Cortica’s Plan to Bring Value-Based Care to Autism

欢迎收听彭博智库《医疗先锋》播客的最新一期，在这里我们会对话医疗行业变革浪潮前沿的领军者们。

Welcome to another episode of Bloomberg Intelligence's Vanguards of Healthcare podcast, where we speak with the leaders at the forefront of change in the healthcare industry.

我叫乔纳森·帕默，是彭博智库的医疗行业分析师，彭博智库是彭博社的内部研究部门。

My name is Jonathan Palmer, and I'm a healthcare analyst at Bloomberg Intelligence, the in house research arm of Bloomberg.

今天我非常荣幸地请到了

I'm thrilled to welcome Doctor.

尼尔·哈坦加迪医生做客我们的节目。

Neil Hattangadi to the program.

他是Cortica的首席执行官兼联合创始人，这家公司最初是依托他妻子——也就是另一位联合创始人——的医疗业务起步的。

He's the CEO and co founder of Cortica, which was born out of his wife and co founder Doctor.

这位创始人就是吴苏珊（Suzanne Go）。

Suzanne Go's clinical practice.

直到现在，苏珊还是这家公司的首席医疗官。

Suzanne is still the company's chief medical officer.

尼尔在这件事上能拿出非常难得、三位一体的独特视角。

Neil brings a really unique triple threat perspective to the table to this.

他是个罗德学者，哈佛医学院毕业，加入Cortica之前，做过股票投资，还在几家成功退出的医疗设备公司担任过高管。

He's a Rhodes scholar with a medical degree from Harvard, and before joining Cortica, he spent time, as an equities investor and held leadership positions at a number of medical device companies that had successful exits.

现在，他和苏珊娜正着手解决医学领域中最分散、也最关键的领域之一——自闭症和神经发育障碍的诊疗。

Today, he and Suzanne are tackling one of the most fragmented and high stakes areas of medicine, autism and neurodevelopment care.

Cortica正在用一种全新的整体儿童模式取代零散的疗法，把神经科、科技和行为健康整合在一起，真正推动了这个领域的发展。

Cortica is really moving the needle by replacing siloed therapy with this integrated whole child model that combines neurology, technology and behavioral health.

我特别想聊聊他们是怎么把这个模式规模化，又怎么应对当前的监管环境的。

I'm really excited to dive into how they're scaling this model and navigating the current regulatory landscape.

尼尔，欢迎做客节目，谢谢你来参加。

Neil, welcome to the program and thank you for joining us.

谢谢你，乔纳森。

Thank you, Jonathan.

能来这儿真的很荣幸。

Really an honor to be here.

感谢你这么客气的介绍。

Thanks for that generous introduction.

不客气。

My pleasure.

那我们先从宏观层面说起吧？

Well, why don't we start at a very high level?

简单说说，Cortica的使命是什么？

You know, what's the mission of Cortica in a few sentences?

我们想彻底改变家庭在孩子自闭症或神经发育障碍的诊断与治疗过程中，不得不面对的支离破碎的医疗体验。

We're really trying to defragment the clinical experience that families would otherwise have to undergo in their diagnosis and treatment for their child with autism or a range of neurodevelopmental conditions.

同时，我们也希望让更多人能享受到全球顶尖水平的临床护理。

We're also trying to democratize access to the highest quality of clinical care that would be available in the world.

通常这种级别的医疗资源只集中在少数顶尖学术中心，我和我妻子很幸运，曾经在那里接受过培训。

Typically, this level of care is only at the greatest academic centers, and I was very fortunate, along with my wife, to train at some of those places.

那里的水平确实没得说。

They're outstanding.

但问题是，排队等太久，就算进去了，服务还是七零八落的。

It's just very hard to access with long wait times, and even within them, very fragmented.

所以我们一直想让更多人能享受到这种服务，把原本支离破碎、令人头疼的就医过程整合起来、协调好。

So, we've wanted to really democratize access to that and defragment and coordinate what is otherwise a very challenging and disjointed journey.

那咱们不妨从公司的起源说起吧。

So maybe let's start with the origin of the company.

就像我开头提到的，公司是源于你妻子的临床实践，但你能聊聊过去十年你们团队发展过程中的几个关键节点吗？

You know, as I mentioned in the intro, it's born out of your wife's practice, but can you maybe talk about some of the milestones as you've guys scaled it over the last decade?

当然可以。

Yeah, absolutely.

这一切其实源于我妻子对临床工作的热情。

So this started with my wife's kind of clinical passion.

我们俩是医学院一年级时认识的，从第一次见她，我就听她讲起她对儿童大脑发育、父母与孩子之间关系的执着，尤其是当孩子有神经多样性时。

We met as first year medical students, and from the first time I met her, remember I hearing about her passion about the developing child brain and the relationship between parents and children, particularly when children are neurodivergent.

那是2000年，那时候自闭症还没像现在这样被大众熟知，媒体上也少有讨论。

This is back in 2000, so well before autism was in in common parlance and and seen a lot in the media.

对。

Mhmm.

说实话，这跟我原本的兴趣完全沾不上边。

And it was very far from my interest, to be honest.

作为医学生，我根本搞不懂生理上到底发生了什么。

It was hard for me to understand physiologically what was happening as a as a medical school student.

其实我在医学院那几年，根本没学到过这方面的内容。

In fact, I learned really nothing about it in my time in in medical school.

我更倾向于那些技术应用起来比较直接的领域。

I I gravitated to where there was kind of an easier application of technology.

比如心脏病学，对我来说就特别清楚明了。

So, like, something like cardiology was very straightforward for me.

你能直接拍到影像，看到病灶。

You could image, see a lesion.

不管是通过体检还是心电图这类电生理手段，都能找出来。

You could find it either physically or electrophysiologically with with things like EKG.

而她则一直坚持着这份热情，在学术训练期间还共同主导了多个学术中心的自闭症项目。

And she continued this passion through academic training, was a part of co directing multiple academic center autism programs.

后来我们有了第一个孩子，她就离开了学术圈，开了家小型私人诊所，以整合的方式服务家庭，就是想摆脱学术体系里那些繁琐的束缚。

And then when we had our first kid, she wound up starting leaving academia and starting a small boutique private practice to treat families in this integrated way, Really to to to get out of the encumbrances of of doing this in an academic setting.

