‘The cherries we want are really sick people’ (The Agenda)

‘The cherries we want are really sick people’

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The gap between haves and have-nots in American health care isn’t just driven by insurance and access to doctors. It’s exacerbated by a deep structural problem: Many poor people suffer from long-term ailments that the system has little financial incentive to treat. But now a New York City start-up thinks it can use Google-level tech savvy to help make progress on that challenge—and save the government money.

Called Cityblock Health, the startup is trying to create a billion-dollar business by doing health care for the urban poor the way experts say it should be done: creating primary care-based hubs in densely populated areas where patients can also get mental health services and connect to shelter, food and jobs.

Many reformers have tried to tackle the problem over the years, often crashing against the realities of caring for a deeply impoverished population with Medicaid or no insurance at all. With venture capital money and brains and technical savvy from former staff with Google and financial data services firm Bloomberg, the company’s backers think they can do the job better by combining millions of data points with the computing power to make sense of a patient’s circumstance and determine the best way to care for him or her.

By meeting the poorest sick people’s key needs, the company hopes to keep them healthier and happier and out of emergency rooms and hospitals where care costs a fortune. Medicaid will save money, goes the theory, and the company will get a share of those savings.

Cityblock, which launched in September and got a major infusion of cash in January, plans to open its first clinic this spring in central Brooklyn. If it works, the hubs will spread to other cities nationwide by the beginning of next year.

Variations of this approach have been tried, with varying success, by a few health care systems and companies, including Commonwealth Care Alliance, the Boston-based insurance company where Cityblock CEO Iyah Romm previously worked. Traditionally, nonprofit and safety net health care institutions provide care for low-income, sick people, who are expensive and hard to manage, while the Big-Business approach to health care is to take the opposite approach, looking for relatively healthy patients and those with conditions more lucrative to treat.

“We are going to cherry-pick, but the cherries we want are really sick people,” said health care executive Mario Molina, an early investor in the project. “We don’t want a bunch of healthy people.” Romm said Cityblock plans to serve a broad population, regardless of how healthy or sick.

The common rule of thumb is that 5 percent of patients are responsible for 50 percent of the spending on health care in the United States. Cutting into that spending is appealing—not just to the government but also to private insurers, said Andy Slavitt, a Cityblock investor and board member who was previously a health insurance executive and former President Barack Obama’s chief of Medicare and Medicaid services.

Two new factors make this feasible. The first is that the federal health care system, and many private insurers, are moving toward what’s called “capitated” care—that is, they are starting to pay doctors and hospitals a fixed amount per patient, rather than paying procedure by procedure. That encourages the health care system to view each patient as a whole person, and to value preventive interventions instead of expensive treatment for preventable illnesses.

The second is data. Coordinating care among patients is difficult—it requires clear communications and information. Molina believes that clinicians will get better at keeping people healthy when they get better tools such as predictive analytics, computer decision prompts and the like.

Romm won’t talk in detail about the software Cityblock is developing—it’s called Commons—but said it brings to bear everything from government statistics to each patient’s medical history, housing history and family connections—along with commercial information about the services the company procures for its patients.

“If you’re a doctor, you want to know, does this person need an MRI? And then, what’s the cheapest place to get it? Is it on a bus line?” said Molina. “These kinds of information could be brought into the clinical system.”

Romm became sharply interested in health care policy in 2007 while in medical school at Boston University—but not because of his classes. Just two months into his first year, Romm fell down a flight of stairs and landed on his head, suffering an injury that caused him to be legally blind for nearly three years.

He learned to walk around with a cane, got somewhat depressed and had plenty of opportunity to see how challenging it is to interact with the health system every day, even for people with money and education.

One day, an eye doctor handed him a printed discharge summary and a pile of papers to take to another specialist. “Do you have any questions?” the doctor asked. “I literally thought he was joking,” Romm said. “Yet we do this to people every day. We have to do better.”

The experience led Romm into health care in the Massachusetts’ state government and eventually to Commonwealth Care Alliance, a small insurer, borne of the disability rights movement, that focuses on physically and mentally disabled people who qualify for both Medicaid and Medicare. It currently has 25,000 or so patients on its rolls.

