This article is sponsored by Polsinelli. It is based on an Autism Business News discussion with Paul A. Gomez, Co-Chair of Behavioral Health practice at Polsinelli; Kate Sheldon-Princi, CEO at 360 Behavioral Health; Michael Flood, Shareholder at Polsinelli; and Scott Kramer, Managing Director at Piper Sandler. This discussion took place on April 9, 2025, during the Autism Investor Summit. The article below has been edited for length and clarity.

Paul A. Gomez: Welcome, everybody. This is a panel on Which Way Are the Autism Investment Winds Blowing. We’re covering compliance, market trends, and value creation. We’ll start with a brief market recap in the autism sector, followed by some key market trends that are currently driving investment—and that we believe will continue to do so moving forward.

We’ll also touch on payment and policy developments that are either currently impacting autism service providers and investment, or that we expect to influence the sector in the near future. We’ll then dive into some key opportunities—and possibly some hurdles—from the perspective of ABA and autism providers as we work to increase access to care.

We’ll finish with a discussion on legal compliance risks and issues, clinical compliance considerations, and the intersection between the two. Then I’ll ask our esteemed panelists to share their key takeaways for the rest of 2025.

I’m your moderator, Paul A. Gomez. I’m a shareholder in Polsinelli’s health care practice group and co-chair of our behavioral health care practice group, which includes autism service providers. We believe we have the largest behavioral health practice group in the country.

I’m fortunate to be joined by a great panel of experts. We have Kate Sheldon-Princi from 360 Behavioral Health; Michael Flood, my colleague from our St. Louis office; and Scott Kramer from Piper Sandler. I’ll ask each of them to briefly introduce themselves. Kate, let’s start with you.

Kate Sheldon-Princi: Hi, everyone. I’m Kate Sheldon-Princi with 360 Behavioral Health. I joined the space about 12 years ago, spent a good amount of time as a clinician, and have served in various roles since. 360 Behavioral Health provides ABA services in California and is just beginning to expand out of state. We’re one of the oldest and most established providers in California. I’m happy to be here today to talk about our services and the industry.

Michael Flood: I’m a shareholder at Polsinelli and a health care regulatory attorney with a public policy background.

Scott Kramer: I’m a managing director with Piper Sandler. I’ve spent most of my career covering the behavioral health space. For those who don’t know, Piper Sandler is a full-service investment bank with a global presence. We cover many sub-verticals. In addition to M&A, we provide strategic advisory, capital markets, restructuring, and sales and trading services. I’m excited to be up here—thank you.

Gomez: Thanks, Scott, and thank you all. Let’s dive in. Scott, let’s start with a market recap and some of the key trends you’re seeing in autism. Specifically, what’s the private equity focus in this space right now?

Kramer: Great question. This probably aligns with what you’ve heard from other panelists earlier. Private equity interest—particularly middle-market and larger-cap firms—is focused on a few core areas.

First is scale and infrastructure. That means investing in IT systems and strengthening your tech stack, but also building out human capital. This industry relies heavily on recruiting—not just BCBAs and BTs, but also C-suite leadership.

Next is growth strategy. Everyone wants to grow, but investors are looking for disciplined growth. Are you expanding into new markets? Adding density in existing ones? Launching new service lines or settings like schools, in-home care, or centers?

Compliance is also a must-have. It’s no longer a differentiator—it’s a baseline expectation.

Lastly, management teams matter. We’re increasingly seeing leadership from outside traditional ABA—people from dental, other PPM models—bringing operational discipline that benefits the sector.

Gomez: Let’s build on that. We’ve seen some notable platform sales in the past 9–12 months. Any common threads or themes that stand out?

Kramer: Definitely. Three main takeaways:

1. Scale and infrastructure were consistent across all the platforms that sold.
   
2. Geographic diversification was also key. Being in multiple states helps mitigate Medicaid-related risks.
   
3. Strong management teams—every successful platform had invested heavily in a capable, well-rounded executive team.
   

Gomez: Appreciate that, Scott. Let’s shift to policy and payment. What are the key developments on the federal and state level that are impacting autism providers now—or that might soon?

Flood: Medicaid has been mentioned repeatedly today—and for good reason. With the new administration’s proposed budget reconciliation goals, there’s real concern about where $880 billion in health care savings will come from. Autism therapy providers are almost certainly going to be affected.

At the state level, we’re seeing major shifts too. Some Medicaid programs are capping hours. Indiana is moving toward a 30-hour-per-week cap. New York has a proposed bill to cap services at 680 hours per year. Nebraska flagged a 1,200% increase in ABA spending and is also considering caps. This is real, and it’s happening now.

