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Toyin, thank you for coming to Giant Ideas.
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>> So, I am delighted to be here.
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>> Really appreciate that.
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Um before we get into your giant idea, I actually want to pick up on one thing I saw you write or talk about, which was just the kind of feeling you have or had as a doctor, cuz you were a doctor before you started this business, and the the sort of all of the the privilege that is to kind of sit by someone's bed.
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I'd love to hear that first.
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>> Yeah, you know, I I went to medical school a little bit reluctantly.
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I I always knew I wanted to solve big problems in the world, specifically around healthcare and access to healthcare for lower-income people and people who sort of got left behind.
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And the sort of social justice mission of healthcare was very compelling to me, and I always thought I would do something more public healthy or more sort of structural institutional.
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Um but getting a medical degree seemed like a good way to sort of gain some credibility and some experience prior to whatever that other big thing is that I was going to do.
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Um and I was actually pleasantly surprised um by how much I really really love being a doctor.
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Just the actual sort of hands-on bedside um the element of being with a person, and you know, it's it's a pretty unique experience to be with someone in what for them will be a singular, potentially the worst moment of their life, right?
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For many people, um particularly the kind of clinical care that I practice, which is acute hospital medicine, um this is like a memorable terrible thing that has happened to them.
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And to be able to maybe make that terrible thing slightly less terrible by being approachable and trustworthy and caring is quite a privilege.
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Um you also get an insight into people's lives that that you wouldn't otherwise.
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And um and I just I sort of fell in love with that.
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>> Do you think doctors should have to become less empathetic in some ways over time or hardened because you see so many terrible things, and you can't, you know, live in every single moment of these awful situations cuz it's unbearable.
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How do you feel about that?
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>> It's a really tricky one.
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I think, you know, a lot has been written and talked about the sort of burnout and the loss of empathy and the depersonalization and dehumanization of health care.
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>> [gasps] >> And a lot of that honestly has been wrought by technology and by the pressures of the business model of health care.
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I think it is possible to be both deeply human and empathetic and also be removed enough and objective enough to do your duty as a doctor.
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It requires work and it requires space and it requires time.
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And we haven't given physicians a lot of that.
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But I think that's really important.
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I think if you if you forget that there's a human being on potentially the worst day of their life sitting in front of you as you're doing whatever it is you're doing that is very routine.
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You you may you won't show up in the way that they need you to and you sort of lose the ability to really offer comfort.
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And sometimes that's the only thing we can do in health care.
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>> Your joint idea as I understand it is value-based care, which sounds, if I'm honest, a bit technocratic and kind of dull and the sort of thing a management consultant would say.
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I In prepping for this, I actually found it the most big idea I've heard in in years actually. Very profound.
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Simple but very profound.
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Could you just tell us a little bit about what that actually means on a human level for patients, for doctors?
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How is it done when it's not done through value-based care in the US?
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And then what is value-based care?
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>> Yeah, first of all, the worst brand you can imagine, right?
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Like you think like value-based health care and they're like the discount aisle, you know, half off kind of [laughter] like it doesn't feel to the patient like something you want.
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But but if you take a step back and kind of look at the way that our the business of health care is is constructed today in the United States.
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And that's very different.
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I trained actually here in London.
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I went to medical school not far from here.
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And in the National Health Service and it's a very different sort of funding mechanism and delivery system.
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But in the US, we primarily deliver health care through what we call fee for service, which means that as a physician, I get paid for the unit of health care I provide.
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That might be a consultation in my doctor's office, it might be a surgery, it might be a wound debridement.
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Um I see the patient in front of me, I do a thing for them, and I get reimbursed for that.
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Which sounds well and good.
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That is how most transactions in our economy occur, right?
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You provide a service, you get paid for it.
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The problem is, of course, in health care, the goal is to actually achieve an outcome.
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And that outcome is quite measurable.
