EP. 31: EXPANDING HEALTHCARE AT THE MARGINS

WITH TOYIN AJAYI

Oct 5

WITH TOYIN AJAYI, MD, MPHIL

The co-founder and CEO of Cityblock Health discusses how she has created a sustainable model of care delivery for marginalized patients.

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Episode Summary

What should we do about the fact that a person's health is affected in large part by social factors beyond the confines of the hospital? For a long time, traditional health care institutions have been inadequate in answering this question. Joining us in this episode is Dr. Toyin Ajayi, co-founder and chief executive officer of Cityblock Health, a tech-driven health care provider for communities with complex health and social needs. With a focus on Medicaid and lower income Medicare beneficiaries, Cityblock Health has been widely recognized as an exemplar of a sustainable model of care delivery for marginalized populations. We are pleased to be joined by Dr. Ajayi to discuss Cityblock Health as well as her clinical work, which centers on patients with chronic complex and end-of-life needs.

Toyin Ajayi, MD, MPhil, board certified in family medicine, is Chief Health Officer of Cityblock Health, the first tech-driven provider for communities with complex health and social needs. Cityblock’s care teams meet members where they are, delivering highly personalized primary care, behavioral health care, and social services to every member, including those who access Medicaid, are dually eligible for Medicaid and Medicare, and others living in lower-income neighborhoods.
Prior to Cityblock, Dr. Ajayi served as Chief Medical Officer of Commonwealth Care Alliance, a nationally renowned integrated health plan and care delivery system for individuals eligible for both Medicare and Medicaid. In this role, she led clinical operations, spearheaded care delivery innovations, and oversaw multi-disciplinary teams of clinicians, community health workers and administrators serving more than 20,000 beneficiaries across Massachusetts.
She received her undergraduate degree from Stanford University, an MPhil from the University of Cambridge and her medical degree, with Distinction in Clinical Practice, from King’s College London School of Medicine. She completed her residency training at Boston Medical Center. She continues to practice primary care and hospital medicine focused on patients with chronic, complex and end-of-life needs.
In this episode, you will hear about:
• Dr. Ajayi’s personal journey from growing up in Kenya to leading Cityblock Health - 1:57
• Why Dr. Ajayi chose to focus her career on patients with complex and chronic health needs - 4:11
• The social determinants of health and its impact on a patient’s ability to seek appropriate medical care - 5:21
• Dr. Ajayi’s story of a chronically-ill patient who appeared ‘difficult’ but in truth was suffering from social inequities that limited his access to health care - 10:35
• A discussion of Cityblock Health, the value-based healthcare provider that Dr. Ajayi co-founded to provide care to the Medicaid patient population - 18:07
• The stigmas around Medicaid patients and why Dr. Ajayi sees opportunities instead of barriers - 22:02
• An in-depth exploration of the services Cityblock Health provides - 27:00
• The challenges of the fee-for-service model of American healthcare, and how Cityblock seeks to address them - 32:36
• Dr. Ajayi’s advice to medical practitioners on how to build trust and rapport with their patients - 37:50
• The future of Cityblock Health and the health equity movement - 40:05
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:28] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] What should we do about the fact that a person's health is affected in large part by social factors beyond the confines of the hospital? For a long time, traditional health care institutions have been inadequate in answering this question. Joining us in this episode is Dr. Toyin Ajayi, co-founder and chief executive officer of Cityblock Health, a tech-driven health care provider for communities with complex health and social needs. With a focus on Medicaid and lower income Medicare beneficiaries. Cityblock Health has been widely recognized as an exemplar of a sustainable model of care delivery for marginalized populations. Dr. Ajayi completed her medical training at King's College London School of Medicine and her residency at Boston Medical Center. Her clinical practice centers on patients with chronic complex and end of life needs. Toyin, Thank you very much for taking the time to join us and welcome to the show.
Toyin Ajayi: [00:01:55] It's my pleasure to be here. Thanks for inviting me.
Henry Bair: [00:01:57] I'd like to start by going back to the beginning of your career. I know that you are trained as a family medicine practitioner. So can you tell us what first drew you to that profession?
