The Numbers That Define the Trade

PLANO, TEXAS — In May 2018, the Blackstone Group paid approximately $600 million to acquire the Center for Autism and Related Disorders from its founder. Five years later, in June 2023, CARD filed for Chapter 11 bankruptcy in the Southern District of Texas, carrying $245 million in debt and reporting a net loss of $82 million in the preceding 12 months. The company that had once operated 265 clinics in 24 states was down to 130 locations.

The founder, Dr. Doreen Granpeesheh, bought most of it back for $48.5 million. Her vehicle, Pantogran LLC, paid $37.4 million for 112 clinics across 10 states and all of CARD’s intellectual property, including the Skills® Global longitudinal database and clinical training system it had spent years developing. Three other buyers split up what remained.

The math of the five-year arc is stark. Blackstone entered at a reported 20-plus times EBITDA. Pantogran exited the auction at roughly 0.3 times trailing revenue. The difference between those two numbers is the most expensive lesson the ABA industry has produced, and the industry is still drawing conclusions from it.

CARD went from having no debt to carrying $245 million in obligations when it filed for bankruptcy. The pandemic did not cause that. The deal structure did.

That is not a comment this publication makes on its own authority. It is drawn directly from the court documents, the public record of the bankruptcy proceedings, and reporting by NBC News, CNBC, Behavioral Health Business, and others who covered the story as it developed. The purpose of this retrospective is to trace the sequence precisely, document what happened to CARD’s clinical quality and workforce during the Blackstone years, and report on what Granpeesheh has rebuilt under Pantogran’s ownership.

What Blackstone Bought in 2018

Doreen Granpeesheh founded CARD in 1990. She had earned a PhD in psychology from UCLA, where she worked with Ole Ivar Lovaas on the foundational 1987 ABA study that established intensive behavioral intervention as a treatment for autism. After completing her doctorate, she opened a practice focused on ABA for children with autism and spent the next 28 years building it into the largest autism services organization in the United States.

By 2018, when Blackstone acquired the company, CARD had approximately 100 clinics and a proprietary clinical curriculum that Granpeesheh had developed over decades. It had built Skills® Global, a longitudinal database tracking patient outcomes that represented a meaningful clinical asset. The company trained its own behavior technicians in-house and had a reputation for clinical rigor built around Granpeesheh’s direct involvement in the organization’s standards.

The deal structure: Blackstone acquired a 70 percent stake in CARD in May 2018 in a transaction valued at approximately $600 million. Granpeesheh received roughly $315 million from the transaction and reinvested $135 million alongside Blackstone, retaining a minority stake. She remained CEO until December 2019, when she stepped into the role of executive director and was replaced by Anthony Kilgore, who had previously run a kidney dialysis company. In November 2018, six months after the acquisition, CARD took on $235 million in debt through a financing arrangement with Ares Capital Corp., funded partly to support expansion and development of its own electronic health record system.

Blackstone’s stated ambition was to scale CARD to more than 500 clinics, using data analytics and centralized management to expand access to ABA across the United States. That plan was consistent with the investment thesis driving the wave of PE acquisitions in autism therapy at the time. CARD was the marquee transaction: the largest buyout ever in the behavioral health sector, at multiples that assumed continued rapid growth and rate stability.

How a $600 Million Company Goes Bankrupt

The deterioration at CARD under Blackstone’s ownership has been documented in court filings, employee accounts, and investigative reporting. The CEPR, in a 2023 report on private equity in autism services, concluded that Blackstone’s debt-loading and overexpansion turned CARD from a sustainable clinic network into a cautionary example of financialized healthcare. Former employees described a company that changed materially after the acquisition.

Training cuts came first. According to a CEPR report based on interviews with former employees, after the acquisition Blackstone began making substantial cuts to CARD’s training requirements, shifting from in-person to online training and cutting the length of new hire orientation. The in-house training that had been a core part of CARD’s clinical identity was scaled back as the company sought to reduce costs and onboard staff faster.

