The Promise of Accountable Care Organizations: “The Code,” Reimbursement, and an Ethical No-Win Situation for Behavior Analysts
Fee-for-service billing can force BCBAs to choose between ethics and income—pilot ACO contracts that pay for outcomes, not hours.
01Research in Context
What this study did
Graber et al. (2019) mapped how fee-for-service billing can corner BCBAs. They used ethics theory, not data. The paper asked: what happens when the payer rewards more hours, but the client needs fewer?
What they found
The authors show a 'no-win' trap. Bill more units and you break Code 1.07 (do no harm). Bill fewer units and you lose income. Accountable Care Organizations (ACOs) were offered as a fix. ACOs pay for client health, not for billable hours.
How this fits with other research
Uher et al. (2024) extends the same ethics worry. Their 2024 Code tips tell you to audit goals with clients. Graber warned about money pressure; Uher gives a checklist you can use today.
Sulzer-Azaroff (1981) saw this coming. The young learners paper lists 'cost' as a top reason good behavior tech dies. Graber narrows the cost lens to BCBA reimbursement.
Brodhead (2019) is a conceptual twin. Both 2019 papers critique the BACB Code. Brodhead targets cultural gaps; Graber targets money rules. Together they show the Code needs updates on two fronts.
Why it matters
You can feel the trap tomorrow. A parent wants to fade hours, but your budget needs the codes. Graber says: don't fight alone. Ask your agency to pilot ACO-style contracts that reward client progress, not face-time. Start the conversation at your next team meeting.
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02At a glance
03Original abstract
Clinical ethics, with its emphasis on the actions of clinicians, risks overlooking the ways in which broader health-care structures influence the behavior of health-care providers. Analysis of a factual case study demonstrates that status quo reimbursement practices may place behavior analysts in a position where, no matter how they act, they risk acting unethically. By contrast, the reimbursement model set by accountable care organizations (ACOs), part of the Patient Protection and Affordable Care Act (also known as Obamacare), may offer a solution. However, making good on the promise of ACOs will require more resources than any individual behavior analyst possesses. In order to encourage institutional structures that facilitate ethical practice, behavior analysts’ professional organizations should engage in contemporary political discussions about the state of American health care.
Behavior Analysis in Practice, 2019 · doi:10.1007/s40617-018-0209-0