Toyin Ajayi: [00:02:10] Yeah, absolutely. I'd always known I wanted to do something in and around health care. I grew up in a in a family. My dad was a public health physician, did a lot of global health work his whole career. My mom has always been, I think, a social justice warrior, if you will, and really focused on community building. And so I always knew that I would want to do something in this space. I grew up in East Africa, in Kenya, Nairobi, and saw a lot of the early impacts of the global HIV AIDS pandemic. And so really experience pretty closely close to firsthand sort of the impacts of massive, massive infectious disease, public health crisis as it played out, particularly for lower income people. And I saw very much and very closely the sort of impacts the differential impacts of some of the structural and societal biases and stigma that exists, particularly around women and women's access to education and health care. And so I had a lot of kind of threads going through my head thinking about public health, reproductive health. But I decided to go in specifically into medicine a little bit later than most.
Toyin Ajayi: [00:03:17] I'd I'd hedged my bets. I was a pre-med in undergrad and sort of thought maybe I wanted to go there, but I wasn't particularly convinced until a little bit later in my career when I was really trying to think about where where I could have an impact the most. So I went to medical school, not necessarily thinking I would practice for a very long time initially, but really just thinking that it would be a really useful anchoring point for a career in health in some way, shape or form. And as luck would have it, I found out that I really, really love being a doctor. I love taking care of patients, I love clinical practice and I love the experience that I get and just the exposure that I get through kind of talking to and sitting with and accompanying patients through their journey. And so decided to do family medicine because it gave me the most breadth that I could and the most access and an ability to to see the entire life cycle for families, which was really compelling for me.
Henry Bair: [00:04:11] Wow. I did not know that you had grown up in Africa. So that's that's a fascinating perspective there. I'm curious because you have made your career you have built your career around taking care of chronically ill patients and patients with complex health needs. What motivated you in particular to focus on on this patient population?
Toyin Ajayi: [00:04:36] I was just very compelled and really felt very passionately about caring for people who have the most complex needs, people who have the most to lose and the most to gain from the way that our health care system treats folks who are marginalized. And as I was training, I saw that folks with chronic conditions, physical health needs, behavioral health needs, people who struggled with addiction and substance use often had the most disproportionately poor outcomes of my patients. And that seemed to me like a reason to double down and to focus on trying to even the playing field at a minimum, trying to advance equity and health and health outcomes with a particular focus on people who have the most challenges to overcome.
Henry Bair: [00:05:21] You talk about the importance of focusing on patient's social needs. Which reminds me of a statement I've heard before that in the US, a person's zip code is far more predictive of his or her health outcomes than his or her genetic code. Now, certainly when I first started medical school, the social needs of patients weren't really something that I was aware of. I grew up in Taiwan, and because of many factors, including the relatively small and homogenous population there and because of the single payer universal health coverage that Taiwan has. Social factors don't seem to have as outsized of an impact on a patient's life there, and are certainly not discussed nearly as much as they are here. So that perhaps somewhat explains my ignorance about these issues. But it wasn't long after I started my clinical work that I recognized that a person's social environment can often profoundly impact what kinds of care he or she can access. So can you tell us more about what social determinants of health are and why it's important to address them?
Toyin Ajayi: [00:06:41] Yeah, absolutely. And I I'm glad you asked the question. And I really hope that over time, as we continue to hone and refine medical education, that this is a core part of the curriculum of aspiring doctors as early in their journey as possible. I think the easiest way to describe it is to maybe just ask folks to take a second and sort of take a walk in the shoes of some of your patients, really, really sort of dig in and listen to their stories and their experiences. And when we think about somebody who say is living in a lower income community, maybe they didn't have access to the most robust education because that we know that that access to education is also distributed very much based on an income. Maybe they don't have healthy, nutritious food readily available in their communities. We see the convergence of lower income communities with with what are called kind of food deserts. So places where there's not access readily available to to healthy, nutritious and cost effective food. Maybe these are folks who don't live in a community where you can just walk outside your front door and go for a walk in the middle of the day or at the end of the day and feel safe doing so. Maybe these are folks who don't have sufficient resources at the end of the week to spend on the exorbitant copays and other fees that are charged in the health care system.
Toyin Ajayi: [00:08:00] Even if you receive health care that's funded through Medicaid or or some other source, for many folks, there's auxiliary things that need to get paid for that that can be challenging to afford and to manage. And certainly for folks on Medicare, the cost of pharmacy, it can be really challenging for people depending on the type of plan that they're on. And so when you walk back and look at the experience of individuals and you say, OC, why is it that folks who are lower income are more likely to present with diabetes or with hypertension when we know that diabetes and hypertension are very frequently contributed to by diet and exercise, by people's access to, again, healthy, nutritious food education to enable them to to really understand how to use that food, how to eat that food, how to balance their diets and places where they can exercise, and the time to do so. That's one basic example, like pick diabetes, right? And then you add on that they're also less likely to receive adequate and high quality preventive care because clinical access is often also distributed very differently depending on whether you're a lower income or a higher income individual. That's add to that. Then if I make a if I write a prescription for a patient, for a medication that may help control their blood sugar, if they have a co pay to pay and they do not have sufficient resources to pay that copay, if they have to get transportation to go to the pharmacy and the pharmacy is only open in their area between nine and five and that's when they're also working.
