Making Care Actually Work

Our next guest is in the healthcare Sector she's a Mainstay at deck wrench Been on a bunch of our stuff from found To TC live Etc and we're really excited To have her because her unicorn company Has completely rethought the way to Bring Health Care to the communities That need it most so please welcome to The stage City Block co-founder and CEO Toyan ajayi and your moderator Daryl Etherington [Music] All right hello hello welcome welcome Thank you yeah so you joined us before During the virtual of this wrap indeed So this is your first time at the in Person everyone's beautiful smiling Faces it's so nice Um so one thing Jordan mentioned there Is you know unicorn company I think many Times over now right I don't know the Valuation last time I saw I think it was 5.7 billion whereabouts in 2021 so you Know capture that all in yeah and you've Raised nearly a billion dollars now Right that's right and amazing amazing Success story for a health tech company But um how How did you do that I don't this is a Probably a long answer but like how did You Honestly figure out like you could Provide the kind of services that City Block provides in a way that is uh

Economically feasible and that payers And insurers will accept yeah I think The the On what the business is and all and also What the opportunity is um so we are a Primary care Behavioral Health and Social care company focused on Low-income marginalized populations Predominant people who receive their Insurance through Medicaid or people who Get Medicaid and Medicare so they have Disabilities as well as being low income Or these are folks who are fail seniors Typically you know living at home in in Marginalized settings and the reality is That our typical Healthcare System just Doesn't do a really good job of caring For these folks right it's transactional It doesn't engender trust it doesn't Really Foster longitudinal care and Access to care and when for so many People as it does the sort of The Chronic compounding impact of lack of Access to education to food to warm safe Places to sleep to social supports add To all of the risk factors for worsening Chronic conditions physical health and Behavioral Health all of this sort of Washes up on the shores of the emergency Room right so people go to the emergency Room because they ran out of their Insulin inhalers rather they're asthma Inhalers or their insulin medication People go to the emergency room because

They're wandering the streets in Psychiatric crisis because they didn't Receive the care that they needed to Keep them safe and in their homes and It's always crisis it's always crisis And it's expensive and it doesn't Actually solve the problem it's like Sort of the definition of wasteful and So when we looked at our model and Looked at the the segment of the Population we really wanted to impact we Know that there are hundreds of billions Of dollars a year of taxpayer money Spent caring for low-income folks and For people seniors and people with Disabilities we know that most of those Funds actually pay for reactive care That is not changing the circumstances Of the people's lives does not address The root cause and we know that Health Insurers have a really really vested Interest in managing that spend over Time and so when you put together sort Of the the market forces a recognition That there's a failure frankly in the Delivery system and there's a care model That can find people meet them in their Homes in the community provide proactive Preventative care across physical Behavioral and social needs close gaps And prevent people from having to go to The hospital in the first place it's it Was like imminently obvious we could Monetize that right and create a scale

Business that actually does things Differently and solves a real problem For every single one of us it impacts Everybody in some way shape or form but Like so when you're talking about Um insurers you're often talking about People who are very sort of like those Legacy businesses right A lot of them Are massive and inertia accounts for a Lot yeah and also like While so they're obligated in many cases To help a lot of these folks who you are Addressing through Medicare and Medicaid Right but do they Was there a conversation ever or Convincing that was required to happen When like they're just like well why why Don't we just let a lot of these people Die or like why it seems so heartless And cruel but I mean the medical system Is nothing if not heartless it does Break your heart over and over again That's for sure and I think that's why Um it's so important to both you know I Come to this work I'm a physician I'm Deeply passionate about caring for Underserved communities I come to this Work from a place of real heart Um this is sort of this is my life's Work right and my mission Um and I'm also a deep pragmatist and I Recognize that there are real economic Forces that drive most of the decisions That people make in our health care

System certainly in the for-profit space But also you know as we we learn more About even in the sort of not-for-profit Space it's it's entirely p l driven and So part of what the the sort of magic I Think of city block is that we have an Opportunity to align what's right for Humans what I believe is moral and good What addresses systemic issue issues Like Health disparities the type of work That I personally would be proud to to Make my life's work with a business Imperative and for these payers there's A there's a real business opportunity Here there's a there's a problem they Need to sell they need solved Irrespective of where your submission And passion is Um there are folks that they are Financially at risk for they hold the Insurance dollars for who they have the Opportunity to make that more viable Profitable for them by caring for them Differently and also The Regulators are Recognizing that we have to sort of like Everything in the free market it only Works if you're you have the right Balance of checks checks the sort of Right checks and balances around that Regulators are pushing payers to say We're not just asking you to hold a Financial Risk and do nothing right ask You to actually take care of these People so we're asking you to um to

