The New England Behavior Analyst BABAT newsletter | February 2017 | Volume 12

Member Spotlight:

Diana Parry-Cruwys (BCBA-D)

Robert Parry-Cruwys (BCBA)

Jackie MacDonald (BCBA-D)

From left to right: Jackie MacDonald, Diana Parry-Cruwys, and Robert Parry-Cruwys recording an episode of ABA Inside Track.

By Thomas Farnsworth, M.S., BABAT Editorial Board Volunteer, New England Center for Children

Are you a BCBA or student of behavior analysis that longs for a convenient forum for hearing informed discussion about classic and contemporary research in the field? Then look no further than ABA Inside Track, the first podcast by behavior analysts for behavior analysts.

In early 2016, BABAT members Diana Parry-Cruwys, Robert Parry-Cruwys, and Jackie MacDonald launched ABA Inside Track. The trio describes themselves as “…behavior analysts with a dream of disseminating knowledge about research in the field of applied behavior analysis…” Though the work of dissemination is formally delegated to professional organizations, according to Morris (1985), “…the effectiveness of informal activities by individual behavior analysts should not be overlooked.” The group likens their podcast to a journal club -- something that is wonderful in theory, but may not be feasible in many cases due to time constraints and geography. In lieu of this, the program provides a platform for behavior analysts to contact research literature and stay current in the field. For those unfamiliar, a podcast is a digitally-formatted audio program available for automatic download over the internet. A strength of the podcast format is its portability. Indeed, with a smartphone, tablet, or MP3 player, behavior analysts can bring that journal club experience with them wherever they go, and while they are going there. Often times, people listen to podcasts while commuting, inspiring the program’s tagline, “It’s like reading in your car… but safer.”

Each episode of ABA Inside Track is a Type 2 CE Event, which means that it is a source for continuing education credits necessary to maintain board certification for BCBAs, BCBA-Ds, and BCaBAs.

The format of the program is that of a discussion between the host of the show (Robert) and co-hosts (Diana and Jackie), along with special guests who join in to discuss their own research. Each episode provides a structured opportunity to contact behavior analytic literature from peer-reviewed journals (e.g., JABA, BAP) by providing a summary of the article’s topic, methodology, results, and limitations. During the last segment of the program, “the dissemination station”, the hosts discuss future directions for research related to the topic and potential implications for practitioners. Bi-weekly episodes of the show cover 2-3 articles related to a given topic, or unrelated articles in “grab bag” episodes. Look for preview episodes that include previews of upcoming episodes, the hosts responding to listener mail, and erratum. While new to our field, use of digital media (e.g., wikis, blogs, and podcasts) as part of education and professional training in the medical field is increasingly prevalent (e.g., Cadogan, Thoma, Chan, & Lin, 2014) and may enhance the learning experiences of students and clinicians (Boulos, Maramba, & Wheeler, 2006), suggesting the possibility of similar success within our own field.

Each episode of ABA Inside Track is a Type 2 CE Event, which means that it is a source for continuing education credits necessary to maintain board certification for BCBAs, BCBA-Ds, and BCaBAs. Per the Guidelines for Responsible Conduct (1.04), behavior analysts are obligated to maintain appropriate awareness of current scientific information in the field. Key words provided at various points throughout each episode allow listeners to purchase CEUs on the program’s website for a nominal fee (proceeds are invested into producing a higher-quality show, e.g., better production equipment), but the trio cautions listeners to use discretion in relying on their podcast for CEUs. Though they stand by the quality of their product in terms of intellectual rigor and entertainment value, which, in this author’s opinion is indeed commendable, they humbly encourage behavior analysts in the field to attend other continuing education opportunities including local conferences, in-person trainings, and other online resources.

To learn more about ABA Inside Track, you can visit their website (abainsidetrack.com), find them on social media (YouTube, Facebook, and Twitter), and, of course listen to their podcast, which is available through multiple podcast services (e.g., iTunes) on your smartphone, tablet, or computer.

Diana Parry-Cruwys received her M.S. in ABA through Northeastern University and her doctorate in behavior analysis from Western New England University. She is an assistant director at the New England Center for Children and teaches at Simmons College. Robert Parry-Cruwys received his M.S. in severe special needs from Simmons College and completed BCBA coursework through Northeastern University. He is currently a BCBA for a Massachusetts public school district. Jackie MacDonald also received her M.S. in ABA through Northeastern University and her doctorate in behavior analysis from Western New England University. She is currently an assistant professor at Regis College.