Toyin Ajayi: [00:09:25] If they lack the data plan on their phone with which to access a digital solution that may solve all of their problems and not have to have them leave their home. We're starting to see all the ways in which social drivers and social factors layer on to exacerbating people's health outcomes if they're already kind of struggling. And that's not even zooming out even further. To talk about the things I alluded to, some of the structural barriers. Why is it that where you live determines the quality of the education that you get? Why is it that the color of your skin determines the level of care and the courtesy and the kindness and the access that you receive when you access the hospital? We're talking about even broader structural, social, political, economic factors that also impact people's health and well-being. And so it is it is truly multilayered. But I think for us as physicians and aspiring physicians, it's really important to understand the role that medications that diagnostics play in an overall health story and how important it is for us to have much more peripheral vision to understand what happens more broadly within the health system, even before the patient came into the door and certainly well after they leave us.
Henry Bair: [00:10:35] And I think that primary care providers, including family medicine doctors, really have some of the most challenging jobs in all of medicine when it comes to addressing the social determinants of health, because you are often at the focal point of coordinating all the different components of a patient's health needs. And even if things like transportation, food and security and all the other factors we've been talking about aren't what we learn about in medical training, it is inevitable that they may come up in practice. Patients will allude to them or talk about them because these are essential considerations when it comes to whether or not they can pay for and pick up the medications you're telling them to take or whether they can adhere to the exercise and diet regimen you're recommending or whether they can fit those specialist appointments you're referring them to into their work schedule. Is there a patient story you can share that really illustrates why addressing these social needs is such incredibly important work for you?
Toyin Ajayi: [00:11:33] I guess it can. And I also would really urge you and your listeners to think that this is relevant for everyone in health care, not just for family doctors. If you're an oncologist and you're providing cancer treatment to somebody and their care requires them to come back for follow up appointments to get labs drawn on a regular basis, We know already and we're just scratching the surface, but we're starting to understand the role that mental health plays in our physical well being. If they're living in a high stress environment with multiple people under their roof, that all impacts their ability to heal, their ability to adhere to the treatment plan set for them. And the same is true for every other specialty. This is not just yes, we hear it more often in the family medicine environment and the primary care environment. But I really believe that every single person who is aspiring to a career that is in clinical care of patients has to understand the way that the holistic picture plays into their overall presentation and their outcomes. I'll give you one example of of a person that I saw, the gentleman I saw a few years ago now who was establishing care with me. He'd been seen by many, many other providers at this point. He was in his sixties, late sixties, and had quite a long history of of chronic physical health conditions.
Toyin Ajayi: [00:12:48] He had high blood pressure, he had heart failure, he had diabetes. He already had kidney disease and had been hospitalized on average a couple of times a year with dehydration, with acute worsening of his kidney failure, with heart failure. So his legs were swollen. He was short of breath, needing a couple of days in the hospital and even on occasion actually of late needing to be sent to rehab after he'd been hospitalized. And he came to see me with his wife feeling unwell, he was short of breath, his legs were swollen, his blood sugar was through the roof and his kidneys were starting to show the signs of having an acute worsening over his baseline kind of kidney failure. And I was really worried about him. That was the moment when I really contemplated, you know, do I do I recommend he goes to the hospital or do I recommend that we can treat him as an outpatient? I started to look through his chart and try to understand kind of how does this presentation look different from the last time he was in the hospital. What was happening then? As we were getting all his labs and his his vital signs back and everything, trying to make a plan with him. And what I saw in his chart was that the the sort of common story about this gentleman was that he was noncompliant with his medications.
