy, right? And then we kind of put together a rainy nest fund, and we said, once we get to a certain point, I'm going to quit my job, and then I'll do this full-time.

SPEAKER_02: 6:17

Was that nerve-wracking, Stephen?

SPEAKER_03: 6:19

Oh, it was, well, you know what? I was, it was pretty good up until I did it. And then about a week after I quit my job, we found out she was pregnant and I was like, what did I just do? Like I had eight weeks of vacation. I had full benefit, like amazing insurance. I think our co-pays were like$5, right? Like it was just, uh, and we didn't have insurance. Like what did, what did I do? And so you're like, just kidding boss, open the clinic at that point, maybe three months later. And we were getting Kaiser audits in our home while you were breastfeeding our son. It was madness. That year was insane. That first year after I quit my

SPEAKER_04: 7:05

job. I was talking to a friend the other day and she's also in the ABA field and she was thinking about getting started and she was specifically asking me questions about the first year. Our first real legit year. I could answer. I don't remember anything other than

SPEAKER_01: 7:24

we made it. You guys left it out of the courses.

SPEAKER_02: 7:30

You might have had some pregnancy brain there too, so that's

SPEAKER_01: 7:33

probably fair as well. It's like pregnancy, right? You're supposed to forget the hardship, otherwise you don't do it again.

SPEAKER_03: 7:38

Exactly.

SPEAKER_01: 7:40

Let me take a step We did a

SPEAKER_03: 7:42

panel, like an ABA business panel with, I think there was six people And five of them were former business owners. So it's like, yeah, that makes sense to us, right? Like, there are a lot... Like, it's hard to do this, right? And if you just want to be a BCBA, then be a BCBA, right? Because you're not going to be one when you start a business anymore, right? It very quickly

SPEAKER_04: 8:08

just turns into

SPEAKER_03: 8:08

something

SPEAKER_04: 8:08

different. Exactly. Well, and then, you know, we were still working out of our house and... We hired our first BCDA. And like you said, we were by that, like a year or year and a half later, we were doing Kaiser audits in our houses before we moved into a clinic space. But that's when I realized, oh, wow, this isn't just about me working with the kids and then hiring a bunch of kids to work with me to work with the kids. I have to lead this team. I have a team. I've got to tell people what to do. And we have to come up with policies and procedures. And the only thing that I could really just try to remember what other companies I worked for. And not even knowing why some of their policies and procedures were in place, but to well that's how they did it so maybe we should try doing it that way yeah yeah

SPEAKER_03: 9:01

and so then going through our first optum audit and kaiser audit was quite eye-opening right and the amount of policies and procedures that they needed and so my background like i've been through aerospace audits and automotive audits for you know engineering so it's kind of my as boring as that may sound that's kind of my wheelhouse and and so that's where i started right i was like You know, we went back and forth, like April said, like scouring the internet. You know, we found the Facebook groups. Well,

SPEAKER_04: 9:32

even then there weren't that

SPEAKER_03: 9:33

many. There weren't that many, but there were some good ones. But I made so many mistakes, right? And then I just went, why are we doing it this way? Why don't I just, like, how I would pass any audit in engineering? And so that's when we started the quality management system, and we just started laying things out. And we probably did that for two years. And we expanded quite quickly. We went from one BCBA to, I think, seven in about two and a half years. And, you know, all the RBT's that went with that. And we went from no clinic and all in home to a 4000 square foot clinic plus in home. and uh april april just hit the gas and she's like dude that's it i'm done or yeah sorry i yeah yeah you were i wanted to hit the gas i was like fan like i was fantasizing about our second clinic and uh and she was like no that's it we're done whoa to go find something else to do. Well,

SPEAKER_04: 10:34

we're not done. I did say we're done, but we weren't growing too fast. I was getting a little too wobbly. And I just didn't have the energy and the skills really still. I mean, I was still like... learning how to manage what I had and things were going a little too fast. And so we did, we decided to kind of, you know, put a pause on that growth so that, because I didn't want it to fall out from underneath us either. Right.

SPEAKER_03: 11:02

And then in the meantime, I saw a bunch of people just like April in Facebook groups saying, how do I pass these audits? What policies and procedures do I need? And And so I reached out to, you know, Robin was my first customer. She's a behavior op. What is it? I'm flaking on the name. Yeah, I'll have to. Sorry, Robin. But yes, she was in Atlanta and she needed some help. And so I shared my policies and procedures with her. And I was like, OK, wow, I can make a business out of this. And yeah. Like I said, I needed something to do. And then I started sharing this with more people. And so probably 2017, February of 2017 is when I opened 3Pi Squared. And then I would say within six months, I pretty much removed myself from Corner Piece and was mostly full-time with 3Pi Squared at that point.

SPEAKER_01: 12:11

Yes,

SPEAKER_02: 12:13

absolutely. So covered a lot of ground with that one. And a few of the questions that we had, we will revisit on some of the things that you said. Wanted to go back to specifically two things that you said. The first part, when you were private pay only, how did you do your marketing? Like, what did that look like? Was that just word of mouth or what did that look like originally?

UNKNOWN: 12:33

Yeah.

SPEAKER_04: 12:34

Yeah, totally word of mouth. At this point, like you said, we were in the suburbs of D.C. And so like it was a good, well, with traffic, a couple of hours drive. And so a lot of providers would not provide services that far or they would charge a drive, like a fee to drive that far. And so once we got our first client, really, it was totally word of mouth. And we had a waiting list before. Yeah, we had a wait list before we even... really got going

SPEAKER_03: 13:06

yeah i know hey i know this person who knows this person that's looking for services too kind of thing right and it just kind of organically grew And

SPEAKER_04: 13:15

I had, you know, from my previous companies that I worked for, I had been in schools and daycares. And so I had, you know, I knew a few people who, you know, once they knew I was starting up, then they would refer. But, yeah, there was no, like, there was no marketing. And

SPEAKER_03: 13:33

really throughout the entire time we had, even after when we got into insurance, Because it was a nine day shift. Right. It was like one day was also pay. And then once insurance came in, everybody that was self-pay was like, yeah, no, I'm not doing that no more. Like, sure. I pay you that much when I can pay a copay, which makes sense. Right. And that's kind of why we had to pivot and grow. And so but yeah, like even when we were like with. insurance and working with regular funders. We never really marketed. I think maybe I spent$150 on Facebook ads. Terrible idea. So we really didn't market. We did join the Chamber of Commerce later in our local area. Best money I spent on marketing was the Chamber of Commerce.

SPEAKER_02: 14:24

Okay. So with that then, your initial setup, how did you arrange that in terms of how long your sessions were going to be? Obviously, we don't have to talk about specific rates, but how did you... How did you come up with that? What's your structure is going to look like? I know you mentioned that it was out of your house before you had the clinic. Obviously, it wasn't physically out of your house. I'm sure you went to their houses. But in terms of your scheduling, because in our field, a lot of times it's like, cool, we got 10 customers and they're all three to six availability. So that's really challenging. How did that look like and how did you manage and stay sustainable so that you could grow from that point?

SPEAKER_04: 15:04

Yeah, in the beginning, we were really fortunate. You know, I just, I look back on that and I think, wow, something really had to fall into place. So I'm so glad that did, you know. But we had a lot of early learners. Like, we had toddlers and preschoolers. Oh. And that's my, that's, like, that's my passion. That's, like, that's my favorite age and developmental age to work with

SPEAKER_00: 15:30

anyway. Yeah,

SPEAKER_04: 15:31

the next two of us. Yeah, so I was already in a lot of preschools. I was already in, there were a couple of private preschools that I already knew people in. Our neighborhood alone, like... between like, you know, just like the sea of suburbia outside of DC, like we, like our neighborhood, and then like several neighboring neighborhoods, like once we knew one mom of a two-year-old kid with a new diagnosis of autism looking for ABA therapy, then it was like, at one point we had, I remember my first little social skills group, it was like a preschool readiness, and the moms like took turns rotating who hosted it in their basement, because like these six to eight kids already knew each other. Oh, that's awesome. It just, it really, it just, it just fell into place. Now, unfortunately it didn't stay that way. It did quickly within, you know, a year's time, you know, really you started getting into the, okay, everybody wants afternoons, you know, evenings and weekends. And that's really when we started marketing. Cause when you were asking earlier, I was thinking about this. It was much later on when we were marketing specifically looking for morning sessions or midday sessions. Because that's when things really started to get tricky, for sure.

SPEAKER_02: 16:55

Interesting. My other question is, I saw your face light up when they were talking about the growth. And it got... it got kind of big, and it was like, whoa, I'm not sure I'm ready to that. Like, I didn't know if you had a question or wanted to speak to that, but I saw your face light up, so I jotted it down.