Engage folks we're holding you Accountable for Quality measurement We're holding you accountable for Access Scores for patient satisfaction scores All of these things play into why a Partnership with City Block is such a Valuable and viable opportunity for them Above and beyond it just being the right Thing to do yeah so that shift too is Something I want to talk about like in The policy shift so it's changing to a Place where I know outcomes based care Is very popular right and I think that's Driven apart through regulatory pressure But before it was sort of like you have To foot the bill if these folks show up And they're in crisis but now it's Become you are responsible for outcomes Throughout right so how much do you play In that world in the policy world and Um how do you kind of build that into The business so that you can anticipate You know what's going to happen Depending on changes in administration Or anything else like that yeah I mean It's it's sort of a push-pull right so Um our business depends on these policy Tailwinds that shift towards value-based Care so getting paid for outcomes Um since we launched the company the the Proportion of contracts the payers right To provide writers that are in these Sort of value-based constructs that hold Them accountable for outcomes has

Doubled so now 40 percent of Medicaid Programs are really pushing towards Value-based care and that's happened Over the last five years in large Parties but spanning uh different Administrations right that's right That's right that's right different sort Of political beliefs this is something That plays I think across both sides of The aisle and that's in part because There are increasingly proof points that That alignment between Healthcare Providers and Healthcare payers around The best interests and the outcomes for A population is a good thing certainly Can't be any worse than our staff than Our status quo right Um and and so I think of our role in That dynamic as being one of those proof Points we help to further policy by Showing what works and being willing to Try new things when the federal Government comes out with demonstration Programs that allow us to better impact Our members we dive in we take advantage Of that we try to figure out how to make It work we give feedback and that's Really important on the other side Though of course there are things that Um that play in other directions and so Understanding kind of politically and From a policy perspective where the um The specific States in which we partner Um and in which we operate are going as

Well as the federal government's going Is an important part of our business and It's just frankly the price of doing Business in in a in a sort of public Sector type of space Um and it allows us to just make sure We're in lockstep with The Regulators Yeah and speaking of you know state by State because it does vary considerably You've just I think over the past year You launched in Indiana and Ohio yeah That's right okay Um and then So how hard is it for you to stand up a New market and do you because it seems Like you move with intention right and You're not like oh yeah five states at a Time or whatever you're taking it I Don't know how many totals we're in Seven markets now seven okay right Um so how do you approach that and how Much kind of like upfront work is Involved and then what's the steady State after that yeah it takes a ton of Upfront work um you've got to align a Lot of things we have to have the right Policy environment Um that supports the type of care that We provide Um there needs to be need right we go to Communities we try to you know really be Humble about the way that we enter into Markets we look to see places where There are socioeconomic disparities

Whether there are Health disparities Where there are access gaps where we Really think we can make a difference And then we look for partners payers Health insurers who we can launch into Markets with and that takes some time And and then pre-launch we spend the Time you know figuring out where exactly In the neighborhood should we be can we Be near you know the public Transportation near are grocery stores Making sure that we're really mapping The ecosystem and showing up in places That are accessible to our members and Also positioning ourselves so we can go To the home and see people from there And then we have to hire recruit teams And stand up all of our facilities so it Does take a while we're really Intentional about this this is a Business that that we're building to Last and that we're building to to Deliver on you know the promise of this Real longitudinal care we intend when we Enter markets to be there for decades so We're not chasing you know a contract And then you know cycling around we're Really looking to build a presence and Grow and so what you'll see is our Historic markets we grow them Significantly over time we launch with You know say we serve 10 000 members in A market then we scale that and scale That and scale that and add on as we as

We're able to really capitalize on the Benefits of our model and also the Density that we then start to create Within within specific communities yeah And I know you uh you talked about the Holistic model but you partner with a Lot of service providers in the Community right so what's the effect There do you see the ecosystems built up Around you when you enter new markets do You take on a lot of that work yourself I would love to see ecosystems built up Around us I really wish there would be Not yet I love them I love that I love That idea um not yet so what we're Tapping into is um is existing Community-based organizations that Provide really essential services to Communities that are often very subscale Very very local you know a food pantry a Couple of shelters over here an agency That helps people with housing or Transitions from the criminal justice System and we map together all these Different networks and then we just Drive volume into those community-based Providers and support them with Loop Closure and wrap around support so that We really become part of their ecosystem More than anything else we think of Ourselves as sort of the part of the Glue within an ecosystem that knits Together existing providers the Specialty providers the hospitals the

