Speaker 1: In the United States, poor people tend to die younger.
Speaker 1: The wealthiest one percent of Americans live more than a
Speaker 1: decade longer than the poorest one percent, and that gap
Speaker 1: has grown wider in recent years. There isn't just one
Speaker 1: reason why this is the case. Where a person lives,
Speaker 1: how much money they make, and how socially connected they
Speaker 1: are all affect their well being. There's an argument in
Speaker 1: the medical world that people would live longer if healthcare
Speaker 1: providers could address patients social needs like food, housing, and transportation.
Speaker 1: Welcome to Prognosis, Bloomberg's podcast about the future of health care.
Speaker 1: I'm your host Michelle fe Cortes. Some healthcare companies are
Speaker 1: trying to create new ways of caring for people with
Speaker 1: complex social and medical needs. They're betting that improving care
Speaker 1: for these patients will cut costs in the long run
Speaker 1: by avoiding unnecessary hospital stays. They're also grappling with systemic
Speaker 1: problems like inadequate housing, low wages, and even discrimination. On
Speaker 1: this episode of Prognosis, bloom Brick News health reporter John
Speaker 1: Tozzi takes us to Brooklyn, where a new company is
Speaker 1: trying to overhaul the way medical care is delivered. Toyan,
Speaker 1: a g E, was a young medical resident when she
Speaker 1: saw up close how the health care system fails people.
Speaker 1: She was training to be a family doctor in Boston,
Speaker 1: working in a community clinic and a safety net hospital.
Speaker 1: A lot of her patients were poor and they had
Speaker 1: serious needs that doctors and hospitals weren't helping them with.
Speaker 1: Toyan told me about it in a recent interview at
Speaker 1: her office in Brooklyn. The people that I really was
Speaker 1: passionate about caring for those are patients whom um, many
Speaker 1: of my colleagues found kind of overwhelming or challenging or
Speaker 1: more difficult to take care of. Those are people who
Speaker 1: often had you know, ten or fifteen medications on their
Speaker 1: medication list. They had physical illnesses, some had disabilities. Many
Speaker 1: patients also had mental health problems or we're struggling with
Speaker 1: substance abuse. They frequently wound up in the hospital and
Speaker 1: their medical care cost a lot of money, but it
Speaker 1: wasn't really helping them get better. What I observed was
Speaker 1: that the healthcare system tended not to dig deep enough
Speaker 1: to ask why, and that when you sat at the
Speaker 1: bedside of someone like this and really started to ask why, um, like,
Speaker 1: what's actually happening for you and what matters for you. UM,
Speaker 1: the picture of their experience emerged that showed me just
Speaker 1: how we were failing to address their needs. Toyan says,
Speaker 1: the health care system just isn't built for the reality
Speaker 1: of people's lives. Think about a single mom who's holding
Speaker 1: down a job but struggling to make ends meet. I
Speaker 1: think about what our healthcare system would ask her to
Speaker 1: do in order to access really high quality health care.
Speaker 1: We would ask her to take some time off work.
Speaker 1: If a is an hourly wage worker, that's like cash
Speaker 1: out of her pocket. Um. We'd ask her to pay
Speaker 1: for transportation. We'd ask her to find child care. We'd
Speaker 1: ask her to come to us to wait in a
Speaker 1: waiting room. UM, sometimes a really long time. After all that,
Speaker 1: she gets just a few minutes with a doctor. She
Speaker 1: may get a prescription or advice to change her diet
Speaker 1: or exercise more. But even feeling a prescription can be difficult.