我之前参与过三家医疗科技公司，帮着搭建和完成交易。

And I was a part of three prior med tech companies, helped build and transact.

当我做完第三笔交易后，正琢磨下一步该做什么，过去我一直在心内科和耳鼻喉外科领域待过，但被她取得的临床成果深深吸引——相比之下，自闭症领域的创新实在太匮乏了，而心内科早就遍地是创新了。

And when I transacted my third, was kind of looking for my next thing to do and had historically spent time in fields like cardiology and ENT surgery and was just fascinated by the kind of clinical outcome she was getting and how desperately needed this kind of innovation was in autism care compared to cardiology where there's a lot of innovation.

现在有五十多家初创公司在研究自闭症的各类治疗方向。

There are 50 some startups pursuing individual therapeutic indications in autism.

但真正能推动进展的寥寥无几，至少在2016年左右——也就是十年前——是这样。

There are very few that are really, like, pushing the needle, certainly at that time, which is back in, like, 2016 or so, about ten years ago.

所以我加入时，是想把一个已经验证有效、当时已帮助了五六十个家庭的模式推广开来，虽然那时还不能接受医保，也没法规模化。

So I joined with the with the intent of taking a model that had been well validated and and showed to be very effective in, at that time, maybe fifty, sixty families, not not really being able to take insurance, not being able to scale at that time.

我的目标就是和她一起扩大规模、提升可及性，对接医保计划，搭建技术底层架构，规划怎么组建跨学科的医护团队，再培训他们协同工作。

And and my goal here was to work with her to to scale, make it more accessible, join with health plans, build the underlying technology infrastructure, how are we gonna hire multidisciplinary care teams and and train them to work together.

对我们来说，关键的里程碑就是证明：她一个人带着小团队能做成的事，别人也能复制、能放大。

So key milestones for us were really about first being able to demonstrate that what she was doing on her own as a single physician working with a small team could be scaled beyond her.

那我们能不能引入其他专科的医生，让她来培训他们，达到同样的治疗效果？

So could we bring in other physicians of different specialties and train her to train them to deliver that same level of of effectiveness?

然后就是能不能搭建一个底层技术平台，让这群临床医生能真正协同工作，因为市面上根本没有现成的电子病历系统能把医疗这边的所有内容整合起来。

Then it was about can we build an underlying technology platform that allows this group of of clinicians to work together because there's no off the shelf electronic medical record that combines everything on the medical side.

你得开核磁共振、安排化验，还得开药。

So you're ordering MRIs and labs and Mhmm.

同时还要对接ABA——应用行为分析的治疗方案。

Prescribing medications to what is done in ABA, applied behavioral analysis.

这工作量可不小，到处跑。

That is a lot of field work.

数据收集也特别繁重。

It's a lot of data collection.

这两种电子病历系统根本是两码事。

Those EMRs could not be more different.

那怎么把它们打通，让两边的医生都能看到对方的数据呢？

And so how can you kind of put those together, make the data from both sides accessible to to clinicians from both sides?

这可是个重大突破。

That was a big milestone.

我总共能列出四个关键节点。

And I'll I'll say sort of four in total.

前面这两个算两个。

Those are two.

第三个是，我们能不能把模式扩展到不止一个地方？

The third a third is around can we scale from more than one location?

很长一段时间，我们只在一个地方运作。

For a long time, we were only in one place.

第四个关键点，是吸引投资。

And then the fourth was attracting capital.

能不能让外部投资者觉得，这跟当时主流的ABA自闭症疗法完全不同，值得投入？

Could this get to a place where outside investors would say, hey, this is outside the norm of of standard autism therapy, which at the time was applied behavior analysis.

我们能不能打动专业投资人，最好是那些代表医保计划或家长组织的战略伙伴，认可这个模式，帮我们把它推广开？

But could we get professional investors and and and ideally strategic investors who represented health plans, parent groups to to buy into this model and and help scale it.

所以，从2016年到2020年之间，这些关键节点让我们真正开始成长起来。

So those were the milestones we sort of saw between say 2016 and 2020 that really allowed us to start to grow.

总结得太棒了。

That was a great summary.

你提到Cortica模式和传统模式，要不咱们再深入一点？

You know, maybe taking it a step deeper, you talked about the Cortica model and maybe the traditional model.

能不能再详细说说，Cortica的治疗方式跟传统的ABA到底有什么不同？

Can you maybe further bifurcate the difference between those two and how maybe Cortica's model of treatment is different than the traditional ABA?

是的，传统的应用行为分析（ABA）有大量扎实的研究数据，都快有二三十年了。

Yeah, the traditional model of applied behavior analysis, ABA, has tremendous great data going back twenty, thirty years.

它根植于心理学，有几十项研究证明了它的效果，数据非常扎实。

It is founded in psychology, great outcomes data spanning dozens and dozens of publications.

过去二十年，自闭症之声这类组织，还有家长倡导团体，成功推动了各州把ABA纳入医保，联邦层面也获得了两党广泛支持，这对整个领域来说是个重大突破。

And Autism Speaks and other industry groups, really parent advocacy groups, were very successful over the past twenty years in in getting ABA covered at the state level and a lot of bipartisan federal support, which was a huge win for the field.

ABA主要靠行为矫正来干预孩子。

ABA relies on behavioral modification for children.

所以关键在于正负强化，搞清楚什么让孩子表现得更好，什么又会导致他们行为失控或自伤，然后在他们表现好时给予强化，表现不好时怎么处理。

So it's about positive and negative reinforcements, understanding what causes a child to behave in an optimal way and what causes a child to behave in in dysregulated or or self injurious ways and how do you reinforce when they're behaving appropriately versus not.

这确实是个很重要的工具。

It's a really important tool.

但作为医生，我们遇到的问题是，它应该只是众多治疗手段中的一种，就像医学其他领域一样。

And the issue that we have had as physicians is it should be one of several tools that are employed just like every other field of medicine.

我经常在心内科，特别是介入心脏病学领域工作，那确实是个很棒的手段。

I spend a lot of time in cardiology and specifically interventional cardiology, which is a wonderful tool.