On the commercial side, the high costs associated with autism care have put a target on providers’ backs. We’re seeing more audits—especially probe audits—and our payer disputes team is busy.

Gomez: Kate, what’s your take? Are you seeing the same things, or is there anything you’d add?

Sheldon-Princi: I’d agree. Medicaid is a hot topic for good reason. But what helps me sleep at night is knowing we have the science on our side. We know this care is effective. There’s bipartisan support. Nobody wants to be the face of cutting essential care for this population.

Still, we as providers need to collaborate. We need to agree on what “good care” looks like, and speak with one voice. Otherwise, regulators and payers will define it for us, and it may not align with what our clinicians know to be effective.

Gomez: That brings up the push toward defining quality in ABA. Is that realistic, given how individualized this care is?

Sheldon-Princi: It’s challenging. If you’ve been coming to this summit for a few years, you know value-based payment discussions have come and gone. The population is complex, and standardizing outcomes is tough. Some progress is being made, but we’re not there yet.

Gomez: Mike, is there any chance we’ll see Medicaid cuts applied more strategically—like sparing pediatric-focused services?

Flood: Possibly. But it’s a political issue, and hard to predict. The industry will need to make its voice heard—both federally and at the state level—to protect vulnerable populations.

Gomez: Let’s talk about opportunities and hurdles now. Kate, what are you most excited about—and most worried about?

Sheldon-Princi: The demand is there. Waitlists are long. The autism prevalence rate is increasing. In California, for example, the equivalent of an entire regional center is added each year.

But the biggest challenge is workforce. While recruiting may have improved slightly at the entry level, retention remains a serious problem—especially with annualized turnover around 90–100%.

Ways to improve this? Consider clinic-based services—retention tends to be better, and productivity is higher. Offer remote options for BCBAs. Telehealth, when paired with on-site support, adds flexibility and improves retention. And focus on culture. People stay where they feel valued. If you’re a great place to work, you can reduce churn—and protect your margins.

Gomez: That helps offset some of the wage pressure, too, right?

Sheldon-Princi: Exactly. Culture reduces turnover, which lowers the pressure to keep raising wages. Add in technology that drives efficiency—automating billing, scheduling, etc.—and you can protect your margins while maintaining care quality.

Gomez: That’s a perfect segue into compliance. Mike, what are the most common or concerning compliance risks you see today?

Flood: For providers going to market—or even just growing—compliance is critical. We see issues in several areas:

• Are you meeting every payer’s unique supervision requirements?
  
• Are you adhering to service hour caps?
  
• If you’ve added OT, speech, or PT, are you complying with state rules?
  

Then there’s HIPAA. Many founder-led businesses haven’t fully implemented HIPAA security requirements. Risk assessments are often missing.

Also, test your revenue cycle. Know where you stand before a buyer—or regulator—finds out for you.

Kramer: I agree. Be proactive. Do a coding and compliance audit before going to market. You do not want to discover problems at the same time as your buyer. That’s a fast way to kill a deal.

Gomez: Kate, does all of this ring true? How do legal and clinical compliance intersect in your world?

Sheldon-Princi: Absolutely. First, compliance is essential to delivering high-quality care. Second, it protects revenue—if you’re audited and your documentation isn’t solid, you risk clawbacks. And third, as both Mike and Scott said, it’s key to successful transactions.

Gomez: Mike, is documentation a common sticking point in deals?

Flood: Yes. Every deal has something—an uncredentialed provider, a data breach, a missing audit trail. If your compliance foundation is strong, you can manage those surprises. But if it’s not, it gets much harder.

Gomez: We’re almost out of time. Final question: What’s your key takeaway about where autism investment is headed in 2025? Kate, we’ll start with you.

Sheldon-Princi: I’m optimistic. If you don’t have a kite yet, go get one—the wind is blowing in the right direction. I believe in the value of the care we’re delivering and the momentum behind it.

Gomez: I like that. First full “optimistic” I’ve heard today. Mike?

Flood: I’m cautiously optimistic. This industry is still in its early days, and it provides an incredibly valuable service. There’s real opportunity—but it needs to be approached thoughtfully.

Gomez: Scott?

Kramer: I’d say it’s like a steady trade wind—gentle but consistent. We’ve weathered some storms, but there’s real momentum now. Sophisticated platforms, strong leadership, and best practices are coming into play. I’m bullish.

Gomez: Excellent. Kate, Mike, Scott—thank you. Please give our panel a round of applause.

As one of the largest health care practices in the country with integrated Health Care M&A and other full service capabilities, Polsinelli attorneys partner with behavioral providers, investors and other stakeholders to navigate a full range of legal issues in the rapidly evolving behavioral health space. To learn more, visit: https://www.polsinelli.com/.