WEBVTT - Fixing Health Care for the People It Often Fails 0:00:04.720 --> 0:00:08.039 In the United States, poor people tend to die younger. 0:00:08.960 --> 0:00:11.840 The wealthiest one percent of Americans live more than a 0:00:12.000 --> 0:00:15.800 decade longer than the poorest one percent, and that gap 0:00:15.840 --> 0:00:19.759 has grown wider in recent years. There isn't just one 0:00:19.840 --> 0:00:23.080 reason why this is the case. Where a person lives, 0:00:23.120 --> 0:00:25.960 how much money they make, and how socially connected they 0:00:26.000 --> 0:00:30.040 are all affect their well being. There's an argument in 0:00:30.040 --> 0:00:32.760 the medical world that people would live longer if healthcare 0:00:32.840 --> 0:00:37.720 providers could address patients social needs like food, housing, and transportation. 0:00:39.000 --> 0:00:42.800 Welcome to Prognosis, Bloomberg's podcast about the future of health care. 0:00:43.360 --> 0:00:48.040 I'm your host Michelle fe Cortes. Some healthcare companies are 0:00:48.080 --> 0:00:50.519 trying to create new ways of caring for people with 0:00:50.640 --> 0:00:55.200 complex social and medical needs. They're betting that improving care 0:00:55.240 --> 0:00:57.800 for these patients will cut costs in the long run 0:00:58.280 --> 0:01:03.040 by avoiding unnecessary hospital stays. They're also grappling with systemic 0:01:03.120 --> 0:01:08.480 problems like inadequate housing, low wages, and even discrimination. On 0:01:08.520 --> 0:01:11.760 this episode of Prognosis, bloom Brick News health reporter John 0:01:11.800 --> 0:01:14.560 Tozzi takes us to Brooklyn, where a new company is 0:01:14.600 --> 0:01:22.600 trying to overhaul the way medical care is delivered. Toyan, 0:01:22.680 --> 0:01:25.560 a g E, was a young medical resident when she 0:01:25.600 --> 0:01:28.839 saw up close how the health care system fails people. 0:01:29.840 --> 0:01:32.120 She was training to be a family doctor in Boston, 0:01:32.400 --> 0:01:35.120 working in a community clinic and a safety net hospital. 0:01:36.040 --> 0:01:38.399 A lot of her patients were poor and they had 0:01:38.480 --> 0:01:42.080 serious needs that doctors and hospitals weren't helping them with. 0:01:43.040 --> 0:01:45.520 Toyan told me about it in a recent interview at 0:01:45.560 --> 0:01:50.720 her office in Brooklyn. The people that I really was 0:01:50.720 --> 0:01:55.560 passionate about caring for those are patients whom um, many 0:01:55.600 --> 0:01:59.320 of my colleagues found kind of overwhelming or challenging or 0:01:59.320 --> 0:02:02.000 more difficult to take care of. Those are people who 0:02:02.280 --> 0:02:05.600 often had you know, ten or fifteen medications on their 0:02:05.600 --> 0:02:11.160 medication list. They had physical illnesses, some had disabilities. Many 0:02:11.200 --> 0:02:14.520 patients also had mental health problems or we're struggling with 0:02:14.600 --> 0:02:18.680 substance abuse. They frequently wound up in the hospital and 0:02:18.720 --> 0:02:21.720 their medical care cost a lot of money, but it 0:02:21.800 --> 0:02:24.239 wasn't really helping them get better. What I observed was 0:02:24.280 --> 0:02:27.359 that the healthcare system tended not to dig deep enough 0:02:27.440 --> 0:02:30.120 to ask why, and that when you sat at the 0:02:30.160 --> 0:02:34.120 bedside of someone like this and really started to ask why, um, like, 0:02:34.160 --> 0:02:37.160 what's actually happening for you and what matters for you. UM, 0:02:37.200 --> 0:02:40.600 the picture of their experience emerged that showed me just 0:02:40.639 --> 0:02:43.680 how we were failing to address their needs. Toyan says, 0:02:43.760 --> 0:02:46.840 the health care system just isn't built for the reality 0:02:46.919 --> 0:02:50.160 of people's lives. Think about a single mom who's holding 0:02:50.160 --> 0:02:52.560 down a job but struggling to make ends meet. I 0:02:52.639 --> 0:02:55.000 think about what our healthcare system would ask her to 