Behavior Analysis in Practice

, Volume 12, Issue 1, pp 247–254 | Cite as

The Promise of Accountable Care Organizations: “The Code,” Reimbursement, and an Ethical No-Win Situation for Behavior Analysts

  • Abraham GraberEmail author
  • Matthew O’Brien
Discussion and Review Paper


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.


Ethics Reimbursement Accountable care organizations The professional and ethical compliance code for behavior analysts Affordable care act 


Compliance with Ethical Standards

Conflict of Interest

As the spouse of an applied behavior analysis (ABA) service provider, Abraham Graber has an interest in the reimbursement rate for behavior analysts. As a clinic director and an ABA service provider, Matthew O’Brien has an interest in the reimbursement rate for behavior analysts.

Human and Animal Rights

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. APA Practice Organization. (2013). More Q&As about the new psychotherapy codes. Retrieved from
  2. Arkansas BlueCross BlueShield. (2015). Coverage policy manual. Retrieved from
  3. Association of Professional Behavior Analysts. (2010). Ethical guidelines. Retrieved from
  4. Behavior Analyst Certification Board. (2017). Professional and ethical compliance code for behavior analysts. Retrieved from
  5. Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health Affairs, 27, 759–769.CrossRefGoogle Scholar
  6. BlueCross BlueShield of Louisiana. (2017). Professional provider office manual. Retrieved from
  7. Catania, A. C. (2007). Learning (4th interim ed.). Cornwall-on-Hudson: Sloan.Google Scholar
  8. Centers for Medicare and Medicaid Services. (2014). Accountable care organizations. Retrieved from
  9. Centers for Medicare and Medicaid Services. (2016a). All Medicare shared savings program (shared savings program) accountable care organizations (ACOs). Retrieved from
  10. Centers for Medicare and Medicaid Services. (2016b). Pioneer ACO model fact sheet. Retrieved from
  11. Centers for Medicare and Medicaid Services. (2017). Medicare shared savings program: shared savings and losses and assignment methodology. Retrieved from
  12. Cooper, J., Heron, T., & Heward, W. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River: Pearson Education.Google Scholar
  13. Graber, A., Carter, S., Bhandary, A., & Rizzo, M. (2017). The case for enrolling high-cost patients in an ACO. HEC Forum, 29, 359–365. CrossRefGoogle Scholar
  14. Hafferty, F. W., & Franks, R. (1994). The hidden curriculum, ethics teaching, and the structure of medical education. Academic Medicine, 69, 861–871.CrossRefGoogle Scholar
  15. McConnell, T. (2014). Moral dilemmas. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Fall 2014 ed.). Retrieved from
  16. Muhlestein, D. (2015). Growth and dispersion of accountable care organizations in 2015. Retrieved from
  17. RTI International. (2015). Accountable care organization 2015 program analysis quality performance standards narrative measure specifications. Retrieved from
  18. RTI International. (2016). Accountable care organization 2016 program quality measure narrative specifications. Retrieved from
  19. Rubin, H. R., Pronovost, P., & Diette, G. B. (2001). The advantages and disadvantages of process-based measures of health care quality. International Journal for Quality in Health Care, 13, 469–474.CrossRefGoogle Scholar
  20. Shain, B. (n.d). Adaptive behavior assessment and treatment: CPT coding summary. Retrieved from
  21. Sisti, D. A., & Ramamurthy, C. (2015). From alienism to ACOs: integrating psychiatry, again. Psychiatric Services, 67, 372–374.CrossRefGoogle Scholar
  22. Skinner, B. F. (1971). Beyond freedom and dignity. Indianapolis: Hackett Publishing.Google Scholar
  23. Thompson, T. (n.d.). Behavior analysis CPT code workshop. Retrieved from
  24. ValueOptions. (n.d.). Applied behavior analyst (ABA) provider frequently asked questions. Retrieved from

Copyright information

© Association for Behavior Analysis International 2018

Authors and Affiliations

  1. 1.Department of Philosophy and ClassicsUniversity of Texas at San AntonioSan AntonioUSA
  2. 2.Center for Disabilities and DevelopmentUniversity of Iowa Children’s HospitalIowa CityUSA

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