SPEAKER_01: 17:11

I guess what was the biggest concern? It couldn't have been a fiscal concern, so it had to have been something about your clinical implementation, the quality of your services? Am I on the right track there? Talk to us a little bit about that.

SPEAKER_04: 17:23

Yeah, I mean, I really wanted to know all of my clients. Like, looking back on it, I just wasn't ready, like, personally. It was more of a personal opinion. Now, Stephen... we really had a lot of tension there for a while because he was like, wow, this is really working and this is doing well. Look at how many kids we're helping and we're actually making money on this and let's keep going. Let's open a second. And I really at that point, I don't know, I just put... I put my brakes on because I did I got to the point where I didn't know I didn't know the faces of the kids right that I was serving and I was such a hands-on person and I had such a passion of really working with the little guys like that like you know witnessing their first words and you know whatever right like I just was really so into that and up and like for years into it, I made sure that I went out to do home visits on like a regular rotation. And also like we didn't have KPI, we didn't have like, and so really for me at that point, the only way that I could take a temperature on things and make sure like things are going out was like to over micromanage, right? Looking back on that. Yeah, I could have stepped back and I could have done some of the things that we talk about doing now and some of the things we did later in the career. But, yeah, I just wasn't ready for growth. I just wasn't ready. I didn't want to get big. I still had a small child that, you know, I wanted to be home with in the evenings. And, yeah, so it was just a personal choice, really. But we kind of really rode that wave.

SPEAKER_03: 19:03

Yeah, and I think also, like, you know, I think the big thing is as we started to grow, we added those policies. And the other thing is just not really having– I guess the issues that we would see is just BCBAs not getting enough parent training hours, avoiding parent training, or not getting their treatment plans in on time, things like this, and

SPEAKER_04: 19:32

then

SPEAKER_03: 19:33

cancellations on the RBT side, but even on the BCBA side, but mostly on the RBT side. what you would see like is that we just we didn't have enough clear systems in place and so that that's when you start feeling those pain points and so when i'm working with someone else like that that's kind of where it gets right like and i think we we had i don't know if we've released this podcast or not but like there's a point where you can micromanage it pretty well, right? Like you can just be in every, you're the quality manager, you're the ethics manager, you're the security officer, you're the clinical director, you're the intake specialist, you're the biller, you hire everybody, you fire everybody, you're the family coordinator, right? Like you're everything, right? And you're working 80, 90 hours a week and you can do that. Everybody can do that for a certain amount of time. some people can do it for six months some people can do it for two and a half years but everybody has a breaking point and then that's where you start to see the quality go down right and then they will come to us and I've heard this so many times like I quit my last job because I didn't I felt uncomfortable with what they were telling me to do I felt like it was unethical and now after you know two years or whatever I now find myself in that very same place except I own it right i own the mess um and so like that's why you know we harp on this all the time but it's just so important it is like it's very scalable it's easy to scale it if you have the right things in place but if you grow too fast too quickly without those things in place it's gonna it's gonna like you know it's gonna fall apart on itself right um under its own weight and so that that's Yeah, and we've been there many times. Like, you know, it was like the tension between us, right? Where... It was good and bad, right? It was terrible for the marriage. But it was very helpful for the business, right? She was very, very focused on quality of care. And I was very focused on revenue and profitability. But they worked, right? It worked.

SPEAKER_04: 21:58

You

SPEAKER_03: 21:58

have to have both. They really

SPEAKER_01: 22:00

do. Interesting. That's the balance there, right? It might be far apart, but that's sort of the balance there. Okay, go ahead, Dan.

SPEAKER_02: 22:05

I was just going to say, I think you touched on two really interesting points that I wanted to elaborate and see if you wanted to speak more on or if you feel like you've said your piece on it. The first one, you talked about the scale and going from the micro to the larger scale. And you mentioned the RBT cancellations being challenging. And it's interesting because from a small perspective, let's say you have a couple of RBTs, right? And they get canceled on for a session. And it's like, ah, it's like 50 bucks. We'll just pay your... Pay your two hours that you would have gotten. You know, it's 50 bucks. What's 50 bucks? Not a big deal. But then when you scale it, now all of a sudden it's like a larger thing and we have to have policies and procedures for a large amount of RBTs because we can't necessarily pay 50 people 50 bucks. Now it starts to become more of a thing where... From a smaller niche outfit, it's, oh, we can take care of some of these things. But on a larger, as you scale it, now there has to be the policies and procedures. So that was the first question I had. And the second question, you can speak to either one or neither of them, is you mentioned that it created tension both in your professional and personal lives. And I think we see this a lot from a lot of the ABA outfits that grow and sprout up, is that a lot of times it's some sort of private equity entity, a business person, and And then a BCBA. And a lot of times they can have differing opinions on how we should do things because the money comes with scale. So it's like, let's scale it as fast as we can from the business person or the private equity or private entity. The money, it's scale, scale, scale. Let's get it out there. And then the clinical person... Sometimes it's like, no, it's scaling a little bit too fast. I know we've seen that with multiple examples out here and that can lead to some strife or some tension, both professionally and a lot of times it's not a husband and wife, at least in my experience. But I imagine it can create some tension as well in your experiences. So I don't know if there was anything else you wanted to say in terms of the scaling and what that looked like or the tension it creates between the business person and the clinical person.

SPEAKER_03: 24:08

I mean, there's so much tension and so much tension that our dog is barking downstairs. So I don't know if you're going to, but like, we would, we would have issues, you know, with, with, yeah. So cancellation rate was one of the things that I looked at all the time. Right. It was, was our billable hours on our cancellation rate. I looked at daily. But like, as, as far as like, you know, how, like I, I maybe even lost her question to a certain extent, but there is definitely like, How do you... This is something that we both agreed that we would do differently because when April left her practice, like her last job, I should say, to start her business, she sometimes would travel six hours in a day and not get paid for that, right? And then she would get maybe two hours of session time with the kid, right? And so it's like it cost her more to drive And she was getting paid. And it's like, how is that possible? So that was something that we both agreed we wanted to do differently with our techs, where it was to pay them reasonably, give them time off, give them benefits. And one of the things that we found we did differently in our area more than anybody else was like, all of our texts are salary. Once we really, I would say three years into it, we switched everybody to salary. And it was really important for us. So they all had a big salary. And then based on billables and a quality goal, they could get a bonus. And we did our bonuses every pay period. That was for both of our BCBAs and our techs. And so we really reduced our turnover rate when we did that. And that's the biggest thing is like, I find is the turnover rate and really affect the business side of things. And then, as you mentioned, how do we pay all these people for canceled sessions? And there's even some incentive there almost. Tech calls them up. You sound a little like you guys are sick a little. Should I come over? And not that it's built into the system, but it's kind of built into the system. So that can also be difficult, right? And how do you then take that tech? and use that time in a different way you know and so that was one of the things that we did on cancellations like okay your session's canceled but you got to come into the office and you've got to help our our BCBAs do some you know do some admin work or something like that so I don't know if you have anything else to add to that

SPEAKER_04: 27:04

April no I mean I think that yeah as I'm trying to go back to the point of the question, but scaling it.

SPEAKER_02: 27:15

Scaling and then the tension between the business and the clinical

SPEAKER_04: 27:18

person. No, I mean, definitely that tension piece was really difficult.

SPEAKER_03: 27:26

I mean, like it was never off. That was a big thing for us, right? It was like... especially when it was in home, right? When we were working out of our home.

SPEAKER_04: 27:36

Oh, yeah, yeah, yeah.

SPEAKER_03: 27:39

It was 24-7. It was always business intermingled with our personal relationship. There was a lot of tension there, right?