Speaker 1: Copas are high and significant, and the burden of getting
Speaker 1: to the pharmacy and getting your meds is not an
Speaker 1: insignificant thing for a lot of people in this country. UM,
Speaker 1: and lifestyle modifications is so dependent on you know, do
Speaker 1: you have a safe place to go take a walk
Speaker 1: around your block? Can you even do that? Um? Can
Speaker 1: you afford to buy organic, healthy, nutritious food or is
Speaker 1: the you know, the four dollar burger meal from Wendy's
Speaker 1: the best you can afford to do? And how in
Speaker 1: the world can I think about my nutrition when I
Speaker 1: don't have the resources to begin to even meet my
Speaker 1: daily needs Toalian began to think about what it would
Speaker 1: look like to deliver healthcare that accommodates the complex reality
Speaker 1: of people's lives. There was sort of a fundamental overhaul
Speaker 1: in the way that we think about ourselves as healthcare
Speaker 1: providers relative to the patients that we're trying to serve.
Speaker 1: That needed to occur in order for us to ever
Speaker 1: have the hope of expecting better outcomes for them. Tony
Speaker 1: and co founded a startup in to do that. It's
Speaker 1: based in Brooklyn, New York, and it's called City Bloch Health.
Speaker 1: The company aims to combine primary care, mental health care,
Speaker 1: and assistance with a lot of the other non medical
Speaker 1: things that can affect people's health. It matters if you're housed,
Speaker 1: It matters if you have a warm place to sleep
Speaker 1: at night. It matters if you have enough food to eat.
Speaker 1: It matters if you have electricity to stay warm in
Speaker 1: the winter and cool in the summer. This is an
Speaker 1: idea that people in healthcare are talking about more and more.
Speaker 1: Many aspects of people's lives outside the clinic and the
Speaker 1: hospital have big consequences for their health. And there's an
Speaker 1: argument that society could reduce what we spend on medical
Speaker 1: care by spending more on social services. But that's a
Speaker 1: contested notion. Here's Ashish Ja, a physician and Harvard Public
Speaker 1: health professor. All of the evidence says that spending on
Speaker 1: social services, if targeted well, can really have a profound
Speaker 1: impact on people's lives in very positive ways. But it's
Speaker 1: not going to pay for itself. It's not going to
Speaker 1: save you enough money in the health care system to
Speaker 1: justify doing it. You should do it because it's the
Speaker 1: right thing to do. The same goes for increasing access
Speaker 1: to primary care. Primary care and preventive services are good
Speaker 1: things to do to improve people's health, but the reason
Speaker 1: to do them is for the health reasons. Uh. The
Speaker 1: reasons to do them is not because it will somehow
Speaker 1: again magically pay for itself with all the savings you'll
Speaker 1: get down the road. There's almost no evidence that it
Speaker 1: ever does. A recent study in the New England Journal
Speaker 1: of Medicine showed some of the challenges. Researchers looked at
Speaker 1: a high profile experiment in Camden, New Jersey. A randomly
Speaker 1: selected group of patients who were frequently hospitalized got assistance
Speaker 1: and home visits from nurses, social workers, and community health workers.
Speaker 1: The goal was to prevent them from being hospitalized again,
Speaker 1: but after six months, the patients who got this extra
Speaker 1: help were just as likely to wind up in the
Speaker 1: hospital again as similar patients who didn't get the intervention.
Speaker 1: But Tollan argues that improving care and social support can
Speaker 1: reduce costs in the long run, at least for the
Speaker 1: patients who cost the most and who the existing system
Speaker 1: often fails. Those are the people. City Box is focused
Speaker 1: on patients with complex medical and social needs. They often
Speaker 1: don't get help with the things they really need, even
Speaker 1: though they cost the health care system a lot of
Speaker 1: money through frequent hospital trips and emergency visits. A core
Speaker 1: piece of City Box approach is also caring for people's
Speaker 1: mental health and addressing substance use. These problems are staggeringly
Speaker 1: common but the medical system often doesn't treat them well,
Speaker 1: so trauma, anxiety, and depression being the main ones UM
Speaker 1: that make physical health worse. It's really hard to motivate
Speaker 1: to take your medications for your diabetes, your blood pressure
Speaker 1: when you are feeling so low you can't get out
Speaker 1: of bed. City Blok is trying to stitch all these
Speaker 1: things together, physical health, mental health, and social assistance in
Speaker 1: a seamless way. The company is focused on people who
Speaker 1: are on public insurrence programs including Medicaid and Medicare. Those
Speaker 1: cover people who are lower income, elderly, or disabled, and
Speaker 1: City Bok takes on the most expensive patients. They're struggling
Speaker 1: with multiple chronic physical health needs UM, they have mobility
Speaker 1: needs or disabilities, people with serious mental illness and or
Speaker 1: substance use, and many of them have deep social needs.