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And so, instead of paying for did you get better or is your health improved or did you actually pick up that prescription and feel improved from whatever symptom you came in for, we're just paying for getting doing the thing.
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It's like, you know, if I pay for a haircut, it is because my hair was cut and I got an outcome that I wanted. >> Right.
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>> And so, the sort of transactional nature of that makes sense.
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In health care, paying for inputs doesn't actually secure outcomes, right?
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And so, what we have is a system in which the incentives to do things are the predominant driver of our health care system and its economy.
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And the the ways that we think about sort of improving the P&L of health care providers is by doing more stuff that costs more money.
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No surprise, that is entirely antithetical to what is necessary to make a person healthy because actually often the things that make you healthier are cheaper and are reimbursed lower and don't result in a massive surgery or a massive hospital stay that creates more revenue for the hospital.
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And so, we have this entirely backwards.
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What value-based care seeks to do is to basically tie reimbursement for health care to outcomes. >> Okay.
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>> So, instead of getting paid on a per unit of care delivered, you get paid for outcomes.
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So, did this person have to go to the hospital for their diabetes because it got worse and they ended up needing an amputation or actually were able to keep them safe at home?
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If so, we should pay more money for the keeping them safe at home and less money for the bad outcome.
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And so, what we've done is built a business that is oriented around those financial principles.
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And what's really interesting is that when you do that, you then create a totally different healthcare system because the incentives are completely different and your your investments need to yield a different very different type of outcome and result.
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And so we are now incentivized to pay for things like community health workers and social workers to do home visits.
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It's not enough to wait for the patients to come to me and then bill for whatever I do for them.
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I actually have to go find them because sometimes the right intervention is preventing a hospitalization and preventing a person coming to you.
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Sometimes the person who needs you the most is the least likely to come to the doctor's office.
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And so that that sort of structure, the business model of value-based care actually then creates and engenders a totally different care delivery system that is actually potentially fit for purpose to change outcomes.
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>> So to maybe figure it out a little bit, a health insurance company say, let's say a patient who's on Medicaid might cost them $60,000 a year. >> Mhm.
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>> And is the idea that, you know, instead of doing that, they will give you $55,000 a year to City Block and then it's up to you to make sure that that patient doesn't incur more than 55,000.
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If if it's a that patient incurs 40,000, you can keep the profit, but if it ends up, you know, in a situation where the patient has a very expensive surgery and it's $200,000, City Block has to pick up the bill.
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>> Is that basically how it >> Yeah, that's basically how it works. Essentially, yes.
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And and then there is of course underneath that, right?
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Like there are expectations around quality >> Okay. >> and service, right?
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You can't you can't just make it cost $45,000 >> by doing no healthcare. >> Right. >> Right?
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You have to make sure that you actually provide more.
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And so there there are real checks and balances and incentives aligned around making sure that we're actually investing in the right types of care.
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>> In terms of the way it's currently done or was done before you guys turned up, what are the let's talk about the on the individual kind of doctor and patient level.
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These incentives to basically as a doctor, you're going to get paid by doing more procedures, more expensive procedures, do a surgery, you know, prescribe the expensive drugs.
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Would you say that, you know, on average in America doctors are kind of knowingly doing that?
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They're knowingly, you know, over prescribing.
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They're they're over doing surgeries.
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Or is it more of a kind of pernicious way that people are trained and the kind of nudges are there?
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Yeah, how broken is it on the individual doctor level? >> a great question.
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I think that, you know, people go into health care wanting to do the right thing.
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I was that person, you know, every day seeing patients.
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It's There There certainly is evidence that that that physician behavior is influenced by incentives. That is true.
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So, as an example, if you are a urologist and you also happen to own a lab, you tend to take more biopsy samples than maybe you might otherwise because you get paid for the the other procedure.
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So, there's there's things there, right? Like, for sure.
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But the I think the biggest and most pernicious part of it is that the entire operating model isn't set up for success.