支架植入、斑块清除这些技术不断进步，但我们一直清楚，它只是众多选择中的一个。

There are lots of of innovation in stenting and and plaque excision and things, but we always knew that it was one of many tools.

我们更希望从源头上预防，尽量避免做介入手术；有些情况根本不适合介入，必须开刀。

I mean, you you want to actually avoid the need for interventional procedures by being preventative on the front end, and then there's a category of lesions where you need surgery and and intervention is is inappropriate.

同样地，在自闭症治疗上，ABA固然重要，但它应该和对每个孩子的全面医学评估并行，也就是搞清楚他们的遗传基础。

So similarly, in in autism, ABA is a very important tool, but it should sit alongside a thorough medical understanding of each child, and that's about understanding their genetic underlying conditions.

有没有代谢方面的问题在影响孩子？

Are there metabolic issues that that are that are happening?

所以是线粒体功能障碍、维生素缺乏、免疫失调、肠道菌群失衡这些问题。

So mitochondrial dysfunction, vitamin deficiencies, immune dysregulation, microbiome dysfunction.

这些在神经科和发育行为儿科学领域都已经研究得很透彻了。

All of these have been very well characterized and understood in the neurology developmental pediatrics fields.

关于癫痫的管理，也有很多内容。

There's a lot around seizure management.

有百分之二十到三十的自闭症儿童其实伴有潜在的癫痫问题。

Twenty to thirty percent of children with autism have underlying seizure disorders.

如果这些没被发现，最糟糕的情况是，孩子明明是癫痫发作，却被当成自闭症的行为问题，比如刻板动作，用行为干预去纠正，其实根本该用生酮饮食、对症药物来治疗。

If those aren't treated, and sometimes in in the worst case, you'll see a child who has issues of seizure, but they are seen in the ABA field for for very valid reasons as self stimulatory behaviors and treated with behavioral modification, whereas really it's a seizure that needs to be treated with appropriate ketogenic diet, the right medication management.

饮食方面也很关键，得让孩子吃对东西，才能维持良好的肠胃健康。

There's a lot around feeding, making sure children are eating the right foods that then lead to the right GI health.

睡眠、多动症的药物管理，这些问题也都不能忽视。

There's a around sleep, medication management for conditions like ADHD.

还有感官处理、精细和粗大运动技能这些发育目标，得靠语言治疗、作业治疗来支持；而孩子和家庭的整体健康，则需要心理咨询、社工服务来跟进。

And then there are developmental goals around sensory processing, fine and gross motor skills that are addressed by things like speech therapy, occupational therapy, and then overall child and family wellness, which are addressed by psychotherapy, counseling, social workers.

所以我们，我个人坚信，ABA非常重要，它是帮助孩子和家庭时不可或缺的核心工具之一。

And so we we deeply believe, I deeply believe that ABA is very, very important and it's a huge part of of the toolkit in in in working with children and their families.

但它单独来看并不完整，就像医学的任何一个领域都不会认为单靠一种即使非常有效的手段就能解决所有问题。

It's just not complete on its own in the same way that every other field of medicine wouldn't view a single tool, though highly effective, to be complete on its own.

而Cortica和传统ABA疗法的不同之处在于，我们承认ABA确实非常重要，但它只是我们整体工作的一部分。

And and Cortica differs from kind of conventional ABA therapy where we say, this is really important, but it is a part of what we do.

它是我们团队里规模最大的一部分。

It's the largest single part of our workforce.

我们目前有大约2200名员工。

We have about 2,200 employees.

其中一半以上都是做ABA的，甚至更多。

About half of them are in ABA, even more.

但我们还会搭配其他所有必要的服务，就像学术医疗中心那样，力求做全面的多学科评估，再据此制定综合性的治疗方案。

But we complement them with all the other services that are required similar to what's done in academic medical centers where they really try to bring together a holistic evaluation, a multidisciplinary evaluation and use that to come up with a multidisciplinary treatment plan.

那这些服务现在都是在Cortica旗下统一提供的吗？

So do all those services sit or are those different services sit under Cortica's roof or umbrella today?

是的，都在我们旗下。

They do.

对，都在我们这儿。

Yeah, they do.

这些年我们摸索出了怎么用最少的临床人员类型来提供所有这些服务。

We we we've figured out over the years on how to deliver all those services with the fewest number of clinician types.

大概就那么五六种吧。

And so it's only about a half dozen or so.

但我们的医生和执业护士都非常全能。

But our our physicians and and nurse practitioners are very versatile.

我们会培训他们，让他们能全面处理遗传问题、代谢问题、睡眠问题等等。

We we train them to be well rounded clinicians in being able to work up where appropriate genetic issues, metabolic issues, sleep.

我们内部有专家专门研究癫痫、神经遗传学这些领域。

We have experts within Cortica who specialize in things like epilepsy or neurogenetics or Mhmm.

还有专门负责精神药理学领域的药物管理。

Medication management, specifically in this field called psychopharmacology.

但每个中心的医生和护士执业医师实际上都扮演全科医生的角色。

But the physicians at each center, the nurse practitioners at each center really function as as generalists.

同样，我们有认证的行为分析师（BCBA），他们做ABA治疗，但更会思考：这些其他症状和表现是怎么来的？我该怎么跟身边的医疗团队协作？

And similarly, we have BCBAs, board certified behavior analysis, who who do ABA, but are really thoughtful about how are these other symptoms, signs arising, how can I coordinate with this interpersonal care team around me?

所以我们虽然处理的病例很多，但都是由最少的团队完成的，大概就六种类型的医护人员。

So though we treat a lot, it's done by kind of the smallest group we can, which is about a half dozen clinician types.

你刚才简单提了一下，那具体是怎么协调护理的呢？

So you mentioned it briefly there, but how does care coordination work?

是医生负责，还是BCBA负责，还是两者结合？

Is it by the physician or those BCBAs or a combination thereof?

是两者结合。

It's a combination.

我们有专门负责护理协调的岗位，虽然是行政性质的，但核心就是做这个。

We have a couple roles that are really dedicated to they're administrative roles that are really dedicated to care coordination.

