CEO Turnover In ABA, Payor Disclosures, And APBA Conference
We are talking about so many fun things. We are going to talk about CEO turnover some Central each downtime and the impact it has. We are also going to give a quick conference recap so let’s dive in.
Before we dive in, I thought we could give a shout-out. It is International Women’s Day. Shout out to all of the women out there, working hard, taking care of their families and doing all the things we do. I know for me, International Women’s Day was literally a day where I worked, cleaned my house, went and picked up my grandson, decorated for Easter so that it would be perfect for him and went to bed at midnight.
Do not even get me started. I feel like every day should be International Women’s Day.
You have a two-year-old. How is it balancing all of that with being a CEO, a mom and everything that you do?
It is tough. I have so many providers reach out to me that are female founders who text me and say, “I had a kid.” Three providers who had babies reached out to me being like, “How do you do this?” I’m like, “No one is doing it. You are figuring it out.”
It seems cliche to say do not be hard on yourself. It is not because I think the key is, do not be so hard on yourself. You are going to have days where you feel like you are terrible or you are on top of the world. Some days, I feel like I’m the only person in my house who knows where anything is.
While we are at significant events, if you haven’t heard, there is a very sad thing going on in Ukraine. I do not know if you know this, I speak Russian and my dad is from Ukraine. I’m part Ukrainian. My mom is from a different part of what was the USSR. It has been so sad to watch. For those of you who are somehow impacted and have family out there, it has been a tough week listening to all that is going on. I do not know how you have heard about it, Anna, in your neck of the woods.
A lot of it is coming through on different social media platforms and specific journalists that I follow that provide good reporting. I was going to ask you because I knew you were Russian but I was not sure what part and where you were from. Do you have any thoughts for us other than sending prayers? I saw that you posted something about how we could financially help them.
I have been someone who can speak the language following the more local news. I’m like, “I do not even know how to help.” I have heard about this trick that people are doing, which is you can book a room in Airbnb in Ukraine and basically cancel the rooms. You do not go and you just send them money. I did that to a couple of places and that felt good but aside from that, it is hard to figure out what to do and not to be a downer.
It is so important. It was interesting. I will go off on one more tangent and then we will get back to what is on our agenda. For those of you reading something that is encouraging in our all-staff Slack channel is what we use to communicate. This kindergarten group put together a hotline. It is so sweet and on MPR. To me, I thought when the journalist started talking, he was saying, “There is so much going on.” We have to stop and realize it is a lot and affects your day-to-day life. I think people are dealing with a lot. I feel super grateful we are certainly not dealing with a lot of the things that those are in countries that are at war. Everybody is dealing with a lot of things now and the impact.
It is okay not to be okay too. I think this idea that you constantly have to be okay. There is no telling what will impact your day in and day out. Speaking of events and being okay or not being okay, I will get that rough segue. Let’s circle back. We spent our last episode talking about turnover. We talked about technicians and clinical directors. What we failed to talk about was this idea of CEO turnover.If you're in an executive role, learning how to hire and how to fire is like an art form. Click To Tweet
We know that turnover is an issue with our direct care staff because there is a labor shortage. It is important to note that there has been a high volume of CEO turnover. Five of the largest ABA organizations had their CEOs leave for one reason or another and some have been replaced so others have had interim CEOs. It made sense to talk about it because this is where we talk about the things that no one else is talking about. CEOs are getting removed from their role either willfully or not. I think that has a lot of implications for our field. I will pose the question to you, Anna, what has your experience been with executive turnover and what are your thoughts on it?
I think it certainly has an impact on any organization. I had an experience with a CEO turnover. In my case, it was pretty abrupt and a quick shift with that CEO wanting to make a change and do something else. They brought someone new in fairly quickly. There were leadership style differences and a lot to get used to and adjust to within that. For our leadership team, we had to make a pretty quick adjustment to how things were different, which is not a bad thing. It is just an adjustment.
When you are running an ABA company, whatever position you are in on a leadership level, you can’t stop for a moment. When you are dealing with those kinds of significant changes in leadership, it does take time. It can slow things down in other areas when you are working to ensure that all those kids get the hours that they need, your authorizations do not expire and your billing is going out. For us, it was the fact that it was quick. I think that made it a little bit more challenging for sure.