0:02:55.080 --> 0:02:57.440 do in order to access really high quality health care. 0:02:57.440 --> 0:02:59.360 We would ask her to take some time off work. 0:02:59.720 --> 0:03:01.800 If a is an hourly wage worker, that's like cash 0:03:01.800 --> 0:03:03.800 out of her pocket. Um. We'd ask her to pay 0:03:03.840 --> 0:03:06.160 for transportation. We'd ask her to find child care. We'd 0:03:06.200 --> 0:03:08.200 ask her to come to us to wait in a 0:03:08.240 --> 0:03:12.320 waiting room. UM, sometimes a really long time. After all that, 0:03:12.480 --> 0:03:15.360 she gets just a few minutes with a doctor. She 0:03:15.440 --> 0:03:18.000 may get a prescription or advice to change her diet 0:03:18.200 --> 0:03:21.919 or exercise more. But even feeling a prescription can be difficult. 0:03:22.360 --> 0:03:25.520 Copas are high and significant, and the burden of getting 0:03:25.560 --> 0:03:27.240 to the pharmacy and getting your meds is not an 0:03:27.240 --> 0:03:30.519 insignificant thing for a lot of people in this country. UM, 0:03:30.520 --> 0:03:33.360 and lifestyle modifications is so dependent on you know, do 0:03:33.400 --> 0:03:35.600 you have a safe place to go take a walk 0:03:35.760 --> 0:03:38.120 around your block? Can you even do that? Um? Can 0:03:38.160 --> 0:03:41.280 you afford to buy organic, healthy, nutritious food or is 0:03:41.360 --> 0:03:44.560 the you know, the four dollar burger meal from Wendy's 0:03:44.600 --> 0:03:46.560 the best you can afford to do? And how in 0:03:46.600 --> 0:03:48.440 the world can I think about my nutrition when I 0:03:48.440 --> 0:03:50.840 don't have the resources to begin to even meet my 0:03:50.880 --> 0:03:53.840 daily needs Toalian began to think about what it would 0:03:53.840 --> 0:03:57.560 look like to deliver healthcare that accommodates the complex reality 0:03:57.640 --> 0:04:00.440 of people's lives. There was sort of a fundamental overhaul 0:04:00.440 --> 0:04:02.840 in the way that we think about ourselves as healthcare 0:04:02.840 --> 0:04:05.080 providers relative to the patients that we're trying to serve. 0:04:05.080 --> 0:04:07.800 That needed to occur in order for us to ever 0:04:08.000 --> 0:04:11.040 have the hope of expecting better outcomes for them. Tony 0:04:11.120 --> 0:04:14.720 and co founded a startup in to do that. It's 0:04:14.760 --> 0:04:17.599 based in Brooklyn, New York, and it's called City Bloch Health. 0:04:18.400 --> 0:04:21.839 The company aims to combine primary care, mental health care, 0:04:21.960 --> 0:04:24.400 and assistance with a lot of the other non medical 0:04:24.480 --> 0:04:27.600 things that can affect people's health. It matters if you're housed, 0:04:27.640 --> 0:04:30.159 It matters if you have a warm place to sleep 0:04:30.200 --> 0:04:32.240 at night. It matters if you have enough food to eat. 0:04:32.480 --> 0:04:34.680 It matters if you have electricity to stay warm in 0:04:34.720 --> 0:04:37.440 the winter and cool in the summer. This is an 0:04:37.480 --> 0:04:40.440 idea that people in healthcare are talking about more and more. 0:04:41.160 --> 0:04:43.960 Many aspects of people's lives outside the clinic and the 0:04:44.000 --> 0:04:47.600 hospital have big consequences for their health. And there's an 0:04:47.680 --> 0:04:50.440 argument that society could reduce what we spend on medical 0:04:50.480 --> 0:04:54.560 care by spending more on social services. But that's a 0:04:54.600 --> 0:04:58.599 contested notion. Here's Ashish Ja, a physician and Harvard Public 0:04:58.640 --> 0:05:02.720 health professor. All of the evidence says that spending on 0:05:02.720 --> 0:05:06.600 social services, if targeted well, can really have a profound 0:05:06.600 --> 0:05:09.800 impact on people's lives in very positive ways. But it's 0:05:09.839 --> 0:05:11.360 not going to pay for itself. It's not going to 0:05:11.440 --> 0:05:14.560 save you enough money in the health care system to 0:05:14.720 --> 0:05:16.760 justify doing it. You should do it because it's the 0:05:16.839 --> 0:05:19.600 right thing to do. The same goes for increasing access 0:05:19.640 --> 0:05:24.200 to primary care. Primary care and preventive services are good 0:05:24.240 --> 0:05:27.599 things to do to improve people's health, but the reason 0:05:27.640 --> 0:05:30.240 to do them is for the health reasons. Uh. The 0:05:30.320 --> 0:05:33.320 reasons to do them is not because it will somehow 0:05:33.360 --> 0:05:36.680 again magically pay for itself with all the savings you'll 0:05:36.720 --> 0:05:38.719 get down the road. There's almost no evidence that it 0:05:38.760 --> 0:05:42.520 ever does. A recent study in the New England Journal 0:05:42.520 --> 0:05:46.560 of Medicine showed some of the challenges. Researchers looked at 0:05:46.560 --> 0:05:50.839 a high profile experiment in Camden, New Jersey. A randomly 0:05:50.839 --> 0:05:54.760 selected group of patients who were frequently hospitalized got assistance 0:05:54.839 --> 0:05:58.880 and home visits from nurses, social workers, and community health workers. 0:05:59.680 --> 0:06:02.599 The goal was to prevent them from being hospitalized again, 0:06:03.440 --> 0:06:06.240 but after six months, the patients who got this extra 0:06:06.279 --> 0:06:08.279 help were just as likely to wind up in the 0:06:08.320 --> 0:06:11.800 hospital again as similar patients who didn't get the intervention. 0:06:14.600 --> 0:06:18.440 But Tollan argues that improving care and social support can 0:06:18.560 --> 0:06:21.359 reduce costs in the long run, at least for the 0:06:21.400 --> 0:06:24.679 patients who cost the most and who the existing system 0:06:24.800 --> 0:06:28.760 often fails. Those are the people. City Box is focused 0:06:28.760 --> 0:06:33.640 on patients with complex medical and social needs. They often 0:06:33.640 --> 0:06:36.640 don't get help with the things they really need, even 0:06:36.640 --> 0:06:38.800 though they cost the health care system a lot of 0:06:38.839 --> 0:06:43.080 money through frequent hospital trips and emergency visits. A core 0:06:43.160 --> 0:06:46.239 piece of City Box approach is also caring for people's 0:06:46.279 --> 0:06:51.120 mental health and addressing substance use. These problems are staggeringly 0:06:51.240 --> 0:06:54.200 common but the medical system often doesn't treat them well, 0:06:54.640 --> 0:06:58.680 so trauma, anxiety, and depression being the main ones UM 0:06:58.720 --> 0:07:02.880 that make physical health worse. It's really hard to motivate 0:07:02.880 --> 0:07:05.320 to take your medications for your diabetes, your blood pressure 0:07:05.360 --> 0:07:07.240 when you are feeling so low you can't get out 0:07:07.240 --> 0:07:10.520 of bed. City Blok is trying to stitch all these 0:07:10.560 --> 0:07:14.920 things together, physical health, mental health, and social assistance in 0:07:14.920 --> 0:07:19.040 a seamless way. The company is focused on people who 0:07:19.040 --> 0:07:23.840 are on public insurrence programs including Medicaid and Medicare. Those 0:07:23.880 --> 0:07:27.680 cover people who are lower income, elderly, or disabled, and 0:07:27.720 --> 0:07:31.360 City Bok takes on the most expensive patients. They're struggling 0:07:31.400 --> 0:07:34.920 with multiple chronic physical health needs UM, they have mobility 0:07:35.000 --> 0:07:39.240 needs or disabilities, people with serious mental illness and or 0:07:39.360 --> 0:07:42.680 substance use, and many of them have deep social needs. 0:07:42.760 --> 0:07:45.200 On top of that, the people are struggling with housing 0:07:45.200 --> 0:07:48.880 and security, or food and security, or UM social isolation 0:07:49.280 --> 0:07:53.360 challenges with transportation UM all of those things um coalesced 0:07:53.360 --> 0:07:56.640 to increase the likelihood of poor outcomes for populations with 0:07:56.680 --> 0:08:01.200 complex needs. The company uses technology to or stand those challenges. 