SPEAKER_04: 27:47

But I think, too, even if you're not in a marriage or in a friendship and you're still, like, you have that, like, clinical person and then you have the financial person, the business-minded person, and it... It can get so tricky as far as like who's right, right? And like the clinical person not losing sight of the quality, right? And then the money person, like how far do you push to change clinical, right? And so it's this constant dance because there are some things that I– Now, looking back on it, we probably could have grown. Maybe I could have said, Stephen, hey, not so fast, but let's take a step here and let's really talk about it and plan because you just want to take it and go. And I was like, whoa, I'm scared. No, I'm not ready for this. Like we already said, I have to be able to have my hand in everything because we didn't have– in place to be able to do it. But I think too, if we would have like a, that's where like the leadership team that we talk about and really being able to have someone else there to buffer too and like really focus on those values as well because like if you have your values and the financial person and the clinical person, they have agreed on those values, then it gives you at least a meeting point there of being able to discuss

SPEAKER_03: 29:20

And find that common ground. We winged so much of this, right? And that's the other thing that I highly recommend everybody, if you're thinking about starting a practice, make sure that you have those financial goals, at least some kind of... The thing is that it's so... One of the things, at least I hope that I did, because I feel like I did and I tell everybody I did, was I never interfered with... how many billable hours a child was required to have, right? Like, I'm not in that space. I am not a clinician. I have no business being in that, right? Where I come in is, are you optimizing those clinical hours that you said that child needed? That's where I came, right? But as far as, does this kid get 20 hours, or do they get 30 hours, or do they get five hours? Like, man, that's a morning kid. Sure would be nice if they got 25 hours, but, you know, That's fine, right? And so I just kept that out. I just did not get involved in that. I think that's where a lot of BCBAs can be... I don't know if it's manipulated, but... The BCBAs that I know, they just want to help. They want to help as many kids as quickly as they possibly can. And so it's easy for them, in my opinion, to get pushed into doing things that may feel a little bit uncomfortable, but it's for the greater good. And maybe they move too quickly or they do things that they wouldn't necessarily do on their own. And that's one thing that I... When people do come to me and they're like, hey, should I start a franchise or should I go with a PE person? Like my, you know, I'm like, no, don't, don't. Right. Why, why would you do that? Like, like you're going to invest all of this time and sweat and, and tears into this business. And then somebody else is going to come in and take all the profit. Right. Or they're going to demand that you perform at a certain level. And isn't that what you're leaving right now? Isn't that because somebody is telling you how to do things and you don't feel like that's good. So, So why would you do that now? And you can really go as slow as you need to. And so many BCBAs that we work with, they still have a full-time job. And they're slowly getting in network with funders. And some of them, it's just like, okay, I want to dip my toe in and see how it is. But I'm going to take one case on my own and see if I even like it. And if that's as slow as you need to go, go as slow as you need to go, right? And then if you are working with a partner, Highly recommend you have like service agreement in place, right? Who can spend, what can you spend on? What are the profitability, you know, how much revenue do you need to make in a certain amount of time? What's the profit level? You know, what are you going to do about cancellation rates? You know, even writing down, like you said, April, writing down your values, going separate ways, and you both write down your own values and then come together and see, do these match at all? Because if they don't, Maybe you guys aren't partners. Maybe you're friends, you know, but you're not partners. And so those are really important things to do. Because you just, yeah, it's very easy in this environment, especially with this environment of terrible rates, most of the country. where you can get pushed into doing things that you wouldn't necessarily do if it was a different environment. I don't know if that makes sense, if that answers

SPEAKER_01: 33:13

your question at all. It answered the question and more. And more. You covered so much ground. I do want to say really quickly, though, that I can't wait to use, next time I'm explaining medical necessity, he's a morning kid. I'm going to quote you and see how far that takes me. I hadn't thought of that argument yet, and I like it. So I guess there's a million routes, a million places we can go. Did you have a specific route you wanted to go?

SPEAKER_02: 33:39

Well, I did have a question, but I don't want to steal too much of the time. So you talked about paying RBT's salary and really focusing on the RBT, and I think that's something that's near and dear to our hearts. Me starting in the RBT field, then I've been a trainer forever, so I've been face-to-face with all the RBT's who've come into my company in the last 15 years of the various companies that I've worked at. And that's something, like I said, that's near and dear to both Mike and I's heart. So can, first reflecting back, we have an episode that we're very proud of, RBT Person or Service. It's one of our more listened to episodes. Can you speak to the sustainability of what you think currently is feasible for the RBTs in the ABA field? Is it a sustainable career? Is it something that somebody can only do for a couple years and then they have to either move up or move out? Can you speak to kind of your thoughts on what the current RBT position looks like and entails?

SPEAKER_01: 34:37

And that certainly brings in the discussion of rates, right? So feel free to pepper that in there as you like.

SPEAKER_04: 34:44

Yeah, I mean, the sustainability of RBT as a career, we've had several techs that worked with Corner Peace, with our agency, that they were amazing. And they were right where they wanted to be, and they would be there for 50 years if they could. But for the most part, people want opportunity to grow and to develop and to move up and to make more money and even have more responsibility. And so one of the things that we... worked on but never really never we were never able to bring it to fruition with the three with corner piece but we're working on it with three pi squared is like really working on those tiers of text and helping them to be able helping companies be able to provide the training and also the needs to be able to pay them um which It means you need to be able to get paid from insurance. We'll get to that in a second. Okay. But we found a lot, though, money is so important. You have to be able to pay, and you have to be able to pay. enough that they want to stay, of course. But then there are also other opportunities that are important to techs as well. Wanting to be able to grow and to learn, even if they don't want to become a BCBA, but they want to grow and learn and be able to advance in the field in your company, working with others. And so really looking at those skill sets and being able, like with the RBT checklist, being able to offer that training

SPEAKER_02: 36:37

The tiered model is always a tricky one, right, April? Because, and we've talked about it too with the concept of admin and something that at our previous, two previous jobs ago, because of our funding, we were really able to allow those consistent, we gave guaranteed hours like you did with the salary. And we were really able to do that. The issue with, and please speak to this, because you all can see it much more on the macro scale than we can. Insurance companies, for the most part, only allows reimbursement for the direct hour. So all of that either has to be done at the expense of the RVT or at the expense of the company, which can certainly create some challenges in the ABA field. How do we allow for somebody to get reimbursed for some hours that they're not working directly?

SPEAKER_01: 37:20

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SPEAKER_04: 39:57

And that's the key, right? I would love to be able to offer all this training and offer other responsibilities and growth within the company as an RVT. But... How do I pay for that?

SPEAKER_03: 40:11

Right. I mean, this in itself could be an entire podcast. And so let's see how many. how many short comments I can make and see what the responses will be to the people that hear it. So if the rates are bad, don't accept them. Stop accepting bad rates. Just period. Stop doing it. You're ruining it for everybody. Stop submitting your contracted rate on your CMS forms because you're ruining it for everybody. So stop doing that stuff. How do you really feel?

SPEAKER_01: 40:46

Don't miss words, Steve. You can give us a straight story, that'd be great.

SPEAKER_03: 40:50

Go ahead, sir. Yeah, yeah, yeah. But these are two things that I did. So, like, I was part of the problem, right? And so I've learned. And so hopefully somebody listening to this will stop doing it when they hear this. But this is going to help everybody. And then, you know, the big thing that providers have to do to get anywhere on this is, oh, what state is it? They're doing this right now. I think it's Colorado is one that they're doing it. And there's another state I was just talking to somebody where a bunch of ABA providers are getting together along with their state organizations and they are lobbying the state government to increase the Medicaid rates. Let's go on sustainable. And hopefully, hopefully it will embarrass the funders enough that they will actually pay something reasonable because you don't really have much room. to push the private funders. But if the Medicaid rate is that much better, then maybe they'll, you know, have to adjust their rates as well. So like that's the issue, right, is like well-meaning... amazing bcbas are accepting shit rates and so when you do that you can't pay your tax right and you can you can want to provide quality awesome ethical services but if you're making 40 an hour on a direct service rate and your cancellation is 10 because hey i love everybody and i i'm not going to get mad at anybody if they cancel sessions then then yeah you're going to have terrible profitability you're you're probably going to be losing money you're i certainly Certainly you're not making a salary. And again, we get to that burnout issue and, you know, like burnout on the text, burnout of the owner, burnout in the BCBAs if they're there. And you're providing terrible services because everybody's burnt out and no one's getting paid. So, you know, like that's just kind of the state of ABA right now. Can you do this better? Yeah. Yeah. If your rates are 50% better, then of course you can. But if that's what There are a lot of people coming to me that their rates are$40,$45 an hour for tech. I don't know how you do it. I don't know how you do that. The math doesn't work for me. That

SPEAKER_01: 43:13

would not work in California. Oh, boy. I'll tell you that much. It would not work at all. I'm hoping we can... We're eating up our time very nicely here. I knew that we would. We have a lot to talk about. All the... Variables that you've been mentioning, Steve, here are going to have an impact on the clinical service and the quality. You've alluded to that already. ABA is getting a pretty big kickback from the neurodivergent community. What's the blend there? I know that as BCBAs, we would love to say, no, nothing about what's being said is valid. We know that's not true. In fact, it behooves us to listen, and we're very close listeners to that very fair criticism. How much of that is fueled by the poor funding, by the fact that we have to dilute the quality of services as we try to get more clients, and we extend our RBT's hours, and they want to make a livable wage, so here they are working four or five clients a day, which to me seems like an impossibility. I can do three as a supervisor, and after that, I'm pretty spent. If I've put my time in, I'm pretty spent. We've got RBTs doing a lot more work, and then we've got people complaining about the quality of service and even it being traumatic to a certain extent, yet maybe a lot of people on our side still won't listen, despite all the variables and problems you've decided. You guys can speak to that a little bit. What's the answer? What's the worst part of it, and then what's the shining Is there a light at the end of this tunnel here? That's a lot.