Toyin Ajayi: [00:13:57] He didn't follow his medication instructions. He wasn't taking his diabetes medicines as he was told to. He wasn't taking his cardiac medicines and that every so often he would come back to the hospital and we'd do the same thing over and over again. And so I was a little bit worried about sending him home with a treatment plan, knowing this per his chart, at least per some documentation with other clinicians. But we started to talk and I was trying to figure out what was going on with him. And I said, Can you tell me a little bit about all the doctors you see and what appointments you have coming up? And he pulled out his phone and he had a little document that he stored on his phone that listed all of his doctors, their phone numbers, the appointments, what he had coming up. And you scroll down and you can see all the medications listed, talked to his wife and asked what his daily routine was. And she does all the cooking. And she described how she'd been reading up and asking for advice on what the right foods were for him. And I looked at him again. I said, I I'm confused. Your chart here suggests that you don't take your medicines. You don't remember to take your medicines. It makes it sound a little bit like you don't understand them or you can't remember to take them.
Toyin Ajayi: [00:15:01] But that seems really surprising to me, given how how on the ball you seem, tell me what's really happening. And he said, Oh, you know, sometimes it's hard to remember. And I said, I'm just not buying it. And we spent a few minutes going back and forth and finally in tears, he shared with me for the first time with his wife as well, that he could not afford the co-pay for his medications and that he'd been rationing his medications for many, many weeks. And that often when he gets to this point in time in the year where part of this is the nuances of the way that his health care benefit works, he was. Facing a lot more out-of-pocket costs than usual. He would start to ration his meds. When I look back, sure enough, his hospitalizations were all around the same time in the year. But he was so proud and he'd never felt safe enough to share either with his clinician or with his wife that this was what was happening. And that was because it was so easy to make an assumption about him, so easy to label this person he doesn't understand. He's an African American man. He didn't finish high school. He couldn't possibly understand his meds. And then the sort of implicit story is like, well, it's kind of his fault. Right? And that's never said explicitly in the chart, but you can imagine how people who encounter him in the system might treat him thinking this about him when the reality is he, like so many millions of people in this country, is struggling to make ends meet.
Toyin Ajayi: [00:16:25] And he was making trade offs between putting food on the table, between supporting his family and his own health and well-being. And once we could have that conversation very transparently, we could figure out actually he was eligible for subsidies, he was eligible for support. There are programs we could put in place. He needed some help getting there. And we're actually were able to really make a difference for him. And I'm really happy to say that that his health has been transformed truly through the sort of advocacy and support that we've been able to provide to him. But it took that like, let's just sit here for a minute. Let's really try to understand each other and let's build that sense of safety, to ask about some things that are really deeply personal. They're very, very hard and recognize that not everybody has as easy a path as I do to say, okay, there's a prescription, there's a medicine, I should go, I'm just going to go get it. For him, That co-pay was was a deal breaker and it was really, really profound and had really profound impacts on his health and his life.
Henry Bair: [00:17:24] That's an incredible story. And, you know, I when I was on my family medicine rotation, I think I encountered I got a taste of what you're describing, which is that health care is fundamentally it's a very human pursuit. You are dealing with people and it's important to situate whatever they're experiencing, whatever medical condition you've diagnosed, whatever is happening physiologically, pathologically, inside their bodies. It's important to contextualize that within their own narratives of who they are as a person, where they've just come from, where are they going, literally and also metaphorically, you know, what brings them meaning and what their greatest sources of support and their fears are. So I just love that that that story perfectly illustrates that. And so I'd love to explore next, your work with Cityblock Health, which is this health care startup you found it that delivers care to the Medicaid population. And I'm sure we're going to delve much deeper into how it works. But for now, can you just briefly tell us like a quick overview for our listeners who may not be aware what Cityblock Health is and what it does?
Toyin Ajayi: [00:18:35] Absolutely. It's a Cityblock Health is a value based provider. And also to unpack that, a little bit of primary care and behavioral health and social care services. And so we contract with health insurers that have accountability for being the insurer for people who receive Medicaid. So folks who fall under the income threshold in their specific state, that entitles them to to state funded support for their health insurance. We enter into relationships with these health insurers that allow us to invest in really engaging people with complex needs on Medicaid, building relationships of trust, the sort of thing that the story I described, and then providing them with person centered primary care, behavioral health and social care services that over time help to reduce the progression of their illnesses and the progression of their clinical needs and improve their health and reduces their their hospitalization rates. So like the story I told you of this gentleman who gets hospitalized a couple of times a year, if we can get him the primary care and the mental health and the social services and the connections and the relationship that he needs so he doesn't have to go to the hospital. His overall medical spend goes down, his quality goes up. He gets to spend more time at home with his family and his clinical metrics improve and then we get paid for those improvements as opposed to getting paid for every visit that we do. And so we're incentivized very differently to invest in in those relationships and that engagement in that clinical care and supports in the social care and supports that actually move the needle for folks who have such complex needs.
