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Autism care can be disjointed and difficult to navigate for parents and children. Individuals with autism are often dealing with a number of comorbidities, including gastrointestinal and feeding issues. These factors can put a large burden on families.
However, some providers are taking a more integrated approach to care. For example, Boston-based Cortica is a tech-backed provider that offers traditional autism services, such as applied behavior analysis (ABA), as well as specialty services, including neurophysiology, genetics, gastroenterology and nutrition.
In this BHB+ TALKS conversation, senior editor Laura Lovett sits down with Dr. Neil Hattangadi, CEO of Cortica, to discuss integrated care, value-based payment models and technology’s role in the industry.
Lovett: Hello, and welcome, everyone. I’m Laura Lovett. I am the senior editor at Behavioral Health Business. Welcome to our BHB+ TALKS. Today, we are joined by Neil Hattangadi, who is the CEO of Cortica, which is an autism service company that I think a lot of folks have heard about. It’s really been making waves in the autism service industry.
I wanted to remind everyone that you can ask questions and this is a pretty informal format. We want to make sure that there’s engagement.
Neil, I would love to dig into some of these big questions I know folks have. Could you maybe just start off by sharing an example of how Cortica’s whole-child approach differs from that traditional model that we usually see?
Hattangadi: Yes, thanks, Laura. It’s a real pleasure to be with you. I appreciate all the folks on the call and love the idea that this can be informal. We’re really a village working together, and I would love to hear folks’ thoughts and questions so we can all move the field forward.
In terms of your question, it really gets at why we started Cortica. We started as a clinic almost 11 years ago in 2014. It was in response to what a number of us as academic physicians were seeing when parents were coming to us in the context of autism and neurodevelopment, which is that there really are a whole host of challenges that they would see. To give you an example, it’s not unusual for parents to come in and say, “Hey, for my four-year-old, my preschool teacher has noticed a challenge with behavior, communication and socialization.” Those are the core features of autism.
“We also have challenges getting them to sleep at night. They wake up multiple times and then the whole house is waking up, and so I’m not sleeping well and my other kids aren’t sleeping well. I’m concerned about his motor tone and his balance. I’m concerned that he may require an alternative augmentative communication device. I’m concerned about the way they respond to auditory sensations like loud noises or even the sensation of certain clothing.”
They may have a feeding challenge where they’re very selective in the things that they eat. It’s a very restrictive diet and then also leads to gastrointestinal pain and constipation. That sort of constellation of symptoms is really not unusual in our patient population. In fact, 90%-plus of children with autism have multiple co-occurring conditions alongside the core features of autism.
When we started Cortica, it was really in response to academic physicians wanting to be able to help solve all these problems at once. In contrast to the conventional model it is really think through all of those problems that a parent is presenting with and be able to solve them all as opposed to requiring the parents to go out and work with many different providers on their own. It’s taken many years to develop a way of working so that this interdisciplinary care team can really take care of, really, all those issues that I listed.
Lovett: It’s so interesting. As we’ve heard so much more about integrated care, it just makes sense to have a lot of these services in one place for folks, because it can be really hard, I think, for parents to try to go and find all the resources. I think it’s really interesting. Digging into that, what is that value of the whole person approach specifically to the neurodivergent child and their family?
Hattangadi: It’s really important for parents to be able to focus on being parents, as opposed to what we ask them to do in the conventional health care system, including the physician world that I’m a part of. In that traditional world, you’re asking the parents to quarterback and coordinate across all these different providers. You’re asking parents to also become an expert so that they hear from their psychiatrist about medications they should be on. They hear from the sleep specialist around other medications they should be on. The geneticist tells them that these are areas of concern. Then they’re trying to translate that to their ABA provider and their OT provider and their school system.
That burden, alongside being a great parent to your neurodivergent child and the other children you may have, that’s a lot. We’re trying to unburden the family of that. Then for the child themselves to know that they’ve got a care team that’s thinking about all the challenges they’re facing, that’s really the value proposition we’re solving for. I know much of the field today, including in ABA programs, are really thinking about how to — because we’ve acquired ABA companies, we partner with ABA companies who do exclusively ABA — they’re also thinking about how to collaborate across a broader health care and school ecosystem so that they can really start to help families in a bigger way.