Community-based organizations and Creates this sort of seamless experience For our members for the people whom we Serve What's interesting is that they are in Many ways their business models are also Kind of tenuous and and vulnerable right And so we saw in covid as an example A Lot of these community-based Organizations just couldn't get either The workforce to continue to come to Work Um they're you know they're operating on Tiny margins they're Grant funded and so Sort of subjected to some of the Vagaries of the of the grant funding Cycles Um and so in many ways we have to also Be prepared to just step into the Gap Where there is nothing Um you know our teams packaged up food And brought groceries to people Um uh provided a bunch of those services And supports where there are gaps Because we're ultimately accountable for Making sure that our members get what They need irrespective of kind of what It takes to get there yeah right Especially like you said like if you're There for for good yeah right so if Something goes away yeah but when Doesn't that add a lot of like Variability and unpredictability to Model or can you kind of Build That Into

The Upfront cost because especially now Let's say we're going into a recession Probably right like I imagine that's Going to get worse in a lot of cases a Lot of those the funding is going to Disappear from any of these Organizations how do you build that into Kind of your long-term plan yeah I know It's a really good question I mean this Is um uh it's a it is a complex business No doubt um and you know part of the the Beauty of it is that we have capitation We have these these sort of resources Per member per month that we're Accountable for managing and we can Invest as we believe they need on a Population basis to make sure that we Close the gap for people and so as long As there's a return on investment Realize really through reducing Hospitalization improving quality Improving engagement we can make those Decisions Um at a relatively local level that Allows us to while the business is Scalable we're really very tailored to The local environment Um you talked about the recession though You know and um and just the economic Downturn and the impact that's having on People it's going to be really Interesting to see I think more than Anything this moment in time calls for Businesses like ours that are addressing

Folks would get left behind otherwise we Know that the need for social supports Is going to increase and has already Increased we've seen over the pandemic Through the public health emergency the Number of people on Medicaid increase And so all of that creates for us more Opportunity to prove our model to be of Value and to demonstrate that that a Different way of doing this allows us Actually societally to be resilient to Some of these kind of exogenous Challenges that we may face more broadly Yeah and so You you mentioned scale too right like How do you how do you bring Tech into it Because we talked a lot about already How high touch you are right and you'll Go to people and you're in the Communities so what is what efficiencies Is Tech providing and why is that an Essential part of the model yeah it's Key so so Tech plays a number of roles For our business the first is in data Um understanding what to do for whom Um in in sort of what dose even is is Really nuanced and really important it's A great application for data science Um and a really really useful Application for the technology tools That we've built in-house to direct our Team so I have a population of Individuals that includes some young Folks some older folks some folks with

Disabilities some folks with mental Health challenges I have to engage all Of them who do I go after first right Who do I call First who's gonna who's Gonna go to the emergency room tomorrow Unless they get a phone call from us Um who's not home today because they're Likely out working or who's likely to be Engagable on the weekend those are types Of things that we can use our data and Our data products to help us better Refine so we're able to get to our folks As quickly as possible Right modality Right time and earn their trust The next thing is then what do you do For them if a person has a multitude of Challenges like many of the folks we Care for what's the most important Unlock for them we know for folks who Are living on the streets or who are Marginally housed who are unhoused that Almost before you do anything else You've got to get them a safe place to Sleep right so there's no point saying I'm going to titrate your insulin I'm Going to write a new prescription for Acts or why I'm going to make a referral To Z if they literally have no place to Sleep that's more obvious you can sort Of build that in but there are nuances To all of the interventions that we Deploy spanning across community health Workers social workers Behavioral Health Primary care acute care and

Understanding the right dose right time Is another really important application Of our tooling and then it allows us to Really direct Workflow management tools because now You've got folks members our members People who we care for who are engaging In our Mental Health Services or Engaging in our Primary Care Services or Engaging in our you know at home Urgent care services make sure Everybody's on the same page we all know What the care plan is we know what's Going on for them we know what matters To them we know you know that they like To be called Mike and not Michael that Stuff really matters where do you house That information to allow and enable That trusted longitudinal relationship Across which we're deploying clinical Interventions and social interventions Yeah and that's the role of technology For us yeah when you talk about that Like it becomes apparent in retrospect How many things happen Wrong because there's most cares acute And most care is fracture right so it's Not coordinated at all yeah and it's so It's duplicative it's costly and it's Abrasive to people you know when we Interview our members about what they Dislike about the traditional Health Care System it's like I got to tell my Whole story over and over again right

And then you add on the layers of Discrimination and stigma that many People face you know more than half of Our members are people of color because That's the that's the representation of Medicaid and duly eligible populations Um I have a mental illness you know for Folks they go in there and they say well You know are they going to treat me Badly because they know I have bipolar Disorder and so telling your story over And over again seems benign but a Healthcare System makes people tell Their story over again actually subjects Them to friction abrasion sometimes even Trauma right yeah um that that is Entirely counterproductive to a Therapeutic relationship that's going to Result in Better Health outcomes right And so even Alleviating that is such a meaningful Lever for us and it's part of the way That we're able to really ground our Care Aaron in that trusted relationship And earn the trust of our members yeah So I have to ask them back to the Ecosystem question because you mentioned You know you would like that to happen And it seems like a population level Analytics would unlock so much for Potential Partners or You know services that address other Gaps that you see so how much do you Think about that what would you like to