Henry Bair: [00:20:16] So what motivated you to go from a health care practitioner? And I know that you're still practicing what motivated you to go from a clinician to CO founding your own company, this rapidly growing company? Like what was that process like? At what point did you realize that you needed to do something? Else besides just seeing a patient one at a time.
Toyin Ajayi: [00:20:39] Yeah. I wish I could tell you that. It was like some sort of, like, well thought out process and an epiphany that happened. But the truth is, I think, like many things in your lives and your careers, I think I evolved towards that. I started my career, as I said, very much focused on on caring for and improving outcomes for for folks who are most marginalized and most vulnerable in a health care system and learned a ton through a number of different experiences and opportunities that I had to to think about what it means to be a clinician, what it means to be an academic clinician, what it means to be a teacher and a trainer of others, what it means to be an administrator in a system or in a health plan, like really starting to figure out all the different pieces of the pie that I needed to understand. And when the opportunity to co-found Citywalk arose, it was not that I was looking for this. It was not that I thought, No, no, no, I must be an entrepreneur. But it was very clear to me that something was missing and that we needed to start from scratch. Building fit for purpose for this population and seeking to bring together all of the different skills and experiences certainly that I'd gained, but also that my co-founders had gained that that we're seeing across the ecosystem and try to try to build something for this population from scratch. And so it was very opportunistic in some ways. But I think just an evolution of of the focus that I'd already had.
Henry Bair: [00:22:02] So I am I'm in the business school in addition to the medical school, and during my time at the business school, I've had the opportunity to talk to a lot of people who are working on new health startups, whether they are digitally enabled, health care or otherwise. And you soon recognize that there's. There's a pattern where you can have the most clinically validated tool that works better than any existing intervention. But if you can't figure it out a way for people to get paid for that tool or that intervention, it's going to be really difficult to see widespread adoption. And in fact, I think that just seeing a lot of these companies come in and out, I think that might in fact be one of the biggest stumbling blocks is how do you get from creating a viable solution, a good solution, a good health care solution to getting traction. The obstacle there is usually making sure that the reimbursements and the payment model is in place and it makes sense and a sustainable. And with all these considerations, I think for a lot of people, the Medicaid population has historically been something that many founders of digital health companies have been careful about reaching out to just because there are so many inherent difficulties in that. I think there's a stigma around that population, both in terms of from the reimbursement side, how are we going to get enough money to to keep this operation sustainable from that regard, but also the patients themselves, Because there's this idea, I think, that these patients are harder to reach. It's harder for them to be adherent to the care plan that you provide. And so a lot of companies have stayed away from that particular population. And yet Cityblock Health has managed to engage that population successfully and to grow and to make a viable business out of it. I'm wondering if you could tell us what your process was as you thought about this issue.
Toyin Ajayi: [00:23:59] The reality is that when you take a step back and look at the data, Medicaid is a significant proportion of our health care funding ecosystem, right? In some states, health care is a very significant proportion of coverage for for populations, Health care makes up about 40% of some states budgets. There are millions of people across the country on Medicaid who certainly deserve and require very different and better health care services than they're receiving today. And so I think the idea that the market doesn't exist is is just false. When you then look at the other side, you look at, well, is there an opportunity to to make outcomes dramatically better and at a lower cost such that we can create a viable business? From a unit economics perspective? Again, there are the data would argue absolutely. When you look at the proportion of hospitalizations that are for ambulatory care sensitive admissions. So things that could have been managed in the community, asthma, mild cellulitis, other conditions like that, we realize there's a lot of waste in the system. And then when we look at the ways and the levers that we know exist to to move the needle, things like primary care, advanced behavioral health access, access to substance use, disorder, treatment, some of the social care interventions that I described that are not expensive but are massively impactful. There is a real opportunity there. And so I think that there's this sort of lure that is just not borne out by the data that I honestly think is a little bit of an excuse for the real issue, which is the issue you raised, which is people think this population is hard to engage, they're hard to care for, for all the reasons I described earlier, It's stigma.