Lovett: I know another part of what Cortica does is integrating this all through technology. How does technology play into that care model, both when you’re looking at assessments, when you’re looking at treatment? How do you think about that?
Hattangadi: There’s technology that we use in terms of the tech that we adopt off the shelf from software, and then we’ve built a lot on our own. It’s required custom technology because there is no single electronic medical record that lets you do ABA care, which has its own set of demands. You’ve got BTs in the field. They’re typically not choosing their own CPT code. There’s a lot of rigor around data collection and making sure that parents are signing off on the time, the location.
You have the other end of the spectrum, physicians who are ordering labs, they’re looking at MRI or EEG results, they’re sending in prescriptions. Then you’ve got speech and OT and counselors who have their own programs, some of which need to be confidential from parents based on their own notes that they’re putting together. There’s no single EMR. We’ve worked with two off the shelf, customized them to the maximum extent possible, and then built on top of that a whole scaffolding that’s taken years of development.
It’s probably the single largest investment we’ve made over the history of Cortica in the area of technology. It allows us to capture clinical data across all these different domains, and then share them with clinicians, and also start to think about clinical insights that can be drawn from one clinician and passed on to others so that the care model is really benefiting from all these different data points.
There’s also an operational component of the technology we do, which is like the scheduling here is very complex. You’ve got about 12 to 15 different types of therapies, including things like feeding therapy, counseling for parents, counseling for the child, ABA parent training, sibling therapy, along with the core stuff I talked about. How do you make all of that work in a way that matches against clinician schedules and patient and parent schedules? There’s a lot of tech that we’ve built on the operational side as well.
Lovett: We do have a question. I think we answered part of the question, but the question is, does your differentiated approach require a different tech stack from typical ABA practice management? Maybe this part we could talk a little bit about, but also in clinical tool platforms used by most ABA providers. I know we can touch on the clinical tool platform piece of that.
Hattangadi: It’s a good question. Yes, we do require everything that an ABA company would have in terms of both operational, clinical, billing, and then a separate one for non-ABA, which is medical developmental therapies, counseling, and other services. Then in order to make the data from both systems available to all clinicians, we’ve built a tech stack around it. It has been challenging. This was an undertaking.
I think when I led this off by why we started the company, it was really around a clinical need that we saw, and our clinical founder, Suzanne Goh, is a pediatric neurologist and BCBA, really saw this as a need. I think we under-appreciate the complexity of a few things, including the tech stack that would be required. It’s quite an undertaking to build it. Now that it’s built, I think it’s much easier for us to operationalize.
Lovett: What are some of the benefits you’re seeing now as part of the tech, and what challenges did arise during the implementation process?
Hattangadi: The benefits are really showing clinicians the 360 view of the patients that they’re working with. We acquired a provider in the Northeast, we’re really proud of, called Springtide. Like many ABA companies, the BCBAs were very thoughtful about, “Oh, this client I’m working with is on some psychiatric medications. I’m noticing these adverse effects. Let me try and get the psychiatrist on the phone.” Or, “I’m noticing the child has GI pain, or they’re really sleepy in the afternoon. Let me try and get the PCP on the phone.”
It’s hard. There’s no payment for that coordination, neither on the ABA side or the physician side. A benefit we’re seeing is that clinicians get to really practice the kind of care that they want to practice. Parents get a solution that looks at their needs holistically. We’ve been really rigorous around collecting outcomes data because most of our — at each of our centers, we have a physician. Most of those folks have come from academic settings. We’re all used to publications and the research rigor that comes from where we were before.
We’ve been really diligent around collecting outcomes. We’ve seen that holistic outcomes get better faster than conventional care in this integrated setting. They span metrics of communication, behavior and daily living skills. They also span things like sleep disorders getting better, seizure disorders, GI symptoms, are we able to reduce medications, and a number of metrics around HEDIS that really track medication management, hospital admissions. We’ve really tried to track those things to show that it’s worth it to do this extra level of care and the technology that’s required.
Lovett: What innovations are you looking forward to in the next, say, three to five years that could really be a game changer for kids with autism?