See kind of prop up and are you open to Kind of data sharing anonymized or Whatever but population level oh my gosh It's like music to my ears I would love To see that I mean we are at a community Level struggling even on basic things Like you know our health information Exchanges right that those are supposed To be Publicly available at least accessible To Health Care Providers repositories of Who gets admitted to the hospital when For what diagnosis who gets discharged When For What and like the coverage of These things they're so variable from State to state Um the the sort of loopholes and and Challenges and gaps in those data it's Profound and so a solution that solved That would be critical but you can't get Around that without thinking about Interoperability and so we've got these You know massive hegemonic electronic Health records right whose entire Business is predicated on not sharing Data because their data is their wedge And their moat they have no incentive to Share and there's no obligation for them To do so so there's all this data locked Up in places that no one can access it And it's entirely to the detriment of All of us yeah consumers patients but Particularly people with complex needs Who are touching the healthcare system

So frequently yeah so but do you once You have your data trip like are you do You see it as a value of resource to be Defended or do in fact do investors Perhaps pressure you to do that right Because you can see how that would be Like well we put a lot of money in here And this is quite valuable and maybe we Want to turn that around it so I mean I Think that we're not we're not sort of In in the business of monetizing our Data at all and that's certainly not a Conversation we're having I think that The question for me is to whom to what End and can you do it safely and legally You know and there's a lot of like Appropriately real protections around People's data Um that um that I think are absolutely Right I think you can't do this on a One-off basis outside absent a big like Ecosystem infrastructure really strong Policy regulatory guidance to make sure It is safe and of course like opt-in Consent and opt out abilities for for Patients whose data it actually is so This is not one of those where where we Could be like we believe this and we're Just going to make it happen here's our Data right that's dangerous and and Would certainly get us into a lot of Trouble and certainly would undermine The trust that we're seeking to build With our members but if there was a real

Concerted and I think it has to be like At the federal level Um real policy efforts to make this Possible Um and and sort of you know an Obligation for all players to play Together Um I would welcome that and I think Again if done well I think consumers and Patients would really benefit from it Yeah yeah so I have to ask the Obligatory Canadian question which is uh Do I want to move to Canada not that I Mean It's a nice place but uh I think so Policy whenever I talk to people in the Healthcare industry right I ask about Like would you rather do more Fundamental policy change or whatever Like would you rather switch to a Socialized care model if you had your Way you could wave magic wander have Whatever or would you rather work with The way you are now with the for-profit And doing you know yeah I mean it's such A difficult Um we can answer the question it's Magical thinking magical thinking wave a Magic wand like do I believe that Healthcare is a right that should be Available to all people irrespective of Their ability to pay and then it should Be distributed equitably yes 100 Um I think there are a lot of like

Absolutely and there are a lot of ways Of achieving that our system is not set Up for that to be the default outcome Right so like would I pick this if I had A magic wand to design a Healthcare System a healthcare system that leaves People behind desperately every single Day a healthcare system that says that Someone like me who looks like me just By virtue of my race has a three to six Times more likely chance of dying in Pregnancy because of systemic factors Because of a like completely unchecked Racism in our system and our society and Our healthcare system because of stigma Because of lack of Equitable access to Services like absolutely not and Here we are and so like what do you do You know you sit at the sidelines you Complain you pick it you Demonstrate you create a trickle-down Model we do not do that that's a Throwback to last year if people want to Watch them don't do that but we we pick Ourselves up together and we say we're Building a movement meant that believes That it is still possible to do things Better and differently and it refuses to Accept the status quo just refuses to And for me that is that's what city Block is about but frankly that's what This movement that I think we've been Certainly a part of helping to stimulate Has been about is to say hey folks like

Stop this isn't working for a lot of People yeah they're not represented in This room but we have to bring their Voices into these conversations we have To build for them because it's Unacceptable it's unacceptable in 2022 That we're looking at exactly the same Data that we're looking at 15 years ago About Healthcare disparities Healthcare Outcomes all exacerbated by covet Everyone's like oh my God black and Brown people are dying more from covet Oh my God poor people are dying more From covet oh my God like essential Workers who don't have health insurance We knew this stuff give me a break Um so Yes yes I would I would very much have Designed it differently yeah and I'm Also not content to and moan about It right we got to do something no and You're yeah this is the this is the System you have right and make it work Better and you're speaking the language Of the system you have right dollars and Cents and it's working yeah Um yeah I think you're doing a great job And thanks very much for being here with Us and coming out to this room thank you For having me I always love talking with You yeah that's great it's great we're Actually buddies we are really good Thank you Don't do any

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