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So, as an example, I'm a primary care doctor in a clinic.
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I'm doing my abs I like well-meaning.
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I'm working in an underserved community.
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I'm serving primarily Medicaid patients.
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I get in every day and I've got 30 patients on my schedule and I've got 10 minutes to see each one of them.
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And I'm just turning through, right?
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Back of my head, I think, gosh, there's that person I saw last week, you [snorts] know, when I explained their new medicines, it it wasn't quite clear to me that they got it.
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I'm not sure what's going on at home, but like my spidey sense says that maybe there's no one there to help make sure that they actually remember to take their meds.
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>> [gasps] >> Uh, >> [sighs] >> goodness.
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Um, but I have no time, nor do I get paid to make the follow-up phone call, to try to find his daughter and communicate with her, to God forbid do a home visit and actually open, you know, the medicine cabinet and sit at the dining room table and go through everything with them.
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And so, when this patient shows up in the emergency room a week later, despite the fact that I just seen them and give them a prescription that I thought would work, because they didn't understand the meds, because they didn't have the support they needed, it is of no surprise to me.
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But I was not set up to do anything about it.
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And [snorts] I'm not penalized for that.
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So I have no incentive to change my behavior either, right?
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Um and that's where it that's the where the perniciousness comes, right? It's it's so inbuilt. >> Yeah.
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>> It's so inbuilt into the systems and and and ecosystem around healthcare that I'm incentivized to see the 10 people who showed up in front of me.
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And gosh, if somebody doesn't show up, like I'm going to take a breather and have a cup of coffee and catch up on my notes and maybe I won't have to stay up until midnight documenting in the electronic health record. What a relief.
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I'm not incentivized to think, gosh, that person who didn't come, is it because they're passed out overdosing on a park bench and they just need somebody to go find them.
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Is it because they got incarcerated and maybe we can help them next time avoid that outcome.
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Is it because they're in an emergency room?
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I have no idea, nor do I have the incentives to do anything about it.
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>> When I was preparing for this, someone told me to ask you about your first patient, because they said that was a great way of kind of understanding how this thing works.
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I think it was an an elderly man in New York.
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>> My very first patient, goodness gracious.
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>> With City Block, I mean.
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>> Um so our very first patient was It's funny that I remember this.
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I can't believe I just Did I talk about this? I don't know.
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Um when we first started City Block, I was I was the only physician on the team and so I was sort of building the clinical model and also seeing patients in Brooklyn.
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And the very first patient we found um lived He was an elderly man.
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I can't believe that I I cannot believe you pulled this up out of the archives.
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Um he was an elderly man and he lived um in He had a He had an like a a home, an old brownstone.
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But um like many families in in New York, the cost of upkeep and taxes were completely insurmountable and it's it unclear sort of who owned the thing.
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But he basically lived There was only one part of the home that was habitable.
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And he lived right in the bottom, the basement of it.
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Um when we got there, there were the lights were out.
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There was no electricity.
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He was partially blind, had barely left the house, had multiple comorbidities, um and was living in what felt like squalor.
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I mean, I I you know, I don't know how else to describe it, especially in the context of this being the United States.
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Um it was shocking to me the conditions in which he was living.
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Um he had not seen a doctor in a very long time.
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Um he was taking the meds the best he could, but he couldn't see particularly well.
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Um I was concerned about his physical safety, his ability to get up and down the stairs if he needed to.
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Um the home was not particularly sanitary.
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Um and that is that is not an atypical um experience.
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In fact, we've seen many, many people um in our Cityblock experience living in conditions that would rival many of the developing countries that I've worked in.
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And so, what did you find?
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Well, the first thing we did was just show up and say, "Here we're here.
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Let's figure out what's going on for you."
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Um the the benefit of being able to bring a clinical team to the home is that you can see and do so much more than you would otherwise.
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So, you know, we could pull out his meds and say, "Well, what is he taking?