Hattangadi: Thanks for asking that. My background prior to Cortica was really around clinical research and innovation. Something that I was really passionate about starting was just a pet project on the side, but it’s become really a part of what we do is called the Cortica Innovation Network, which is a way to study innovation that’s happening in the field. This is in the research context. I might break it into a few different buckets. There’s devices versus therapeutics or drugs. There’s more on the diagnostic side versus the therapeutic side.
Just to give you a sense of a few things that I’m really excited about that we have studied in trials. One is a device-based therapeutic for virtual reality called Floreo. It is commercially available. They have been really rigorous around structuring randomized studies that are informed by the FDA that will pursue a formal autism therapeutic indication. The really cool thing about that is that the founder, Vijay Ravindran, developed the technology working with his son with autism. He’s a former early Amazon engineer and found that his son was really responsive to VR, picked up the headset, and it was a great way for him to engage with the world.
What we found in our clinical studies is it’s an amazing adjunctive tool alongside other therapies to help kids progress and engage in lessons they wouldn’t have otherwise. That’s a really cool technology — among many. I’m happy to talk about more, but it sounded like you were about to ask something, Laura, so I didn’t want to cut you off.
Lovett: No. If you have more, go for it. One other topic in that, something everyone’s talking about, is AI and machine learning. Do you see that as playing into it? What’s the role there?
Hattangadi: Yes, absolutely. AI and machine learning are incredibly impactful in a couple ways. I think it’s one around data capture and then a second around data analysis. That’s even apart from all the operational ways it can help an ABA company or an autism services provider. Clinically, one aspect is around data capture, that a lot of the data that we’re gathering in autism is manual, especially in ABA, the BT gathered data. If AI can be used to gather that more systematically, that’s fantastic. I think there’s a fair bit of validation that needs to happen in order for that to really be reliable.
A couple examples of companies that have done this really well in terms of validated publications that are in journals, Floreo around collecting that VR data, using it to enhance the learning and progression of kids. Then a company called EarliTec that’s based on 20 years of science from two really fantastic PhDs previously at Yale, now at Emory, the Marcus Autism Center, Ami Klin and Warren Jones, two papers in JAMA last year that showed that if you track where a child looks in response to stimuli on a video, you can learn a lot about their autism features, you can diagnose, you can phenotype them. There’s a big role for AI around helping to really understand what that data means.
There’s another component around data analysis where we’re sitting on so much data now, especially if you think about what Frontera is doing on capturing data via video, VR data, eye tracking data. Then we at Cortica had our physicians sit on tons of data for a long time. It’s everything from genetic information, metabolic data with mitochondrial function, we run EEGs where needed, microbiome data from stool samples.
All this stuff is really hard for a clinician to say, “Hey, based on all of this, what is the best therapy for a child at any given moment that will maximize their progression?” It’s beyond what clinicians or humans can really comprehend and process. The opportunity to use AI to come up with phenotypes and predictive trajectories and treatment selection, I think that’s the kind of thing that a few years out is going to be really powerful.
Lovett: I’ve heard a lot of complaints about how it can be really hard to break down data silos. Can you see a little bit more of that patient picture because of this integrated approach? Maybe being able to see this child’s feeding therapy progression and whatever GI meds they’re on, whatever ABA services they’re getting. Does that help at all being able to see that fuller picture? What do you think about looking at that data?
Hattangadi: Yes, absolutely. It helps tremendously. I think it helped in Cortica’s development. I’m not an autism physician expert. That’s our clinical co-founder, Suzanne, who’s a neurologist in BCBA, as I mentioned. My background came from cardiology, where you just take for granted that you have the full 360 perspective. The patient comes in with chest pain. It’s very clear that you’re running certain blood biomarkers. You’re running an imaging study. Based on that, you decide a pathway. Is it drugs alone? Is it an interventional catheter-based technology? Are you actually doing surgery? You know you’re successful because there are images or EKGs that tell you you’re doing well.
That world of all the data being together, quantitative biomarkers of progression, that’s the world that we’re aspiring to. It helps a ton. You gave great examples, like the ABA team to know what meds the child is on and being able to relay back to the physician, “Oh, you just onboarded this med last week. It’s helping or it’s not.” From the physician’s standpoint, you’re otherwise really relying on parents to give you their recollection of history. Parents aren’t always the best historians because they have selective recall around things.