在初期阶段，会有接诊协调员帮助家长，根据他们来之前已经掌握的诊断信息，引导他们完成合适的评估和检查。

So on the initial stages, it's an intake coordinator who helps guide the parents to the right evaluation and workup depending on how much diagnostic information they have before they arrive.

接下来，在初期做医学检查、安排各种检测时，会有医学助理帮忙。

Then it's a medical assistant in the early days as the medical workup is being done and various tests are being ordered.

我们不是所有检查都在内部做。

We don't do all the testing in house.

我们会做基因检测。

We do genetic testing.

脑电图我们会做，但抽血化验这类就不做了。

We do EEGs, but we don't do labs, for example.

我们诊所不太喜欢抽血。

We don't like blood draws in our clinic.

所以医学助理会帮他们联系外部的学术中心或检测机构来完成这些项目。

So the medical assistant will facilitate that often with sometimes outside academic centers or lab facilities.

之后还有一位排程协调员，等完整的治疗方案定下来后，他就负责确保家庭需要的每项服务都能在最合适的地方安排好——比如有些治疗在家做效果更好，因为更容易迁移到日常生活里。

And then we have a scheduling care coordinator who once that comprehensive treatment plan is developed, that scheduling care coordinator makes sure that every type of service that that family needs is available to them in the right site of service in in in the sense that some of those are best delivered in the home because it it most generalizes the the type of of therapy.

诊所的环境当然更固定、更受限，但在这里治疗往往效果不错，这也很棒。

A clinic is a much more constrained and fixed environment where you're most likely to get good results, which is great.

到某个阶段，我们希望把服务慢慢转移到家里去做。

At some point, you wanna fade that into the home.

我们有些服务可以通过远程医疗完成，特别是那些只面向家长、不直接接触孩子的部分。

Some of our services can be done by telehealth, particularly when they're parent facing, not working with the child, but only with the parents.

所以这位协调员要确保家庭在正确的时间、正确的地点、由合适的医生获得所有必要的服务。

And so this care coordinator makes sure that all the different components of care are available to the family at the right time, at the right side of service, by the right clinician.

这些服务确实有排队等候的问题，尤其是在高峰时段。

We do struggle with wait lists with some of these things, particularly at, like, prime time hours.

放学后的时段特别难约，他们也得帮忙管理这些排队名单。

A lot of the after school hours are are are hard to come by, so they kinda manage the the wait list as well.

我们除了行政岗位，临床团队本身也会通过查房来做协调工作。

So we have those administrative roles, and we also have the clinicians themselves doing care coordination via rounds.

我们每周都会专门留出时间，让整个团队聚在一起讨论。

So we have every week a dedicated time where the whole team comes together.

这跟学术机构的做法非常相似。

It's very similar to what's done in academia.

这种做法也有人叫‘多学科会诊’或者‘肿瘤委员会’，就是把不同领域的专家聚到一起讨论。

Rounds or tumor board is another way people kinda think about this where you bring multiple experts together.

我们每次要审阅15个案例，特别有意思的是，比如在孩子家里做行为干预的技术员可能会说：‘我注意到孩子每天下午三点左右特别犯困。’

You have 15 cases to review, and it's a fascinating exchange where a clinician, a behavioral technician who's working with the child in the home may see may say, I noticed the the child's getting really groggy around 3PM.

那我们之前对他的药做了什么调整？

What have we done with his medications?

医生听了就能调整剂量，或者发现孩子在这几个时间段特别情绪失控。

And the physician can adjust the dosage or, you notice the the child's really dysregulated around these times.

那我们怎么改进他的辅助沟通设备（AAC）？让他能更顺畅地表达，情绪和行为自然也就缓和了。

How do we improve the AAC, which is alternative or augmentative communication device so they're able to better communicate and therefore back down on some on some behaviors.

这种协作氛围特别棒，我们的协调服务在这里才能真正发挥出效果。

So it's a very collaborative, cool environment where where our care coordination really flourishes.

你刚才说的这些复杂情况，我明白了。

Got the complexity you just described there.

我在想，那些没有这种协调员帮忙、全靠自己硬撑的家庭，得多难啊。

I'm thinking of a family who doesn't have this this opportunity to to work with a care coordinator trying to do it all by themselves.

这简直是个全天候的工作。

It must be a full time job.

说得对。

Yeah.

你一句话就说中了。

You said it perfectly.

你知道吗？是什么让我投身这个行业的？

You know, what what made me get into the field?

你刚才提到我的背景，其实……

And, you know, you you mentioned my background.

我以前是买方的证券分析师，专门研究哪些医疗领域或市场值得投资。

I was a securities analyst on on on the buy side, trying to figure out, like, you know, whether markets or or individual kind of areas of health care were worth pursuing.

为了判断自闭症领域的这个项目值不值得做，我访谈了十户家庭。

And when I spoke to 10 families to to understand is is is this venture in autism a worthy one?

结果，我听了十遍你刚才说的那些话。

I heard exactly what you said 10 times.

最常见的就是，双职工家庭里，总得有一方辞职，专门管这些事儿。

It was the common story is, you know, the two parent working household, one of the two parents leaves the workforce to do all this quarterbacking.

这确实是个难题。

It is a challenge.

以前呢，家长都会有个文件夹，把诊断心理医生的报告拿给儿科医生看。

And in the old days, they used to keep a binder where they would have the medical records from the diagnosing psychologist, give that to the pediatrician.

儿科医生就说：

The pediatrician say, hey.

你去挂个消化科吧。

Go to a GI specialist.

然后家长就去把检查做完。

They would then get that workup.

再把结果交给ABA治疗团队。

They would hand that to their ABA team.

所以这事儿真就是个全天候的活儿，家长得特别特别懂行，知道啥管用、啥不管用。

And so it it really is a full time job quarterbacking it, and and parents have to get very, very smart about, you know, what works, what doesn't work.

对于自己的孩子，他们得记录海量的数据。

And for their own child, they are a lot of data capture.

嘿。

Hey.

当我们让孩子接触这些事时，好事或坏事就会发生。

When we expose our child to these things, these good things happen or these bad things happen.

所以他们一直在点头确认。

So they're Mhmm.

