Health Equity Conversations
Toyin Ajayi (Part 2)
Through Health Equity Conversations, Joshua Liao hosts a series of discussions featuring people and groups around the country working to improve equity and health through systems change.
In this episode, Josh spoke with Toyin Ajayi, MD, MPhil, co-founder and CEO of Cityblock Health.
This is the second of two condensed parts of the conversation between Dr. Liao and Dr. Ajayi, and has been edited for clarity and length. A condensed version of the first part can be found here. For full-length discussion, please access the audio recording (available episodes accessible via Apple Podcasts and Spotify).
Joshua Liao: [In discussing the interplay between physical, behavioral, and social needs] You talked about one size not fitting all. I can think of communities and groups that say, as a clinician or provider organization, we’re not one size fits all as well. There are smaller solo practices that feel that they’re not equipped to meet [some of those identified or intuited patient] needs; and there are large, integrated delivery systems that may make targeted investments or joint ventures with other groups that do this work.
How have you thought about different organizational structures, and how that interplays with some of these patient factors that you’re talking about?
Toyin Ajayi: That’s a really interesting question; there’s lots of nuances to it. When you talk about the large integrated health systems and delivery systems, a big piece of what they have that others don’t is that they have a balance sheet that enables them, and sometimes a tax code requirement that they reinvest in communities. So often they fund a lot of these interventions out of their corporate social responsibility or out of their community benefit, as opposed to out of health care dollars.
Toyin Ajayi, MD, MPhil
Co-founder & CEO, Cityblock Health
Because a lot of these folks are straddling the fee-for-service world that gets them paid for units of health care that are delivered to people in very prescribed ways. And the world we’re hoping to get to where we’re thinking about value and real outcomes for patients. And they bridge that by making investments for things that they think and believe are really important in a way that doesn’t always allow them to be tied back to care delivery at the patient level.
So that is one thing that I am seeing, and I don’t know if that is an optimal structure for the long term because it makes it very hard to attenuate in the way that we described. It makes it very hard to link interventions to outcomes at a patient level or at a community level. It lends itself to perhaps some of the big brush strokes that we talked about, this “give everybody metformin” approach as opposed to the “let’s really nuance this and go deep for some folks, and perhaps accompaniment and other approaches for others.” The flip side is that it is a start and at least we’re having that conversation in some places.
I think for us what has been really important from an organizational structure, to your point, is by starting with real intentionality about what we’re solving for and making sure that our business model is aligned with what we’re solving for. For us that means we are a value-based care delivery organization. We take financial risk, quality risk on the total population based on their outcomes. Therefore, from the outset in everything that we do, we have the alignment of reimbursement models and incentives that enable us to really make those investments as part of our usual care delivery.
The second thing is really privileging social care alongside physical health and behavioral health. Recognizing that that is not relegated to a case worker’s notes somewhere, or relegated to an outreach program that works for some folks but not for everyone. It really needs to be part and parcel of the work that we do. We’ve been building our team around the notion that social care is a critical component of care, period. We’re thinking of it as three legs of a stool – the physical, behavioral, and the social. And the interplay between those is reflected in the way that we document the information we get from our members, the interventions that we carry out, the teams and the constructs of the teams, our focus and emphasis on our community health partners as a critical part of the team - folks who are really oriented to building trust, building longitudinal relationships with members, understanding their social needs, and then delivering care in accordance with those needs. That is critical and I think that organizational structure is so important in enabling us to deliver the types of outcomes we’re beginning to see, and seeking to scale.
JL: Are there things that we’re measuring now in value-based care delivery or payment that either matters less than we think, or really doesn’t matter as much, in terms of having a just system that prioritizes equity? [Amid calls to add more data and metrics] what do we take away?
TA: Such a really great question. I hate to be contrarian on this one because I do hear you – prioritization makes a difference. I still think we’re in this early phase of discovery. I don’t think we know yet what really matters. Again, we can intuit some of it and I think there are some strong hypothesis-driven intuitions, but I don’t think we know enough yet to say that we’re going to cut back. Because we have been operating in an environment of real paucity of data around what matters to people, and for people.
We’re like a chimera in some ways: we’re overdeveloped in some parts and highly underdeveloped in many others. We are highly underdeveloped in our understanding of behavioral health and our understanding of social health and wellbeing. We certainly need to understand what their daily lived experience is; what do they eat every day; who do they live with; how much sleep do they get; what impacts that; what are they afraid of; are they taking substances that we did not prescribe to them? We need to understand that, even at a very, very superficial level, way more than we need a whole lot of the data points that we have today on the physical health side, for sure.
This is not to in any way imply that we are scaling back or we’re changing the threshold for what excellent health care looks like. The same clinical end points matter to our patients who have medical and behavioral and social complexity as they do to folks who don’t have as much social complexity or behavioral health complexity – that is not what I’m saying. What I am saying, however, is that we probably over measure in things that we understand and feel comfortable with in health care, and we’ve been trained in a very, very medical model. So we measure a lot the metrics that we know and understand. But what we don’t yet fully understand is the antecedents to and the surrounding data points that are actually incredibly important in helping us actually impact the work for our members.
There’s two different answers when people ask me, “what’s the most prevalent diagnosis for our members?” The first answer is the answer that we measure the most, probably diabetes. The real answer I believe is trauma. It’s just that we don’t have really good ubiquitous measurements for trauma. We don’t have really solid, well recognized, universally applied measures for chronic, life-long trauma. And even the recognition that that matters.