There are definitely some challenges with a quick exit because I think no one sees that usually coming except the person involved in it. It is interesting. I have a lot of opinions on how to exit executives appropriately. Unfortunately, if you have been in the CEO role or an executive role, you have had to make tough decisions in terms of how to hire and fire. It is more of an art form because, ultimately, it is never an easy decision. As a CEO, you have a responsibility to your board and the organization and the people that work for you too, to make sure that the company remains viable.
If you are in a nonprofit, you have the fiduciary responsibility to your sponsors, your donors, or your board. You constantly have to think about the big picture as opposed to the individual sometimes. In the different roles that I have had, I definitely felt there are some ways to exit executives that leave you feeling like you have a bad taste in your mouth. It is never an easy decision but there are ways to do it where you can sleep better at night. It is usually harder for you as a CEO to exit people in that way. I think a quick exit is tough for everyone and there are smoother ways to do it.
What you have seen done well is my question.
I think that whenever there is some type of leadership or executive change, it is typically not a surprise to most people involved in that decision. Whether it is a board or a CEO who has to make a larger shift at the executive level, it is not a surprise for the executive. Ideally, if you are at that level, you are getting regular feedback, had a review and gotten direct communication about what may or may not be working unless there is an egregious ethical issue or something like that.
If you are in that position, my recommendation would be to have the conversation that, “I do not think it is working out. I want to make sure that we can exit in a way that allows you to have the time that you need, us to have the time that we need,” and basically put together an exit strategy with that executive where they can communicate their story or dialogue as to what happened.
Their dialogue about what is happening and taking the time to make it smooth for everyone involved allow them to say goodbye to the people they work with. Pat their back on the way out because no matter what the differences you have with that person, they did contribute to the organization in some way.
That being said, it is hard to do that sometimes especially when you have philosophical differences. I do think that we spend so much time thinking about onboarding and it is as important to think about off-boarding in the exact same delicate way. Ultimately, that is the last perspective that person is going to have about you and your organization. You want them to leave with a positive taste in their mouth.
At BHCOE, we certainly have people who have gone and come over the years. I’m proud we have BHCOE Alumni that I can look back to you and say, “They worked at BHCOE at one point. We love them. It didn’t work and that is okay.” You still see these people out and about and there is no bad blood. I think that is important. If that person is not part of that alumni group, there must have been something wrong. Those are people who are going to be your ambassadors after they leave your organization.
It is so good. I appreciate you bringing that perspective. When I think about successful exits, I do think that you are right. It is a situation where someone’s not happy whether it is the individual who is leaving because they are not happy or the organization or board is not happy. Generally, the people on the ground that are doing the work, the staff that is out there with our kids with autism and things, they do not know all of that stuff.
You want to keep stability too. Make sure everyone knows that nothing is changing for them. They keep doing the good work that they are doing. I think that is very important in that whole picture when those things occur. As I have thought about some of the changes that have occurred, do you think these changes are an indication that our industry is facing difficulties beyond the hiring turnover? I know we do a lot of reporting and data analysis on that. What are your thoughts about that?
I’m curious what you think too but I think that there are a couple of things that we take for granted in our field, which is that we have a lot of Founder-CEOs. Founder CEOs typically have a much longer tenure than non-founder CEOs. When you do see that uptick in CEO turnover, for me, a lot of those folks that we know turning over are not founders. They are CEOs for hire, which is different considering the fact that their tenure is a lot shorter. A lot of CEOs have been dealt a tough hand with COVID. The last few years have not been easy on businesses.
When you enter an organization as a CEO, you have this honeymoon period where you have eighteen months to get it together. You come up with a 100-day plan, onboard, and get to a point where you are showcasing what you are going to accomplish. After those eighteen months, it gets “real” very quickly because you need to be able to showcase results whether it is growth, quality, or marketplace initiatives that you are putting forward. I think that COVID dealt a lot of CEOs a tough hand because even if you come in with a strong plan, there were some factors that were outside of their control.
I agree with that. I also think that everyone was braced in 2020 for COVID. I feel like some organizations in the States that were hit harder than others maybe saw some tougher situations but I feel like the aftershock is what has been difficult. I’m sure for all of the leadership teams out there, the CEOs, CFOs, COOs, and even the clinical leadership, that has been a difficult place because we have seen this pull back from the market with being able to hire. You saw what you had to pay people to increase. You have less people that you can hire and the cost to hire them went up without any change to reimburse it right.
There have been some organizations that I have commended because they have had BCBAs or clinicians who worked up the ranks who became clinical directors, regional directors, and operations. I know a couple of BCBAs who I have known for a long time who are now CEOs of these organizations. I think, ultimately, the role of running an ABA organization is a very people-centric and people-heavy business. You need someone in that role too, who understands the plight of the RBT and the BCBA. That has been interesting to see as well.