If you onboard a new medication or you’re adjusting dose up or down, to have to rely exclusively on parents as opposed to this other clinical team that’s also giving you data that you can observe yourself, it helps a lot to have all that in one accessible place.
Lovett: Yes, that makes a lot of sense. We do have another question from the audience. The question is, BHB recently highlighted an article that talked about payers backtracking a bit on value-based care due to Medicaid funding cutbacks. You mentioned that you’re tracking outcomes. Assume these are whole-person based, are you continuing to get traction with payers on agreeing or at least considering specific metrics for value-based care?
Hattangadi: Thanks for the question. Yes, the funding challenges make all of health care tricky, autism in particular, because the prevalence has been rising due to awareness and other reasons. The recognition that therapy is needed, ABA especially, it just created a large trend problem for both commercial plans and Medicaid. The opportunity value for value-based care is really how do you drive savings while also delivering clinical quality.
The question’s a really good one. We track holistic outcomes, so it thinks beyond behavior alone. We really try to tie that to the spending that the system would be seeing in the conventional paradigm. A good example of that is in the Medicaid population, it is not unusual for parents to feel overwhelmed, particularly for complex phenotypes. You imagine self-injurious behavior, injuring others, nonverbal, potentially like seizures or GI issues. It is not unusual for a parent to feel overwhelmed. The result of that is seeking an ED admission, which then would lead to either an inpatient or residential stay. That happens a lot.
It’s not the best setting at all for the child. It’s not great for the family. There’s some terrible high-profile cases of kids who are nonverbal with seizures. Seizure goes unrecognized in the ED, and a child has died because EDs are the worst place to manage this kind of phenotype. Working with health plans and realizing the spend that is happening, that’s like one example of it. Sometimes the case of just lots of utilization of lots of things for long periods of time. If you can reduce that, then that’s ways to get that cost curve to come down while still delivering good care.
The challenge is payers are often strapped for time to really dig into this. These services we’re talking about span multiple silos. Payers are siloed between behavioral, medical, developmental. They often have different leadership structures for Medicaid versus commercial. The state is involved in Medicaid. You have a state versus managed care plan dynamic. How do you get all these people to come together?
A lot of it is driven at this point by necessity because the spend is really, really high. I think that the outcomes are certainly getting better, but they’re not as good as they could be when you look at other areas of medicine. I think there’s a greater sense of collective urgency that something has to happen, but it is a challenge to get all these stakeholders together to really implement value-based care.
Lovett: Maybe sticking with the value-based care conversation, could you talk to me a little bit about how Cortica has implemented value-based care models? How unique is this in autism? I feel like I don’t hear about it too much. We hear about it more in behavioral health as a whole than maybe substance use disorder or mental health. If you could talk me through that, that would be great.
Hattangadi: We really started on this initiative three years ago or so because our model necessitates it. I think if you are an exclusive ABA provider, there is a fee-for-service paradigm that works. You provide a service, there’s CPT code-based reimbursement for it, there’s a playbook that’s evolved. In our model where all these services are coming together and there’s lots of collaboration, we use a lot less ABA, we use other things as well, and we’re tracking things like HEDIS scores and inpatient admissions and all these other things.
The model just works better in a value-based care environment. Out of necessity and out of a vision for what the future of the field could look like, we embarked on this a few years ago. Our approach has always been that it’s a whole child program construction, that you need these different pieces coming together in order to create value-based relationships. The components of value span a few different areas. One is around these outcomes that I’m talking about. One is around cost savings, primarily coming from these areas of unwanted spend.
I don’t think anyone would argue that having kids sit in inpatient environments or residential environments is a wanted place to spend money. It’s trying to divert dollars from there, divert dollars from over-utilization in certain therapeutic areas. Then there’s an access component, particularly on the medical side. It’s really a shame that most physicians who specialize in autism are either cash pay or they sit at academic centers that are really long wait times.