0:08:02.000 --> 0:08:05.280 They built a custom electronic medical record system that tracks 0:08:05.280 --> 0:08:08.280 members social needs as well as their physical and mental health, 0:08:09.360 --> 0:08:12.640 and it allows clinicians and other workers to communicate smoothly 0:08:12.960 --> 0:08:15.640 to keep members from falling through the cracks. We have 0:08:15.720 --> 0:08:18.080 visibility across all of those things and then have tools 0:08:18.080 --> 0:08:21.000 with which to help deliver better care on the social 0:08:21.040 --> 0:08:22.840 side as well as on the physical health side. We 0:08:22.840 --> 0:08:25.400 should disclose at this point that one of city Box 0:08:25.440 --> 0:08:29.600 investors is Sidewalk Labs. That's a subsidiary of Alphabet, the 0:08:29.640 --> 0:08:32.560 parent company of Google, and it's run by Dan Dotorff. 0:08:33.000 --> 0:08:36.120 Doctor Off was CEO of Bloomberg News parents Bloomberg LP 0:08:36.440 --> 0:08:44.440 until he's on the board of City Block. But let's 0:08:44.440 --> 0:08:47.760 get back to toy In. A handful of healthcare organizations 0:08:47.840 --> 0:08:51.920 across the country have built reputations for improving healthcare for 0:08:51.960 --> 0:08:54.880 the type of complex patients that City Block works with. 0:08:55.840 --> 0:08:58.600 Toyan worked at one of them, a nonprofit health plan 0:08:58.679 --> 0:09:02.640 in Massachusetts called the Commonwealth Care Alliance. The inspiration for 0:09:02.720 --> 0:09:05.000 me and for the rest of our founding team was 0:09:05.040 --> 0:09:08.320 really about the opportunity to take clinical models that we 0:09:08.360 --> 0:09:11.920 had seen and tested um and bring them to scale 0:09:11.960 --> 0:09:14.760 to populations that wouldn't otherwise have access to these types 0:09:14.800 --> 0:09:18.720 of interventions. City Block is betting that it can deliver 0:09:18.800 --> 0:09:21.960 better care to people who the medical system often fails. 0:09:22.520 --> 0:09:25.679 But it's more than that. Toyan believes that doing so 0:09:25.800 --> 0:09:30.400 will also reduce overall spending on medical care. Fundamentally, for us, 0:09:30.960 --> 0:09:34.359 our business is about proving that there is a sustainable 0:09:34.400 --> 0:09:39.520 business case for improved care and for an improved experience 0:09:39.559 --> 0:09:42.480 of care for communities who very frequently have not received 0:09:42.520 --> 0:09:45.640 those things. And so it matters a lot um that 0:09:45.679 --> 0:09:49.200 we are not just adding services to the system UM 0:09:49.200 --> 0:09:53.120 with the promise of um them being sort of globally 0:09:53.160 --> 0:09:55.200 felt to be beneficial, but that we're actually held to 0:09:55.800 --> 0:10:00.160 real world economics. This is definitely not a charity. The 0:10:00.200 --> 0:10:04.200 company has raised more than eight million inventor capital. City 0:10:04.200 --> 0:10:06.439 Block agrees to take care of some of the sickest 0:10:06.480 --> 0:10:10.160 and most vulnerable patients. It has contracts with inferrors like 0:10:10.240 --> 0:10:13.079 Emblem Health in New York and Blue Cross blue Field 0:10:13.080 --> 0:10:16.520 of North Carolina, and City Block makes money if it 0:10:16.559 --> 0:10:20.080 can reduce the costs for the expensive complex patients it 0:10:20.160 --> 0:10:23.400 takes on by keeping them out of the hospital. Let's 0:10:23.640 --> 0:10:26.160 invest the vast amount of money that we spend in 0:10:26.200 --> 0:10:29.200 healthcare today. Let's invest some of it on things that 0:10:29.240 --> 0:10:30.840 we know are going to move the needle for people 0:10:30.880 --> 0:10:33.720 that really matter, and let's do so with an intent 0:10:33.920 --> 0:10:37.000 to reduce waste um and to reduce suffering, and to 0:10:37.080 --> 0:10:40.680 improve time spent at home with people's families and their communities. 