Leaning into Discomfort

How COVID-19, undoing systemic racism, and value-based care should shape the future of healthcare

Toyin Ajayi and Iyah Romm

Where we are today

When we wrote about the crisis within the crisis back in April, we were in the first chapter of the COVID-19 pandemic. Since then, our worst fears about the disproportionate toll that would be borne by Black and Brown communities, the fissures and disparities that COVID-19 would lay bare, have been realized.

Meeting the needs of our Cityblock members and our teams during this incredibly challenging time in our country’s history has required us to grow as leaders, to shift and change our ways of working as an organization, and to remain ever focused on meeting our members where they are. As a transformative, value-based healthcare provider focused on marginalized populations with complex needs, we’ve been focused around the clock on how we deploy primary care, behavioral health, and social services to our members, whenever and wherever they need them.

Though we needed no reminder, this pandemic continues to show us all that the people who will always suffer the most are communities of color, folks with disabilities, those who are LGBTQIA+, and people with limited economic means. There are 110 million people in the US living in lower-income communities that desperately need better-integrated care. They need a revolution. And they need it now.

As we approach the height of the summer, and as COVID-19 soars nationwide, we are charting a path forward to build the health system anew.

COVID-19 has reaffirmed the need to radically transform community health at scale — in particular for those with the greatest needs.

The shift to value-based care is urgently needed.

The impact of COVID-19 on healthcare provided by traditional fee-for-service practices has been devastating. Traditional primary care is in crisis — more than 8 in 10 primary care providers reporting that their practices are under “severe or close to severe strain” due to COVID-19, primary care visit volume has declined by up to 60% during the height of the outbreak, and along with it, revenues have simply disappeared for already low margin practices that rely on fee-for-service billing. Lay-offs and furloughs abound. Some estimates suggest that upwards of 60,000 medical practices may close due COVID-19. And although the rise of telehealth volume provides some relief, the significant digital divide in the U.S. means that lower-income communities, and the providers serving them, lose out. Community-based behavioral health organizations and many social services providers are equally challenged.

As a result, nearly half of US adults state that they or someone in their household have skipped or postponed care due to coronavirus. Traditional primary care is ill-equipped to meet the needs of vulnerable communities during this global pandemic. The fundamental economics of fee-for-service reimbursement have failed to safeguard truly essential clinical services at a time when they are needed the most.

Our experience as a value-based provider has highlighted an alternative reality; one that must become the norm in order for health services to reach those in greatest need. In response to the COVID-19 outbreak in some of the hardest-hit communities in New York City, we more than doubled our weekly member encounters, aided by new analytics models to help us identify those at highest risk of COVID-19. While other practices have struggled to keep their doors open at all, we built new care models to enhance our in-home urgent care capabilities, launched a pregnancy care program, grew our membership, and showed up for the communities we serve in novel and high-value ways. We are able to do this because our relationships with our payer partners incentivize us to deliver outcomes. Our financial structure squarely aligns the health needs of our members with our reimbursement — so that when our members need us the most, we’re able to show up. The clarion call for a hard-shift to value-based care has never been stronger, both to incentivize better-integrated care delivery, and to ensure that primary care has a clear and strong path into the future.

We’re excited to continue to grow our existing partnerships with progressive, member-centered health plans — allowing us to serve more members and catalyze better outcomes for communities like Brooklyn, Queens, central Connecticut, and central Massachusetts. And in North Carolina, where Governor Roy Cooper just last week signed a bipartisan bill to advance transformation of the State’s fee-for-service Medicaid program, we are bringing innovation and value-based care to tens of thousands of members.

Place-based and virtual care will shape the future of healthcare delivery

The recent increase in COVID-19 cases across the country reinforces the reality that this virus will be with us for the foreseeable future. This means that individuals like the members we serve, who have complex health and social needs will continue to need to receive care at home, both virtually and in-person, until a vaccine is developed. We have been able to leverage Cityblock’s technology platform and existing trust-based relationships with members to increase our use of video visits by more than 2,000% between March 20th and June 30th — demonstrating that it is possible to engage lower-income populations with telehealth modalities as an effective alternative to in-person care. At run rate, we expect that more than half of our provider visits will be via video. This approach, bolstered by our long-standing reliance on continuous SMS-based care, will enable us to provide more care to our members with better access.