References

  • Boulos, M.N.K., Maramba, I., & Wheeler, S. (2006). Wikis, blogs, and podcasts: A new generation of web-based tools for virtual collaborative clinical practice and education. BMC Medical Evaluation, 6(41), 1-8.
  • Cadogan, M., Thoma, B., Chan, T.M., & Lin, M. (2014). Free open access meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J, 0, 1-2.
  • Morris, E. K. (1985). Public information, dissemination, behavior analysis. The Behavior Analyst, 8, 95-110.

Some Challenges Facing ABA Practitioners Within Insurance-Funded ABA Services

  • By Ashley Williams, M.S. Behavior Analysis, LABA, BCBA, BABAT Professional Practice Committee Volunteer, ABACS, Simmons College
  • By Brandon Herscovitch, Ph.D., LABA, BCBA-D , BABAT Professional Practice Chair, ABACS

A Brief Chronology Leading to Insurance-Funded ABA Services in New England

Within the past decade, legislation has changed rapidly in the Northeast, resulting in funding for ABA services becoming available to the vast majority of children with autism in need of such services. In New England, autism insurance reform began in Connecticut in June of 2009 and just two years later, by June of 2011, all six New England states had passed legislation that mandated increased insurance coverage for children with autism (Autism Speaks, 2017a). Simultaneously, each state experienced changes in funding and access to care as a result of the passage of the Affordable Care Act (ACA), which was signed in to law in March of 2010 (Patient Protection and Affordable Care Act, 2010). The most notable of changes occurred in January, 2014, when ABA was included as an essential health benefit for qualified health plans in 5 of the 6 New England states (i.e., Connecticut, Maine, Massachusetts, New Hampshire, and Vermont; Autism Speaks, 2017b). Licensure of behavior analysts further expanded the network coverage of behavior analysts in states where licensing for behavior analysts has been enacted.

With these legislative changes, appropriately credentialed ABA providers could bill services to insurers. Initially, many insurers used HCPCS codes, or “H-codes”, to reimburse ABA services (e.g., H0031, H0032, H2019, H2012), then in 2014 the American Medical Association (AMA) released the temporary codes (e.g., 0359T, 0360T, etc.) outlined in the CPT Assistant (American Medical Association, 2014).

Inevitably, such a dramatic shift in landscape of funding for Applied Behavior Analysis has been incredibly beneficial to our field and our clients, though it has also been fraught with challenges. Our field’s entry in to the medical arena has been a learning curve for practitioners. Behavior analysts must now wear many hats – negotiator, policymaker, advocate, and medical billing specialist, to name a few. Five crucial challenges facing behavior analysts today are described below.

The Challenges We Face

1. Contracts and Negotiations

Navigating the contracting process can be both time-consuming and cumbersome. It is extremely important to read and understand all of the terms of the contract prior to entering in to or re-negotiating an agreement with an insurer. Contracts should identify the services that will be reimbursed and clearly define the services and associated rates. Understanding the definitions provided by AMA for the different codes is important; however, these definitions do not have to be adopted by insurers or may be modified and interpreted differently. Contracts should additionally list the applicable plans covered by the agreement, and identify timelines for payment, authorizations, statute of limitations, etc. ABA service providers who are participating in the contract negotiations should know their bottom line, having calculated their practice expenses and overhead against the proposed fee schedule, and understand any relevant state or federal guidance that impacts the contract.

2. State and Federal Law

Providers should be familiar with the state and federal laws that affect the services they provide. For example, practitioners should be aware of state laws that affect fully funded insurance policies (i.e., small group, large group, and individual), state health plans, qualified health plans under ACA, and state-specific Medicaid guidelines. In New England, this includes each state’s Autism Mandate. Practitioners should also be aware of Federal law that can be used to protect consumers, such as the federal Mental Health Parity and Addition Equity Act (MHPAEA), guidelines within Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, and the Americans with Disabilities Act (Americans with Disabilities Act of 1990; The Centers for Medicare and Medicaid Services, 2014; U.S. Department of Labor, 2016). Providers also benefit from being familiar with Federal regulations surrounding the appeals process. Additionally, antitrust laws are pertinent to all providers by offering guidance on how to have productive conversations with other providers without violating the law.