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What should he be taking?
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When was the last time he was seen?"
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We can get labs done in the home.
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Um we were able to communi- communicate with the family and find out just, you know, what the social supports were around to make sure he had food and support.
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Um and we were able to both refresh his diag- noses and understand what he needed, actually rationalize his medicines.
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Often what happens for older people is if they've had a couple of hospitalizations, some nursing home stays, three or four specialists, they have a lot of meds, many more than they need, some of which can actually worsen cognitive decline and um worsen their ability to care for themselves.
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And so, we actually shortened that list and were able to keep him safe at home.
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>> And so, because of the incentives where you are, you know, on the hook for the upside and the downside of someone's actual health results.
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You are able to do things, home visits, preventative care, that are just not happening in the usual model of health care. Is that right? >> That's right.
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And the proactive outreach.
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So, it's even before you even get to do the home visit, you have to find the person.
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Um and you know, if you're a person on Medicaid like most of our our patients are members are, um you have a lot of demands on your time and energy.
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Uh there's the cognitive burden of keeping track of your appointments and going to see doctors, but there's also your time, which is your most precious asset.
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Um and the opportunity cost of taking a day off of work and going to a doctor's office and waiting for an hour in a waiting room and only getting 10 minutes of a visit.
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Um often the math does not math for folks to come into the clinic. >> Yeah.
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>> Um in a traditional health care system knowing what they're going to receive from it, right?
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Which is 10 minutes of a doctor's time.
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Um often doesn't feel like they're paying attention to you cuz they're so busy typing.
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Um and and often unresponsive to the sort of broader social needs that are driving people.
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Um and so and so finding people actually is non-trivial. >> Okay.
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>> These are a lot of folks who don't want to come to see traditional health care.
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And so we have to go to them, find them, um earn their trust, find a way in to to to to be able to support them so that they acquiesce and agree to being part of our care model. >> Mhm.
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>> And then providing them the care they need.
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>> And give us a sense of how many people there are.
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How many people are on Medicaid in the US for example?
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>> Yeah, there's about there's about 70 million people on Medicaid.
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>> So, this is a huge part of the US population. Correct. Okay. Okay.
14:59
>> And then [snorts] think another 70 or so who are on Medicare.
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So, we're talking about 140 million people.
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>> What strikes me is that that is an enormous societal, importantly uh cha- challenge to solve.
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It's also an amazing business opportunity.
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And and it's been completely overlooked basically apart from Cityblock as this huge success story.
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One of our fastest growing startups we backed at Cityblock RX diet, who who provides um meal kits, AI generated meal kits for people often on Medicaid.
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>> [snorts] >> And they their revenue growth is like nothing else, you know, it's absolutely extraordinary.
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They're creating incredible value for patients and they're building an amazing business.
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But other than them, and they're very early stage, and and City Block, there are very few examples.
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And and it feels like the kind of the startup community, the venture community, just like totally missed this.
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But you had this kind of I guess experience arbitrage because you and your co-founders have been right.
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You you just were living in this world of treating people in this world and saw something that most people in Silicon Valley just didn't see.
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>> Yeah, I mean, in in sort of VC speak, right?
15:58
Like this is a massive TAM, right? It's a huge huge market.
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And it is it's quite a stable one, right?
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Even though we're going through flux with Medicaid, um and we expect there'll be some shifts to the number of people on Medicaid in the next few years, we're still talking about ten- tens of millions of people um who receive and whose ultimate payer is the US government or a state in the US um that is, you know, co-funded by the US government.
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So you think like, okay, we've got a very very very stable, huge potential customer base.
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We've a very stable payer.
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That's huge and deep pocketed.
16:36
Um uh you know, all of these these sort of these entitlements are enshrined by Congress in the legislature, right?
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We have to provide these supports to these people.
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Um and we've a massive massive massive like perceived need on the part of the payer and the managed care, the insurance organizations because the pace of increase of medical trend of costs is so high. And so it's it's big.