Toyin Ajayi: [00:25:45] It's they're undereducated, lack access to resources. Don't follow a directions like hard to engage, don't prioritize their health and well-being. All of that. Is is the manifestation of what it looks like and feels like to have been marginalized, who have been discriminated against, who have been denied access to the services that they need to have grown up in poverty, to live in trauma, to have to make decisions on a daily basis about whether you pay the light bill or whether you put food on the table. So those are all things that are symptoms of the structural problems we're seeking to solve. They're not inherent to the people whom we care for. And I think, you know, having spent my whole careers caring for lower income populations, living in communities where folks get treated this way and get stigmatized in this way, like I just know and I firmly believe that not only is this population deserving of a differentiated, tailored, high quality, respectful and dignified experience of care, that there's also an opportunity to make a business about this that is that is scalable and sustainable because there's so much opportunity and we're demonstrating that at Cityblock.
Henry Bair: [00:26:59] Wow. I'd like to see if we can get concrete about the kinds of services and care that patients can receive through Cityblock. So let's say that there is a patient with long term, long time history of of high blood pressure, and they've historically been having difficulty with getting their medications on time, with sticking to the diet plan that their doctor has recommended. And now they come to Cityblock and they're trying to establish care. What are what are the concrete services that and the professional expertise and what kinds of are we talking about social care workers? Are we talking about primary care doctors? Are we talking about some someone else, some community health coordinator? What does that patient get from Cityblock Health?
Toyin Ajayi: [00:27:45] Great question. All of the above. So start with the first touchpoint. So this patient is the patient you describe is unlikely to be coming into the office, the doctor's office regularly. We just know that that's again borne out in the data. Why? Because for them going to see the doctor requires them making an appointment six weeks in advance between the hours of eight and five, taking a day off work or a half day off work, find someone to watch their kids or run errands for them, getting transportation to the doctor's office waiting. Sometimes it's an hour to see somebody for 10 minutes to get the same sort of instructions they've been told already. Exercise. Lose some weight, take your meds. The value proposition for them is not super high. Right. And so it's no surprise that no show rates at clinics and health centers serving these populations can be upwards of 40%. And it's no surprise that that many, many folks who need routine preventive care don't access it in a calendar year. So the first thing that we've got to do is we've got to go find this person and we've got to earn the right to talk with them about what's actually going on for them And the first sort of person that they will encounter on the Cityblock team is is a member of our outreach and engagement team and or one of our community health partners. And these are folks who are hired from the communities we serve.
Toyin Ajayi: [00:28:56] They represent the community. They are experts in their community. They're experts in trust building and engagement in partnership with members. They're not clinicians definitionally and deliberately. They're not clinicians. And what they're able to do is to show up to meet people where they are without stigma, without bias, without barriers, or even without an agenda. Their entire agenda is to is to get to know a person and understand what matters for them. And we will will outreach a person in their home. We will call them. We will go see them. We'll meet them on a street corner. We'll walk with them to the Dunkin Donuts down the road. We will show up in the hospital. If they get admitted to the emergency room, we will do whatever we need to do to find them and to help explain to them who we are and what we do. And so the first experience that will have is of being listened to in an unhurried way by someone who really gets where they're coming from. And what we're seeking to do there is to understand what's going on for this specific person. Because you described a person who's struggling to keep up with the dietary plan and to take their medicines regularly. There could be a thousand reasons for that. It could be that they don't understand the meds that they're taking. Could be that they took the meds and had side effects and couldn't get any answers.
Toyin Ajayi: [00:30:09] When they called the doctor's office, they didn't get a call back. Could be that they're really depressed and no one's noticed it or talked about it and they have trouble doing anything in their day to day lives. Could be that they can't afford the co-pay or the medication in some way. Could be that they don't have food to go with it. Say it was a diabetes medicine or a medication we want someone to take on a full stomach. Could be that they are living in multiple different addresses. They don't have a stable house and sometimes they don't have their meds with them because their meds can make them at risk for being targeted for a robbery or something like that. We don't know what the answer is until we get to know this person. And we're not going to know until or unless they trust us to tell us what's going on. So the first thing we need to do is figure that out. Once we understand what the barriers are and what the challenges are that this person is experiencing, we then need to work with them to build a plan of care that not just includes. Take your meds. That would be simple. That's what they get when they go to see their doctor. Generally, that includes let's understand all the other barriers. If this is an issue around cost, let's figure out what your options are.
