Small or new autism therapy organizations have to compete on the same playing field as the largest and most developed companies in the sector.

That means companies have to make some of the inherent features of a small or new organization a strength. At Behavioral Health Business’ INVEST 2025 conference, autism therapy leaders stressed that early leaders must lean into developing a compelling company culture. Specifically, they highlighted that founders and owners must play a major role in shaping the organization’s culture as often as possible and must consider the growth of their most valued employees in tandem with the organization’s growth.

“I couldn’t compete financially early on; there was no way,” Brian Marrier, founder of Newport, Vermont-based Autism, Advocacy and Intervention (AAI), said during a panel discussion at INVEST 2025. “It took me 10 years before I could be in the top percentile in the community for pay. How the hell do you navigate that? It’s culture.”

Merrier and the other panelists noted that smaller organizations are often at a disadvantage when hiring board-certified behavior analysts (BCBAs) and other staff. In part, the lower pay is a challenge during that process. While just one part of the hiring experience, it is the one that can’t simply be changed by a company, given the control that payers have in the economics of autism therapy organizations.

AAI operates locations in California, Georgia and Vermont. It offers ABA and other services in the home, school and clinic settings.

Rather, the key for Merrier was to show employees that the company walked the walk. That included being very transparent with employees about several aspects of the business, including the fight to secure higher reimbursement rates.

“Every time I was able to fight the fight with the insurance company to increase funding, they knew I was doing that, and they knew it was going right to their pocket as well,” Merrier said. “There’s a lot of pride as a collective group you can have in this work.”

Similarly, transparency and accessibility among top leaders, especially CEOs and owners, can have a major impact on hiring and retention.

Adam Kay, CEO and founder of Alpharetta, Georgia-based Elevation Autism Center, said that he has made it a priority to stay close to the hiring process, including phone screenings, training and onboarding, “so that I can make promises that I know we can keep.

“They then know a key decision maker in the organization,” Kay said. “They don’t experience that when they apply to four other competitors down the road. That is what has allowed us to maintain momentum despite higher-paying offers down the street.”

Behavioral Health Business

This kind of involvement addresses key cultural components in a business: visibility of leadership, accessibility of decision-makers, familiarity with ownership and an overall sense of being seen and known in a new organization.

However, this advantage for new organizations is fleeting. As a company scales, it will be less and less tenable for a CEO or owner to get into the day-to-day of the business. Eventually, a growing organization will need to have the cultural dynamics explained and executed by employees.

“I think it will become difficult. You’ve got to understand what it is that draws people to your company, why people want to join your business specifically,” Matt Shofner, a partner with the private equity firm Havencrest Capital, said during the panel.

Havencrest Capital founded the Dallas-based autism therapy provider Apara Autism Centers in 2018. It operates clinics in Missouri, Nebraska, New Mexico and Texas. It also offers in-home services.

“We’ve got … large competitors that are well-funded, more well-funded than we are, but we know why people join our organization, and that’s what we have to go sell,” Shofner said.

Avoid costly mistakes

When there isn’t much cash to go around, it’s vital to avoid self-inflicted wounds at all times. Sometimes, this requires difficult investments that would be costly in the short term but disastrous down the line if not made.

“The best decision that we ever made for our business was implementing a business operating system,” Kay said. “That was the first piece of advice I got six years ago when we started. I didn’t listen to it. I paid dearly for it.”

Two years ago, Elevation Autism Center rolled out the Entrepreneurial Operating System, which “transformed the way [they] do business” and brought several parts of the business into concert, Kay added.

In founding Apara Autism Center, Havencrest Capital hired a CEO with parental lived experience and paired them with a clinical leader and a revenue-cycle-management leader. Reflecting on the earliest days of the organization, he said that everyone joining the company must be “excellent,” noting the similarities between patients and their families and the service industries.

Behavioral Health Business

He also noted that it was key to have business and the clinical experts working together on day 1, echoing sentiments Merrier also shared on the panel.

“In the beginning, I had great intentions but made lots of mistakes and lost hundreds of thousands of dollars in the beginning because I was a board-certified behavior analyst, enjoying the work,” Merrier said. “I decided to open up an organization. I didn’t have experience running a business. … In this industry of BCBAs enjoying the work, deciding to open up their own organization, they can cause a lot of harm because they don’t really know how to run an organization.”

Growing when you can or when you have to

Early organizations may be eager to add locations. But that is easier said than done. For organizations that can access and service capital, this can be done much faster. But for others, it may require a business to wait and focus on driving an initial location to profitability to help finance the new location, Shofner said.

But then, where should the autism therapy organization open a new location?

“I’m a big believer in density,” Shofner said. “It just makes it a lot easier, operationally speaking, to grow — and more efficient.”

Apara Autism Center opened its first location in Sugar Land, Texas. Its next clinic opened five miles down the road. Doing so allows center staff to support each other, especially regarding clinical needs. It also assists market capture and can facilitate moving patients between locations should the need arise.

Kay added that adding locations may be necessary to retain dedicated and high-performing staff, especially clinicians. This was the case for Elevation Autism Center.

“We did it [expanded] when we were going to lose talent if we didn’t expand and provide future growth opportunities for our team,” Kay said. “The reality was we were able to attract a lot of people because they saw not only the values and the quality of service we were providing but also a future that they could be a part of and grow within the company.”

AAI’s focus on rural communities gave the company another key indicator for potential expansion.

“Our reputation has to lead the way, so when the neighboring county or community says, ‘Hey, [we’ve] heard what you’re doing,’ that’s our flag that we’re ready to do something to go,” Merrier said. “Our reputation is strong. Trust is there. Word of mouth is operating well.”