SPEAKER_03: 44:44

I'm going to be the negative

SPEAKER_01: 44:45

person.

SPEAKER_04: 44:47

Yeah, I mean, before you get into it, though, before you get on here, because I could just see it in your face.

SPEAKER_01: 44:54

He liked that question. He was ready to go. Thank you, April, for holding him at bay for a little while, letting him simmer a little

SPEAKER_02: 45:01

bit. Steve, did you say I'm the negative person? I feel like there's that relationship. The realist. Yes, the realist.

SPEAKER_04: 45:10

I mean, now, luckily, since I've closed my business and we're now working at 3PiSquared together, our relationship has gotten so much stronger. Good,

SPEAKER_01: 45:20

good, we're glad.

SPEAKER_04: 45:21

As far as text, we have to put more time and effort into training. The amount of people that I've been consulting since I started working at 3PiSquared, who think that they can hire tech one day and throw them out into the field the next day. No, we cannot do that. We cannot do that. So, you know, clinically speaking for quality, we have to put the time and effort into training our staff before they step foot into the, you know, the session, whether it's home or clinic. In clinic, you have a little bit more there's other people in the building, right? And there's a little, sometimes a higher rate of supervision or there's more people in the space. And so there's a little bit more accountability there because of that. But in home, you don't, they're going perhaps down to the basement with like one-on-one with no one else around. Hopefully your policies are that some adult outside of, you know, should be home. Please don't leave your staff.

SPEAKER_03: 46:32

Your

SPEAKER_02: 46:37

face is almost as red as your shirt now, Steven.

SPEAKER_04: 46:41

We have to train our staff, but to be able to do that, we have, I get it as a business owner, you have to make the money to be able to put your staff in.

SPEAKER_03: 46:51

I mean, just go on Reddit for a little bit, right into those RBT groups. And like, uh, yeah, it's tough. I would not like, I would not want to be an RBT ever, ever. It's a thankless job and it is a hard job and they do some amazing things. And so I guess like my issue where I go with this is like I've heard people say, There's no way that you can fix the turnover rate. You just have to have a robust hiring process. And I just, like, that makes me want to scream. It really frustrates me beyond belief. And that, yeah, like you were saying, like, you got to, like, we don't, we can't pay for training, right? Like, man, like, I don't know how you do this. So, like, it's just really frustrating to me. Those comments.

SPEAKER_04: 47:45

I think I said, we were, you know, sometimes Stephen will share some comments. I don't, I don't, I don't frequent social media on that side of it for a certain reason, but Stephen will share some things with me. And my, my, my, my, what I said yesterday was, if you don't have the money. to appropriately train your staff. If you don't have the money and the ability to put together policies and procedures ahead of time, then don't start a business.

SPEAKER_02: 48:13

Yep. So speaking to what you said, April, that really it's open to me because I've been the trainer for, like I said, the last 15 years. I left my first company where I was a trainer for probably about five, six years. The first four to five were great. I facilitated everything. the 40-hour training that we collaborated to construct. It was great. It was in person. And then the last year was literally, I think they went to... Relias or whatever the online training was, or maybe they even created their own training. This might have been before Relias, where it was 40 hours in the iPad because the company had expanded, so they wanted standardized training. And me as the trainer, I literally just sat and watched people on 40 hours attain all the information, which would glitch, and they would be three-quarters of the way through a module, and it would glitch, and then they would have to restart. And at the last company I was at, it was kind of a hybrid, and the people that had done the online training just expressed that it was meant to meet the BACB-RBT requirements, just that the retention was so low that there wasn't really any retention. It was easily overdone by the frustration of the glitches and things like that. Even eight years later, apparently, it's still very glitchy. And this idea of you can give somebody this 40-hour training, which they're probably not even really paying attention to. They're doing it in the background just to get off the 40-hour training. And then they're getting thrown into, like you said, a home session. With a clinic session, it's a little easier because you have the other people there to support. And this idea of, yeah, well, we'll train them when they get in the home. And I think in theory, that makes sense. But in application, at least from my experience, and please speak to it, you know many more experiences than I do. It's like the supervisor will come out the first day and explain it. And then because a lot of funding sources don't allow a whole lot of supervision compared to the direct, they might not see that person for three And while they're saying, oh, we'll really support you in the field, the training was lackluster. They come out very confused. They're kind of thrown into the situation where they say they'll get the infield training, but they don't. And that's my soapbox. I could speak for hours on that. So I appreciate you bringing that up, April, because the training is, I think, part of the, not the downfall, but part of the struggle with how ABA is being implemented now.

SPEAKER_04: 50:31

Well, I mean, even with our, you know, the last couple of years that we were in business, that Corner Piece was in business, we were having, well, I mean, it was COVID, right? And so having staff. keeping staff, hiring staff just became a huge issue that we hadn't really dealt with as much. We had it random or a few here and there. But for the most part, we were able to hire really great staff and keep great staff. And so I really get a taste of what it's like to have such a high turnover when everything changed. And even during that, when it was a little tempting to... push people through training so that we could get them out to get them in the homes to provide the service. I just couldn't. I just couldn't speed it up too much because we had, like, my thing was we had a certain, even if you came to us as an RBT who's been working for five years in the field, we still made you go through all the competencies. We still went through the training. We still, like, tested things out you still had to come in well we did it it was virtual there for a while but I really liked having people come into the office to have to do the trainings and I tried to make the training that first couple of weeks like kind of difficult right because I needed to know that you were going to be able to show up that you were going to be able to produce that you were going to be able to learn that you were going to be able to learn on you know under pressure that all of these things but I feel like we were also at a point where we were able to pay them a decent

SPEAKER_03: 52:07

amount and we had

SPEAKER_04: 52:09

the

SPEAKER_03: 52:09

we were good enough we

SPEAKER_04: 52:13

still wanted to do a whole lot more but we had just enough that we were able to you know to pay them what they were worth although some people might not think they wanted a lot more than what we could pay but um but they were definitely um We were able to give them the benefits. We were able to give them security. And training was important.

SPEAKER_03: 52:34

And again, if you're making$40 an hour, I don't know how you do any of this stuff. And this is what you get, right? You get low quality training. I turn over, and then what the funder can then do is say, look, ABA's terrible. Why would you even do that? We need to cut the rates and cut the hours. And then you have the anti-ABA that is, I'm not going to say 100% right, but probably 80, 85% right. And because I would not trust my child who can talk very clearly and tells me all of his feelings better than I can share my feelings with someone with 20 hours of experience. I wouldn't trust them. So why would we expect that a child that may be nonverbal and a population that is abused at a higher frequency, why would we expect to put them in that situation? And I think it's unfair for everybody involved. And it's in an environment that, how else do you see this going? You're watching the car wreck. Like, of course, yeah, yeah. It's snowing outside. The roads are icy. It's a sharp turn. And you're going Yeah, that was going to happen. I saw that coming a mile away, right? And so this is low rates, poor training requirements that... 40 hours? Really? 40? Wow. Who came up with 40 hours? I can't tell

SPEAKER_04: 54:24

you how many texts came to interview over the years who said that they did not even get competency.

SPEAKER_03: 54:32

Well, yeah. I remember interviewing an RBT that was certified and had a year's experience, and we asked them what the definition of man was, and they couldn't give it to us. Oh, Lord. You know what I mean? Like, this is...

SPEAKER_04: 54:44

Yeah, like, oh, oh, we didn't do that in our past company. Our supervisor just signed off. Like, why do I have to do this?

SPEAKER_03: 54:51

And so it's just, like, and again, we've set up this environment, and now we're saying, why is the house on fire, right? Well, because you lit the match and used gasoline, right? Like... Yeah, what do you expect? I mean,

SPEAKER_04: 55:06

sadly, ultimately, that's why I just made the decision to close.

SPEAKER_03: 55:10

And we could probably sell our rights. Anybody listening wants a really good rights in Virginia.

