A Pound of Prevention
Cityblock co-founders Iyah Romm, Toyin Ajayi, MD, and Bay Gross are proving the value of personalized, tech-enabled, value-based preventive care for underserved communities.
By David Sokol
Photographs by Paul Newson
When Iyah Romm was a first-year medical student at Boston University, he fell down a flight of stairs and landed on his head. The fall left him legally blind for three years.
“I was a patient for the first time, said Romm, “and it was a miserable experience.” He walked with a cane and had trouble navigating the hospital tower where he would receive care. He found himself confounded when healthcare staff handed him a stack of papers to convey from one specialist to another. The experience gave him a front-row view of clinical medicine’s fragmented data and the system’s refusal to treat the whole person. “Nobody asked me how I was living at home, getting to appointments, or paying rent,” he remembers, “They only asked me about my eyes.”
This wasn’t the first time Romm had seen the barriers to quality healthcare up close. Growing up in Atlanta, Romm’s mother provided midwife services to women of Caribbean descent in their community. Through that lens, Romm saw firsthand how race, socioeconomic status, and other identifiers created barriers to care.
Romm left medical school to pursue a career that allowed him to tackle the policy behind these healthcare problems. He studied biology and health policy at Brandeis University and then landed a job working for the Commonwealth of Massachusetts. While there, he met Dr. Toyin Ajayi. Ajayi was working for the Massachusetts-based Commonwealth Care Alliance (CCA), where she recalls, “I was helping to build a community care model that allowed us to provide 24/7 care in homes as an alternative to hospitals.” The not-for-profit wanted to dispatch paramedics to its Medicaid- and Medicare-eligible members’ homes on evenings and weekends as an alternative to traditional PCP delivery, which required special dispensation from the state government. Based on her conversations with Romm, Ajayi adds, “We realized we had a shared passion for solving hard problems and for improving timely high-quality care to underserved and difficult-to-reach communities.”
Romm eventually went on to work for CCA, alongside Ajayi, where he focused on improving care delivery as Chief Transformation Officer. But together they began to envision something much bigger — a personalized, high-touch, value-based healthcare delivery model that could operate at scale.
“We both had a fantastic experience at CCA,” says Romm. “But the organization served thousands of people at the time, and we had to figure out how to do this at 100 times the scale in order to have a meaningful impact.”
That vision began to come into focus in November 2016, when Romm received a phone call from Google’s parent company, Alphabet. One of their companies, Sidewalk Labs — whose mission it is to “transform urban life” — recognized the potential in Romm and Ajayi’s work. They also recognized that someone was missing from their team.
Intersecting Paths
Bay Gross was a former Google product manager working at a venture capital firm in summer 2016 when Alphabet invited him back to the fold, to participate in its initiative called Sidewalk Labs. The tech giant’s new company was largely focused on next-generation cities’ buildings and infrastructure, splashily announcing that it would develop a neighborhood of the future in Toronto. Yet Sidewalk Labs also had allotted a small number of staff to incubate other businesses related to the intersection of technology and urban life. Gross jumped at the chance to apply his computer-science and investment expertise to disruptive urban public safety and social services.
“I spent some time digging into Medicaid, because it is the singular social safety-net program from which everything else is downstream,” Gross recalls. “I saw a bunch of private equity– and venture capital–backed programs in the Medicare space that had high growth as well as high output. I also saw that nobody had tried to translate that success to Medicaid, and yet urbanization trends, growth in the elderly population, and increasing income gaps all underscored a growing reliance on Medicaid.”
Was there indeed an untapped business opportunity in delivering better care for individuals covered by Medicaid, and could Sidewalk Labs leverage Alphabet’s seed money and technology infrastructure to tap it? Gross decided that a scalable solution depended on partnering with a healthcare delivery expert who believed, in Romm’s words, “that everybody in this country deserves access to high-value, experientially positive services.” Gross posted for an entrepreneur-in-residence, fielded responses, and ultimately found Romm through word of mouth, suggesting that he apply for the gig in that November phone call. “As we met with Iyah and got to know CCA, we saw this singular background that we were looking for,” says Gross.
The timing of the conversation felt uncanny, Romm says, thanks to the recent presidential election. Campaigns had been fought and won on the prospect that the Affordable Care Act could get dismantled, “and virtually every conversation we were having was about what that would mean for Medicaid in particular.” Although Romm prefers to not weigh in on the politics surrounding Medicaid, he notes, “As someone who believes firmly in the value that Medicaid generates for the economy and for individual members, I was interested in spending every bit of my energy to demonstrate that the program is necessary and cost-effective and sustainable.” Sidewalk Labs’ interest in cities further dovetailed with Romm’s understanding that the consequences of systemic racism, classism, and other generation-spanning forces that created barriers to quality healthcare were felt the most by people living in lower-income neighborhoods.
Romm arrived at Sidewalk Labs in March 2017, and Ajayi followed suit two months later. Cityblock spun out from Sidewalk Labs in October 2017, with Romm as CEO, Ajayi as Chief Health Officer, Head of Product Mat Balez, and Bay Gross initially in the role of VP of Operations and Strategy. By July of the following year, Cityblock had begun delivering services to patients in Brooklyn’s Crown Heights neighborhood, with EmblemHealth as its first partner — and using an all-new proprietary healthcare technology platform called Commons to manage the switch from intriguing business concept to sustainable reality.
“We would all benefit from more holistic, more compassionate, more person-centered healthcare, but resourced, educated people are empowered to both demand and create those services. We’re building something for the people who frequently get left behind.” –Dr. Toyin Ajayi, Chief Health Officer of Cityblock
Under the Hood
Cityblock’s introductory group of potential clients comprised 10,000 members of the vaunted not-for-profit insurer EmblemHealth.