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Now, all the reasons to not want to do this is it's hard.
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Um [clears throat] it's very hard.
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These populations are not like the populations that many venture-backed companies build for.
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Um I think many big successful, I would say most big successful venture-backed companies build for customers like themselves. >> Right.
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>> Um and so and so they sort of experience and the empathy gap um and the need for real product driven um thinking, which is like listen to the listening to customers, researching, testing and iterating, making no assumptions about what will work. Um that is it's hard.
17:33
It's a hard business to build.
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The margins are thin, right?
17:37
We're talking about health care dollars here.
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It's a services business. The inputs are costly. They're human beings.
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Um and so I understand um and when we were sort of, you know, starting out eight years ago now when we were raising our series A pitching folks, there were a lot of folks who were just like absolutely not.
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That sounds really hard um and so unlike anything they'd done before.
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Um but but we we persevered and we were able to to to raise capital from an incredible group of investors who really get the vision and understand this is a this is a business that as we've proven out can get ginormous and we're only really just getting started um just given how big the market is and how big the demand is.
18:16
>> Give us a sense of of just how successful it is.
18:19
>> Yeah, so we are we're at about a billion and a half of revenue um annually.
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Um we serve about 150,000 people across 11 states.
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Um we're partnered with all the large Medicaid and and and Medicare insurers.
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Um and as I said, it's just, you know, there's the the demand is humongous.
18:39
There's so much more to do. >> Yeah.
18:41
Let's talk a little bit about the the tension if there is any between building a good business and then doing, you know, the right thing for for patients because, you know, it is so clearly to me a much better way of doing this.
18:54
Much better for patients.
18:54
Like America kind of needs this, right?
18:55
Um but I imagine there must be moments almost every day there are kind of micro choices by all of the people working for you delivering this care.
19:04
There must be micro choices every day to say, you know, we could make more margin for Cityblock if we did a pretty good job, but, you know, didn't go the extra mile.
19:13
We you know, and so a trade-off constantly having to make a trade-off between investing more Cityblock resources versus a kind of better long-term patient outcome.
19:20
What's the kind of framework that you've set as the leader to help people make those decisions?
19:26
>> Such a great question.
19:26
What you do when you're managing sort of a population of people is you make explicit what has been implicit and you try to create a more just and a more data-driven approach to resource allocation. Okay.
19:41
Which is to say I've got a population of people, they all have very different needs in any given moment in time and I have a finite group of resources.
19:46
I've got so many nurses, so many doctors, so many dollars.
19:51
>> [gasps] >> Who needs a home visit from a doctor and a community health worker?
19:53
Who needs, you know, 6 hours of my time figuring out what their psychiatric history is and doing a medication reconciliation issue in their home versus who needs a phone call?
20:04
And before, that would be determined by well, did you have the good luck to show up and see this doctor today?
20:08
Or outside of the Medicaid population, do you have enough money to have a concierge doctor?
20:16
Do you can you afford the supplements and the out-of-pocket costs and insurance coverage and all the other things that are sort of the ways that our traditional system used to sort of rationalize who gets care.
20:28
In in a value-based care model, we try to use data to determine how we leverage resources and tools.
20:35
And what that's led to has been um pre-AI, I would say, a better but not perfect approach to this, which is to say, if you are a frail senior living at home, like this gentleman that we were talking about, you know, in in the basement of the home, who who's visually impaired and may not be able to get out on his own, we're going to send somebody to you.
20:57
And we're going to probably send someone to you multiple times a month.
21:00
And that person's going to be quite highly skilled and quite expensive.
21:03
Um if you are a 22-year-old and you are on Medicaid because you're pregnant and you have sickle cell disease, but actually you get out and about pretty well and you're pretty good with your smartphone, we may not send a nurse practitioner to your home.