We’re in the Boston area. Boston Children’s and Mass General Hospital tend to have 12 to 18-month waits. We entered North Carolina and heard something similar from Duke and UNC. Committing to rapid access, particularly for that kind of 360 evaluation from a physician specialist, that’s another component of how we put these contracts together.
Lovett: Actually, recently at BHB’s VALUE, we were talking a little bit about this idea of prevention as a part of value-based care. You talked a lot about boarding and emergency departments and things like that. How do you think about prevention as a part of that too?
Hattangadi: Yes, it’s a great point. It is interesting. Stepping back when you think about VBC and where it started in a primary care setting, absolutely, prevention is critical. Can you be on top of a patient’s diabetes management? Can you be on top of their kidney issues? Can you be on top of cardiovascular issues that would lead to an ED admission or orthopedic injury? There’s a lot of preventative opportunities in a primary care environment that drive value.
In our space, prevention of autism isn’t possible. I think we’re going to learn much more about the biology of the condition in the coming years, but that’s not the goal. You said this well, Laura, it’s more about, can you prevent the severe progression that would then result in an expensive utilization? Can you prevent years and years and years of utilization at excessive levels? Can you prevent unnecessary medications that are sometimes onboarded at too high a dose for too long a time that can then, particularly with antipsychotics, lead to negative consequences? Those are the things we’re trying to prevent. You’re exactly right that in VBC, that’s the hook to be able to really transform the field.
Lovett: As more autism providers are maybe looking to get into this field, what has your journey been like, and what kind of challenges have you encountered as you’re starting to apply value-based care framework to this field?
Hattangadi: Probably the biggest challenge is the siloing of the payer partners that even if they are in one company — Regional Blues, I think are easier in that, particularly if they haven’t outsourced the BH component. It is housed together. They typically cover a single state or a few states, and they’re not as big compared to a national insurer. Those Regional Blues tend to have a real mandate around whole person health and wanting to integrate, but it still requires some challenges.
I think for the national ones, we have a few of them as our investors. It’s challenging because you’ve got a behavioral health versus medical divide. The behavioral may be national. The medical tends to be local, so either state or regions. You’re having to put together sometimes, in the case of a single company, eight different agreements in order to make it all work. That is a challenge.
For folks who are looking to get into it, we’re more and more getting engaged with partnerships with ABA companies that want to deliver our kind of model. I hope in the coming years, we can do more where we’re partnering with other ABA companies and helping their patients get access to holistic care while continuing to benefit from the great ABA that they’re providing. It’s hard. Getting into whole child value-based care is difficult, but the value proposition, both for the plan and for the patients, ultimately, is really profound.
Lovett: Is there any other part of either behavioral health or even just physical health, I know you come from that world, that maybe has a good roadmap for value-based care that you’ve been able to pull from?
Hattangadi: Yes, there are areas in physical health where you look at multiple specialties needing to come together for the best care for a patient. Oncology is an area that I studied quite a bit, as well as primary care or senior care. Maybe those are two examples I’d give. In oncology, we don’t expect patients to navigate their own journey between the meds they should be on, the imaging studies they should run, the surgery versus radiation.
When you go into an oncology center, that is mapped for you. Then you should have a team that comes in and descends and does the right thing. There is an opportunity to really think about value-based care there that’s less dependent on the individual modalities used, but more are you able to demonstrate mortality improvement or the various quantitative biomarkers that show cancer treatments improving. In primary care, it’s similar. You can be responsible for this group of patients by managing the totality of their conditions, preventing ED admissions or hospital admissions.
Then you’re able to really show that your primary care is working as opposed to counting the individual visits and the phone calls and all of that. Those are the markers we’ve used. It’s been less about ABA value-based care. I think that’s hard to do. I think ABA value-based care is hard to do in the sense that if you don’t control what the psychiatrist is doing or what the GI specialist or others are doing, it’s hard to really manage that population super well. You make a good point, Laura, in that it’s been like other adjacencies that we’ve tried to pull from.
Lovett: It’s interesting. We hear so much about– there’s a lot of advocacy in the autism space. I wonder if some of that is because of the necessity of parents having to figure out the system in some ways too.