Speaker 1: On top of that, the people are struggling with housing
Speaker 1: and security, or food and security, or UM social isolation
Speaker 1: challenges with transportation UM all of those things um coalesced
Speaker 1: to increase the likelihood of poor outcomes for populations with
Speaker 1: complex needs. The company uses technology to or stand those challenges.
Speaker 1: They built a custom electronic medical record system that tracks
Speaker 1: members social needs as well as their physical and mental health,
Speaker 1: and it allows clinicians and other workers to communicate smoothly
Speaker 1: to keep members from falling through the cracks. We have
Speaker 1: visibility across all of those things and then have tools
Speaker 1: with which to help deliver better care on the social
Speaker 1: side as well as on the physical health side. We
Speaker 1: should disclose at this point that one of city Box
Speaker 1: investors is Sidewalk Labs. That's a subsidiary of Alphabet, the
Speaker 1: parent company of Google, and it's run by Dan Dotorff.
Speaker 1: Doctor Off was CEO of Bloomberg News parents Bloomberg LP
Speaker 1: until he's on the board of City Block. But let's
Speaker 1: get back to toy In. A handful of healthcare organizations
Speaker 1: across the country have built reputations for improving healthcare for
Speaker 1: the type of complex patients that City Block works with.
Speaker 1: Toyan worked at one of them, a nonprofit health plan
Speaker 1: in Massachusetts called the Commonwealth Care Alliance. The inspiration for
Speaker 1: me and for the rest of our founding team was
Speaker 1: really about the opportunity to take clinical models that we
Speaker 1: had seen and tested um and bring them to scale
Speaker 1: to populations that wouldn't otherwise have access to these types
Speaker 1: of interventions. City Block is betting that it can deliver
Speaker 1: better care to people who the medical system often fails.
Speaker 1: But it's more than that. Toyan believes that doing so
Speaker 1: will also reduce overall spending on medical care. Fundamentally, for us,
Speaker 1: our business is about proving that there is a sustainable
Speaker 1: business case for improved care and for an improved experience
Speaker 1: of care for communities who very frequently have not received
Speaker 1: those things. And so it matters a lot um that
Speaker 1: we are not just adding services to the system UM
Speaker 1: with the promise of um them being sort of globally
Speaker 1: felt to be beneficial, but that we're actually held to
Speaker 1: real world economics. This is definitely not a charity. The
Speaker 1: company has raised more than eight million inventor capital. City
Speaker 1: Block agrees to take care of some of the sickest
Speaker 1: and most vulnerable patients. It has contracts with inferrors like
Speaker 1: Emblem Health in New York and Blue Cross blue Field
Speaker 1: of North Carolina, and City Block makes money if it
Speaker 1: can reduce the costs for the expensive complex patients it
Speaker 1: takes on by keeping them out of the hospital. Let's
Speaker 1: invest the vast amount of money that we spend in
Speaker 1: healthcare today. Let's invest some of it on things that
Speaker 1: we know are going to move the needle for people
Speaker 1: that really matter, and let's do so with an intent
Speaker 1: to reduce waste um and to reduce suffering, and to
Speaker 1: improve time spent at home with people's families and their communities.