Commonwealth focuses more than most health care payers on home care, an approach Cityblock also intends to take. That company’s success, Romm said, “is a perfect manifestation that nothing can replace the trusting relationships that come from one person talking to another person about their health and those factors around it.”

Romm was brought to New York by Dan Doctoroff, a former aide to New York Mayor Michael Bloomberg and former CEO of Bloomberg who in 2015 founded Sidewalk Labs, an Alphabet company (Alphabet is Google’s parent) that focuses on bringing technology to city life.

Investors and board members appear intrigued by the combination of clinical, business and tech experience behind Cityblock, which Romm developed during a six-month residence at Sidewalk Labs.

Cityblock’s biggest asset, said Slavitt and Molina, is its staff, including Toyin Ajayi, the chief medical officer, also from Commonwealth Care Alliance, whose career has focused on caring for homeless and mentally ill people, and Chief Product Officer Mat Balez, one of the brains behind Google Glass and Google Maps.

Slavitt has started a fund to invest in early stage companies working with poor people with conditions like opioid addiction, difficult pregnancies and kidney disease. He thinks there are tech-powered ways to make money by trying to “improve lives in meaningful ways rather than trying to create the best Fitbit for a well-off 60-year-old.”

Such models have worked elsewhere, if not in a revolutionary way. In 2012, Oregon got the state’s hospitals, doctors and insurers to agree to convert its Medicaid program into 16 regional Community Care Organizations. Over five years, they cut the state’s Medicaid spending increase rate from 5 percent to 2 percent, and exceeded most of their health goals, too, said Jeff Luck, a researcher at Oregon State University—fewer underweight, preterm babies, lower diabetic blood sugar levels, fewer asthma hospitalizations.

“If your goal is to control Medicaid spending, you’re going to try to identify the people with the most complicated and severe problems and ensure they get into a well-coordinated, team-based care environment,” Luck said.

The hardest part, Luck said, has been coordinating mental and physical health care. Different types of providers fight over payments and it’s not easy for primary care doctors to get the information they need about a psychiatric patient’s conditions. Privacy laws limit sharing of sensitive data, and counseling frequently takes place in separate health care facilities.

Cityblock plans to combine data and use it to offer intensely personalized care—a mixture of primary and behavioral health, and social services, with a lot of home care as well as telemedicine and other digital communication with patients.

In some cities, Romm said Cityblock will start from scratch, hiring new doctors, nurses and social workers to kit out new health care-centered hubs. Elsewhere, it will build on existing bases of good primary care. Cityblock hubs might be located in existing health clinics or in church basements or storefronts—but always in neighborhoods near subways or other mass transit.

The motto is, “disrupt but don’t displace,” Romm said. If people are happy with local services, Cityblock doesn’t want to force them to go to new ones. From a business side, Romm said, Cityblock has already drawn intense interest from managed-care companies that are losing money because their patients are getting services in hospitals rather than their communities, he said.

State and federal governments spent nearly $600 billion on Medicaid in 2016. Romm thinks he can run a socially responsible, helpful business that profits off some of that money while returning another chunk of it to taxpayers.

While people make a lot of money off Medicaid, “it’s not serving the people who need it most very well,” Romm said. “We think there’s a meaningful opportunity to shift that to serving the community.” In addition to serving poorer clients, Cityblock plans to hire locally and encourage community businesses to partner with its hubs.

In a conversation at a coffee shop in Williamsburg, an area whipsawed by gentrification over the past decade, Romm acknowledged that capitalist churn “is incredibly disruptive for peoples’ health, social networks and communities.” No matter how the health care system shifts to address the various burdens of poverty that feed into poor health, it can’t be a cure-all.

“There are so many well-documented examples of socioeconomic and gender and racial inequality and inequity,” Romm said. “What I really hope we continue to see more of, and I hope we can be a vanguard for, and soon have competition, is companies bringing business savvy to those problems.”

Arthur Allen is the eHealth editor for POLITICO Pro.

via The Agenda

February 11, 2018 at 03:54AM

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