Rad N Bad: Beyond Driver's Ed Ethics — Conflicts of Interest, Billable-Hour Incentives, and Ethical Decision-Making in Practice

Following the Ethics Code Is Not the Same as Being Ethical

Dr. Jon Bailey said the Ethics Code (the BACB's rules for certified practitioners) is already pretty good. It needs touching up, not a rewrite. He did push back on one popular idea. People like to say ethics means do no harm. Bailey called that too brusque for this field. The heart of the work is acting in the client's best interest. And the client is always the most vulnerable person in the room. You may work with the parents. The child is still your client.

Bailey also described where the Code came from. Hundreds of people added to it over 30 years. Each standard traces back to an incident that happened and will happen again. He said people treat those standards as guardrails. The better move is to think your way through the problem first. Do that well and you never get near the rail.

Zack Stevens added the flexibility piece. You can follow the Code to the letter and still miss the person. For him the difference is compassion and context. Sometimes the Code points one way and the client's benefit points another. Nine times out of ten, the client-centered choice is also the ethical one. Ethics is not black and white, which is why we argue about it. Two clients in similar situations can need different answers.

I think it's possible to be an ethical behavior analyst while following the ethics code to a T, but I also do not think that just because you followed the code means that you're an ethical behavior analyst.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

Why the Ethics Code Says Almost Nothing About Conflicts of Interest

Stevens ran a simple test on the Code. He searched for the word conflict. It shows up four times. It appears in an example about multiple relationships (having two roles with one person) and in a research standard. What is missing is practice. The Code does not spell out why a conflict of interest (when money pulls against client benefit) is a daily clinical problem.

He would fix that in one of two ways. Add far more content on conflicts of interest. Or add a whole new section he would call responsibility to the field. We already cover responsibility in practice and in research. We say much less about what we owe the profession itself. One example he gave: do not make clinical calls that rest on someone else's financial interest.

Bailey brought a live case from the ABA Ethics Hotline. A question had come in the day before. The writer argued that tying pay directly to billable hours (time you can charge to insurance) creates a clear conflict. It can push clinicians to recommend or keep hours past real clinical need. Bailey agreed this belongs in any revision. Working for a company built to make a profit is a conflict. It does not show up once a year. It shows up almost every day, with every client.

In fact, if you control F and type in conflict, it only shows up four times.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

Billable Hour Minimums and the Pressure They Create

Stevens named financial contingencies (pay rules that shape behavior) as the biggest ethical challenge for ABA organizations. The most common version is salary plus a billing minimum. You might owe 100 or 120 hours a month. You might owe 360 in a quarter. Miss it, and your pay gets docked in the next period.

Watch what that does two months in. The clinician checks the timesheet and sees a 20 or 30 hour gap. The natural response is to beef up billing for the rest of the period. Stevens was careful here. That person is not automatically dishonest. The contingency simply starts them looking for reasons to bill more. He gave a clear example. You have supervision hours left over, so you sit in on technician sessions. Is that clinically valid? No. You should deliver the hours you said you would deliver across the authorization period (the span a payer has approved).

Bailey described the same squeeze coming from the top down. A company built on an accounting model drives those numbers onto everyone. Technicians round three hours up to four, and nobody checks until it is too late. Analysts claim supervision they did not really do. He called it drive-by supervision: you spot the technician in the hall, ask how it is going, and log an hour. His blunt summary was that this was never meant to be a profit-making field.

Stevens put the fix at the front end. Decide the hours during the initial assessment, based on that person. Stick to the plan you wrote. If it needs to change, change it when the authorization ends or changes. And as a field, stop putting clinicians in that spot at all.

I think the greatest ethical challenge are financial contingencies.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

Blanket Hour Requirements at Intake

The same math shows up at intake. Many programs advertise a set dose: 25 hours a week, or no spot. Stevens said he does not believe in that number to begin with. The blanket rule also does something to families. Parents who hear that ABA is the most important thing will swap childcare for therapy just to qualify. Some children do need heavy hours. As a policy applied to everyone, it is not right.

Michael Carrero called cookie-cutter authorizations flat out unethical. You cannot prescribe a dose before you have looked at the person. He also drew a hard line around what those hours buy. More availability for a dosage increase is not the same as quality work. A warm body in a room is childcare. Childcare matters, and so does therapy. They are not the same product, and we should not bill one as the other.

Carrero then traced where the damage lands. Families who get sold smoke and mirrors rarely blame one bad provider. They blame the whole science. They had no way to know what good practice looks like, because nobody ever taught them what to look for or why.

I very much, let's give people what they need and not what my bank needs.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

Paying Behavior Analysts for Outcomes Instead of Hours

Bailey's proposal is easy to say and hard to install. Pay behavior analysts for outcomes, not for hours. He wants measurable functional skills (skills the person really uses daily). Under that model, the standardized test stops being the starting point. You ask the family what they want this child to be able to do. You suggest some options. You agree on the list together. Then you teach those skills.

