After the coronavirus slowed things down earlier this year, the Center for Autism and Related Disorders (CARD) is once again revving up its growth engine.
With 235 locations across 27 states, CARD is the largest autism treatment provider in the world. It boasts a research arm, a bevy of service offerings and private equity backing. In 2018, the PE investor Blackstone bought the center-based provider of autism treatment services in a record-setting deal.
Amid the pandemic, that relationship has helped CARD continue to quietly position itself for even further expansion. In fact, the company’s growth rate is expected to return to pre-COVID numbers by Q1 2021, according to CEO Tony Kilgore.
Kilgore, who joined the company in Dec. 2019, recently connected with Behavioral Health Business to discuss CARD’s growth goals and technology ambitions, as well as his priorities in the new position, which include helping to develop a standardized set of outcomes for the autism treatment industry.
You can find all that and more in the conversation below, edited for length and clarity.
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BHB: You’re relatively new to this position, having taken the reins back in December 2019. What a crazy time to step into a new role, by the way. Can you tell me a little bit about your background and what brought you to CARD?
Kilgore: I have been in healthcare my entire career. I started out of college as a pharmaceutical rep in sales. I went into sales management and post-acute for a time being.
For the previous eight years before CARD, I was with a company called Surgical Care Affiliates. It was a spin out of HealthSouth. We ultimately were purchased by Optum, a division of UnitedHealth Group, several years ago.
I was looking for something a little bit smaller. I was getting the entrepreneurial bug, wanting to find something that I could make meaningful contributions to.
A recruiter called with the CARD opportunity, and I felt called to do this.
I have two boys myself. Neither are diagnosed on the spectrum, but they both have pretty significant ADHD, so I know a little bit about what it’s like to have kids that learn differently than others. That gave me a soft spot for what our kids and our families go through, though certainly not to the extent of some of our kids.
I felt like I could do a lot of good here. I could bring some of the learnings that I’ve had in terms of building high functioning teams, mentoring and developing people, helping drive a culture that can be differentiated and then ultimately looking at corporate strategy in a way to continue the amazing growth track CARD has been on for 30 years. Now, we’re doing it in a way to even scale faster and provide services to more people.
Let’s dig into CARD a little bit. Size and scale are important differentiators for the organization, which is the largest autism treatment provider in the world. Back in 2018, Blackstone paid an estimated $700 million to purchase the company in the largest single ABA agency deal in history. First of all, how did CARD become the behemoth that it is today?
It’s really our founder, Dr. Doreen Granpeesheh. It’s been her singular passion to do this work over 30 years, and she has poured her heart, soul, blood, sweat and tears into this business because she has a genuine passion for these kids.
Beyond that, she’s had wonderful buy-in from people, teammates, that have been with Doreen for 25 to 28 years of this journey. So it’s a really good foundation, particularly with our senior clinicians. Because the company has been built and scaled by these clinicians, clinical is at the heart of everything we do.
When you think about our secret sauce, it really resides in the curriculum and the lessons that have been written over 30 years. When you take the sheer volume of work that’s been created and you layer on the number of kids and treatment hours we’ve rendered, that has created tremendous opportunity for our research team to dig deep and build analytics.
How can we be most efficient? How can we help our kids gain skills at the fastest rate? What’s the right order to plan our lessons in? How can we reduce challenging behaviors based on our lesson planning?
We’ve been actually able to use machine learning AI tools against our databases. The net of it is an ability to really deliver great results in the most efficient time horizons for our kids and our families. I think that has really resonated with a lot of people.
On top of that, it’s just the dedication of all the CARD teammates across the country. It’s a really special person who chooses to do this work. We provide them great tools, but at the end of the day, it’s the work they’re doing every single treatment hour with our kids that helps drive CARD’s growth.
The investment by Blackstone has allowed us to really think about greater levels of scale. Over the last several months, even during COVID, we have been thinking about the other side of a pandemic. This won’t last forever, and our call is still to scale so we can meet the needs of this community.
We have been investing in our critical IT infrastructure and new practice management software, that will allow us to continue to grow, add sites and scale. We’ve invested in field leadership, both administratively and from a clinical standpoint, pushing resources from the corporate office down into the field so that it’s closer to the kids and we can provide better support.
Those things, from a business model standpoint, should allow us a more scalable infrastructure. My expectation is that certainly by the end of the first quarter of next year, we should be back to expansion at a pre-COVID rate.
Not many providers have their own research teams. What measures does that team look at in determining success and how does CARD capture data to illustrate superior outcomes?
Doreen is an academic by training. And in her mind, it was a no-brainer to invest in a research team. If it helps us do more, better, faster to provide outcomes for kids, it’s money well spent.
CARD is the largest clinical business supporting autism research.