Speaker 1: There's no question that a lot of people get poor
Speaker 1: medical care in the United States and that difficult social
Speaker 1: circumstances make their health outcomes worse. The question is whether
Speaker 1: fixing those problems can also bring down medical costs. Many
Speaker 1: of these services we we as a system haven't yet
Speaker 1: figured out how to quantify the value of You know, how,
Speaker 1: how how valuable is it in dollars? Is it a
Speaker 1: five dollar thing or a ten dollar thing or a
Speaker 1: twenty dollar thing to help support somebody who UM was
Speaker 1: going to get evicted, UM to go to housing court
Speaker 1: and fill out paperwork and keep their home. It's not
Speaker 1: that City Blox thinks there should be a price tag
Speaker 1: on these things. We don't have a rule book. We
Speaker 1: don't have a pricing book for these types of services yet,
Speaker 1: nor do I think we should in a fee for
Speaker 1: service way, because these are actually interventions that have longitudinal value.
Speaker 1: That means city block hopes to improve members health over
Speaker 1: the long term. Even if helping someone keep their home
Speaker 1: doesn't affect their health this week, it might mean they're
Speaker 1: healthier a year from now than if they had been evicted.
Speaker 1: If the company's approach makes patients healthier over time, it
Speaker 1: will lower costs, and City Block will get to keep
Speaker 1: some of the savings. Today, City Block is caring for
Speaker 1: thousands of people in New York, Connecticut, and North Carolina,
Speaker 1: and it's expanding to Massachusetts soon. I visited a couple
Speaker 1: of the company's clin Actually, CityWalk doesn't call them clinics.
Speaker 1: It calls them health hubs because they're intended to be
Speaker 1: more than just a medical office. At a new space
Speaker 1: in a strip mall in Greensboro, North Carolina, there are
Speaker 1: paintings from local artists. Inspirational slogans are printed on the walls.
Speaker 1: Ron Carter, the hub manager, showed me around one day.
Speaker 1: This one here on the wall says what matters to
Speaker 1: you manage to us, and we really believe in that,
Speaker 1: and obviously we want to remembers to feel that. There
Speaker 1: are exam rooms and meeting rooms for counseling. There are
Speaker 1: also respite spaces where members can make private phone calls
Speaker 1: or just sit quietly if they want. Eventually, the staff
Speaker 1: plans to host events like nutrition classes or yoga. The
Speaker 1: idea is to be a little more like a community center.
Speaker 1: Laura Mused, the site's manager for community partnerships, told me
Speaker 1: that was already happening in Greensboro. The members we have,
Speaker 1: we see every every week. Some come in and just
Speaker 1: have a glass of water and say hello. We've gone
Speaker 1: to that level. Since I've visit City Block in November
Speaker 1: in North Carolina, the situation has changed. The company paused
Speaker 1: most of its operations there in mid January. City Block
Speaker 1: has a contract with the state's Blue Cross Blue Field
Speaker 1: plant to take care of Medicaid patients, but an unrelated
Speaker 1: state budget standoff delayed funding for the new North Carolina
Speaker 1: Medicaid program. The company said it hopes to resume when
Speaker 1: the budget impass is resolved. City Block has a doctor's
Speaker 1: like toy In and nurse practitioners and labs. But what
Speaker 1: makes it different from most medical practices is people like Quacy,
Speaker 1: who works for City Block in Brooklyn. When my name
Speaker 1: is quasy Um Quis Peterson m ah Um community health partner,
Speaker 1: every patient that City Box takes care of is assigned
Speaker 1: to a community health partner like Quacy. She has about
Speaker 1: forty patients on her roster, and she might visit six
Speaker 1: or seven of them in any given day, or they
Speaker 1: come here, or I've met people in the community of
Speaker 1: med members at the shelters, UM I I go where
Speaker 1: they act. Quacy worked closely with City Box medical staff,
Speaker 1: but she isn't a condition. She's there to help patients
Speaker 1: with all the other stuff that can affect their health,
Speaker 1: like transportation. I have UM picked them up from the appointments.
Speaker 1: I accompanied them to the appointments. One day, she was
Speaker 1: making a house calm when her client took a long
Speaker 1: time to answer the door. He usually comes to the
Speaker 1: door very quickly, and this one time a president of president,
Speaker 1: but he doesn't come quickly and do I'm like, okay.