Hattangadi: Absolutely, yes. There’s no more motivated group of advocates than parents of kids with autism. It’s wonderful in the sense that I think it’s that movement over the past 25 years that’s led to coverage in all 50 states and the recognition that ABA is important and effective. That’s all great. It’s, on the other hand, sad that that needs to continue because, exactly to your point, I think it’s come out of necessity. I hope that necessity will start to wane that level of advocacy. It’s been helpful to bring up the care access and the care quality over the past couple of decades.
Lovett: Changing gears a little bit. Something I want to talk about is neurodiversity-affirming care a little bit because I know it’s something you’ve worked with quite a bit, but can you explain what it truly means to have a neurodiversity-affirming care model and what it looks like in practice? However, it differs a little bit from traditional approaches in therapy. What are we looking at? How widely accepted is this? Where are we at as an industry?
Hattangadi: It’s a great question. Neurodiversity-affirming care has really come out of your prior point that advocates, especially individuals with autism and neurodivergent individuals, have been advocating for the right type of care that they would have wanted through their experience. Neurodiversity-affirming care is really about recognizing each client that we’re working with has gifts to bring to the world. We don’t want to change their personality traits. We just want to help with skills, symptoms that are getting in the way of their joy. We’re not trying to change who they are fundamentally.
Examples of this are assent-based care. We don’t want to engage in a type of therapy if we know the child doesn’t want to participate. Forcing them against their will, something that was done historically, we know that that’s trauma-inducing, especially if done vigorously. Another example is, and these are a couple of examples on what conventionally would be viewed as good therapeutic practice or historically, which is like asking a child to make eye contact.
If a child doesn’t want to, then making that a goal and persisting that that is the only way for a child to progress when it’s inducing stress isn’t appropriate, or forcing a child to communicate only through speaking means, if that isn’t the child’s preferred way of communicating. We’ve got alternative augmentative communication devices. Really, seeing the child as a sentient being that they know what they want. There’s real goodness there. That’s the fundamental aspect of neurodiversity-affirming care. I think it really has taken hold over the past three to five years. We hear this a lot in the ABA community.
What’s really important here is the balance because the early models of ABA as it was being developed were discrete trials, very effective, and that can be preserved. I think the fundamental aspect of neurodiversity-affirming care is that you can preserve what’s effective while also being compassionate and recognizing the underlying personality that we want to preserve in the child. Also, help broader society be a part of acceptance of neurodivergence. One of the cool things about the past several years in the inclusion movement is in the workplace, understanding neurodiversity accommodations for it and actively trying to put together a workforce that’s neurodivergent because they bring so many gifts into the workplace.
The ultimate vision is, the therapy for the child through childhood is neurodiversity affirming. Then the society they graduate into, school, college, vocation, is a neurodiversity-accepting society because we’re all on this continuum. At the same time, this is a tricky field because there’s also parents, especially those of severe autism phenotypes, that don’t want to downplay the challenges that they deal with. We have a lot of those complex phenotypes.
If a child is self-injurious, they need skills to be able to live independently and achieve what we all agree is important. We don’t want to downplay what needs to happen as part of the neurodiversity movement. This is all things politically fraught, but with common sense, it all is certainly manageable from a clinical standpoint.
Lovett: Actually, to one of your points talking about different stages of life, how do you think about that in treating patients over the course of maybe childhood and then looking at– I know a lot of services are more in the pediatric space, but how do you think about that kind of continuum?
Hattangadi: Yes, it really is a continuum, as you said. The needs for care can change over time. There’s some models that, exclusively early intervention, start at age two to three, by six, you’re out. Our model, because it’s a medical home, starts as young as discharge from the neonatal ICU. That’s not for autism, but it’s for pediatric neurologic conditions or sometimes genetic syndromes, cerebral palsy.
We can see kids very young, and then we see them really through adulthood because sometimes it is challenging when kids age 18 to 21-plus, who do you refer them to if they have ongoing needs? Core to our model was being able to see that full age range. The needs change over time. Just as an example, that early intervention model is a very solid one. You want to get kids diagnosed as quickly as possible, age two or so, have them in programs where by age five, six, they could be mainstreamed into school. Then as they go through school, there may be needs that arise over time.