Toyin Ajayi: [00:31:07] This is an issue around understanding the meds. Let's take the time to explain to you what's going on and why we won't take them. If there's an issue with side effects, maybe we just switch you to another med and we should get you to seen by a doctor if it's an unmet need for behavioral health, let's get you seen by a therapist and start to work on that unmet need and that issue that underlies it. And and that's where the rest of our clinical team comes into play. We we have physicians, we have advanced practice clinicians, we have social workers, therapists, psychiatrists, addiction specialists, palliative care doctors, nutritionists, pharmacists on our team. And we're able to either partner to get the member of the patient back to see their primary care and provide the primary care provider with context about what's going on for them or provide the care ourselves that they need to close that gap. If you've got an issue in the evening, on the weekend, you can call us, We'll triage you. We'll send somebody out to your home to see you. If there are social needs, we'll make sure that our social team is following up. That is the experience that a person gets. And the ultimate outcome is that we're able to move the needle meaningfully on their on their health outcomes.
Henry Bair: [00:32:10] As you describe that, I can't help but think just sounds like good medicine to me. You know, it's not. Yeah, I wish I'd had that help. I wish I had that support if I ever needed it, right? Yeah. It's remarkable how many patients the Cityblock currently care for.
Toyin Ajayi: [00:32:26] So we care for several thousand members and we don't share the sort of full numbers across a number of markets. And so we do have a big population of folks that were now caring for tens of thousands of people.
Henry Bair: [00:32:36] Are there any obstacles to scaling this that you've encountered so far?
Toyin Ajayi: [00:32:41] I mean, I wouldn't call them obstacles, but are challenges, of course. I mean, we're starting something from scratch that we've never that's never been done before. And so as with any business that's growing, there are so many things that that you have to overcome, right? There's kind of things inherent to just building a business funding team, organizational structure, technology. What's the role that all this plays together? There's so much there that is just inherent. This is why entrepreneurship is is wildly exhilarating and also can be so hard. And then there are, I think, inherent challenges in health care, which is that we're still a part of a system that predominantly and disproportionately focuses on a fee for service environment, right? Most people in health care, clinicians, health systems get paid for providing a unit of service to a patient based on a reimbursement scale that has been determined in advance and with no real regard to the outcome on the patient, whether they actually get better. As a result, you get paid irrespective of whether they get better. That is the that is the prevalent mechanism for reimbursement of health care, which then defines and determines the prevalent mechanism for organization in health care, focus and prioritization.
Toyin Ajayi: [00:33:52] That is why in many ways we've underinvested in primary care and behavioral health at the expense of more expensive, higher reimbursed services. That's why we have underinvested in care for Medicaid populations at the expense of folks who are commercially insured with richer premiums and rich reimbursement. And so this this is where we are still we still operate in this ecosystem and building something that is different, designed and deliberately so, but that still depends on the rest of the ecosystem is tricky. And we've continue to work to figure out how to build alignment with other health care providers within the ecosystem because they're important. They're they're playing an important role. Just because a cardiologist gets reimbursed in a fee for service environment does not mean that their role is not really important in caring for members and patients. It does mean that we need to think very carefully about how we interact with them and intersect with them so that we can together deliver the maximum value for the people whom we serve.
Henry Bair: [00:34:46] Yeah, we had the director of Medicare on this show a couple episodes back and we were talking about fee for service because we kind of pressed her on a lot of the not just the inherent issues of medicine, American medicine today, but also the way that clinicians feel about their own practice. You know, there's a lot of there's an epidemic of burnout right now. Physicians feel like they're just a small cognitive wheel. They're just churning widgets, you know, And a lot of that can be attributed to the fee for service system. And she told us that Medicare has been making a lot of efforts to try to increase value based payments. I'm not sure how translatable this is for the Medicaid population, but it seems as if there is some effort to try to increase more value based medicine. And that's the good thing. But I know there have been studies over the last few years showing that in a lot of value based care delivery models, an issue of equity, health care equity comes up in which you'll have safety net hospitals, you'll have hospitals taking care of poor patients getting penalized within the value based framework because if you're paying for outcomes as opposed to what you're doing for the patient, then the population you're caring for in those hospitals are going to be sicker and it's going to be harder for them to have the health outcomes of a population that is that as well off that has easy access to care. So how have you addressed that issue?