不停地收集数据，分析关联，再把这些结果反馈给临床团队。

Constantly taking data and figuring out correlations and presenting that back to their clinical team.

这真的太难了。

It is very, very difficult.

让我震惊的是，你看癌症这种病，本身就够吓人、够棘手了。

And what shocked me is you take a condition like oncology, which is and it's a very scary and and challenging condition.

如果我们要求癌症患者自己搞定手术、吃药、放疗这一整套流程，那简直太荒谬了。

If we expected patients to navigate between surgery, medication, radiation, and that whole pathway themselves, It would just be I mean, that that would make no sense.

整个流程是这样的：先做影像检查、活检、基因检测，然后根据结果进入相应的治疗路径。

The the algorithm is that you get imaging workup, biopsy, genetic workup, and based on that, you're put into a workflow.

病人要做的就是好好恢复、养好身体，专心康复，而不是自己琢磨该在什么时候做什么治疗。

And the patient's job is to recover and heal and focus on getting better as opposed to deciding what should I be getting at what time.

在癌症治疗里，谁会指望病人自己决定什么时候该做手术？这简直荒唐。可我们偏偏就要求自闭症家庭这么做。

Is now the right time for me to get surgery over it's just it's crazy to think that that would be the expectation in in cancer care, yet we expect that of families in in autism.

所以我们才创办了这家公司。

And so that's why we built we built the company.

我觉得，用不了多久，我们回过头来看就会觉得，让父母既要当父母，又要带孩子穿越这么支离破碎的系统，实在太不合理了。

It just feel felt like at at some point in the in the future, near future, I think we'll look back and say it's very unreasonable to expect parents to be parents and guide their children through such a fragmented ecosystem.

说来也挺有意思。

Well, it's funny.

我正想着‘生态系统’这个词，准备问你下一个问题。

I was just thinking about the word ecosystem for my next question.

患者和家庭是怎么进入Cortica这个生态系统的？

How do patients and families enter the Cortica ecosystem?

他们之前在哪？是怎么找到咱们这儿来的？

Where were they and how did they wind up on your doorstep?

很多人都是自己找到我们的。

A lot of them find us themselves.

这是一群特别主动的人，拼命在找适合孩子的疗法。

This is a very active group that are trying to to find the the right therapies for them.

他们有的是在确诊前就来了，比如发现孩子没达到发育里程碑，或者幼儿园老师、儿科医生给了点建议，他们就想找下一步该怎么做。

And they come either pre diagnosis, like, they've noticed a a challenge in in meeting developmental milestones or a preschool teacher or their pediatrician may have sent something to them and they're trying to find the right the right next step.

也有的是已经在系统里被来回踢皮球了，比如反复做ABA干预。

Or sometimes it's they have been in the system ping ponging between, say, lots of ABA.

他们在医院、学术中心之间来回奔波，孩子都十岁、十二岁、十四岁了，问题还是没解决。

They've been in academic center ping pong between different medical providers, and the child is 10, 12, 14, and they're continuing to observe challenges.

所以他们是通过这种方式找到我们的。

And so they find us that way.

这已经占了相当大一部分了。

That's a good chunk.

我们一半左右的患者都是自己通过口碑或者网上搜索找到我们的，就是他们所处的那些社群里传开的。

Maybe half of our patients just they themselves kinda find us through word-of-mouth or online searches, just, you know, the communities they're they're a part of.

我们还收到很多儿科全科医生的转诊。

We also get a lot of referrals from primary care pediatricians.

儿科全科医生一般都有一份发育儿科专家或儿童神经科医生的名单，遇到各种情况都会转过去。

So PCPs in pediatrics are are used to having a roster of developmental pediatrician specialists or pediatric neurologists to to refer a whole range of conditions.

我们接诊的病人里，自闭症大概占一半，另一半则是各种各样的发育和神经问题，比如多动症、头痛、癫痫、唐氏综合征、罕见遗传病、语言发育迟缓、运动发育迟缓等等。

Autism is is about half of what we see, but the other half is a whole range of developmental and neurologic conditions, everything from ADHD, headache, seizure, Down syndrome, rare genetic syndromes, speech delay, motor delay.

所以我们希望儿科医生们把我们当成发育和神经方面问题的可靠转诊渠道。

And so we like to be thought of for those primary care pediatricians as a trusted referral source for anything developmental neurologic.

他们不用非得自己去评估是不是自闭症。

They don't have to work up the autism.

也不用非得先怀疑是自闭症。

They don't have to think it's autism.

只要觉得我们能帮上忙的，都尽管转过来。

Anything that they would feel like we could be helpful, we encourage them to to send.

当个儿科全科医生真不容易。

It's hard to be a primary care pediatrician.

各种问题都往你这儿涌。

You see lots of stuff coming your way.

感染病、骨科问题、发育问题、精神心理问题，啥都有。

Mean, it's infectious things, orthopedic things, developmental things, psychiatric.

我们常说，你看到的那些大概百分之二十五属于神经发育方面的，尽管转介绍给我们，我们很乐意帮忙。

And so we we like to say the maybe twenty five percent that you see that falls under kind of neurodevelopment, send them to us and and we'd love to help.

我们和全科医生之间有个反馈机制，会跟他们反馈孩子转诊后在我们这儿的情况。

And we have this feedback loop between a specialist physician and the PCP to to show them, you know, post that referral, how's the child doing in in our hands.

这两大块是主要的。

Those are the primary two.

现在我们也开始和医保计划合作了，他们做了理赔数据分析，发现我们这种整体模式能帮他们省下不少钱——具体节省项目我就不细说了，但他们发现，平均每个会员每年能省下五到六成的费用。

We we are starting to get some collaboration with health plans where health plans have have done the work of of claims analysis analysis and and found that this holistic model saves them a lot of money compared to I can go through kind of the components of savings, but they they found that that's 50 to 60% savings on a per member per year basis.

所以现在他们越来越愿意把病人转介给我们。

So they're increasingly sending members to us.

但家长并不总是通过医保计划去找资源。

But parents don't always use their health plan to find resources.

这个我懂。

I could see that.

所以这事儿得靠我们主动推。

So it's on yeah.