3. Plan Types and Funding

There are a variety of health plans available to the population we serve. Behavioral health benefits may be contracted to another insurer to manage the benefits of the insured, creating a potentially confusing situation for clinicians and families. To complicate matters more, plan types managed by the same insurer may have different processes and plan limitations of which providers should be aware. Providers should be familiar with the various plan types in their state to best respond to family inquiries.

4. Reimbursement and Billing

Clinicians should be aware of the specific billing practices that are outlined in each of their contracts and be certain that any billing errors are caught quickly and corrected. The ramifications of erroneous billing practices have potentially catastrophic internal and external effects (e.g., negative cash flow, steep federal penalties).

5. Recommendations, Authorizations, and Appeals

Clinicians should ensure that their recommendations are based on the medical necessity of the client, and that any denials or partial denials are provided in writing by the insurer. In cases where the authorization does not match the recommended time, clinicians may work with families to pursue the appeals process, which may include utilization reviews (sometimes referred to as peer reviews) and external reviews.

What You Can Do

Though behavior analysts face many challenges and learning curves in entering the world of insurance-funded ABA, there are many resources available to help educate clinicians in each of these areas. As part of the Professional Practice Committee at BABAT, we’ve developed the following table of resources to help educate members and encourage members to become more involved.

Professional Organizations
Educational Resources
Stay Updated
Relevant Laws & Regulations

A Misunderstood and Overlooked Motivational Variable In the Instruction of Persons with Autism and Developmental Disabilities

By Vincent J. Carbone, Ed.D., BCBA-D, NYS Licensed Behavior Analyst, Carbone Clinic, New York – Massachusetts - Dubai

The list of basic behavioral principles has always included the concept of motivation. The refinement of this important behavioral principle and its practical application in the behavioral literature, however, has had an uneven development fraught with confusion and misunderstandings. In several of his works Skinner, (1938, 1953, 1957) was clear to distinguish between the effects of reinforcement and those variables that led to the altering of the value of environmental stimuli that would eventually act as a form of reinforcement (i.e., motivation). He stated, “It is obvious that reinforcement is one of the important operations that modify reflex strength. Another and perhaps equally important operation is associated with the traditional problem of drive or motivation…” (Skinner, 1938, p.341). Michael (1993) suggested that reinforcement history and motivation are frequently used interchangeably in the field of behavior analysis but they are not the same and should be identified and labeled as separate behavioral variables.

Michael’s conceptual and practical analysis of conditioned establishing operations (CEOs) has been particularly instrumental in extending the application of a behavioral analysis of motivation to the learning needs of persons with autism and developmental disabilities.

Keller and Schoenfeld (1950) were the first to attempt to bring clarity to the issue of motivation and precisely differentiate its mechanism of control from discriminative stimuli. They devoted 65 pages in chapter nine of “Principles of Psychology” to the topic of motivation. The chapter includes many of the same issues Skinner (1938) discussed but in more a comprehensive manner. The first two (2) topic headings in their chapter are “A New Line of Inquiry” and “The Need for the Concept of Motivation”. They offered the name establishing operation as a behavioral variable to identify any activity, stimulus, or condition that altered the value of consequent stimuli and therefore altered responses which in the past have produced those consequences.

Through a series of writings on the topic of motivation Michael (1982, 1988, 1993, 2000, 2004, 2007) adopted Skinner’s (1938) analysis of motivation, differentiated discriminative from motivational control and refined Keller and Schoenfeld’s term. Michael’s writings led to a resurgence in the use of the concept of motivation and it began re-appearing in basic and applied research reports in the 1980’s and has continued to the present. Initially, the concept of the establishing operation appeared in the functional analysis literature (Smith and Iwata, 1997). Since then Michael’s conceptual and practical analysis of conditioned establishing operations (CEOs) has been particularly instrumental in extending the application of a behavioral analysis of motivation to the learning needs of persons with autism and developmental disabilities.

In an important paper on teaching the mand, Michael (1988) gave names to two specific CEOs, the warning stimulus and blocked response EOs. Years later he further refined these concepts and re-named them the reflexive conditioned establishing operation (CEO-R) and the transitive conditioned establishing operation (CEO-T), respectively (Michael, 1993). In this paper he described the practical application of each in the treatment of language disordered individuals and went out of his way to emphasize how these variables were frequently mistaken for discriminative stimuli. It is the concept of the CEO-R that has received little attention in the behavioral literature and clinical practice despite its importance in the reduction of problem behavior during the instruction of persons with autism and related disabilities.