Toyin Ajayi: [00:36:17] Yeah, that's a great question. It's a really good observation and I'm sure that your conversations with the Medicare director also sort of framed some of this up. There have been lots of attempts to address this. One of them most prominently has been what's called risk adjustment, which is to say that folks caring for a population or an individual with more complex needs need to be reimbursed more money to care for those people and to address those needs. And that's been, I think, in principle, a very positive approach, because the thing we cannot do is have different goal posts. The outcomes have to be expected and our goals and our targets need to be, particularly on the clinical quality side, we need to hold ourselves accountable to the same outcomes, but to acknowledge that it takes more to get there when we're overcoming more challenges for certain populations and others, I think is a really thoughtful way to do that. And then the federal government has tried that in many different ways, including disproportionate share payments to safety net hospitals that they've been doing for a long time. So there's lots of different approaches to that. What I think is new is that many of these systems have not explicitly taken into account social drivers and social factors. So there's an opportunity to update and to refine these models to additionally recognize the challenges around some of the social barriers that we talked about and ensure that providers who are caring for folks who with social challenges are being. Compensated to do that work in a way that allows them to achieve the same outcomes. So that's that's part of the story and certainly a part that we've been really interested in.
Henry Bair: [00:37:50] One of the the salient things that I noted as you were talking about, all the different things, the services that Cityblock can do for the hypothetical patient that I proposed earlier was your ability and your focus on sitting down and listening to the patient's story, taking that time to build that rapport, trust, you might say. And I think for a lot of patients who are historically underserved and especially black populations, they have very justifiable reason for for having a distrust for medical practitioners, for health care institutions as a whole. So there are a lot of challenges there to establishing trust in that for those patients. I'm wondering how you have navigated that as a health care services provider and what advice you have for clinicians who are trying to improve their ability to establish trust with with these patients.
Toyin Ajayi: [00:38:52] First, to acknowledge that that most people who go into this profession, I'd say, all have a desire to to help and to heal and to accompany and to build relationships with folks. And so some of it is about sort of unlearning what you get taught as you train. For many of us, certainly in my generation in health care, and that is that it's okay to be human, it's okay to be present, and that it's really important that we sit and take the time to build a real human connection with people. That's probably the biggest thing. But we have to acknowledge some of the challenges that that clinicians are under and physicians are under, namely the lack of time that people have to spend with patients and the burden on documentation. And that is real. It's really real. And I think it contributes very much to to the burnout that folks are experiencing. So I don't know that I have some sort of like, you know, earth shattering piece of wisdom. We all know inherently what it's like to build a relationship in some way, shape or form. We take it from our personal lives. It requires reciprocity, presence, listening, active listening, engagement, compassion, empathy. These are all things we know. It's how do you bring that back and create the space back to allowing that to be important and central in that relationship in that time.
Henry Bair: [00:40:05] Thank you. Where do you see the future of Cityblock? Is this something that you think more health systems and more hospitals should be adopting?
Toyin Ajayi: [00:40:14] I would like to think so, yes. I think we're excited to partner with health care payers and with providers to kind of scale the experience of care that we deliver for sure. I think we're also very excited more broadly to see more and more entrepreneurs, innovators and more health systems and health plans, talk about health equity, talk about access to care for lower income communities, talk about what they're doing and whatever space they can with whatever resources they can to move the needle for these populations. That's really important, right? This is going to take all of us, and this is certainly bigger than one company. This is about a sea change in the experience of care for millions of people. And it requires everybody to kind of play a part in that.
Henry Bair: [00:40:58] So with our last few minutes here, I would love to ask, you know, you have dedicated your career to taking care of the people in our society who are most in need of care of this kind of unique focus that you have been able to create through Cityblock What unique insights about what matters most for patients have you gleaned throughout your career?
Toyin Ajayi: [00:41:25] So I don't know that I can answer that question. I think it's so specific to each individual. I think that's part of the point, right. Like, you know, I think resisting generalization, resisting that easy sort of extrapolation and really taking a minute to to speak to the individual I think is very important. I will say there's some general themes that we hear over and over again. Again, that will not come as a surprise. People want to be listened to. They want to be heard. They want to feel seen and valued and respected in their health care experience. And again, it's no surprise we're coming in that moment with our hardest, scariest, most personal, most consequential challenges. It is such a deep and intimate relationship. It's also such a deep and intimate moment, often in people's lives, that, again, it should be of no surprise to us that people want to feel like they were actually considered as an individual and that their needs were actually considered in that interaction and that the follow up supports the idea that they matter. That's been a very, very consistent theme across our work and certainly across my career.
Henry Bair: [00:42:28] Well, with that, I want to thank you for your time for joining us in conversation, for sharing your story or insights. And we really appreciate all the wonderful work that you are doing.
Toyin Ajayi: [00:42:39] Thank you. Thank you so much for having me on.
Henry Bair: [00:42:44] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:43:03] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:43:17] I'm Henry Bair.
Tyler Johnson: [00:43:18] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.