I think it is a lot harder to learn about the industry than it is to learn things like financial reporting, audits, taxes, lending, and all that. That has been interesting too. It is this idea of as a CEO, you need to talk to your people, go out into the clinics and be in the trenches to understand that role. It will help you make better decisions about the business as well.
I love that point, Sara. Someone who reported to multiple CEOs within my career and went through more changes in that position than in the CEO position, one thing that I think I would love to say to any leader is, to go out and see the clinic, how ABA is delivered and go meet your clinicians. Even if you did that once a year or doing that as an onboarding part of your job, go out and see how it is run in that clinic where you are serving kids because it is not like any other healthcare service.
I do want to caveat that. It is not to say we should not be held accountable. We talk about that a lot at BHCOE. We want to be treated like all other healthcare services that we need to act like a healthcare service. At the same time, ABA is unique and it is delivered in a tiered model. Good luck to all the CEOs is what I want to say out there. We need you to do well because the kids need service. As the person who is going back to always being a mom, we want everyone to be successful.
Anna, next up, I wanted to talk to you a little bit about an announcement we made in our last newsletter called BHCOE Payor Disclosures. Can you tell us a little bit about what that means? Why do payor disclosures matter to accredited organizations and payors?
I’m excited because we have been doing this but more manually if that is the right way to say it. When we have providers or payors that reach out, we are letting them know who the accredited providers are in their state. If it is a national payor, send them a list if they ask for it. What we are doing now is being very deliberate about that. Every time we get a new batch of accredited providers that we are so proud of, we are sending that to all payors.The people that you offboard are going to be your ambassadors after they leave your organization. Click To Tweet
Maybe you are not even in a network with them but you are going to be so they would have access to know that you are an accredited provider. It is going to be exciting so that those providers that are in-network or those that are working on in-network status, those payors already know that they are accredited. Our hopes are that it can help speed up that process because you have gone through the accreditation. I think it is going to be a good way to start showcasing those providers.
I didn’t go to APBA in 2022. We obviously have a lot going on at BHCOE. I would love to hear how it went. It was in a fun city. I’m sure that was fun but who did you see? What were the hot topics that you felt everyone was interested in while you were there? Would you recommend attending the APBA conference?
For those of you who do not know APBA, it is the Association of Professional Behavior Analysts.
The Association of Professional Behavior Analysts (APBA) is a 501(c)(6) nonprofit organization whose mission is to promote and advance the science-based practice of applied behavior analysis. APBA carries out that mission by representing the interests of appropriately credentialed professional and paraprofessional practitioners of applied behavior analysis, working with federal, state, governmental, and third party entities to enhance recognition of appropriately credentialed professional and paraprofessional practitioners of applied behavior analysis, promoting public understanding of the professional practice of behavior analysis. And so much more!
It is always a great conference.
I will start by saying New Orleans is a great town. It was a bit of a bummer to see how quiet the conference was. It felt a little lighter than most conferences but what I understand is that is what’s happening across most conferences anyways. You are getting half of the people that you normally get. I always love the conference because they start with a CEO/Directors meeting. In 2022, it was run by Rebecca Womack who’s at BlueSprig and Allyson Moore from CABA.
It was informative but I had a couple of providers come up to me saying, “It seems like it is always about licensure whenever we are at those meetings.” We have already passed the autism mandate in all 50 states. Licensure is happening in some. I wished we would have talked about labor shortages, billing, and credentialing delays, or training. Rebecca is the incoming APBA president.
I think licensure is important to BCBAs. It means something different to CEOs. I’m on the policy side of things a lot and hear a lot of feedback from CEOs or COOs. They are dealing with a lot of barriers to trying to get kids access to care. I think that is at the forefront of a lot of their concerns with what has happened with a lot of these bills that have passed creating licensure. Licensure is important absolutely, improving quality and ensuring that their states know who’s practicing and things like that.
I was at the capital about House Bill 412 in Georgia. We had some great discussions right before the Senate hearing. I think it’s going to be critical how are we ensuring that we’re not adding an additional 90 days to an already huge delay in credentialing. I thought it was a meaningful discussion. Potentially, there’s an opportunity to have some of these discussions where there are big barriers, like in Arizona. Obviously, New York has its own fund state. That is interesting that that was the topic. I do think it’s a valuable topic for BCBAs.