Staffing levels declined. Granpeesheh told NBC News in 2024 that the average number of behavior technicians at each CARD clinic had been 20 when she ran the company. By the time Blackstone sold, it had dwindled to 11. Wages for behavior technicians had not increased since 2019, the year Granpeesheh stepped down as CEO. The combination of stagnant pay and reduced professional development led to turnover that compounded the company’s operational problems.

“I did have a number of parents reach out to me and tell me stories that I would have been pretty upset about if I was in a position to make any kind of change at CARD during those years.” — Doreen Granpeesheh, founder of CARD, NBC News (2024)

Granpeesheh resigned from the CARD board in early 2022, citing disagreements about training and certification program cuts that had begun in 2020, how revenue was being spent, and bonuses being paid to senior executives. In a 2022 LinkedIn post that has since become one of the most-cited documents in the industry’s debate about PE in ABA, she wrote: “People always ask me if I regret selling CARD to a PE firm. I do!”

That year, CARD exited more than 10 state markets, shedding clinics under the pressure of inflation, wage increases it could not sustain, and reimbursement rates that had not moved in proportion to costs. As of February 2022, CARD had 221 locations in 24 states. By June 2023, when it filed for bankruptcy, it was down to 130.

The financial picture at bankruptcy: Court filings show that in the 12 months ending April 2023, CARD generated $160 million in revenue and posted a net loss of $82 million. EBITDA was a negative $22 million. The company carried $245 million in total debt. Medicaid and state-focused private health plans accounted for 90 percent of revenue, a payer mix that left the company highly exposed to rate pressure and utilization management decisions it could not control.

Blackstone’s spokesman disputed that its ownership had caused the quality decline. He attributed CARD’s financial difficulty to industry-wide pandemic impacts and insufficient insurer reimbursements, and noted that nearly 80 percent of Blackstone’s purchase had been funded with equity. Industry observers have pointed out that the debt load, which grew from zero to $245 million over five years, substantially increased CARD’s cost structure going into the pandemic in ways that a zero-debt organization would not have faced.

The Auction: A Four-Day Process

After CARD filed for bankruptcy on June 11, 2023, Granpeesheh and her business partner Sangam Pant had already formed Pantogran LLC and positioned it as the stalking-horse bidder. The initial stalking-horse bid was set at $25 million for most of CARD’s assets.

Over the following six weeks, CARD engaged with 84 parties. Five submitted bids, two were certified as qualified, and the process triggered what the court documents describe as a five-day auction featuring multiple rounds of bidding and around-the-clock negotiations. Pantogran and Audax Group emerged as the successful bidders, nudging out a competing offer from Behavior Frontiers and its backer Lorient Capital, which was retained as the backup bid.

The final structure split CARD into three pieces. Pantogran paid $37.4 million for 112 clinics across California, Texas, Louisiana, Colorado, Arizona, Illinois, Washington, Maine, Kentucky, and Florida, plus two New York locations, and acquired all CARD intellectual property including the Skills® Global database and clinical training platform. Proud Moments ABA, an Audax portfolio company, paid one dollar for CARD’s facilities in New York, New Jersey, and Nevada. New Story, also an Audax company, paid $11 million for all CARD locations in Virginia, including three special education schools and nine ABA centers.

The IP transfer: Pantogran’s acquisition of Skills® Global and CARD’s longitudinal clinical database was strategically significant. The database represented years of patient outcome data and the infrastructure for CARD’s clinical training system. Without it, the company Granpeesheh was rebuilding would have had no advantage over any other operator starting from scratch in the same markets.

The bankruptcy court’s approval of the sale came on July 27, 2023. Granpeesheh resumed operational control in August, one month after winning the auction. Her statement at the time was direct: “I am eager and excited to get back to work helping CARD families and supporting CARD’s clinical teams. As long as we put families and clinicians first, I have no doubt that we will ultimately create access to ABA for everyone who needs it.”

Pantogran’s CARD: Two Years Later

As of 2025, CARD under Pantogran is a functioning, revenue-generating company. Based in Plano, Texas, it reported approximately $151 million in annual revenue in 2025, down from the $160 million it had at the time of bankruptcy but representing stabilization rather than further decline. The company employs roughly 1,263 people. Granpeesheh serves as CEO. Sangam Pant serves as President.