0:10:41.160 --> 0:10:43.560 There's no question that a lot of people get poor 0:10:43.600 --> 0:10:47.280 medical care in the United States and that difficult social 0:10:47.320 --> 0:10:51.800 circumstances make their health outcomes worse. The question is whether 0:10:51.880 --> 0:10:55.959 fixing those problems can also bring down medical costs. Many 0:10:56.000 --> 0:10:58.199 of these services we we as a system haven't yet 0:10:58.200 --> 0:11:00.640 figured out how to quantify the value of You know, how, 0:11:00.679 --> 0:11:04.200 how how valuable is it in dollars? Is it a 0:11:04.200 --> 0:11:05.880 five dollar thing or a ten dollar thing or a 0:11:05.880 --> 0:11:08.959 twenty dollar thing to help support somebody who UM was 0:11:08.960 --> 0:11:11.720 going to get evicted, UM to go to housing court 0:11:11.840 --> 0:11:14.679 and fill out paperwork and keep their home. It's not 0:11:14.720 --> 0:11:16.840 that City Blox thinks there should be a price tag 0:11:16.880 --> 0:11:19.320 on these things. We don't have a rule book. We 0:11:19.360 --> 0:11:21.880 don't have a pricing book for these types of services yet, 0:11:22.280 --> 0:11:24.520 nor do I think we should in a fee for 0:11:24.559 --> 0:11:27.800 service way, because these are actually interventions that have longitudinal value. 0:11:28.760 --> 0:11:31.720 That means city block hopes to improve members health over 0:11:31.760 --> 0:11:35.079 the long term. Even if helping someone keep their home 0:11:35.240 --> 0:11:38.200 doesn't affect their health this week, it might mean they're 0:11:38.200 --> 0:11:41.199 healthier a year from now than if they had been evicted. 0:11:41.600 --> 0:11:44.840 If the company's approach makes patients healthier over time, it 0:11:44.840 --> 0:11:47.520 will lower costs, and City Block will get to keep 0:11:47.679 --> 0:11:51.480 some of the savings. Today, City Block is caring for 0:11:51.520 --> 0:11:54.760 thousands of people in New York, Connecticut, and North Carolina, 0:11:55.040 --> 0:11:59.160 and it's expanding to Massachusetts soon. I visited a couple 0:11:59.160 --> 0:12:02.640 of the company's clin Actually, CityWalk doesn't call them clinics. 0:12:02.920 --> 0:12:05.880 It calls them health hubs because they're intended to be 0:12:05.960 --> 0:12:10.080 more than just a medical office. At a new space 0:12:10.120 --> 0:12:12.880 in a strip mall in Greensboro, North Carolina, there are 0:12:12.880 --> 0:12:17.199 paintings from local artists. Inspirational slogans are printed on the walls. 0:12:17.800 --> 0:12:20.800 Ron Carter, the hub manager, showed me around one day. 0:12:21.240 --> 0:12:22.760 This one here on the wall says what matters to 0:12:22.840 --> 0:12:25.160 you manage to us, and we really believe in that, 0:12:25.440 --> 0:12:27.880 and obviously we want to remembers to feel that. There 0:12:27.880 --> 0:12:30.680 are exam rooms and meeting rooms for counseling. There are 0:12:30.720 --> 0:12:34.000 also respite spaces where members can make private phone calls 0:12:34.080 --> 0:12:38.360 or just sit quietly if they want. Eventually, the staff 0:12:38.400 --> 0:12:42.000 plans to host events like nutrition classes or yoga. The 0:12:42.040 --> 0:12:44.640 idea is to be a little more like a community center. 0:12:45.400 --> 0:12:49.200 Laura Mused, the site's manager for community partnerships, told me 0:12:49.280 --> 0:12:52.280 that was already happening in Greensboro. The members we have, 0:12:52.440 --> 0:12:55.480 we see every every week. Some come in and just 0:12:55.520 --> 0:12:57.480 have a glass of water and say hello. We've gone 0:12:57.520 --> 0:13:01.360 to that level. Since I've visit City Block in November 0:13:01.440 --> 0:13:05.720 in North Carolina, the situation has changed. The company paused 0:13:05.800 --> 0:13:09.520 most of its operations there in mid January. City Block 0:13:09.600 --> 0:13:12.079 has a contract with the state's Blue Cross Blue Field 0:13:12.080 --> 0:13:15.080 plant to take care of Medicaid patients, but an unrelated 0:13:15.120 --> 0:13:19.280 state budget standoff delayed funding for the new North Carolina 0:13:19.360 --> 0:13:22.959 Medicaid program. The company said it hopes to resume when 0:13:22.960 --> 0:13:26.400 the budget impass