To illustrate Cityblock’s financial model, Gross replays the company’s pitch to the 3.1 million-member company. Surveying Emblem’s New York members, “We see about 100,000 people on Medicaid in Brooklyn who are costing Emblem a lot of money,” Gross told the company’s execs. “This is where data analysis comes in: Give us four to five years of medical claims for these 100,000 people, so that we can identify the ones who have a real complexity of healthcare whom we think we can help — people who cost $30,000 to $50,000 a year, who take a dozen or more medications, who seek care in hospitals, and who are poorly actualized in terms of results.” From its initial shortlist, Cityblock identified 10,000 Emblem members who had a confluence of longitudinal chronic disease and social determinants of health. Cityblock offered to take over these members’ primary care and to finance patient management through the cost savings achieved via high-touch prevention. Under this value-based model, Cityblock planned to save insurers millions, and then receive a share of those savings.
Cityblock was confident that by bringing together primary care, behavioral health care, and social services under one value-based care model, they could address multiple factors of a member’s health at once, improving outcomes while driving down costs. After all, as Gross says, “One day in the hospital is equivalent to several months of food stamps or 20 Uber rides to the doctor’s office. Utilization is so expensive compared to caring for somebody from a social perspective.”
From a patient perspective, the core Cityblock experience involves meeting with an interdisciplinary team of professionals to create a plan for their overall health; and this includes managing the events of their day-to-day life.
“Think of a person who is struggling to work a couple of jobs, has diabetes, has hypertension, has some depression,” Ajayi says, painting a picture of a hypothetical new Cityblock member. “That person has seen their PCP over a few years and has gotten 10 minutes at a time, half the time typing at the computer, and gotten advice to eat nutritious food and exercise more. But that person leaves feeling judged and unable to explain that they eat McDonald’s three times a week because they can’t afford to buy leafy vegetables. And that exercise is hard to do when there’s no gym and your community isn’t safe enough to put on some jogging shorts and go running around.”
The Cityblock experience provides the antithesis to that all-too-common scenario. Crafting an action plan requires a care team to listen closely to a member — about family history and recent symptoms, sure, but also about seemingly disparate concerns like the availability of fresh produce, household income, and transit equity — and to envision health goals and measurable improvements collaboratively. Nor is the Cityblock member left on their own to effect change. Besides meeting with members at home or wherever else it is most convenient, the care team will help with budgeting, access to food stamps, transportation, or whatever other daily concern that can influence health.
“One day in the hospital is equivalent to several months of food stamps or 20 Uber rides to the doctor’s office. Utilization is so expensive compared to caring for somebody from a social perspective.” –Bay Gross, VP of Operations & Strategy at Cityblock
A cornerstone of Cityblock’s tech infrastructure is Commons, the platform designed to assist care teams on the job. Collaboratively designed by care providers and engineers, Commons processes data from a range of sources in order to help streamline care between interdisciplinary teams in the field and improve the decision-making responsibilities they share with patients. Commons consolidates a patient’s medical, behavioral health, and social background information — from electronic health records, pharmacy claims, community data, and other sources — into one holistic view, and it keeps care providers apprised of a member’s wellbeing in real time by way of hospital admission alerts, a video portal, and other means. The platform also offers workflow tools like clinical decision support and evidence-based protocols, so that teammates may make informed choices about a member’s course of action. The platform even makes new suggestions for care as all the underlying data are refreshed.
Of course, Cityblock’s leadership acknowledges that all the technology in the world is useless without the right people driving it, and the company is building a workforce of determined, indefatigable believers in its vision. They certainly have heavy lifting to do, starting with enrollment. Patients can be difficult to reach, thanks to the social factors like housing or job insecurity. In the end, for the Cityblock team, it’s all about meeting potential members where they’re at.
That said, even when located, someone might not buy into the Cityblock message, says Gross. A Community Health Partner — the person who leads one of Cityblock’s interdisciplinary care teams — may have to show up at the ER or visit and chat with a person five or six times before achieving enrollment.
If enrolling a member is an exercise in building trust, the care team has to work hard to maintain it. “Trust is the thing that unlocks the door to the outcomes and attributes in the system we want to build,” Ajayi says. “By systematically asking about social needs and non-medical health-related drivers, and following the logical threads of those answers, we can deploy and prioritize interventions, coach behavioral changes, and champion healthcare resources for better outcomes.”
Romm calls Cityblock “a fundamentally new type of health system.” Although he is careful to note that the business is constantly evolving and willing to take growth very slowly, there are undeniable signs that Cityblock’s invention is striking a chord in the industry. In addition to EmblemHealth, the company recently partnered with ConnectiCare to care for members in the Waterbury, Connecticut, area, and it is gearing up to do so in North Carolina in partnership with Blue Cross and Blue Shield of North Carolina later this year. “I would say that we continue to receive really positive reception, and our member experience scores are higher than anyone on our team has seen before,” Romm says.
“We would all benefit from more holistic, more compassionate, more person-centered healthcare,” Ajayi agrees, “but resourced, educated people are empowered to both demand and create those services. We’re building something for the people who frequently get left behind.”
Today, Cityblock is not only filling a critical gap in the healthcare industry, but it also may become a rallying cry for even more systemic change.
Message Iyah Romm on StartUp Health HQ. Learn more about Cityblock Health.
Learn more about StartUp Health Moonshot Academy and the Access to Care Health Moonshot.
Sign up for StartUp Health Insider to receive industry news, funding insights, special access to events, and more delivered to your inbox every Wednesday.