The return of experienced clinical staff has been the most notable operational development. Granpeesheh told NBC News in early 2024 that a significant number of senior clinicians who had left CARD during the Blackstone years had come back. That pattern is consistent with what happens when a founder returns to an organization whose culture had changed under outside management: the people who left for cultural reasons rather than financial ones often return when the culture changes back.

The clinical priorities Granpeesheh has stated publicly center on what she describes as putting clinical quality ahead of everything else, a deliberate contrast with the direction she says the company took during Blackstone’s ownership. CARD still offers center-based, home-based, school-based, and remote clinical services. The Skills® Global platform remains operational and is central to CARD’s training and outcome-tracking approach.

What the footprint looks like now: CARD under Pantogran operates across the 10 state markets it acquired in the bankruptcy sale, a significantly smaller geographic presence than the 24-state footprint it had at its 2022 peak. Whether Granpeesheh will pursue expansion into additional states is not yet clear from public statements. The company has not announced any acquisitions or new market entries since completing the buyback.

The financial recovery is unfinished. Revenue in 2025 remains below the pre-bankruptcy level, the workforce is substantially smaller than the 2,500 employees CARD reported at filing, and the debt structure inherited from the bankruptcy remains a factor in the company’s capital position. What Granpeesheh has accomplished is keeping the core clinical operation intact, which was not guaranteed at any point in the June-August 2023 process.

What the Industry Learned

The CARD bankruptcy reset valuations across the ABA sector in ways that continue to shape deal terms in 2025 and 2026. James Cassel, chairman of Cassel Salpeter & Co., told Behavioral Health Business at the time of the bankruptcy that the proceedings were “resetting values” and that the elevated multiples of the 2018 era would not hold. They have not.

The specific conditions that made CARD’s collapse possible are worth documenting for the current generation of operators and investors working in the space. CARD entered the Blackstone period with no debt. It left with $245 million. It entered with a nationally recognized training system and clinical culture. It left with training cuts, a frozen wage structure, and a workforce that had shrunk by nearly half at the clinic level. It entered at a time of relatively favorable payer rates. It filed for bankruptcy in an environment of rising labor costs, stagnant reimbursement, and post-pandemic utilization pressure.

None of those factors was individually decisive. The combination was. High debt service costs make companies less able to weather revenue shortfalls. Reduced training investment makes clinical quality harder to maintain. Wage stagnation drives turnover. Turnover drives instability in patient care. Families who lose their behavior technicians leave. Revenue declines. The cycle accelerated until CARD could not service its debt and operate at the same time.

The lesson that several firms investing in ABA in 2026 have drawn from CARD is about payer mix and debt structure. Companies that are 90 percent dependent on Medicaid and state-managed care plans have narrow margins for error when rates do not keep pace with labor costs. Loading those companies with debt reduces that margin further. The wave of deals done at 2018-era multiples for Medicaid-heavy ABA providers produced predictable stress when the labor market tightened and rates did not move.

The cautionary tale dimension: The CEPR described Blackstone’s CARD investment as “a cautionary example of financialized health care.” That framing resonates across the ABA community in part because CARD was not a marginal operator. It was the company Granpeesheh spent 28 years building from a single practice to 265 clinics, with a clinical database and training system that influenced how ABA was practiced nationally. The collapse of that company under PE ownership, and its founder’s subsequent decision to buy it back at a fraction of the original price, is the reference point the ABA industry uses when evaluating the risks of large-scale PE investment in behavioral health.

For Granpeesheh and Pantogran, the question now is whether a company rebuilt from a bankruptcy auction can restore the clinical reputation that the original CARD built over three decades. The early indicators from senior clinician returns and stated clinical priorities suggest a serious attempt. The revenue and employment figures suggest the recovery is real but incomplete. What comes next depends on whether the company can rebuild its workforce, stabilize its payer relationships, and eventually grow back into the geography it lost between 2022 and 2023.

AT A GLANCE

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