SPEAKER_01: 55:16

We'll talk about that off the air, if that's okay. No need to disseminate those too far. We'll take care of those. Thank you, Steve. Go

SPEAKER_04: 55:26

ahead. Sorry. That's why I made the final decision to close. Because I couldn't keep up. We couldn't give what we needed to give to be able to keep and sustain quality services. And I would rather not provide services. and try to help on this end of things, then be part of the problem. I just couldn't keep staff. And we had decent rates. Could we have had better rates? Heck yeah. If we had better rates, would I have been able to keep more quality staff to continue to have more quality services? Probably. I

SPEAKER_03: 56:11

mean, I hate that it comes down to this, but it does, right? Like if... If you don't have sustainable rates, and they're not going to give you a rate, like, you know, again, I talked to providers, and I haven't gotten a rate increase in 10 years. And I said, yeah, man, like, you know, like, especially in the last two years, like inflation, inflation is good now, right? Like, it's all fixed. But before, like six months ago, it was pretty bad. But, like, and so, you know, now no one can afford a home. They can't afford rent. And so, you know, you need$30 an hour, you know, just to break even probably. And maybe, maybe I'm wrong on that.

SPEAKER_02: 56:52

Yeah. Depending on

SPEAKER_03: 56:52

the area, right?

SPEAKER_02: 56:54

Yeah, yeah. I hear inflation's getting so bad it's even hitting you Canadians up there.

SPEAKER_03: 57:00

But, like, if you need to give somebody$30 an hour and you're making$45, like... We haven't even touched on workers' comp. You've got to pay for professional liability insurance. You've got to pay payroll taxes. You've got to pay training. You've got to pay for practice management, all of this stuff. Yeah, man, it's tough out there. And so I don't want to be super pessimistic, but I'm pretty pessimistic. And so unless people start to push back against these terrible rates... It's going to get even tougher. And

SPEAKER_04: 57:38

I think rates are a huge part of it, but also we have to take care of our techs, and we have to train our techs, and we have to train our staff, our BCPAs. We have to train our staff. We have to support our staff. We can't expect more from them than we're giving to them.

SPEAKER_01: 57:55

It's a good thing that RBT's don't need time off and never get sick. At least that's the word out on the street, the way I see things being practiced. I had one

SPEAKER_02: 58:08

quick question, if you don't mind, Mike. Steve, you were talking a lot about rates. I think we talked about this in one of our previous podcasts, Mike, that the argument can become circular. And this is what we've heard from people on the insurance side is, well, the rates are low because you all ask for so many hours. And ABA people ask for so many hours because the rates are low. So now it becomes a circular piece of who's going to break the circle to help the rate discussion. Any thoughts on that?

SPEAKER_03: 58:35

Yeah, I mean, I think that, you know, the 40-hour model, I don't think this survives, right? Thank

SPEAKER_00: 58:43

you. I don't know if it's

SPEAKER_03: 58:44

three, four years away. but I don't think it like I just I don't see that happening I don't know that it is necessary but you know what I'm not a clinician so I don't know but I don't I don't see it surviving in this way like we had Andy Bondy on the podcast and he said he said flat out like I don't even know why we're in the medical field right like why are we even here who decided this because this is an education thing right and so So that was kind of his point of view, and I said, yeah, that makes sense. So I just don't see that full-time case surviving much longer, and I see it coming down to probably, you know, a typical case can be 10 hours a week, something like that, right? But that's my...

SPEAKER_04: 59:35

Well, I mean, and clinically, too, I think that we do have to look at medical necessity cases Not so much just in, is it medical necessary? But clinically, are we really looking at what, the child or the individual truly needs? And especially when you're looking at young children, also, are we supporting the parents in teaching them what they need to be able to sustain things?

SPEAKER_02: 1:00:14

So my question with that... Pick up my question so I can ask it the way I wrote it down. And I agree. That was literally our first episode on the podcast ever is 40 hours to answer. And maybe it was with Lovaas in 1985, but it seems like we've progressed enough and have enough school supports and things like that.

SPEAKER_01: 1:00:33

Well, it's a starting point, right? Yeah. So the 40, we had kids that were being institutionalized. Lovaas said, hey, 40 hours of this fixes it. And then somebody more recently said, hey, 25 hours works. And then I think what we're saying is it works. How do we give you access to it? do it and make it comfortable access.

SPEAKER_02: 1:00:50

So with what you are talking about and maybe changing the game, thoughts that we've had, and you've probably experienced this with some of the people that you consult with, is more of the BCBA direct model. Because we find it kind of interesting, and it's kind of how it's been set up, and maybe insurance perpetuates this. So please speak to it on whichever, whether you're talking the clinical level, the rate level. You all have much more knowledge and experience than we do with what this looks like on the macro scale. But it seems very interesting that the way the model is is now is, okay, you're having a difficult time with your child, so what we're going to do is put this person who's like 20 years old and show them, show the parent, oh, this person can get your child to do stuff and then leave. Whereas maybe a BCBA direct model, which would be less quantity but more quality of coming in once or twice or maybe even three times a week, demonstrating a couple of things but making sure the parents are involved. might be the answer, but I don't even know if that's feasible with the way some of the insurances, I think they only allow maybe 20% BCBA direct or things like that. So I don't know if you all could speak to that from the clinical and the rate level on if you think that is the or an answer.

SPEAKER_04: 1:01:59

Yeah, I mean, clinically, I really... I'm kind of for it, you know? I really am. And I'm also shifting, like, I'm working on, like, something completely different from this. I'm working on, like, a parent coaching certification and kind of trying to marry some more, like, conscious parenting type style things with ABA, and I'm going down the whole path there.

SPEAKER_02: 1:02:25

Can we talk about that later, April? I've got a whole parent training curriculum that has been my, like, bread and butter for the last 10 years.

SPEAKER_04: 1:02:32

I'd love to. But that kind of being a part of some parent coaching outside of the ABA world has really kind of opened my eyes. And I've really been working on my own cognitive flexibility lately of being able to kind of see outside of this tunnel. And I really feel that giving the parents, the guardians, the caregivers, the tools, and really supporting them And helping them, one of the big things, of course, like, you know, helping them to regulate their nervous system to help them to show up for their kids versus like, oh, just stay calm. And why you ignore that? Like really helping. And I know that like, as far as the capacity right now is insurance, like you're very limited on what we can do. And with our scope as behavior analysts, we're really limited what we can do with how things look right now of supporting the parents and teaching them certain skills that then in turn support, you know, the individuals that we serve. But I really feel like we need to move more in that direction. And I definitely feel like That could be part of the solution, you know, supporting those. Now, no, not everyone is in early intervention, though, right? I also know that a lot of individuals are older children, teens, young adults, you know, on into, you know, late adulthood. So, you know, but even still, depending on the developmental and the skill sets of those individuals, some form of that might also work. Yeah, I don't know. Sorry,

SPEAKER_03: 1:04:15

I was looking for somebody. I wish I could remember better. There's a guy that he's made an app where they have, like, trainings that the parents can then use as well with their BCBA. I'll try to find his information. Do you want to go up? Go ahead. I'll try to find his information and then maybe you can share it. But, you know, so that that may be very helpful for that kind of a model where, you know, you're working in the app with the parents and it's more of this type of a model. But a lot of funders just flat out won't allow the BCBA to do a lot of direct service. And I know there was an insurance in Washington state that flat out wouldn't let a company credential until they had an RBT on staff. So, you know, doing that model for an extended period of time, it can be very difficult, right? And there's a lot more hoops to go through. Could it be successful? Probably. But I think that it's going to be a lot more back-end work for whoever chooses to do something like that.

SPEAKER_01: 1:05:33

Well, that's really interesting that the funding source would, I mean, I guess I understand they're the ones that credential, but the idea that From a medical model, they would tell the doctor that they can't be doing vitals or they won't get paid. Again, it speaks to a whole other... Right, no, it speaks to a whole other... Episode or the theme for discussion here in terms of how much these medical insurances are doing with their regulations That ends up dictating if we're not careful how we actually implement and practice and I think that's something that becomes very challenging for everybody and and again going back to my previous question in terms of how some of that kickback from the neurodivergent community then You can't help but listen to it and go, oh, yeah, okay. Yep, people are doing that. Yep, I've seen that happen before. And once in a while you feel really good about the fact that you're not doing that anymore for whatever conscious reason, and that's a good thing. But there's a lot to be explored there in terms of how much spillover there is from rules and regulations, whether it's your block scheduling or just things that become– sort of gray areas in terms of now the consumer having to do many more things or many more hoops to jump through other than just say, hey, I've got this condition. My medical insurance covers for your service. Can you just give me access? Why does this have to be all these rules and stipulations about how many hours and what days I have to be available or the idea that And there might be good reason for this, but the idea that maybe I'm not sending my child to early childhood special education services through their preschool because I'm choosing ABA, which I know from a business perspective is going to be very good. I think that there could be some good clinical outcomes there, but at the same time, you don't want a consumer to be forced into that. The idea that you can go make friends at your community school and get ABA services at some point would be the best answer. But I do agree, and that's been very frustrating to learn more about, is how much of these insurance regulations are dictating our practice and our clinical procedures, which doesn't make sense. Anything to comment on that there?