is resolved. City Block has a doctor's 0:13:26.440 --> 0:13:29.520 like toy In and nurse practitioners and labs. But what 0:13:29.640 --> 0:13:33.400 makes it different from most medical practices is people like Quacy, 0:13:33.440 --> 0:13:36.280 who works for City Block in Brooklyn. When my name 0:13:36.360 --> 0:13:41.720 is quasy Um Quis Peterson m ah Um community health partner, 0:13:43.000 --> 0:13:45.840 every patient that City Box takes care of is assigned 0:13:45.880 --> 0:13:49.520 to a community health partner like Quacy. She has about 0:13:49.520 --> 0:13:52.320 forty patients on her roster, and she might visit six 0:13:52.400 --> 0:13:55.480 or seven of them in any given day, or they 0:13:55.480 --> 0:13:59.319 come here, or I've met people in the community of 0:13:59.480 --> 0:14:03.760 med members at the shelters, UM I I go where 0:14:03.760 --> 0:14:07.840 they act. Quacy worked closely with City Box medical staff, 0:14:08.160 --> 0:14:11.360 but she isn't a condition. She's there to help patients 0:14:11.480 --> 0:14:13.680 with all the other stuff that can affect their health, 0:14:14.040 --> 0:14:19.360 like transportation. I have UM picked them up from the appointments. 0:14:19.680 --> 0:14:23.160 I accompanied them to the appointments. One day, she was 0:14:23.200 --> 0:14:25.480 making a house calm when her client took a long 0:14:25.560 --> 0:14:28.120 time to answer the door. He usually comes to the 0:14:28.160 --> 0:14:31.200 door very quickly, and this one time a president of president, 0:14:31.320 --> 0:14:34.160 but he doesn't come quickly and do I'm like, okay. 0:14:34.280 --> 0:14:37.800 He did come and he can barely walk. He's a 0:14:37.880 --> 0:14:41.240 diabetic and he fell. The man had injured his knee 0:14:41.280 --> 0:14:44.480 a few days earlier, but he hadn't gotten any treatment. 0:14:44.920 --> 0:14:47.840 So Quasi called toy in. She said, okay, bring him. 0:14:47.880 --> 0:14:49.840 Don't let him go to the e R. He's gonna 0:14:49.880 --> 0:14:52.640 wait there too long. Toyan examined him at the connect. 0:14:52.800 --> 0:14:55.160 So she came here. I brought him here in my car, 0:14:55.880 --> 0:14:59.200 you know, and um, she took him in right away, 0:15:00.040 --> 0:15:04.000 did the xt ray, she gave them crutches, the ice 0:15:04.080 --> 0:15:05.840 BacT all these sort of things. He left her with 0:15:05.880 --> 0:15:08.680 a little bag. It's impossible to say what might have 0:15:08.760 --> 0:15:12.080 happened if Quacy hadn't visited the man and discovered that 0:15:12.120 --> 0:15:15.760 he was hurt. Even minor injuries can become serious for 0:15:15.840 --> 0:15:18.680 people with diabetes because their wounds are slow to heal. 0:15:19.480 --> 0:15:23.600 An infected wound could even lead to an amputation. Clinicians 0:15:23.720 --> 0:15:26.960 often see situations where a serious illness could have been 0:15:27.000 --> 0:15:31.240 avoided if they had reached the patient earlier. So my 0:15:31.360 --> 0:15:35.520 name is Joanna Humanis Mahiah, and I'm an e respectitioner. 0:15:35.840 --> 0:15:38.920 Joanna worked in hospitals and home care before coming to 0:15:39.000 --> 0:15:42.760 City Bark. I felt that it was with some patients, 0:15:42.920 --> 0:15:45.480 very very challenging to keep them out of the hospital, 0:15:45.960 --> 0:15:48.200 And in my opinion, it was because we were coming 0:15:48.240 --> 0:15:50.760 to these patients when they were already very sick, and 0:15:50.800 --> 0:15:55.520 they were already acute, and we were we were just 0:15:55.600 --> 0:15:58.560 a little too late for what they actually needed. City 0:15:58.560 --> 0:16:01.080 Box is trying to build a system that reaches patients 0:16:01.120 --> 0:16:04.560 before it's too late, when there's still an opportunity to 0:16:04.640 --> 0:16:07.240 keep them healthy and out of a hospital or nursing home. 0:16:07.960 --> 0:16:11.000 It relies on people like Quacy. It also relies on 0:16:11.040 --> 0:16:14.720 communications software to keep pack of patients needs and coordinate 0:16:14.720 --> 0:16:18.200 their care. If members give permission, City Box care teams 0:16:18.240 --> 0:16:20.640 will get real time alerts when somebody goes to the 0:16:20.680 --> 0:16:24.000 emergency room. The alert pops up in the chat software 0:16:24.000 --> 0:16:27.680 Slack that all the City Box staff use. Here's Quazy. 