Speaker 1: He did come and he can barely walk. He's a
Speaker 1: diabetic and he fell. The man had injured his knee
Speaker 1: a few days earlier, but he hadn't gotten any treatment.
Speaker 1: So Quasi called toy in. She said, okay, bring him.
Speaker 1: Don't let him go to the e R. He's gonna
Speaker 1: wait there too long. Toyan examined him at the connect.
Speaker 1: So she came here. I brought him here in my car,
Speaker 1: you know, and um, she took him in right away,
Speaker 1: did the xt ray, she gave them crutches, the ice
Speaker 1: BacT all these sort of things. He left her with
Speaker 1: a little bag. It's impossible to say what might have
Speaker 1: happened if Quacy hadn't visited the man and discovered that
Speaker 1: he was hurt. Even minor injuries can become serious for
Speaker 1: people with diabetes because their wounds are slow to heal.
Speaker 1: An infected wound could even lead to an amputation. Clinicians
Speaker 1: often see situations where a serious illness could have been
Speaker 1: avoided if they had reached the patient earlier. So my
Speaker 1: name is Joanna Humanis Mahiah, and I'm an e respectitioner.
Speaker 1: Joanna worked in hospitals and home care before coming to
Speaker 1: City Bark. I felt that it was with some patients,
Speaker 1: very very challenging to keep them out of the hospital,
Speaker 1: And in my opinion, it was because we were coming
Speaker 1: to these patients when they were already very sick, and
Speaker 1: they were already acute, and we were we were just
Speaker 1: a little too late for what they actually needed. City
Speaker 1: Box is trying to build a system that reaches patients
Speaker 1: before it's too late, when there's still an opportunity to
Speaker 1: keep them healthy and out of a hospital or nursing home.
Speaker 1: It relies on people like Quacy. It also relies on
Speaker 1: communications software to keep pack of patients needs and coordinate
Speaker 1: their care. If members give permission, City Box care teams
Speaker 1: will get real time alerts when somebody goes to the
Speaker 1: emergency room. The alert pops up in the chat software
Speaker 1: Slack that all the City Box staff use. Here's Quazy.
Speaker 1: So then I would meet them at the hospital if
Speaker 1: they happen to go into the emergency room and they admitted,
Speaker 1: and um, even if they're not ante, I'll go to
Speaker 1: the era. Finally, what's going to And you should see
Speaker 1: the face they'd be so surprised. Quazy shows up at
Speaker 1: her patients houses and at the hospital, but she also
Speaker 1: shows up to support them in ways that healthcare workers
Speaker 1: don't normally do. Even going to court, I have members
Speaker 1: I go to housing court for I have members that
Speaker 1: I tell them what's the process, what's because I have
Speaker 1: been the tenant going to court for not paying right
Speaker 1: because I also lost my job. This is an important
Speaker 1: piece of City Box model. The people working as community
Speaker 1: health partners are from the places they serve. Quzy understands
Speaker 1: the challenges that her client's face because she's faced them herself.
Speaker 1: My position got phased out at Brooklyn Hospital when my
Speaker 1: son was born, so I had no job, new baby,
Speaker 1: rent to pay, and you have savings. But when you
Speaker 1: have a newborn, you're looking for a job that's saving
Speaker 1: and you're paying rent, and you're paying this and it
Speaker 1: depletes quickly. That kind of experience helps Crazy relate to
Speaker 1: members who don't always trust doctors or medical institutions. I
Speaker 1: have people who don't trust. I'm dealing with the distrust
Speaker 1: of the medical field. So with me, now UM for
Speaker 1: me to build a trust like I will meet them
Speaker 1: where they're at and talk normal. I'm not trying to
Speaker 1: talk any nine letter words. You know. I would tell
Speaker 1: them to like I would if you understand, I have
Speaker 1: to get to their level and they will see that
Speaker 1: I'm not be asking them. Toyan says building trust with
Speaker 1: patients is essential to improving care over the long term,
Speaker 1: and it's one of the ways the medical system has failed.