The other thing was that the opening of that CEO Director’s meeting is usually like the evening before. The next morning, I did a ton of opening of keynote, which was on substance abuse. That was interesting because the majority of clinicians are not working in that field. It was cool to see that there is someone working in that field and something that APBA was choosing to highlight. There was a presentation on value-based care led by CentralReach. It was interesting.
There was definitely some buzz about the CentralReach situation. If you are not familiar with CentralReach, they are a pretty popular EMR. They had an outage in February 2022. It lasted about a week’s worth of time. It is five business days where basically you would be intermittently kicked out of the app or everything was slow. There was a pretty big loss of data. It happened again about 2 to 3 weeks later. I know CentralReach ihas fully resolved this issue and that many have reported that it is running better than ever post outage. As you walk through the vendor space, you see so many more EMR vendors than ever before.
It used to be Therapy Brands or AccuPoint, CodeMetro, and CentralReach and that is it. Now, it was every other booth was an electronic medical records or practice management software. The CentralReach outage was definitely a point of conversation. The implications of the revenues loss and some people said likely, “That wasn’t true about revenue loss because even though we pay our RBTs or technicians and supervisors to fill out notes, we had to pay them at a later date to do it,” but others were like, “No, we couldn’t even figure out what to bill so we had not to bill because that was confusing.” I thought that was an interesting thing that is still lingering even a couple of months later.
How was the value-based pay presentation? Was it more about how their platform is being prepared for that?
Full disclosure, one of our directors for accreditation was there through the entire presentation. I had to jump out for a phone call during part of it so I do not want to speak ill-informed about it. From what I understood, they were showcasing a lot of the more granular data that they collect at the CentralReach side. I do not think it was focused on value-based care per se but more on the readiness piece. How can you make sure that you are collecting the right data?
At the same time, there were many great conversations about it. At that presentation, there was a conversation around school-based services and quality with school-based services. Scott Page, one of our clinical evaluators, attended that one and sent our team that Virginia has a whole ethics code specifically for school-based behavior analysts. I remember hearing about it but he sent the actual code. I was like, “This is incredible.” It’s cool to see that type of information being disseminated and thinking about how much the setting makes a difference in the way we provide care.
That is so interesting. School-based service has been a pretty big topic in Colorado. They have a piece of legislation right now to help ensure kids can access services in the school setting. It has been a hot topic that I think is very important. Kids spend a lot of time in school. Some states are much more open to allowing that. Some payers are more open. I know Florida also had some legislation because they had this odd policy that the school districts interpreted in a way that would say RBTs could not work in the school. They were working on some legislation to remove that. That is such an important conversation.
Parallel to that, there were some conversations around licensure and certification. I ended up skipping that one because I felt I got a good dose of licensure issues at that CEO and directors meeting. The cool part was there was a whole presentation at APBA about the importance of accreditation, which was, to me, like preach. I was so excited. We’ve been talking about the importance of accreditation for years. It was validating to have a whole session on the importance of accreditation coming from someone who isn’t us, which is very validating that we’ve been marching in the right direction and the field is finally rallying around so that was awesome.
I have to brag about my team for a second, Anna. It’s your team too. Our evaluators presented some of the longitudinal data that they’ve been collecting and the people that were involved in that. Obviously, Dr. Kazemi, our Chief Science Officer, was the chair. She led that conversation and coached the team but this is the presentation that we have largely done in the past in different capacities.
It’s evolved as our data set has gotten bigger but Nikki Williams, one of our most senior clinical evaluators, has been with us since BHCOE started pretty much. She started her PhD program when she started working for us and is now a PhD, if that gives you any context of tenure. She started by exploring indicators of a healthy business and how do you define high-quality ABA. After that, Micah is our Director of Accreditation and he talked a little bit about patient and guardian satisfaction, which was awesome.
The funny part of Micah is he’s like a preacher’s kid. Whenever he gives his presentations, he’s very inspirational. People started clapping in the middle of his presentation, which I thought was awesome. Micah was focusing on compassionate care in this concept of behavioral artistry and the idea that some of the characteristics he associates with behavior analysis are not warmth, sensitivity, sense of humor and humility. Those are the type of things that we need to see for parents to be happy. I think that was meaningful to a lot of the people who do that within their practice.