SPEAKER_03: 1:07:43

Yeah, I mean, it kind of like, again, we kind of did this to ourselves, right? Yeah, in many ways. Like Florida as a state, right, where they kind of put the moratorium on Medicaid, and they just said, we're not letting any other ABA providers in because you're all committing fraud all day long. Good point. And then you have that company in South Carolina that, you know, what was it,$10 million in double billing? And it's like, yeah, I can see why they would do that Right. And yeah, it's there's just it's it's not there's not one simple answer. Right. Well, well, rates would help a lot. Rates would help a lot. But I think it was the ACQ guy. What's his name? ACQ. You remember his name?

SPEAKER_02: 1:08:36

Oh, my goodness. We'll do a part two where Steve comes back with all the names of the people he

SPEAKER_03: 1:08:40

forgot. He was saying, like, Eric. There you go. We got one name.

SPEAKER_01: 1:08:49

Nice.

SPEAKER_03: 1:08:52

So, yeah, he said, like, the average level of BCBAs is three years in the field. So when you're dealing with a young field, That also can be very difficult, right? That has a whole other animal that has been created, right? With just not having the skill that is necessary to do a very difficult job. So, yeah.

SPEAKER_01: 1:09:25

That's a good point. I was listening in on the Autism Partnership Foundation presentation conference, which was on Friday. And they were talking a lot about the training part and then university programs. The idea that even those have maybe become a little bit diluted in response to the need. So then you're pumping out a lot of young professionals and we still have six to eight month waiting lists. So is there something else you guys think we're missing? What else? Clearly there's a need. There's a backlash for our service based on how quickly... We

SPEAKER_03: 1:09:57

were talking to a university and they were... I'm not saying the name of the university. Not because I can't remember it, but because I'm not saying the name of the university. Can you all still hear us?

SPEAKER_01: 1:10:10

Yes.

SPEAKER_03: 1:10:13

Just had a quick glitch, but we're good. We were asking what the pass rate... Okay, great. So we were asking what's their first pass rate on the BACB test for these. And I think they prided themselves on a 60% first pass. And I'm like, is that good? Just to pass the test? Yeah. And so, you know, like, again, it's a young field and then the university courses, a first pass rate, and this is a big, this is a big one. And so, you know, 60%, it's like, man, and we're hoping for 70% next year. And I'm like, wow, okay. So, you know, it's just... There's a lot of headwind in this industry, in this field. There's so many things that we need to do better.

SPEAKER_04: 1:11:06

So I just need to backtrack for a minute back to what we were talking about earlier as far as, like, BCBA's delivering direct service. I completely spaced on this, but it just occurred to me. Ontario, have you guys heard about Ontario? They are, as of, I can't remember, it's soon. It's super soon. RBTs are no longer allowed, and BC ABAs are no longer allowed to practice ABA in Ontario. Wow. So that would be something, if you haven't already, look into that, because I'm wondering if this is going to be a forward motion from that. I don't know.

SPEAKER_01: 1:11:44

I mean, especially, would it force the issue of raising the rates? I don't know. Hopefully, right? I mean, you're paying somebody with a higher credential, and hopefully that would make a difference. Now that you mention it, I was doing an RBT renewal, and I noticed something on the website pointing to Ontario. It must have been what they were talking about, so... Okay, interesting move. Interesting move. Mr. Dan, what else you got for us on the list over there?

SPEAKER_02: 1:12:09

I have a couple more questions if you guys have a couple more minutes. That's okay? Kind of changing gears because I really do think you all have a very unique perspective of both being from the inside but also overseeing so many people. Actually, how many... BCBAs, do you all, I don't know if you can disclose that, I assume you would, do you all consult with or work with? Because you all see hundreds, right, of different people in the field, if not thousands?

SPEAKER_03: 1:12:39

Yeah, so I think our customers, it's above 1,000 now. Awesome. I'm not exactly sure. Total, yes. Yes, over the seven years that we've been working on this. So, yes. 1,000 businesses. I'm sure some of them have probably been, you know, acquired by someone else.

UNKNOWN: 1:13:00

Sure.

SPEAKER_03: 1:13:00

Yeah.

SPEAKER_02: 1:13:02

So that really gives you the unique

SPEAKER_03: 1:13:04

perspective. The average size of the companies that we work with is about 25 employees.

SPEAKER_02: 1:13:10

Okay.

SPEAKER_03: 1:13:10

So you're probably talking two or three BCBAs.

SPEAKER_02: 1:13:14

So with that then, what would be your suggestions? And you mentioned this to April in the beginning of kind of even

SPEAKER_03: 1:13:21

just... It looks like you guys are kind of frozen.

SPEAKER_02: 1:13:23

Oh.

SPEAKER_01: 1:13:25

Let's see. Are we back? Let's try that again. Sorry about that. You listening at home, just a little bit of a glitch. Let's try that again, Mr. Dan.

SPEAKER_02: 1:13:32

A little bit of technical difficulties, but we were just talking about how you all have the very unique perspective to be able to be both on the inside and the outside of the ABA service delivery and see so many young professionals. So my question with that is, what is your thought on clinic versus home sessions when maybe starting at your own ABA practice or things like that? I know you mentioned April. that your, was it called Cornerstone, I think?

SPEAKER_03: 1:14:00

Cornerpiece.

SPEAKER_02: 1:14:00

Cornerpiece. Started in home and then grew to the clinic. Do you all recommend that? Do you recommend starting in the clinic? That's obviously more overhead, but then you do get the dynamism of everyone being there, the less travel. What is your all's thoughts on home session versus clinic sessions for an ABA outfit kind of getting started?

SPEAKER_04: 1:14:23

So, I think if you would have asked me this a few years ago, I would have said a different answer. I would have said start at home, just like I did. It was a lot easier. But no, I think that you should start with clinic first. And the reason that I say that is because it kind of forces you into having a little bit more in place, that you do need to have more policies and procedures in place. and just generally speaking, right? Versus when people start in home, they tend to just like hop right in and it's a little bit more casual. And I feel like a lot of times there, it's not everybody, right? But I do feel a lot of times they're like, okay, let me just start this in-home services and I'll just start seeing some kids in home and then maybe I'll hire some people. And then they start hiring people and the next thing you know, it's like, it's getting out of their hands, out of their control. So I would say that like, first of all, is like being able to have you're kind of probably smiling at what I was saying earlier today when we were talking, but it's like, if you don't have the money to start a business, don't start it. You have to have the money to put things in place. You have to be aware that you're going to take the time and write policies and procedures or whether you're going to purchase it or whether you're going to do all the research of all the bits and pieces that you need to know or you're going to pay somebody to tell you. Whatever it is, you have to be able to have the money to get started to... Yeah. And so, anyways, I'll get off of that. But, like, so I think that in clinic, you... also have that staff all together in one place, and you have that team, and I don't know. I'm kind

SPEAKER_03: 1:16:17

of surprised.

SPEAKER_04: 1:16:18

I know. I really believe in in-home services. I wouldn't say have clinic. Would you have both? Yes, I would have both, but I would start with clinic. I really would because then you'd have a better idea. I don't know. You just have a better market. Maybe it's a control thing. I don't know. You have a little bit more control. You kind of have to have things. a little bit more standardized, I think it's a little slippery slope. It's a little easy to send people off in home and you're not really on top of things. And I don't speak for everybody because there's a lot of amazing in-home services. We had good in-home services.

SPEAKER_00: 1:16:57

Of course we did.

SPEAKER_04: 1:16:59

I would say that my answer would be to start a clinic, even if it's small. It doesn't have to be big. But I do believe that providing in-home is also important, so some kind of hybrid. Yeah.

SPEAKER_03: 1:17:16

So I have a different take, so I'm going to definitely need office space. Definitely need office space. I highly recommend you have somewhere where you can train your staff. Maybe you can do some cases. And maybe that's

SPEAKER_04: 1:17:27

what I mean, like, small clinic. Like, even if you do in-home from the beginning, but, like, have, like, that clinic base, maybe that's, like, maybe that's kind of, yes, office with

SPEAKER_01: 1:17:36

that, too. So not necessarily treatment space, you're saying, just an office space to sort of formalize the business.

SPEAKER_04: 1:17:42

I don't know. I'm still thinking there's some

SPEAKER_01: 1:17:44

treatment space there.

SPEAKER_03: 1:17:45

Yeah, that's good. So I'm going to say give me better rates because my rates suck and I can only do it at home. I know. That's a

SPEAKER_04: 1:17:54

lot more money.