Speaker 1: You think about what, um, what it feels like for
Speaker 1: somebody to walk into a hospital or a clinic. Um,
Speaker 1: it's an unfamiliar space. UM. You are kind of at
Speaker 1: their mercy. UM. You're in a thin paper gown. You
Speaker 1: sit where you're told to sit. UM. And the person
Speaker 1: comes in and they've got a white coat on it,
Speaker 1: and they've got all these letters on their name, and
Speaker 1: they are you know, they're typing a computer. You can't
Speaker 1: see the screen. You don't know what they're saying about you.
Speaker 1: There's so many ways in which we reinforce this notion
Speaker 1: of power UM. That is UM that is so antithetical
Speaker 1: to trust building. The problem is particularly acute for people
Speaker 1: who have historically been marginalized by the medical system or
Speaker 1: society more broadly. You know, when I talked to my
Speaker 1: my African American patients, I not and frequently will people
Speaker 1: say to me like, I'm scared to go to the the
Speaker 1: hospital because I don't feel like they treat people like
Speaker 1: us well. And none of us can in today's day
Speaker 1: and age, with all the reporting around this faint shock
Speaker 1: about that, we can't say, oh, no, it's just you're
Speaker 1: making that up. It's true, it's true. They feel it
Speaker 1: because they know it to be true. And the way
Speaker 1: we pay for healthcare only makes this gap and trust wider.
Speaker 1: Doctors are reimbursed for the volume of care they deliver,
Speaker 1: and the cost of that care is often hidden from patients.
Speaker 1: It creates incentives to do things to people, um, even
Speaker 1: when they may not actually deliver value to them. And
Speaker 1: and and we're we're basically not at all transparent around prices.
Speaker 1: The pressure on doctors to see more patients in less
Speaker 1: time has further eroded trust with patients. The worst thing
Speaker 1: that we've done is we've created such pressure on our
Speaker 1: clinicians in particular that we have um made it almost
Speaker 1: impossible for them to just be humans and be human
Speaker 1: with their patients in ways that for a long time,
Speaker 1: I think it's surmounted all the other barriers, right Like,
Speaker 1: if I can just sit with you, look in your eyes,
Speaker 1: you know, put my hand on your hand, and tell
Speaker 1: you that I'm like, I'm here because I want to
Speaker 1: do best by you, That I will tell you the
Speaker 1: truth as best as I know it, that I will
Speaker 1: do my very best to help you live your best life.
Speaker 1: If I could, if I had ten minutes to just
Speaker 1: do that with you, perhaps all the other stuff wouldn't matter.
Speaker 1: But we've stripped even that away. UM, so that now
Speaker 1: our clinicians don't even have the ten minutes to do that.
Speaker 1: City Box is up against some of the biggest challenges
Speaker 1: that face our health care system and our society. It
Speaker 1: treats the most expensive, complex patients. It's trying to re
Speaker 1: engineer a health care system that often doesn't work well
Speaker 1: for them. And if it does all that, toy and
Speaker 1: believes that City Bok can save the system money while
Speaker 1: improving the lives of the people it's so often fails.
Speaker 1: And that's it for this week's prognosis. Thanks for listening, yeh.
Speaker 1: Do you have a story about healthcare in the US
Speaker 1: or around the world We want to hear from you.
Speaker 1: Find us on Twitter at Fay Cortes or at Jaytaws.
Speaker 1: If you're a fan of this episode, please take a
Speaker 1: minute to rate and review us. It really helps new
Speaker 1: listeners find the show and don't forget to subscribe. This
Speaker 1: episode was produced by Toe for Foreheads. Our story editor
Speaker 1: was Rick Shine. Special thanks to Healthcare team leader Drew Armstrong.
Speaker 1: Francesca Levie is head of Bloomberg Podcasts and We'll be
Speaker 1: back next week with the new episode. See you then.