Sometimes the field says graduation is the end-all, be-all. Assuming that if you reassess the healthcare system, there’s been a mistake somewhere, either by those providers or the parents or the school system has failed them. The reality is kids and parents need support throughout the journey. It could be that in elementary and middle school, we’re working on socialization. There may be ongoing motor or sensory needs, so we do some OT, some OTPT, maybe some speech on communication, maybe a bit of ongoing like parent training.
Sometimes into adolescence, there may be a regression, there may be medical issues that arise, there may be co-occurring psychiatric conditions, rental health conditions, ADHD is really common, but also anxiety, depression. Making sure there’s a place for kids to plug into through that. You’re exactly right that the needs change over a lifetime and it’s important for the healthcare system to flex on the types of services, the amounts over time with the ultimate goal of like, we’re trying to avoid the big spends, which is years and years and years of lots of ABA. It’s appropriate for each stage of a child’s journey and then be able to graduate them, but know that there’s always a home ready to receive them as needed.
Lovett: That’s really interesting, just being able to have that support when you need to go back to it. I wanted to also look at the future a little bit, but what gives you the most hope about the future of autism care, and what do you think will be the biggest positive change in the field over the next decade?
Hattangadi: Yes, thanks. I’m really encouraged by the basic science research and applied research that’s happening in autism, particularly around understanding the biology of the condition. Big initiative over the past 20 years from the Simons Foundation to really understand genetic markers that hasn’t panned out too many findings of key implicated genes. It’s a very complex condition, but what the broader research environment is helping us understand is what are all the different pathways that are implicated, and are there ways for us to think about therapeutics that get at some root cause issues, as opposed to the meds being used now, which are largely like psychiatric meds.
The biggest drugs that are used in autism for severe autism are, and I should correct, not just severe. It’s behaviors that are challenging. The meds used are antipsychotics, which are developed for schizophrenia. High use of stimulants around ADHD. Can we find multiple types of therapeutics that really go after the root cause issues in this population? One example that I’m really excited about is there’s a fair bit that’s been understood around the microbiome and the role of microbiome dysregulation in autism.
Some great work out of Caltech shows that in mouse models, if you introduce a dysregulated microbiome, you can create autistic-like features. If you then sequester the kinds of metabolites that are produced in that dysregulated microbiome, you can turn the autistic features off. Some great early human data. That’s an example of a very safe way that’s not drugs. It’s really like re-engineering a microbiome to be more normal. If that has an implication for behavior, what a great way to help a subset of children with autism without having to use potent drugs. Great research is happening there.
I think there’s also a lot of exciting things around AIs. We were saying like so much data coming at us, the use of AI to better understand phenotypes. I think right now, we are treating a very, very heterogeneous condition somewhat homogeneously, but to be able to really phenotype, like we do in cancer, a personalization of each child’s autism and what is the optimal therapeutic pathway for them. Those are the things I’m excited about over the next 10 years from a tech perspective. I think from a broader perspective, we hit on a couple of these themes. I think that the payer recognition that this is a condition worth spending time on and thinking about holistically.
There are a handful of conditions you really have to think about from a whole-person perspective. I think it’s just the only way to treat it. This is one of them. I think a collective call to action from the payer community to integrate services, bring together their own silos, make the member journey easier, bring down costs, I think that’s really exciting. I also think that real attention to the workforce, the clinical workforce in this area. It’s historically been, particularly in ABA, a young workforce. There’s been too much turnover.
I think the collective effort between companies, between providers, the clinical providers themselves, the payer community to really focus on how do we create a great clinical experience so that this can be a lasting career. There are other fields in medicine where the average 10 years is a year amongst your clinician who’s delivering most of the care, like the BT population. We want to make these sustainable careers that are multi-multi-year, which means investing in development, making it a really viable economic value proposition. I think that’s really exciting, too, to build a workforce that’s committed to the field for decades, like we have in other areas of medicine.
Lovett: That makes so much sense because a lot of these patients will be with providers for a little while to have that relationship.
Hattangadi: Totally, yes.
Lovett: Great. Thank you so much for coming on. I am so excited about a lot of the research you were talking about. I’m going to go look myself now at some of that and just have a great time talking about value-based care. It was great to have those questions from the audience. Thank you so much to all of our audience members for engaging.
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