Michael’s distinction between the discriminative stimulus and the CEO-R has not been widely relied upon in the applied literature to differentiate the behavioral mechanisms that account for problem behavior maintained by negative reinforcement (Langethorne and McGill, 2009). Michael (1993) defined the CEO-R as a stimulus that has been correlated with a worsening set of conditions and therefore its presentation establishes its removal as a form of reinforcement and evokes behavior that has produced its removal in the past. This concept has important implications for reducing problem behavior during high demand instructional sessions. Mistakenly identifying instructional demands that evoke problem behavior during discrete trial instruction as discriminative stimuli may lead clinicians to an over-reliance on stimulus control solutions, e.g., high rates of extinction. In addition, overlooking the benefits of abolishing the CEO-R can lead to inappropriate reliance on negative reinforcement to strengthen academic responses during instructional sessions (McGill, 1999). As an alternative, Michael (2000) recommended abolishing operations in the form of improved instruction or curricular revisions to reduce the effects of the CEO-R and improve cooperation during instruction. Following Michael’s suggestion, Carbone, Morgenstern, Tirri, and Kolberg (2010) provided an analysis of instructional demands as CEO-Rs and a list of instructional methods to abolish the CEO-R and increase learner cooperation. These methods include stimulus demand fading, errorless teaching, fast paced instruction, interspersal training, and others Abolishing the CEO-R may alter the function of demands from conditioned aversive stimuli to discriminative stimuli for responses as suggested by Michael (2000). The benefits may include an abating of problem behavior and an increase in responses to instructional demands leading to greater acquisition of important skills.

A thorough understanding of the principle of motivation and an analysis of instructional methods as abolishing operations can provide behavior analysts with a powerful technology for reducing problem behavior during instruction. With knowledge of the concept of the CEO-R, practitioners may be better equipped to evaluate, select, and implement instructional methods that reduce the escape motivated behavior exhibited by a large percentage of children with autism and related disabilities. A conceptually systematic approach to determining the influence of antecedent motivational variables will equip instructional decision makers with a wider range of choices of teaching methods and, perhaps more importantly, provide a natural science approach to analyzing and modifying instructional methods when the performance of learners with autism and developmental disabilities does not result in expected outcomes.

References

  • Carbone, V.J., Morgenstern, B., Tirri, G., & Kolberg, L. (2010). The role of the reflexive conditioned motivation operation (CMO-R) During Discrete Trial Instruction of Children with autism. Focus on Autism and Other Developmental Disabilities, 25(2), 110-124.
  • Keller, F. S., & Schoenfeld, W. N. (1950). Principles of psychology. New York: Appleton-Century Crofts.
  • Langthorne, P & McGill, P. (2009). A tutorial on the concept of the motivating operation and its importance to application. Behavior Analysis in Practice, 2, 22-31.
  • McGill, P. (1999). Establishing operations: Implications for the assessment, treatment and prevention of problem behaviors. Journal of Applied Behavior Analysis, 32, 389-418.
  • Michael, J. (1982). Distinguishing between the discriminative and motivational functions of stimuli. Journal of the Experimental Analysis of Behavior, 37, 149-155.
  • Michael, J. (1988). Establishing operations and the mand. The Analysis of Verbal Behavior, 6, 3-9.
  • Michael, J. (1993). Establishing operations. The Behavior Analyst, 16, 191-206.
  • Michael, J. (2000). Implications and refinements of the establishing operation concept. Journal of Applied Behavior Analysis, 33, 401-410.
  • Michael, J. (2004). Concepts and principles of behavior analysis. Kalamazoo, MI: Society for the Advancement of Behavior Analysis.
  • Michael, J. (2007). Motivating Operations. In J. O. Cooper, T. E. Heron, & W. L. Heward (Eds.), Applied behavior analysis (pp. 374–391). Upper Saddle River, NJ: Prentice Hall/Merrill
  • Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. Englewood Cliffs, New Jersey: Prentice Hall.
  • Skinner, B. F. (1953). Science and human behavior. New York: The Free Press.
  • Skinner, B. F. (1957). Verbal behavior. Englewood Cliffs, New Jersey: Prentice Hall.
  • Smith, R., & Iwata, B. (1997). Antecedent influences on behavior disorders. Journal of Applied Behavior Analysis, 30, 267–278.

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