Dr. Ronit Molko on Investing in the Autism Services Industry

Middle Market Growth – A Qualified Opinion

Dr. Ronit Molko is the founder and CEO of Empowering Synergy, a provider of specialist health care and consulting services for private equity investors and service providers with a focus on the autism, traumatic brain injury, home health and senior health care sectors of behavioral health. A licensed clinical psychologist and board-certified behavior analyst, Molko is the co-founder of Autism Spectrum Therapies, which she led until 2014, and author of the book “Autism Matters: Empowering Investors, Providers and the Autism Community
to Advance Autism Services.” Molko corresponded with MMG about M&A activity in the autism services industry.


Q How much M&A activity is happening in the autism services industry?
A There has been a dramatic increase in M&A activity. Over the past five years, there were over 75 transactions. Last year saw the highest
activity, with 25 deals completed. Now there are over 20 “platform” companies looking to scale services organically, expand into new markets, and acquire smaller competitors. Over 80% of the service provider market remains highly fragmented and it’s still in an early growth phase, supporting the rationale for consolidation. Even more deal flow is expected in 2020.

Q What’s driving M&A and private equity investment in this industry?
A Increasing demand for services is one driver. The incidence of autism has continued to grow—today, 1 in 59 children in the U.S. is diagnosed with autism. The demand for support and services still far outweighs the supply of providers. Additionally, the funding for autism services has expanded considerably. In 2019, Tennessee became the 50th state to require health benefit plans to cover medically necessary treatment for autism. Although relatively new to autism services, private equity plays an important role in the industry. Because the market is relatively unsophisticated from an operational perspective, investors are providing capital needed for growth and expansion of services,
managing risk and compliance, and professionalizing the industry from a business and operational standpoint.

Q What are some of the risks of investing in autism services providers?
A Talent and data present two key risks in this industry. Registered behavior technicians and board-certified behavior analysts are the drivers for growth and service delivery, yet the industry has faced challenges with both groups. There is high turnover among registered behavior technicians, who provide daily intervention in clients’ homes, in a clinic or center, or a hybrid. Annualized attrition rates range from 50% to 125% for the in-home service delivery model. For center-based services, attrition rates can be as low as 10% to 15% and up to 50% to 60% for small providers.

Board-certified behavior analysts make up the supervisor tier, and their credential is a requirement for commercial, federal and state funding sources. The market continues to experience a shortage of these professionals, which impacts a provider’s ability to meet the regulatory requirements of funding sources and the ethical requirements of the credentialing board. With respect to data, the autism market does not have the outcome data that is typically available in other areas of health care—such as group studies to determine the effectiveness of a medical intervention. Instead, the outcomes of autism therapy are determined individually, based on each client’s unique needs and goals. As autism services moves toward a value-based reimbursement model, the lack of widespread outcome data presents challenges in establishing new models of reimbursements and new standards of intervention and outcomes.

Q How can emerging technologies be used to improve autism services?
A Technology has the potential to improve outcomes for service providers, autistic individuals and business owners. Tools embedded with artificial intelligence and machine learning are already changing diagnostics and self-management. Companies have introduced wearable technologies to help adults manage daily activities, such as navigating their environment, coping with anxiety and interacting socially. Meanwhile, several companies are piloting technologies to diagnose autism in one session, a diagnostic process that now can take up to a year. Technology will also transform the service provider market. Existing technological tools for practice management and business optimization are marginally adequate at best. They largely do not support effective daily data dashboards and predictive analytics, and most companies are still managing their businesses with limited real-time operational visibility. Many providers are attempting to develop technologies to manage the nuanced aspects of clinical programming, data collection and reporting, compliance and employee activities,
and operational aspects such as scheduling.


How to Overcome Sensory Issues While at The Dentist – by Dr. Greg Grillo

After 17 years of practice in North Central, Washington, nobody’s more familiar with dental anxiety than I am. For dental patients who have autism, especially children, this anxiety is compounded by challenging sensory elements such as bright lights and loud noises.

Dental care is an extremely important part of living a healthy life and living with autism shouldn’t prevent you or your child from getting the care they need. Fortunately, many dentists—including myself—are sympathetic to the needs of those who experience sensory overload. Here are a few things you can do to help overcome sensory issues while at the dentist:

Talk to your dentist

Before you schedule your first appointment, you should speak with the dental professional in question and ask them what accommodations they make for patients with sensory issues. If the answer is “none”, it’s time to find a new dentist.

However, most dental practitioners will be “on your side” and will want to make an autistic patient’s visit as comfortable as possible. Here are a few things a dentist might do to help avoid sensory overload:

  • Schedule a desensitization appointment (see next section)
  • Schedule the main appointment at a time that is less busy
  • Use the patient’s favorite toothpaste flavor—a taste sensation that they’re already comfortable with
  • Provide the patient with a soft blanket to use during the appointment
  • Provide the patient with sunglasses which can help with the bright lights
  • Provide the patient with headphones that will play soothing music or sounds during the appointment

If there is something specific which you know your autistic child needs to feel comfortable, tell your dentist about it and they should do whatever they can to accommodate that need.

Schedule the Desensitization Appointment

Desensitization appointments (sometimes known as “familiarization appointments”) are becoming a standard procedure in the growing field of special care dentistry and are one of the best things a dentist can do to make a patient with autism more comfortable. Despite the scary name, the idea is quite simple: a desensitization appointment is an appointment scheduled before the actual procedure in order to show the patient the operating theater and explain the function of every piece of equipment in the room. This is a great opportunity for your child to meet staff members and become familiar with the dentist office before any work is done on their teeth.

Practice at Home

If you have a child with autism, sensory calming strategies at home can be one of the most useful ways to make sure they’re comfortable with going to the dentist. You can do your own version of the “desensitization appointment” by showing your child pictures or videos of a dentist’s office, or by reading them storybooks about dental appointments. This can help your child become more familiar with the practitioner’s office and what goes on there before their actual appointment, which can help them feel more at ease and less likely to experience unpleasant sensory overload.

Some parents I’ve spoken to have also found that turning the dental visit into a role-playing game helps their child become more familiar with the unfamiliar concept. In this fun and interactive form of practice, you can play the dentist while your child takes on their actual role of the patient while you act out some of the basic steps of a dental appointment. This is a particularly good way to work through some of the physical aspects of their visit: have your child lie flat with their hands on their stomach and practice opening their mouth as wide as they can.

I understand that the dentist’s office can be an overwhelming and frightening place, but regular checkups are essential for any person’s physical health and happiness. As long as you find a dentist who is dedicated to making the visit as comfortable as possible—and I’m happy to say that I truly believe that’s the vast majority of practitioners—the appointment can become a great learning experience for both you and your child. I hope these tips will help you overcome any sensory issues you may experience so that all involved can have a positive experience the next time you visit the office.


Visit dentably.com to get in touch with Dr. Grillo.