The importance of the social determinants of health, and the intersection of social, emotional, and physical care have never been more clear

To keep our members healthy and out of the hospital, providers must go beyond the typical understanding of physical drivers of health to address the fundamental barriers to health reflected by poverty. So much of what determines health outcomes for individuals is rooted in the communities in which they live, work, and socialize. Well before the COVID-19 pandemic hit, providing social and behavioral health services to our members was core to our integrated care model. And during a pandemic, our members’ needs for those services, and for social connection, increased at the same rate as their medical needs. We also saw further crumbling of the social safety net amidst COVID-19, and in particular, are bracing ourselves for the impact of the rapidly widening disparities gap in food access, housing stability, and education. Perhaps most impactful have been our virtual community forums, both reminding us of the deep trauma experienced by our members every day, as well as the power of trusted relationships.

We must name race and its impacts on health

The national dialogue about race has highlighted the importance of anti-Black racism as a public health crisis, which strikes at the heart of the populations we serve. We have long recognized the intersection between poverty, medical, and behavioral complexity, and race. The approach we’ve taken since the beginning of hiring our teams from the communities we serve, who reflect the lived experiences and social histories of the members we serve, speaks to the importance of diversity, representation, and direct attention to the legacy of bias in helping to build trusted relationships with individuals from marginalized communities, driving both better lasting impact and a better business. We, like the rest of society, have a long way to go. But we are humbled and inspired by one of our members, a gentleman in his mid-70s who grew up in the segregated South, who recently reminded us:

Just imagine what my ancestors went through. We’ve been suppressed for a long time. What’s on top is gonna fall to the bottom and what’s on bottom will rise to the top. Nothing stays the same forever… There’s always going to be a change… These things take time.

So we continue on. Even once this wave of protests subsides, when the public’s attention has moved on to other topics, we will continue to be committed to building an anti-racist company, to holding ourselves and the structures around us accountable for doing the hard work of naming and addressing racism in all aspects of our lives, and to taking action when we see it in our structures of care delivery. So that one day, real change will be realized.

Where we go from here

While there is so much unknown that lies ahead of us as a society, what we do know is that we can and we should choose a better way forward — one that breaks disparities down at their roots, that builds towards a just and equal society, and that improves the health of all of our communities. We can leverage the imagination of our teams and our partners, bolstered by value-based business models that are stable and scalable, that incentivize the right investments for health, to build for lasting impact.

We are committed to Cityblock being a driving force for this change. We are a healthcare provider focused on improving outcomes for underserved communities by rebuilding trust and eliminating disparities. We will continue to deliver personalized medical, social, and behavioral health services to communities with the greatest needs. We will reduce costs and enhance quality to radically transform community health at scale.

And today, to help us continue to build this movement, we’re excited to announce that we’ve brought new partners and capital into our community, with $53.5 million in a Series B+ round of funding. Our new investment round was led by Kinnevik AB, with participation from AIMS Imprint of Goldman Sachs Asset Management and Alphabet. Existing major investors, Maverick Ventures, Redpoint Ventures, Town Hall Ventures, Thrive Capital, Emblem Health, 8VC, and Echo Health Ventures also joined the round.

We are honored to have such well-respected, impact-oriented groups joining us and supporting us in our mission. These teams understand and support our vision and are committed to creating radical change with us. This investment demonstrates conviction in the potential of integrated, value-based care to fundamentally transform health across the nation. It will help us continue to deliver strong clinical programs for our members, further develop our technology capabilities, including Commons and our virtual-first service modalities, as well as begin to serve new communities we serve. There are 110 million people across the nation who deserve better care. And there is $1.2 trillion in annual spending on Medicaid, Medicare, and dually eligible individuals, filled with opportunity for new value-creation for our communities. We can and will do better.

We look forward to working with you as we lean into the opportunity ahead, getting closer to our goal to serve 10 million people in 10 years.

More soon. Onward!