And so, let’s start to shift the balance of what we’re measuring so that we get a better view of what’s going on for people and then we can start to attenuate. I don’t think we’re there yet.
JL: One quick question related to virtual care. I know that’s part of Cityblock Health’s approach. How is Cityblock thinking about virtual care and how it might affect equity for its members?
TA: I think the really interesting, less broadly discussed findings around virtual care particularly at the height of the pandemic are exactly as you’re alluding to: people mean different things when they say virtual health and virtual care. Typically, the nuance here is it falls on income and the ability to pay.
If you are a commercially insured individual with ready access to clinicians, ready access to data on your smart phone, virtual care typically means a video visit that is quick, on demand, with a licensed clinician who is able to at least reassure you, if not solve your problem.
If you are, particularly at the height of the pandemic, a lower income individual, who does not have smart phone access, whose primary care provider or usual provider of care did not have the technology ability to very quickly pivot to video visiting, virtual care really meant you got a phone call. And that is not always sufficient. We learned that it is more than we thought – we can do a lot more than we thought we could using virtual care, absolutely. That is an incredible lesson for us more broadly as a healthcare system to apply as we continue to recalibrate on what health care looks like post pandemic. But I think we would do ourselves, and most importantly our patients, a massive disservice by pretending those two things are equivalent when they are not.
For us, this was in many ways, it wasn’t a massive new learning. We have been, and had been, building our model around meeting our members where they are in whatever way, shape, or form that we could across a multitude of modalities – with the idea that we should be able to integrate physical health in person in our clinics, with physical health in person in their homes, with virtually enabled or physically enabled virtual care where there’s a person at the bedside in the patient or the member’s home facilitating a higher level of clinical care with another clinician.
There are so many ways to do this that I think address some of the challenges and the concerns that we’re seeing more broadly from an equity lens. And also, for many of our members, texting and calling are time-efficient approaches to receiving care for certain needs that they really want, and relish and have appreciated. So the answer is again that it is not one size fits all. We’re not going to replace our historical health care system with a virtual-only health care system that will meet the needs of any population, let alone a low-income population.
But recognizing that virtual care, if deployed appropriately, can be a really powerful tool in improving equity because it improves access for people who may not be able to get to their doctor’s office between the hours of 8-5, Monday through Friday; who may not want to have to pay for a copay for a doctor’s visit if all they need is to hear their lab results and get a recommendation on next steps for their clinical care. There are so many ways in which virtual care can be really powerful in enabling equity. It just has to be attenuated and nuanced in a way that recognizes what the overall goal is, which is to extend access, improve access, improve equity, and most importantly, be responsive to what our patients, our members, and our communities are telling us that they need and want.
JL: What are one or two things in health care payment that if changed, you feel would yield the biggest or most equitable improvements as we go forward here?
TA: I like where you’re going with this. I think risk adjustment is such a third rail in many conversations right now. But if we go back to the stated intent, the intent here is to ensure that we are right sizing at a population level the investments required to provide quality access and outcomes to populations with the most complex needs. And what we know is that most risk adjustment methodologies, particularly those deployed by CMS as an example, probably under reimburse at the far extremes of complexity. And that we are very nascent in our understanding of the ways in which social needs and social drivers are reflected in those methodologies.
I think it’s a really important part of the conversation. I think there is absolutely a risk that if we throw out the baby with the bathwater, focus on some of the negative, unintended consequences of a system like this, that we forget that we have at least an approach, or “v1” of an approach that needs to be iterated on, to ensure that we are funneling the right level of resources and investments to achieve the outcomes that we hope for – for the folks who are most marginalized, the folks with the most complex needs, for the folks who have the most to gain from that. I think that there’s a real opportunity here.
I think the other place is in recognizing payment for, reimbursement for social interventions. In Medicaid in particular, we’ve long had this challenge around paying for housing. And that’s a real challenge when we know especially at the state level, often the right pocket pays for housing, the left pocket pays for health care; it’s coming from the same place. When you take a further step up and you look at the populations with the most complex needs over time – kids in the foster care system who become young adults who are struggling with mental health and with early development of physical health comorbidities, who become older adults who now have all the sequelae of the combination of social challenges and behavioral challenges and lack of really informed, and intentional access to health care through their early childhood – they then become individuals in many instances who are more likely to be dually eligible for Medicare and Medicaid where we know that the spend associated with them is going to be incredibly high.
The longitudinal, usual source of reimbursement for care is ultimately the taxpayer. It is Medicare, and it is Medicaid. If we start to think about our collective responsibility for caring for folks across the continuum of their lives, particularly people with the most complex needs (you could say the same thing for someone who’s born with a physical disability; for a person who graduated from the NICU [neonatal intensive care unit] and struggles with intellectual disability and delay; for the person who suffered injury early in their childhood and was unable to recover their physical wellbeing), there is a cohort of individuals that we really can think differently about care for when we recognize this will be the usual source of reimbursement for care.
And therefore, we can create a longitudinal, accountable approach to investing up front and quite intentionally in delivering longitudinal care. That I think is a really wonderful opportunity that I would love to see us lean into as policymakers, particularly as we think about financing care over time.
JL: Toyin, thank you again for joining me and for this conversation. And thank you for the work more importantly that you’re doing through Cityblock Health.
TA: Thank you for having me and thank you for the work that you’re doing. This is a really tremendous series of conversations, so thank you for spearheading that.