SPEAKER_03: 1:17:56

Yeah. So, I mean, what normally happens is, yeah, a BCBA will come to me and say they want to start their own thing. They're going to do it at home. That's what they're going to do. Like nine times out of ten. Probably... And then they'll start off maybe hiring one or two techs. And the ultimate goal is to get a clinic the vast majority of the time. I'd say probably 80% of the time. They want a clinic. There are some people that are just like, no, I love in-home. I think it's better. The skills will be more generalized. There's going to be a higher level of parent training that you won't get with clinic.

SPEAKER_04: 1:18:40

Those tend to be the BCBAs who aren't planning on hiring other BCBAs. Or some of them are like, maybe I'll hire one BCBA. But a lot of people, they'll start and they'll be like, it's just going to be me. Maybe I'll hire one BCBA. We'll have a few techs. We'll do in-home and that's it. But then they typically come to Stephen a little bit later saying, oh, now I have like five BCBAs and we have the, it's so, you know.

SPEAKER_03: 1:19:00

And so I'm not counting, I'm not counting the office space of the clinic though. But yes, I highly recommend that you have some kind of physical location where you can train your staff. RBTs can come and, you know, get toys. They can get, you know, they can laminate stuff and whatever they need to do right so you're not all right the the pay is terrible already and now you expect me to have my own printer my own laminator right uh you're not gonna you're not you're not gonna pay for mileage so i have to pay for my own gas i gotta pay you know i gotta pay to change the tires all this stuff and uh i could just go to mcdonald's and probably make it make out better so like You know, like these things at least, right? At least they can come somewhere. They can talk to their BCBA face-to-face. They can ask them some questions, right? But if you're completely in-home and you have no space at all, that is a model that I would not recommend. So, you know, some people will do that. Like they'll have like a... little office in their basement, and that's fine, right? There are reasons why I wouldn't do that, but that can at least be a start, right? Because we did it, and it... Yeah, like, you just, you know, maybe you don't want these people knowing where you live, right?

SPEAKER_01: 1:20:13

That's a good... Especially now that you're about to fire them royally, right? But I like the distinction. You're saying an office space in terms of a workspace, and then we're talking about office space in terms of treatment space, and then in addition, the idea that in-home services from a clinical perspective, for example, are going to lend a certain amount of parent participation, for example, that could be of benefit. So that's really good, the way you guys answered that. I don't think that I had quite thought of it from all three of those angles, but it makes a lot of sense that, yeah, printer paper, making materials, whatever it is, coming by to talk to somebody in person about your schedule or about something wrong with your pay, whatever it is, there's a formalcy to having an office space, to having a space where business is conducted. And then for our purposes, there's treatment space on top of that. And so that starts to sort of build up the overhead for a lot of BCBAs. That seems probably to be the... their main concern, and then we circle back to the rates. Can we improve those, and then everybody's happier, right? Well, we've covered a lot of ground for us. Go ahead, Steve.

SPEAKER_03: 1:21:17

Sorry to interrupt you, but especially with a husband and wife team, which we do see quite often, the BCBA, the husband's kind of like me, kind of doing the tech work and the back-end work, and the BCBA's taking care of the clinical stuff. Like, In that situation, I wish we would have had an office. When we got an office, finally, man, that was so nice. We could then set that, okay, we're... And April followed this very well. I'll give you an A-plus on this. She would... Work stopped as soon as we left the office. Me, I would have panic attacks in the middle of the night and say, did you bill that service? But having that... that you conduct business and then yeah that separation is so important and even for like bcba partners right where they're not married they're but just having that space where you you can uh do your work and then you shut it off outside of that and that the other piece that i would add to that is you know you need a business phone right or at least some way that you can shut off your personal phone so that business is done during business hours and then you have some like way to escape it. And I think like this is on the RBT side and the BCBA side, there's just so much burnout. And I think just as an, you know, as a North America, like there's just because we're all connected all the time to everything. And what else would you expect? Right. And, and so in such a, in a helping field where, you know, It's hard anyway. There has to be that disconnection. There has to be that ability to disconnect. Well,

SPEAKER_01: 1:23:06

we would have to agree with that for sure. Now, I think we're coming down to one final question. We could probably do this for hours. Just

SPEAKER_03: 1:23:13

one more thing to add to that. If you do go that route with office space only, hopefully you can find a place where there is the ability to expand. Right. So, you know, maybe you got this little, you know, 10 by 10 office, but you know, Hey, if I want to expand in six months or a year, he's got office space open. I can expand right there. I don't have to change out of the move. Right. Um, so that would be the ideal thing to do if you can. Um, That's

SPEAKER_01: 1:23:47

a good call, because then you're preparing for that prospective growth, hopefully, and looking at not just having a workspace, but then not having treatment space, and that's probably a little bit tricky. So this is kind of a funny way to end. Having been in the field as long as I have, this has always been a little bit of a pet peeve for me, and now I understand a little bit more about why it happens from a day-to-day operations perspective, but the idea that you're either billing... Insurance is daily for your services toward your recoup, or you're doing weekly, or you're doing monthly, and then how that translates into the workflow for the RBTs. And the BCBAs. How much are you pestering them and reminding them to convert their time? What's your take on that? I know that that can become a... A little bit of an annoyance for people on the clinical end, right? The idea that you're always sort of being dictated to and being told, hey, you've got to convert your time. It doesn't matter how good your clinical day went. You didn't convert your time, and now you're in the hot seat. But you have to understand the administrative end, too. You're getting paid for these things. So the notion that you're submitting this billing daily is probably going to get you a little more money a little bit faster. And if you're not doing that, then you're waiting a little longer. Is there a balance in your experience?

UNKNOWN: 1:25:01

Yeah.

SPEAKER_02: 1:25:01

That was the most diplomatic I think you could have asked that question, Mike. I'm trying

SPEAKER_01: 1:25:05

to be.

SPEAKER_02: 1:25:06

I thought your face was going to be as red as Steve's shirt.

SPEAKER_01: 1:25:09

When you get the reminder that says don't forget to convert your time, for me it's like I'm pretty sure I didn't forget. In fact, I can tell you for sure I put it aside because I was exhausted and I'll get to it in the morning, but then I know that I've got some very kind billing person waking up early to try to get those things done, and now they're stuck on your particular clients because you failed to convert it on time.

SPEAKER_04: 1:25:35

Yeah, this is a perfect time for me to apologize to my previous bosses back when I would sit on my paperwork and

SPEAKER_03: 1:25:47

not get it done on time. I would

SPEAKER_04: 1:25:59

like to say that I got better at, but honestly, it's just because I didn't bill anymore.

SPEAKER_02: 1:26:05

So about that tension, how did you do that?

SPEAKER_04: 1:26:08

It's, I can see both sides. And that's one of my biggest things I've been so conflicted about, like, as I might tell people, please get in your time, please get your time sheet, you know, get all the things in because we have, you know, at the same time, I'm getting why they're not. They're exhausted. They, you know, whatever, all these other things. But yes, it is so important. One of the things that I... One of the things I think is super important is to get that done ASAP as soon as possible, whether that's daily. I mean, we tried to get it daily.

SPEAKER_03: 1:26:49

We did a good job. We

SPEAKER_04: 1:26:50

did. We did. It took us a while, but we were finally able to get that consistency. Once you stopped. Once I stopped doing that sample. Because here's another thing, too. Like, if your staff were to quit... or you had to let them go and that piece wasn't racked up, then... I

SPEAKER_03: 1:27:13

hear that all the time, all the time. That's probably my

SPEAKER_04: 1:27:16

biggest, that's probably my biggest reason for daily, um, is just so that you can end the day, um, making sure you have everything that you need to be able to bill, whether you're actually billing the next day or not, but whether you have, so that you have everything that you need, or even if they get sick or, you know, something happens to them or for whatever reason, they're not physically able to be there, um, to, to turn in everything that they need to turn in because then you can't, you can't bill for it.

SPEAKER_03: 1:27:42

Yeah. It happens all the time. All the time. Every ABA company that you talk to will have this happen at least once. I just wasn't paying attention. I let this tech or this BCBA go 30 days, and I didn't check their session notes, and they quit, and now... how do I get that time because I can't bill it right and so now you got 30 days so like you know I often ask people like how much risk are you willing to take like for me I'm not I'm very risk adverse right I want my money because it's important right I'm giving you a salary I need to do your job so and but other people they're like yeah it'll be fine I'll check every couple weeks and that's you do you but like everybody has that horse story I've heard it many times so you get burned once and then you're like you button that up pretty quick right and so you just have one person quit and you get a recoupment audit and like oops did we submit those you know and the session notes done to the quality that you would like or it's missing things that it absolutely needs and now the funder is asking for money back on top of the time it took to do this recoupment audit and research all the mistakes like it's just uh yeah i i get the reason why and you know you don't want to push these people too much because it's a stressful job and they're already burnt up but if we don't have the proof we can't bill it right yeah

SPEAKER_01: 1:29:18

Anything that worked particularly well for you guys to motivate these folks to get their things in daily? Was it just kind of hounding them, supporting? So they were advised.

