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