0:16:27.920 --> 0:16:30.240 So then I would meet them at the hospital if 0:16:30.280 --> 0:16:33.200 they happen to go into the emergency room and they admitted, 0:16:34.080 --> 0:16:36.920 and um, even if they're not ante, I'll go to 0:16:36.960 --> 0:16:39.320 the era. Finally, what's going to And you should see 0:16:39.320 --> 0:16:42.560 the face they'd be so surprised. Quazy shows up at 0:16:42.560 --> 0:16:45.400 her patients houses and at the hospital, but she also 0:16:45.440 --> 0:16:48.120 shows up to support them in ways that healthcare workers 0:16:48.200 --> 0:16:51.160 don't normally do. Even going to court, I have members 0:16:51.200 --> 0:16:54.280 I go to housing court for I have members that 0:16:54.400 --> 0:16:57.360 I tell them what's the process, what's because I have 0:16:57.480 --> 0:17:00.480 been the tenant going to court for not paying right 0:17:00.520 --> 0:17:04.000 because I also lost my job. This is an important 0:17:04.040 --> 0:17:07.720 piece of City Box model. The people working as community 0:17:07.720 --> 0:17:11.959 health partners are from the places they serve. Quzy understands 0:17:12.040 --> 0:17:15.960 the challenges that her client's face because she's faced them herself. 0:17:16.600 --> 0:17:20.040 My position got phased out at Brooklyn Hospital when my 0:17:20.119 --> 0:17:24.959 son was born, so I had no job, new baby, 0:17:25.560 --> 0:17:30.240 rent to pay, and you have savings. But when you 0:17:30.280 --> 0:17:32.960 have a newborn, you're looking for a job that's saving 0:17:33.119 --> 0:17:37.119 and you're paying rent, and you're paying this and it 0:17:37.200 --> 0:17:41.399 depletes quickly. That kind of experience helps Crazy relate to 0:17:41.440 --> 0:17:45.639 members who don't always trust doctors or medical institutions. I 0:17:45.720 --> 0:17:49.080 have people who don't trust. I'm dealing with the distrust 0:17:49.160 --> 0:17:53.840 of the medical field. So with me, now UM for 0:17:53.880 --> 0:17:55.560 me to build a trust like I will meet them 0:17:55.560 --> 0:17:57.359 where they're at and talk normal. I'm not trying to 0:17:57.400 --> 0:18:00.640 talk any nine letter words. You know. I would tell 0:18:00.720 --> 0:18:02.960 them to like I would if you understand, I have 0:18:03.040 --> 0:18:05.840 to get to their level and they will see that 0:18:05.920 --> 0:18:09.439 I'm not be asking them. Toyan says building trust with 0:18:09.480 --> 0:18:13.159 patients is essential to improving care over the long term, 0:18:13.200 --> 0:18:15.880 and it's one of the ways the medical system has failed. 0:18:16.920 --> 0:18:19.040 You think about what, um, what it feels like for 0:18:19.080 --> 0:18:22.840 somebody to walk into a hospital or a clinic. Um, 0:18:22.840 --> 0:18:26.280 it's an unfamiliar space. UM. You are kind of at 0:18:26.280 --> 0:18:30.080 their mercy. UM. You're in a thin paper gown. You 0:18:30.119 --> 0:18:32.399 sit where you're told to sit. UM. And the person 0:18:32.440 --> 0:18:33.879 comes in and they've got a white coat on it, 0:18:33.880 --> 0:18:35.439 and they've got all these letters on their name, and 0:18:35.480 --> 0:18:38.120 they are you know, they're typing a computer. You can't 0:18:38.119 --> 0:18:39.800 see the screen. You don't know what they're saying about you. 0:18:39.840 --> 0:18:42.399 There's so many ways in which we reinforce this notion 0:18:42.440 --> 0:18:46.520 of power UM. That is UM that is so antithetical 0:18:46.600 --> 0:18:50.600 to trust building. The problem is particularly acute for people 0:18:50.640 --> 0:18:53.960 who have historically been marginalized by the medical system or 0:18:54.000 --> 0:18:56.920 