The recent explosion of autism services in the United States over the past two decades has raised questions about how healthcare businesses should be organized, financed, and managed. With the growth in the number of cases and rising demand for developmental services, various business ownership models have been developed based on different concepts of organization, development, financing, and clinical management. Such business models include non-profits, physician partnerships, independent businesses, private equity firms, affiliated hospital enterprises, and, recently, franchises. The variety of business structures stems from the nature of healthcare service provision in the rapidly expanding industry.
According to the Centers for Disease Control and Prevention, the frequency of autism among children in the United States grew from roughly 1 out of 150 cases in 2000 to 1 out of 31 cases in 2022. Combined with changes in insurance coverage laws and increased awareness of the problem, this led to substantial growth in the autism treatment market during the 2010s and 2020s. Market analysts estimate that the autism treatment industry generates several billion dollars per year in the United States, with Applied Behavior Analysis (ABA) as one of its largest markets.
Traditionally, autism service providers in the United States have been comprised of non-profit organizations, hospital systems, academic medical centers, and small independent clinics. The traditional role of the non-profits was to provide community-based services, advocate, educate, and develop long-term service programs. Non-profits involved with autism have traditionally had extensive regional infrastructure and relied on grant funding, donations, Medicaid reimbursement, and public contracts. Organizations like the Autism Society of America have been instrumental in developing community support infrastructure before the explosion of commercialism associated with autism services in subsequent decades.
Another ownership tradition has been that of physician-owned and clinician-owned organizations. Physician- and clinician-owned organizations have generally grown out of the private practices of developmental pediatricians, psychologists, behavior analysts, or other multidisciplinary healthcare groups. The proponents of clinician ownership have maintained that clinician ownership will promote better clinical control and patient-centered decision-making. However, historically, organizations owned by physicians and clinicians have been characterized by shortages of capital, administration, geographical expansion, and talent acquisition.
The development of independent autism clinics became popular during the expansion of Applied Behavior Analysis in the early 2000s and 2010s. Those kinds of organizations were usually created by an individual BCBA, autism specialist, or parent of a child diagnosed with autism spectrum disorder. Independence enabled the organization to remain autonomous and respond to local communities’ needs. At the same time, independent providers faced various challenges related to the complex reimbursement process, staff shortages, regulatory compliance, insurance contracts, and infrastructure.
Since 2010, private equity ownership has become a driving force in the autism treatment market. According to research conducted by experts from Brown University, RAND, and the Harvard Pilgrim Health Care Institute, published in JAMA Pediatrics, private equity fund investments in autism-related organizations increased significantly between 2015 and 2024. Numerous acquisitions in the field of autism treatment were found during that period.
The private equity model generally emphasizes consolidation through mergers and acquisitions. Under this approach, investment firms acquire existing providers and combine them into larger regional or national organizations. Supporters have argued that consolidation may improve administrative efficiency, facilitate geographic expansion, and provide access to capital needed for growth. Critics, however, have questioned whether acquisition-driven expansion adequately addresses workforce shortages, geographic disparities, and access to treatment. Researchers have also examined whether financial incentives associated with healthcare investment models influence operational priorities and service delivery patterns.
As ownership structures diversified, alternative approaches to organizational growth also emerged. One such approach involved healthcare franchising. While franchising has long existed in sectors such as hospitality, retail, home healthcare, and urgent care, its application to autism treatment remained limited until the late 2010s. In 2018, Nichole Daher established SOS Franchising following the earlier founding of Success On The Spectrum in Houston, Texas, in 2015. According to company materials and subsequent media reports, the organization introduced what it described as the first franchise model dedicated to center-based Applied Behavior Analysis services in the United States.
The franchise model adopted by Success On The Spectrum differs structurally from both private equity consolidation and traditional independent practice ownership. Rather than acquiring existing providers, the organization expands through locally owned franchise operations that function under centralized operational systems. According to publicly available company information, franchise locations operate under standardized policies related to clinical procedures, staff training, quality monitoring, and operational oversight. This organizational structure has been described as combining decentralized ownership with centralized administrative frameworks.
Operational accountability represents one area where franchise systems have attracted attention within autism services. According to Success On The Spectrum’s publicly available materials, the organization conducts operational audits. It monitors clinical, administrative, and staffing practices across franchise locations. The company has also stated that franchise operators receive training, ongoing supervision, and standardized operational support. These practices reflect broader efforts within healthcare franchising to balance local ownership autonomy with organizational consistency and quality assurance mechanisms.
Local ownership incentives have also become part of the broader discussion surrounding autism care delivery models. According to company information, a portion of Success On The Spectrum franchise owners are parents or family members of autistic individuals. Proponents of local ownership models have argued that community-based operators may possess stronger local relationships and longer-term investment incentives. At the same time, researchers continue to study how different ownership structures influence treatment outcomes, workforce stability, organizational accountability, and access to care.
With increasing prevalence rates of autism and growing demand for developmental treatments, the debate on how to organize autism treatment facilities is still ongoing amongst researchers, policy makers, providers, and parents. In addition to non-profits, independent centers, private doctors’ practices, hospital-affiliated organizations, and private equity-backed companies, franchise networks, like Success On The Spectrum, have become yet another organizational model for treating autism. The potential advantage of any particular form of organization over other options remains an open research issue; however, the diversity of organizational models has become an essential element of the contemporary autism services market environment.