SPEAKER_03: 1:29:29

That would not let that go, right?

SPEAKER_04: 1:29:31

Yeah, so I think one of the things is training. And, like, how you collect data, how you take your notes, how you do the things that you need to do within the session. Because, you know, we're not going to get into the whole, like... That would be a whole other podcast going into the whole, like, can you use the end of the session to bill or not and all that debacle, right? However you do it, that you decide is best for, according to your contracts with your payers, just don't just tell a tech that, oh, well, you can't spend the last... bit doing your notes or, oh, you have to do your notes afterwards, even though we're not paying you all that. Right. teach them how to embed it within the session, teach them how, you know, and support them how to do that. And then also having a conversation with them. Once we started the leadership team and on our leadership team, we had an RBT on our leadership team and she became privy to a lot of information that we chat about in some of these meetings. And she was like, well, I had no idea. I had no idea that my timesheets, my session notes, me getting this in had such an impact on, on, on the Like, she didn't know. So, you know, educating, right? Being clear and communicating and educating your staff on what that means.

SPEAKER_03: 1:31:00

Go ahead.

SPEAKER_04: 1:31:00

I was going to say, you know, we would have, like, incentives and things like that. We played around with it. And even though I was one of the biggest offenders for so long, like, it just really gets irritating. Just turn your sheets in. Just get your work done. And as much as I would say that, I would also know there were barriers. So sitting down with... You're probably going to have some of the same employees in this position over and over. you know or behavior analysts sit down with them trying to figure out their reason what's the barrier what you know what's the barrier what's the skill set that's missing perhaps you know like really looking into that to like try to solve that problem together also and then sometimes maybe that person's just not the right person for your team

SPEAKER_03: 1:31:46

and then the last thing i'll say on that is like what what we had to implement sometimes with some employees was your first session doesn't start until all your session notes are in so if that means we Oh. And that goes along with that transparency. Look, this is how this works, right? Like, I don't want to do this either. If I'm being completely honest with you, I don't want to have to submit these. I don't want to have to chase you around. I would much rather not, but this is how it works. This is how we get paid so that we can pay you. And so that, yeah, those are the recommendations.

SPEAKER_01: 1:32:36

That education piece sounds pretty important. I don't know that, I'm not sure how much it happens, you know, widespread and I'm not sure how much it gets retained so it probably needs to get revisited but I think that that's a really good point

SPEAKER_03: 1:32:47

guys session notes are like something that you have to like it's just continuous it's ongoing all the time to keep up with session notes and make sure they're done correctly

SPEAKER_04: 1:32:58

there's a lot of drift that happens and so like you really at minimum you have to revisit that with the whole team at least quarterly of like restating expectations but but honestly like you need to have those internal internal audits to keep on top on top of that

SPEAKER_03: 1:33:14

um like especially if they're you know talking about attention right like uh an rbt that wants to be thorough and and do their session notes correctly and make sure they have everything in it and you're telling them hey you got to get this done during the session and you can't bill after because we're not paying you and all of that right like not getting into the legal part of it but let's say that's the pressure that they have on them how what is their the incentive here yeah well if i copy and paste a note i mean i'm Yep. Sounds like it.

SPEAKER_01: 1:33:54

Well, it's interesting because the funding source themselves will oftentimes, in our experience, they'll accept that cut and paste as long as it's got certain words in there and it's a long enough sentence. I mean, you make an excellent point there.

SPEAKER_03: 1:34:05

Here's the thing is that they'll accept it until they won't. Until they won't. Because that's cloning, right? That's cloning. And so as soon as they do the recoupment, they're going to want that money back, right? And so that's the issue that you run

SPEAKER_01: 1:34:18

into. And then it begs the question, if you didn't see it until this late, then what is the individual note matter anyway other than to torture me as the clinician. Anyway, we could probably do a whole other episode on this. Steve and April, we have covered a tremendous amount of ground. We could no doubt sit here for another two hours. We will not do that to you as much as we would enjoy it, but it certainly behooves us to circle back and either we jump back on with you guys on 3Pi or you come back on here sometime in the near future. Any closing thoughts? Anything that you want to share here as we close up, as we wrap up? You've said a lot.

SPEAKER_03: 1:34:55

Just as far as collaborating, we could probably do this on a monthly thing, right?

SPEAKER_01: 1:35:00

Just go back and forth. Careful what you ask for. Yeah. Tell me we could do pretty well here. We're all good talkers for sure.

SPEAKER_03: 1:35:10

But yeah, I mean, it's just like April said, if you... If you don't have the money to start a company, don't start a company. It's very difficult, right? Probably the happiest moment I sometimes get is someone buys the membership, like you all are going through, and they say, hey, Steven, I talked to my current company. They asked me to stay. I'm going to get a raise. This is too much for me. I don't want to open a business, right? So I have stopped the BCBA from starting a business. Yay, we can sell it now. And they're happy. It's like what you're doing is meaningful. It's honorable. And we all want to do it right. And like, you got to get into this for the right reasons. And so if you look at the TRICARE rate and you're like, dang, that's a lot of money. I'm not making that much. You know, like there has to be another reason for starting a company than looking at that hourly rate. Right. That's all. We like that. Yeah.

SPEAKER_04: 1:36:24

I was going to say to balance your past with them, but you

SPEAKER_03: 1:36:28

were

SPEAKER_04: 1:36:28

like

SPEAKER_03: 1:36:28

the worst. Pretty good, right? I've been told I'm a realist. A realist.

SPEAKER_02: 1:36:33

We did

SPEAKER_01: 1:36:34

say

SPEAKER_02: 1:36:34

that earlier. Yes, we did. We

SPEAKER_01: 1:36:35

did

SPEAKER_02: 1:36:35

allude to that. It's like the glass half full, glass half empty, or twice as big as it needs to be,

SPEAKER_01: 1:36:40

right? There you go. Now for the glass half full, April. You've got the floor.

SPEAKER_04: 1:36:45

Yay. So, yeah, no, I just, quality is so important. And, you know, I don't think, and Stephen has said this numerous times, like, no one goes in the business saying, oh, I want a crappy business, but... You know, quality is just so important. And, you know, you have to treat your staff well. And you have to take care of your staff. You have to take care of yourself. You know, don't lose sight of yourself as a business owner. And, you know, there are so many successful ABA business owners and people who are really doing some great work out there. So it can be done. But, you know, reach out for support from other ABA business owners. I wish we could all do that more. I would love to see more collaboration amongst ABA business owners because we really need each other.

SPEAKER_01: 1:37:34

With six to eight-month waiting lists, is there really competition? Shouldn't we all be collaborating? I mean, there's got to be plenty to take out there, right?

SPEAKER_03: 1:37:41

Yeah, absolutely. They're not your clients. They're not my clients. They're people that need help, right?

SPEAKER_04: 1:37:48

Yeah, these services. And so, yeah, so, like, that's kind of, like, my hope is that it can be done and with the right intention.

SPEAKER_03: 1:37:56

We see it all day, every day. We see it done

SPEAKER_04: 1:37:58

right. There are a lot of quality services out there, you know, a lot of really good intentioned business owners who are also providing those.

SPEAKER_03: 1:38:07

Don't accept shit rights.

SPEAKER_01: 1:38:10

I like that. I like that. That's going to be the closing thought there, Mr. Dan.

SPEAKER_02: 1:38:14

So, yeah, closing thought on our end, just can I can't speak to the choruses enough, like the three-pi-square material for anybody out there listening that's thinking about starting or, like Stephen said, investigating and realizing it's not the best option for you, regardless of which end route you take. Can't speak enough to the coursework. Definitely check it out. And it was incredibly enlightening.

SPEAKER_01: 1:38:39

Or if you're up on your certification cycle, you need to understand better the ins and outs of what your employer goes through. I think that even if you're not interested in starting a business, it's so informative with regard to understanding the ins and outs of, you know, even for me, right? Why do you need to turn it, convert your session times every night? All right. Well, we cannot thank you enough for your time and all your knowledge and for coming on on to the podcast. Yeah. Thank you for all the knowledge you're imparting. Keep doing the good work. And as we like to say at the end here, always analyze responsibly. Cheers. Cheers.

SPEAKER_00: 1:39:16

ABA on Tap is recorded live and unfiltered. We're done for today. You don't have to go home, but you can't stay here. See you next time.