Melissa Cottengim presented on predicting employee satisfaction and then Scott Page took it home with some presentation on organizational outcome data. I was super blown away by them. I knew the data that we were collecting and its impact on it. They have an incredible job. I was proud to see them be able to present years of the work that we’ve been doing.
That made me think of a conversation you and I had. I would like to pivot a second to talk about this. We have all been in this experience with, “Do you bring your employees back to the office? Do you let them work from home? Do you go to conferences? Do you have in-person meetings? What is the impact of that? Does it make a difference?” I’ve been reading a lot and listening to podcasts myself. Brene Brown has done a lot of talks about that too. You had some unique perspectives that are worth sharing with everyone because everyone is asking that question right now.
When we talk to our team members, everyone is like, “I do not want to go in the office every day.” I think we can all agree there’s some convenience around not going into the office. The number of conversations we were able to have within our team and the connection you feel when you are together in person is hard to overcome virtually. You can’t connect in that way virtually. It’s like seeing the people around you. I had so many colleagues that I hadn’t seen in forever. You can have a sidebar or real conversations.If you're working in the ABA industry, go out and see how ABA is delivered. It's not like any other healthcare service. Click To Tweet
Sometimes on Zoom, you get on, you are there to talk about one thing and get the work done then you lose the human element. I walked away thinking, “We need to do this more often.” We already meet a fair amount in person as a team. We need to make time for it as an organization because there’s so much information that you lose on the virtual side.
There are some good data coming out about that because companies see the impact when you do not have that relational connection. I know for me, it was definitely a challenge. When I first started working for BHCOE, it was literally during the pandemic. It was so incredible getting to meet everyone for the first time. It gives you this sense of trust that you have when you are with people in person. I wanted to decipher that because in many situations if you are asking yourself, does it matter if we’re in person or not? Does it matter if I go see the BCBAs that I’m working with or all that kind of stuff? I think it does matter. To your point, you can do a lot of the daily grind at home and things like that. There’s something to connecting that is important.
Michele Trivedi, who’s on our ANSI Commission and I do not know if you know her, Anna but she passed the autism mandate in Indiana. She’s a parent and was at the convention. She and I can email, text or we connect in other ways. I go up to her and give her a hug and be like, “Thank you so much for all your hard work. Our ANSI standards are going through their next round of public comment. Thank you for all your revisions.” No matter how much you email or text, you can’t communicate some of those things virtually.
Also called is Charna Mintz, who is the outgoing president of APBA from Action Behavior Center. Jim Carr was there from the BACB. I didn’t get to go to any of their sessions but I imagine it was a nice update on where the field is moving towards. You see all the people that we’re used to seeing at the conferences. I had a great time and hope that we have more people coming in 2023.
You have to pick and choose. We had a lot of great feedback that so many people had such a great time. What’s next? I think CASP has their conference coming up.
Yes. We always co-host an event with Bolton & Company during that conference. We have been doing that for the last few years. I’m excited to do that again in 2022. The Autism Investor Summit is coming up. I’m so excited about that. Dr. Elli Kazemi is presenting at TxABA. That is coming up.
One of my great friends and colleagues in the field raves about TxABA.
I’ve always wanted to go and I’m so bummed because it’s during my daughter’s spring break. The Autism Investor Summit is the 18th or 20th of April 2022. TxABA is the 21st to the 24th 2022 as soon as the summit is done because you know how it is planning a conference. I’m like, “I’m going to take those four days off.” Elli will be there presenting, which is awesome. There is a Four Corners ABA Conference, April 8th through 9th so that is a little bit earlier. VirginiaABA is the 29th through 30th. CASP is the 2nd through 3rd of May. You get into the MassABA and ABAI Convention, which I feel are the big ones in May. It is going to be a nice time to see people and the sun is out. It’s spring.
If you are reading this, Anna and I would love to know is this the stuff that you guys want updates about? Do you guys read what’s going on at the conference circuit? Is this of interest to you? We have an email address specifically for any type of feedback. It’s TSR@BHCOE.org. Email us and let us know if this is helpful. If you have not been able to go to a conference but want us to recap these, we will do it. Let us know.
- Dr. Elli Kazemi – LinkedIn
- Micah Friddle – LinkedIn
- Melissa Cottengim – LinkedIn
- Scott Page – LinkedIn
- Nikki Williams – LinkedIn
- Michele Trivedi – LinkedIn
- Charna Mintz – LinkedIn
- Jim Carr
- Autism Investor Summit
- Four Corners ABA Conference
- ABAI Convention
- Payor Disclosures
- School-Based Standards