The data part already exists in most programs. Technicians take data in session. If you take data, you can graph it. If you graph it, you can see an acquisition curve (a line that shows learning), a flat line, or a slide backward. So pay on skills acquired under your watch, plus some validation that the teaching happened.

He has pitched this to insurers and gotten blank stares. His opening pitch to insurers is that outcome-based pay would save them large amounts of money. Right now, he argued, payers (insurers who fund the services) buy more time than the work requires. Pay for outcomes and you get outcomes. You also find out it does not take 30 hours a week. Bailey said he is presenting a paper session that asks whether the billable hour is dead.

Sean Yocum asked how fast the 30 to 40 hour standard would fade if the billing contingency vanished. Bailey guessed a week to ten days. Insurance companies turn on a dime when money is on the table.

It seems to me that what we ought to be reinforced for as behavior analysts in the field is outcomes.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

What New BCBAs Are Least Prepared For

Stevens had a note ready for this one: real world social validity (whether goals matter in daily life). New analysts learn to teach straight from the assessment. The assessment tells you where skills sit. It does not tell you what this person needs in this home, this school, this neighborhood.

He laid out the bind honestly. Most payers require some standardized assessment (a fixed test with set scoring). Many teams reach for the Vineland (a standardized developmental assessment) because it is less ABA specific. Not everyone is qualified to run it. Stevens is not sure it is always ethical to use a tool that does not fit the learner. It is also sometimes the only door to getting that family help. His workaround is to put the truth in writing. Run what the payer requires. Then say plainly in the report that the test was required. State that it did not fit the client, and name the skills that do fit.

The second gap is insurance. Stevens said his own graduate program never touched it. Now most of his company's work runs through insurance or Medicaid. In weekly group supervision, his senior analysts walk supervisees through each payer's requirements, client by client. They also say out loud whether the required measure is valid for that person.

Carrero pushed the same idea onto goal selection. If you cannot connect a goal to life three, five, or ten years out, do not run it. Matching should lead somewhere real, like ordering at a store.

How does this add value, meaning, and context to your life?

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

Supervision After Driver's Ed

Yocum's driver's ed picture anchors the episode. Here is the book. Memorize the rules. Do not speed. Congratulations, here is your license. Then we hand someone the keys to a Ferrari and send them onto I-40 at rush hour. The handbook never covered the thing now happening in front of them.

He was clear that the Code still matters. It is the floor. Do not exploit clients. Protect confidentiality. Stay inside your competence. Those are not suggestions. The trouble is that following the Code and thinking ethically got treated as one skill. They are not the same skill.

Supervision drifted the same way. It became a count: the 2,000 hours, the unrestricted activities (fieldwork spent doing analyst-level work), the signed monthly form. Yocum compared it to checking into a hotel. Breakfast runs 6 to 9, the pool closes at 10, here is your certification, good luck. We taught people to finish fieldwork instead of how to be professionals.

His fix came from an old baseball coach: more is caught than taught. Supervisees watch what you do far more closely than they read what you assign. So model the hard moments. Show them what you do when a treatment is not working. Show them how you admit you were wrong. Show them how you respond when a payer cuts services. Yocum also named the quiet failure. You can document everything perfectly and still build a family that cannot function without you.

I don't think there's an ethics code standard that says, here's what to do when insurance cuts your authorization in half, your BCBA just resigned.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA

Measuring Success Outside the Therapy Session

Bailey told a hotline story that makes the point. A father wrote in, unhappy with his child's provider. The team was teaching letters, colors, and matching. What he had asked for was help with severe tantrums, and those had not changed. When he asked about it, he was told the other work had to come first. He could not take his child out of the house. Nobody had taught him what to watch for, what set the tantrums off, or what happened after them. Bailey told him to take that message to the owner and start fresh somewhere else.

His other prescription is older than the insurance era. Observe before you treat. Graduate students tell him families are not getting trained. He asks whether they observed the family first. The answer is always no. If the problem is the morning routine, drive over at seven and watch breakfast. If it is bedtime, be there at six thirty. He noted that the earliest studies in the fifties and sixties worked exactly that way. When one analyst told him insurance would not fund it, Bailey asked an insurance contact directly. The answer was that they want people to do that.

Stevens builds the whole case around one intake question: what do you want to get out of our treatment? Then the outcomes become the family's outcomes. Can they eat dinner at a restaurant together? Did you teach sitting, ordering, and using utensils? Plans should keep running when you are not there, carried by parents, grandparents, stepparents, even siblings. He added one group we skip too often: the client. Ask them what they want whenever you can get that input.

Yocum named the terminal goal (the end skill you are building toward) in plain words. The point is not great therapy. The point is therapy that is no longer needed. Carrero's version is a better intake question. Ask what the family wants when all of this is done. One parent's answer might be ten quiet minutes to take a phone call. That answer tells you which leisure and daily living skills to teach first.

You need to go in the home and sit in the corner with a notepad and just observe and figure out what's going on.

From the talk — Dr. Jon Bailey, BCBA-D, Zack Stevens, BCBA, Sean Yocum, MA, BCBA, LBA & Michael Carrero, BCBA, LBA