society more broadly. You know, when I talked to my 0:18:56.920 --> 0:19:00.920 my African American patients, I not and frequently will people 0:19:00.960 --> 0:19:02.159 say to me like, I'm scared to go to the the 0:19:02.200 --> 0:19:03.919 hospital because I don't feel like they treat people like 0:19:04.040 --> 0:19:08.040 us well. And none of us can in today's day 0:19:08.040 --> 0:19:10.080 and age, with all the reporting around this faint shock 0:19:10.480 --> 0:19:12.560 about that, we can't say, oh, no, it's just you're 0:19:12.560 --> 0:19:15.840 making that up. It's true, it's true. They feel it 0:19:15.880 --> 0:19:17.880 because they know it to be true. And the way 0:19:17.920 --> 0:19:21.520 we pay for healthcare only makes this gap and trust wider. 0:19:22.320 --> 0:19:25.199 Doctors are reimbursed for the volume of care they deliver, 0:19:25.760 --> 0:19:29.040 and the cost of that care is often hidden from patients. 0:19:29.160 --> 0:19:33.160 It creates incentives to do things to people, um, even 0:19:33.160 --> 0:19:37.280 when they may not actually deliver value to them. And 0:19:37.280 --> 0:19:40.560 and and we're we're basically not at all transparent around prices. 0:19:40.800 --> 0:19:43.640 The pressure on doctors to see more patients in less 0:19:43.680 --> 0:19:47.320 time has further eroded trust with patients. The worst thing 0:19:47.440 --> 0:19:49.479 that we've done is we've created such pressure on our 0:19:49.480 --> 0:19:53.639 clinicians in particular that we have um made it almost 0:19:53.640 --> 0:19:56.840 impossible for them to just be humans and be human 0:19:56.880 --> 0:19:59.960 with their patients in ways that for a long time, 0:20:00.040 --> 0:20:03.199 I think it's surmounted all the other barriers, right Like, 0:20:03.280 --> 0:20:06.000 if I can just sit with you, look in your eyes, 0:20:06.720 --> 0:20:08.400 you know, put my hand on your hand, and tell 0:20:08.440 --> 0:20:10.919 you that I'm like, I'm here because I want to 0:20:10.960 --> 0:20:13.240 do best by you, That I will tell you the 0:20:13.240 --> 0:20:15.520 truth as best as I know it, that I will 0:20:15.560 --> 0:20:18.760 do my very best to help you live your best life. 0:20:18.800 --> 0:20:21.199 If I could, if I had ten minutes to just 0:20:21.359 --> 0:20:24.359 do that with you, perhaps all the other stuff wouldn't matter. 0:20:24.720 --> 0:20:27.680 But we've stripped even that away. UM, so that now 0:20:27.720 --> 0:20:29.920 our clinicians don't even have the ten minutes to do that. 0:20:30.320 --> 0:20:32.680 City Box is up against some of the biggest challenges 0:20:32.760 --> 0:20:35.840 that face our health care system and our society. It 0:20:35.920 --> 0:20:39.520 treats the most expensive, complex patients. It's trying to re 0:20:39.640 --> 0:20:42.640 engineer a health care system that often doesn't work well 0:20:42.680 --> 0:20:45.399 for them. And if it does all that, toy and 0:20:45.480 --> 0:20:48.480 believes that City Bok can save the system money while 0:20:48.520 --> 0:20:51.520 improving the lives of the people it's so often fails. 0:20:56.400 --> 0:21:00.359 And that's it for this week's prognosis. Thanks for listening, yeh. 0:21:06.720 --> 0:21:08.720 Do you have a story about healthcare in the US 0:21:09.040 --> 0:21:11.280 or around the world We want to hear from you. 0:21:11.800 --> 0:21:14.960 Find us on Twitter at Fay Cortes or at Jaytaws. 0:21:16.359 --> 0:21:18.720 If you're a fan of this episode, please take a 0:21:18.720 --> 0:21:21.400 minute to rate and review us. It really helps new 0:21:21.440 --> 0:21:25.720 listeners find the show and don't forget to subscribe. This 0:21:25.760 --> 0:21:28.760 episode was produced by Toe for Foreheads. Our story editor 0:21:28.800 --> 0:21:32.680 was Rick Shine. Special thanks to Healthcare team leader Drew Armstrong. 0:21:33.480 --> 0:21:36.639 Francesca Levie is head of Bloomberg Podcasts and We'll be 0:21:36.680 --> 0:21:39.200 back next week with the new episode. See you then.