When you think about the amount of data that we have and the amount of time and energy that we put into research, it’s meaningful to the forwarding of the science around autism treatment.
ABA is really unique because as we’re interacting with the child, we’re measuring their reaction and it’s often binary. Everybody working with a child is working off an iPad, where they actually capture real-time data associated with those interactions. That feeds into a master database where we can aggregate and store data.
It gives us an opportunity to streamline our treatment planning and to get there faster in terms of what order lesson plans should be delivered. We provide the tools, but our BCBAs in the field provide the final say on how the treatment plan is going to go.
Outcomes are on the horizon for this for this industry. There’s a number of efforts underway to really determine how we as an industry we should start to self-regulate.
The reality is every kid is different. The disorder is a spectrum for a reason.
It would be premature for me to say CARD has the answer for what outcomes should look like, but I would say there’s a lot of really interesting research on that happening both within CARD and externally.
You mentioned that the coronavirus has paused some of your growth goals. How else COVID has disrupted your business model and how have you adapted?
We initially closed our clinics and moved to a virtual setting. Fortunately, we had some virtual content that had already been developed, so we had an advantage meeting our kids’ needs from a virtual standpoint.
We also were aggressive in securing PPE and training our therapists so they could continue some sessions in patient homes. For much of CARD’s 30-year history, we were a home-based model, so we had all the protocols in place. We just had to augment them to keep things safe.
It was a pretty significant shock to the overall business in terms of the number of hours we were rendering to the number of kids that we could support. We certainly had therapists that were uncomfortable, so we allowed them to take time off. We needed to be in a spot, though, where as long as we had kids that wanted therapy and therapists looking to help, we tried to put those two together.
We also tried to leverage a fairly unique thing we have in our arsenal called Camp Discovery. It’s a game platform that we’ve published on in the past. It’s actually been out both on the App Store, Google, Android and iOS for several years. That game-based platform also can help teach them some skills and some of our curriculum.
So we leverage the tools that we had based on the best information we were getting from the CDC and the World Health Organization.
Then, we had a team of folks looking at our centers and how we could ultimately get back to center-based care because we do believe in that model. We were the first organization that published research showing kids retain skills twice as fast in the clinic setting versus the home setting, which is why we pivoted several years ago into the clinic-based model.
What percentage of your business is typically center-based and what’s your vision on that going forward?
Pre-COVID, we were probably 80% clinic and 20% home or other. We do provide services in school settings or in a public environment like a park. That’s really largely at the discretion of the BCBA, who is planning the treatment plan for that individual patient.
There are so many kids in need of these services, and there’s so much addressable market in our core business, so that will remain our primary focus.
We’ll also continue to look at: Are there ways that we can use technology to leverage our offering? If it allows us to reach more people more efficiently, that would be helpful in addressing some of that unmet need and allowing us to scale a little bit faster.
We’ve got research ongoing right now to determine the efficacy of long-term virtual treatment versus in clinic versus home. The data’s not 100% in yet, but my guess is the research will help guide what the future looks like.
Now that you’re about 11 months into your crazy first year with CARD, how have your priorities changed, if at all?
The priorities are the same. If I had to sum it up in a statement, I would say coming into CARD, my role was to honor our past and prepare for the future.
The legacy CARD team has done some amazing work over 30 years. My job is to look at all those elements and make sure the foundation is solid and grounded in our mission, while creating a chassis that is scalable so we can grow even faster and reach more families.
That’s what it was on day one, and that’s what it is today.
If you had to identify your main goals for the company going forward, what are they?
Certainly making progress towards improved outcomes and getting clear about what good outcomes look like is one.
Scale is also very important. That’s what’s going to continue to provide access to the community and the needs of the families we can’t reach today.
Then we want to make sure we’re doing everything we can to take great care of our teammates and make sure that they’re well taken care of to do the job that we need them to do on a daily basis.
When it comes to scale, what does CARD’s growth strategy look like going forward?
We are in the process of finalizing our budget for next year, which will include a target number of centers we will look to open going into next year. Our history would say we can open between 50 and 80. One year was a bit higher than that.
As we think about markets to expand into, a lot of that analysis continues to happen right now. Blackstone has been able to provide data and analytics support to help us identify where need and opportunity are the greatest and how we should be thinking about going to a market.
So less acquisition-based and more de novo?
I think so. I am most encouraged by our ability to create CARD centers in a model that allows us to go much faster.
Coming from a business that was heavily acquisition-based, it slows you down from an integration standpoint and a diligence standpoint, whereas a relatively simple de novo openings should allow us to get to scale faster and in a more predictable fashion.
I think that acquisitions will come, but I don’t think 2021 is going to be that year, partly because we’ve got scale.