目前就只有一对一的对接，不过医保计划也慢慢开始意识到这些情况了。

It's only one pair oh, and health plans are kinda made aware of these situations.

他们就会把孩子转介给我们。

They they send to us.

现在我们接诊的患者里，通过这个渠道来的大概不超过百分之十到二十。

So it's probably no more than 10 to 20% of our of our intake today is through that channel.

嗯，我觉得我们回头再细聊数字、资金和支付这些事吧。

Well, I think we'll come back maybe to the the numbers and the finances and the payments.

不过单说你们的覆盖范围和规模，现在你们在哪些州开展业务？未来三到五年，你们希望拓展到哪里？

But just thinking about your footprint and your scale, what states are you guys in today, and and where do you aspire to be in, I don't know, the next three to five years?

我们现在覆盖了八个州。

We're in eight states today.

主要是西海岸、中西部、东北部，还有北卡罗来纳和南部地区。

So kinda West Coast, Midwest, Northeast, and and North Carolina and the and the and the South.

我们当初是从加州起步的，之后的扩张模式也一直延续这个路径。

And the the pattern has been when we left we started in California.

加州是我们业务最大的市场。

So that's our largest footprint.

差不多占了我们所有中心的四成左右。

It's about 40% of our of our centers.

不过这个比例现在正在慢慢下降。

They're starting to to decrease as a percentage of the total.

我们后来向全国扩展，主要是两个原因。

And then as we expanded across the country, it was kind of for two reasons.

一个是遇到了一位医生，跟我的联合创始人兼妻子苏珊娜特别投缘——都是儿科神经科或发育行为儿科的医生，在学术机构或者多医生集团工作，跟我说：嘿。

One is we found a physician who was very like minded, similar profile to to my cofounder and and wife, Suzanne, so pediatric neurologist, developmental pediatrician who's practicing in, say, academia or a multi physician group saying that, hey.

看到这些家庭做了检查，却没法坚持后续治疗，我真的特别难受。

It's really challenging for me to see these families do a workup and then not being able to really engage in that follow through.

我会给他们推荐ABA、OT、PT，这个我懂。

I I send referrals out for ABA, OTPT Mhmm.

还有学校方面的支持。

For school care.

也会转诊给其他专科医生。

I send them to other specialists.

但有一部分家庭确实能落实下来。

And some percent of the time, they're able to make that happen.

他们会再回来。

They come back.

也确实取得了成效。

They're successful.

但绝大多数情况下，还是没下文。

But the vast majority of the time, they're not.

只有当家长回来反馈时，我才能了解到情况，这让我很难取得我真正想看到的进展。

And I only hear of the feedback when the parent comes back, and it's very difficult for me to to to really make the kind of gains that I'd like.

于是，全美各地的医生，比如德克萨斯、新泽西、亚利桑那的，都主动联系了我们。

And so we had physicians across the country reach out to us in Texas, in New Jersey, in in Arizona.

所以这些地方之所以进入，很大程度上就是因为这些医生的推动。

So those were kind of reasons we we entered those states.

伊利诺伊州的情况特别明显，完全是医生主导的。

Illinois, very physician driven.

我们就围绕这些医生组建跨学科的诊疗团队。

And then we would build around those physicians as inter interdisciplinary care team.

我们扩张的另一种方式是跟医保计划合作。

The other way that we started to expand was with health plans.

随着我们跟更多医保计划接触，他们说：我们发现会员们面临严重的碎片化问题，同一个会员的就诊记录分散在十五家不同的机构。

As we got to to know more health plans, they they were saying, we see this problem of fragmentation for our members, this provider ecosystem where we're seeing for a given member claims coming in 15 different providers.

根本看不出来这些机构之间有谁在沟通。

It doesn't look like anyone is talking to each other.

这些个体医生过度使用服务的情况很普遍。

See a lot of overutilization from those individual providers.

肯定有重复治疗。

Duplication, I'm sure.

重复的情况确实很多。

A lot of duplication.

没错。

Absolutely.

药物被滥用，因为医生不知道患者还在别处接受其他治疗。

Medication is overused because a physician doesn't see that they're also getting other therapies somewhere else.

所以很多情况下，是医保计划主动邀请我们进入这些州的。

So in in multiple instances, we we were pulled into states by health plans.

马萨诸塞州和北卡罗来纳州就是典型的例子，完全是医保计划推动我们进去的。

So Massachusetts, North Carolina were were places where it was really about the plans pulling us in.

亚利桑那州我们现在只是小规模介入。

Arizona now, we had a small footprint.

我们正在大规模扩张，主要是因为和大型医保计划深度合作。

We're massively expanding because of of large health plan collaborations.

我觉得这会是我们的未来。

And I think that will be our future.

我们现在扩张，完全是跟着医保计划的意愿走——他们说：嘿。

We are only now expanding where health plans are saying, hey.

这事儿太合理了。

This makes a lot of sense.

我们正要打造一套全新的激励机制，也就是按价值付费的医疗模式。

We're going to construct a novel incentive system, value based care.

在按价值付费的体系里，我们关注的是整个孩子、整个人的健康，把医疗和行为健康服务整合起来，用每名会员每年节省的费用作为奖励，而不是传统的按服务收费模式。

And specifically in value based care, it's a whole child, whole person value based care where we integrate medical and behavioral and reward coordination of care, reward per member per year savings versus the conventional fee for service model.

现在，全国各地都在积极响应。

And we're seeing receptivity across the country.

说真的，我们接触过的每一个医保计划，没有一个说这主意不靠谱的。

I mean, there's no plan we talk to that says, yeah, this makes no sense.

每个医保计划在很多领域都在这么做，比如慢性肾病、糖尿病、心力衰竭和骨科。

Every plan every plan does this in so many areas, really, chronic kidney disease and diabetes and heart failure and orthopedics.

说到底，趋势就是整合、协调、按价值付费、按质量付费。

Mean, the the the movement is to integration, coordination, paying for value, paying for quality.

所以关键在于医保计划有没有足够的基础设施来落地这些举措。

And so it's really about a plan's kind of infrastructure capabilities to to pull this off.

我们的目标是未来三到五年内，覆盖全国大部分主要都市区，同时在全美50个州都推出线上版本。

And so our our hope is over the next three to five years, we are in most major metro areas across the country and also have a virtual version of our program in all 50 states.

