Starting and scaling a company is hard. Entrepreneurship in autism therapy presents an especially unique set of challenges that distinguish it from other industries.

In short, no one has figured the industry out.

Despite the overwhelming demand for autism therapy services, several nearly unsolvable structural issues require immediate and constant strategic attention. Further, the incumbent platform companies are in flux after trying to apply incongruent lessons learned from other health care consolidation efforts.

“Given where the industry is — it’s a very young industry — I’m not sure that [autism therapy] fits into any of the boxes that a lot of investors have seen, and therefore, the playbook operationally is just entirely different,” David Iklodi, vice president of strategy and corporate development for Behavioral Framework, said during a panel discussion at Behavioral Health Business’ inaugural Autism & Addiction Treatment Forum.

Still, there are lessons to be learned that can applied when it comes to starting out in a growing and increasingly competitive autism therapy market. For example, defining and setting the right priorities and objectives in the earliest days of an autism therapy startup is key. 

For Behavioral Framework, an applied behavior analysis (ABA) and autism diagnostics provider headquartered in Rockville, Maryland, early priorities focused on getting contracts with payers and smoothing out provider credentialing. Then, the focus goes to building some degree of density, with early focus priorities evolving to match specific market needs.

In 2017, Angela West, a board-certified behavior analyst (BCBA), founded Behavioral Framework. She is the company’s chief medical officer. It presently serves about 800 families, almost entirely on an in-home basis. The private equity firm Renovus Capital Partners invested in the company in a deal announced in January.

Companies often quickly attenuate their perceptions of what’s important in the early days of a new business. Once refined, those ideas endure throughout the development of a company. This was a lesson learned at Dallas-based autism therapy provider Apara Autism Centers. Early on, the company put a lot of weight on the clinics themselves since they are embodiments of a company’s care model and strategy, said Kyle Seco, president of Apara.

“Looking back on it, I think opening a clinic is probably one of the easier things we do,” Seco said. “We’re now recruiting BCBAs, finding the families that are looking for services and making sure that we’re providing that high quality service is our No. 1 objective.” 

Dallas-based private equity firm Havencrest Capital Management partnered with Apara Autism Centers founder and former CEO ​​Tyler Moore in 2019 after not finding an autism therapy provider that met their quality criteria. The company operates in Texas, New Mexico, Nebraska and Missouri.

Another approach calls for finding clinicians in underserved cities and helping them with business services close to home. That’s the approach Commonwealth Autism Care founder and CEO Brett Blevins took. A BCBA himself, Blevins got back into behavioral health entrepreneurship after selling his majority stake in a youth mental health startup in 2019. He focused his new venture on responding to the historic operational mistakes of incumbent autism therapy providers, what clinicians were looking for in a workplace, and access to care for patients and their families.

Commonwealth Autism Care now operates 13 centers in Georgia, Indiana, Kentucky and Virginia, according to its website. Getting sites open was a key focus, Blevins said. The focus was to get to three or four locations in three or four states with a specialization in underserved markets, especially rural ones.

Blevins found BCBAs and other clinicians in rural communities who commuted to larger communities but shared his passion for expanding access to care. These clinicians acted as the core of Commonwealth Autism Care’s clinics.

“I’d talk with them and say, ‘Well, why don’t you start your own clinic?’ And they would say, ‘We don’t want to do that; we don’t know how to do that,’” Blevins said. “So it’s more ‘intrapreneurship’ than entrepreneurship. We give them the opportunity to build their own thing with the safety net of us providing some of the upfront capital, negotiating leases, making sure that we can provide them with [equipment], with the staffing and building out some of the processes.”

The nuances of rapid growth

Several lessons for early-stage autism therapy companies center on relationships, as Blevins’ experience with rural clinicians demonstrates. The need to build and manage relationships reach the very top and bottom of a company’s corporate structure.

Seco worked for Havencrest Capital Management for five years before succeeding Moore as the top executive of the company. His experience on both sides of the private equity-backed company dynamic has taught him that the leaders of autism therapy providers must carefully balance the expectations of investors and clinicians. This plays out in the recruitment and retention strategies of BCBAs which make up the core of ABA services and are in short supply.

While private equity investors want to get the most out of employees, BCBAs are in such high demand that, if they no longer find a job to their liking, they will step into a job market that is especially favorable to autism therapy employees.

“How do you find that right balance where providers enjoy working for you but you are getting enough out of them to benefit all parties?” Seco said. “I spend a lot of my time just listening to BCBAs and hearing what they have to say.

“They’re very interesting people, and they want to just make sure what they’re doing is right, and they want to feel comfortable with what the company is trying to accomplish.”

He also said that it’s a mistake to just assume that a clinician’s passion for serving children in need and commitment to autism therapy will make burnout disappear. For example, Apara Autism Centers promotes work-life balance and work-from-home days to help address burnout.

Maintaining mission fidelity

Expansion tests even the best laid plans for a business. Behavioral Framework helps the company stay on track with its strategy and values by placing clinical quality at the forefront of decision making.

“Our clinical team is involved in every strategic decision that we’re making,” said Iklodi, “so we don’t have a situation where the tail is wagging the dog and the business people are making clinical decisions. … If something doesn’t make sense clinically, it’s dead on arrival.”

Viewing the business in this way has helped bridge intellectual and philosophical gaps between business and clinical leaders at the organization, creating greater company cohesion, he added.

In a similar fashion, Blevins and Commonwealth Autism Care use the company’s six core values as its measuring sticks for decision-making. Those values are quality, integrity, creativity, innovation, growth and sustainability. Those values are magnified with the company’s specific strategic and moral imperatives to expand access to care.

“We’re really looking at towns that some of the larger players may steer away from,” Blevins said. “Those are the things that get us fired up, when we are the first providers in a town.”

All three panelists noted that mission fidelity can be strained by M&A. Commonwealth Autism Care, as a bootstrapped operation, doesn’t have the capital or interest in M&A. Apara Autism Centers and Behavioral Frameworks have engaged in M&A.

Apara Autism Services acquired Autism Learning Collaborative (ALC) and Early Autism Services’ Missouri operations in a deal announced in January 2023. Most recently, Behavioral Framework announced it acquired North Carolina-based Behavior Consultation & Psychological Services (BCPS) on July 24.

“If you really want to control quality and control what you’re trying to build, the de novo method is the best method,” Seco said. “It takes more time, and when you have capital sponsors, sometimes they want to move a little bit quicker. … M&A is a good way to get into a new state, get payer contracts that are already up and running and build a presence de novo in those new states.”

Behavioral Framework needs to see significant differentiation and something more special than geography in its potential M&A targets, Iklodi said. It’s looking for features like client experience, patient and provider retention, or unique training programs.

The BCPS deal “had that geography-plus — it fits our density because it touches the states we currently serve and we felt there was mission alignment and differentiation within that asset.”