这个线上版本现在已经在开发中了。

And that's actively in development.

目前我们在运营的八个州，都已经上线了线上服务。

We have that virtual version in all the eight states we operate in today.

不管你在马萨诸塞州还是加利福尼亚州的任何地方，都能通过线上接入我们的服务，我们正打算进一步扩大这个覆盖范围。

So you could look anywhere in the state of Massachusetts or anywhere in the state of California and access us virtually, we're looking to expand that that footprint.

推动我这么拼命扩张的，其实是那种信念——我听过太多来自我们还没覆盖的州、甚至其他国家的家长的故事，他们真的太难了。

And it really comes from this this this ethos why why I feel compelled to expand is I've heard too many parent stories from parents in states we don't operate in, countries we're we're not in, of how challenging the journey is otherwise.

比如，六个月前，FDA一说卢克·奥沃林是万能药，大家就都信了。

Like, they'll hear from the FDA, you know, six months ago, Luke Ovorin is the panacea that you should be thinking about.

其实他们没这么说，只是被误解了。

I don't think they quite said that, but that was the misinterpretation.

确实被误解了。

Misinterpretation.

对。

Mhmm.

于是全国各地的家长都在问：

And so parents everywhere are like, hey.

这玩意儿该不该加进我孩子的治疗方案里？

Should this be a part of my child's program?

但如果你没有专业医生告诉你：

And if you don't have expert physicians to say, hey.

这其实跟叶酸代谢有关，得用对方法研究你孩子的情况才行。

This is really about folate metabolism, which needs to be studied the right way for your child.

如果是这样，那才是合适的。

And if so, then it's appropriate.

如果不是，那就别用。

If not, it shouldn't be used.

但这种事情太常见了，比如：我的孩子该不该被诊断为多动症，然后吃兴奋剂？

But that stuff happens all the time with, like, should my child be diagnosed with ADHD and on a stimulant?

我们是不是该换个思路看待营养，顺便做个化验？

Should we be thinking about nutrition differently and get lab workups?

他们有没有线粒体缺陷？

Are they do they have a mitochondrial deficiency?

在这些患儿里，这太普遍了。

It's very common in this in this patient population.

能帮全美这些家长解决这些问题，才是我和团队真正想做的事。

Being able to solve those problems at scale for parents around the country is really a kind of underlying driving force for me and our team.

咱们再回过头说说你提到的支付方，政府和商业保险的比例大概是多少？

Maybe just going back to one thing you mentioned around payers, what does the mix look like between government and and private commercial pay?

我们现在大概是七五开，百分之七十五对百分之二十五。

We're about seventy five twenty five now.

以前是百分之七十五商业保险，百分之二十五医疗补助。

We were 75 commercial and 25 Medicaid.

而在这部分医疗补助里，大部分都是管理式医疗。

And within that Medicaid, it's mostly managed Medicaid.

所以我们跟各州直接打交道的情况很少。

So we do very little with states directly.

我们主要跟管理式医疗的中间机构合作。

We mostly work with managed care intermediaries.

医疗补助这块业务，我们这边增长得特别快。

That Medicaid side is rapidly growing for us.

对，没错。

Mhmm.

过去一年里，越来越多的保险计划和州政府意识到，这方面的开支增长得太快了——我们待会儿可能会聊到，但最近几个月，这话题已经上了好几篇报道，大家也都在问：嘿。

Because in the past twelve months, more and more plans and state governments have realized that this is a massively growing spend item, which we we may get to, but it's been the pub the the the topic of multiple articles over the past several months and a lot of questions of, hey.

怎么在履行财政责任的同时，妥善照顾那些我们有责任帮助的家庭呢？

What's the right way to to balance their fiscal responsibility with taking care of of families that we owe Mhmm.

你知道，我们确实有这个义务。

You know, we have an obligation to.

但我们的医疗补助业务增长很快，因为他们正在寻找既能满足家庭需求、又符合财务可持续性的解决方案。

But we're seeing that that Medicaid side of our business grow rapidly because they're looking for a solution that best manages the needs of families with with the right financial way to do it.

咱们聊聊媒体上闹得沸沸扬扬的那件事吧。

Well, let's talk about that kerfuffle in the media.

你知道，《华尔街日报》不是刚发过一篇关于印第安纳州和医疗补助领域一些不良行为者的报道吗？

You know, there was the Wall Street Journal article about Indiana and some of the bad actors on the Medicaid side.

你对那篇文章和这个问题怎么看？

I guess what's what's your perspective on on maybe that article and the issue?

另外，我觉得还有一个相关的问题，就是按服务收费和按价值付费之间的矛盾。

And then, you know, I think maybe the secondary question is around the challenge between fee for service incentivizing things versus value based care.

如果你能把这两方面都讲清楚，咱们就能说到点子上了。

I think maybe if you cover both those buckets, we wound up in the same, in an interesting spot.

是的。

Yeah.

不是。

No.

这两件事其实紧密相关，你提得特别好——真正驱动第一个问题的，其实是第二个：按服务付费的激励机制。

You you you they're they're super related, and it's a really good question and insight of of of yours that that it's the second issue, fee for service and incentives around it, that drives the first.

那些报道确实很好地揭示了一些真实存在的问题。

So the the the articles did a really nice job of highlighting some real challenges.

有些是赤裸裸的欺诈和滥用行为。

I mean, some are outright fraud and and true abuse.

比如明尼苏达州就出现过一些公司伪造服务记录，甚至付钱给家庭，让他们谎称自己接受了服务。

So and there there have been stories in Minnesota where where companies are fabricating actually the delivery of services, paying families to say that they were in receipt of services.

这明显就是诈骗。

That's obviously outright fraud.

印第安纳州的那个案例里，有一家公司发现，不管他们提供多少服务，报酬都是按固定比例算的，于是就把每小时的护理费用从原本合理的100美元，一路涨到300、600，甚至更高。

The Indiana story spoke about, you know, a company that realized that they were just getting paid a percent of their build rate no matter what that build rate was, and so went from, you know, a reasonable $100 an hour care for delivered to $300 to $600 and up and up and up.

这明显就是在滥用系统。

And that's clearly, like, just abusing a system.

我觉得这种情况只是极少数，真的很少。

I think that's the minority, truly the minority of cases.

大概就占2%左右。

Like, it's a 2% issue.

98%的问题是过度使用，这其实正是我一开始聊的话题。

The 98% issue is overutilization, which is kind of what I started this conversation with.

我们是从临床角度来处理的。

We approached it clinically.

作为医生，我们觉得不是每个孩子都需要大量ABA治疗。

We just didn't feel like, as physicians, every child needed lots and lots of ABA.

ABA应该作为整体治疗计划的一部分。

It should be part of an overall care plan.

应该根据每个孩子的具体需求来调整用量，同时综合考虑他们其他的治疗需求。

It should be dosed based on the needs of that child and compared to all their other needs.

也就是说，如果孩子本身有肠胃问题、代谢异常需要调理、需要吃线粒体补充剂，还有癫痫、睡眠方面的问题，那这些问题都得先处理好，再配合用量合理的ABA康复项目。

Like, if the major issues around GI health and metabolic workup and mitochondrial supplements and their seizure issues, sleep issues, like, that needs to be attended, taken care of in the context of an ABA program that's that's dosed appropriately.

我们当时完全是从临床角度考虑这个问题的，但这么做在经济层面带来的结果就是，大家其实根本不需要那么多ABA服务。

So we were thinking about it purely clinically, but the consequence of that on the economic side is then you you need a lot less ABA.

但现在ABA的开支之所以被推得这么高，就是因为它被毫无节制、不分情况地滥用了。

And so what has happened to drive up spend is it's been kind of rampantly overutilized and indiscriminately.

我承认确实有一部分孩子是需要这么高强度的ABA服务的，但还有很多孩子根本不需要。

I think there are children who certainly need that level, but there are many children who don't.

这才是那篇期刊论文里提到的问题的根本原因——论文里说过去三年里，大部分州的相关开销翻了四倍，短短三年涨400%，任何一个州的财政都扛不住。

And that's been kind of the root cause of of the of of the problem in in the journal's article that's talking about a four x increase in spend for most states over the past three years, and that's, you know, 400% in three years is very difficult for any state budget to sustain.

再来说你的第二个问题，这两件事其实是完全挂钩的：如果这套系统按服务收费的模式来给机构激励，也就是你只有开出多少时长的账单才能拿到对应报酬，那 provider 作为服务商，自然会想尽可能多开时长。

To your second question, it ties to that perfectly in that if the system incentivizes via fee for service structure, that is, you only get paid for every hour you bill, then of course, as a provider, you are incentivized to bill the most number of hours.

但如果医保计划或者州政府的应对方式是砍预算，说原本给x的报销，现在只给x的80%，那反而会把事态推向更糟的方向。服务商为了维持运营，就只能多开25%的时长来补这个缺口。

And if the response of health plans or states to that is to cut the rate and say, hey, we're paying x and now should pay, you know, 80% of x, it drives the behavior in the wrong direction, which is the provider saying, hey, for me to be sustainable, I now have to bill, you know, 25% more than I So, was before in

这就完全是

it's just

这就成了恶性循环。

like downward spiral.

还会导致人才流失的恶性循环。

It also leads to a downward spiral in talent.

如果你每小时的报酬少了20%，那根本请不到有经验的临床专家——他们要么要价高，要么已经在这一行干了好几年。

If you're getting paid 80% less per hour, it's like, well, I can't hire the experienced clinicians who demand a higher salary or committed to the field for years.

我只能雇些刚入行、半吊子的人，他们可能干个半年一年就走了，但愿意拿远低于市场价的工资。

I gotta hire the dabbler who is new to the field and may only last six months or a year, but they're taking this on at at at a sub market wage.

这种恶性循环太糟糕了，直接导致家庭的孩子得不到应有的治疗效果。

That that downward spiral is awful because it it leads to real, like, negative clinical consequences for for families.

要解决这个问题，唯一办法就是改掉激励机制——得奖励真正的价值，奖励全面的、整体的价值。

The only way to fix this is to change the incentive structure, which is you you have to reward value and you have to reward holistic value.

不只是ABA能解决的行为问题才算数。

That is not just behavioral outcomes that would be treated with ABA.

得奖励家长真正关心的所有结果：睡眠、进食，还有带幼儿的家长常提到的那些问题。

You've gotta reward all the outcomes that parents would care about, which is sleep and feeding and all the things that parents come forward with with a young child.

随着孩子长大，应该奖励他们顺利入学、在校期间的支持，以及一生中进入大学、接受合适的职业培训、找到对口工作、实现独立生活——这些才真正重要。而现在的体系却恰恰相反，只在孩子小的时候大力鼓励ABA干预，等孩子进入青春期和成年后，支持就戛然而止了。

And then as that child ages, reward getting them into school successfully, supporting them while they're in school, and over a lifetime, getting them into college, getting them appropriate vocational training with the right job, getting them into independent living, all those things matter as opposed to the current system, which heavily incentivizes lots of ABA at a young age and then fades away support as the as the child ages into into adolescence and into adulthood.

其实这个问题很好解决，只要搞清楚家庭、自闭症儿童和成年患者真正需要什么，然后奖励这些需求，整个服务生态自然会跟着调整。

So it it's very fixable because you just have to know, which very easy to know, what what do families and and children and adults with autism need and reward those things and then allow the provider ecosystem to respond to those incentives.

这不该变成对医疗领域私募股权的控诉，因为那太容易了。

This should not be a tirade against private equity in healthcare because that's an easy thing to do.

真正的问题是，私募股权带来了大量资金。

It's actually more about private equity has driven a lot of capital.

它们也提升了服务的可及性，这对整个行业其实是好事。

It's driven a lot of access, which has been good for the field actually.

更多中心、更多资源，我觉得也吸引了更多治疗师加入这个行业。

More centers, more availability, I think it's gotten more therapists into the field.

出问题的不是资金，是激励机制本身。

What's broken is the incentive system.

只要把激励机制改对了，这些资本自然会流向真正有意义的结果上。

And if you fix the incentive system, that capital be attracted to the right kinds of of outcomes.