21:19
We may send a nurse at a specific period of time when it seems like you're most vulnerable.
21:23
But otherwise we're going to text you and we'll call you.
21:27
And we get it right most of the time because we've invested a lot in our data and our analytics and our machine learning models to help us figure out who's at highest risk.
21:35
With AI, I think we're we're sort of embarking on this really amazing moment, which you know, my enthusiasm for this is is sort of boundless at this point.
21:46
>> [laughter] >> Because we finally I think are approaching a place in which the marginal cost of every interaction is getting as close to zero as I've ever seen it, which means that I don't actually have to apply quite as rigorous I mean, we'll do it with the data, but it the cutoff is much lower, right?
22:02
We can make a phone call to every single person every single day if we wanted to.
22:08
If we thought that was going to be useful, we'd do it using AI, right?
22:10
We can we can be even more surgically precise about where we need a human for what.
22:18
And we're enabling them with tools that allow their moment in front of the patient to be even more impactful.
22:25
And so it's changing entirely the unit economics of our business both in terms of how we think about resource allocation at large, but also about how we think about um, what is possible for a population of people and where it is possible for us to touch them and engage with them in ways that are really productive.
22:40
The premise with which we sort of founded the business is that we have more than enough resources actually.
22:46
This is not a resource problem.
22:47
It's not a I mean, we're spending in the United States more money per capita on health care than any other country on the planet.
22:52
So it is not that we do not have enough money or that we don't have enough resources.
22:58
It's that we've misallocated them like woefully.
23:00
And so our work has been to reallocate those resources effectively so that everybody gets what they need when they need it.
23:07
And net net what that means for our population is they're all getting more than they would have gotten in a fee-for-service system.
23:14
Um how much more is it dependent on their need?
23:16
What we're able to do now is scale that even further.
23:18
Um and that is like so exciting to me.
23:22
>> With [snorts] AI in healthcare, what we're seeing a giant is at one end of the spectrum, right at the beginning of the healthcare journey in some ways. AI for drug discovery.
23:29
We have vaccine companies that are doing unbelievable things, predicting how proteins interact.
23:34
It is really clear that drug discovery is about to go to a whole new level.
23:37
So, that's really exciting.
23:37
And then in the actual kind of healthcare infrastructure, in the hospital systems, the health systems, at the moment it's slightly depressing to me that AI is mostly being used for sort of back office optimization.
23:49
And and particularly for basically extracting more value for the healthcare systems, the the commercial healthcare systems, rather than really helping, you know, front office, people getting better healthcare.
24:02
How do you think you can change that with Cityblock? >> 100%.
24:05
I mean, I think this is this is where like the incentives really matter.
24:09
And so, we started talking about value-based care and that framework matters so much because I think AI doesn't it just makes us more effective at doing the things we were doing before, right?
24:18
It's not going to change fundamentally who we are and what we are and what we do.
24:24
Um and so, if you have a healthcare system that is predicated on getting paid as much money as possible for every unit of care that is delivered, agnostic to whether or not it delivers an outcome, then you apply AI to that and the most important and most uh potent use cases will be to do that.
24:42
And so, you what you're saying is exactly true.
24:43
I'm like very distressed by this, right?
24:45
Like we're seeing the majority of healthcare AI dollars put behind inflationary like forces in our healthcare system at a time when we can least afford it.
24:58
None of them are really, really tied to value creation for patients or for the health care system at large.
25:04
So, getting paid more money for doing the same procedure I did last week or last year because I'm more effective at billing for it does not make patients healthier.
25:16
And it does not make our health care system more affordable.
25:19
It just means more revenue for the health care providers.
25:22
Until or unless we apply those tools, these powerful, powerful tools on business models that are actually designed to deliver better outcomes at a lower cost, we're not going to see them that sort of materialize, right?
25:34
And so that's partly why I feel so bullish about kind of where we sit in the health care ecosystem is that we've been we've spent the last 8 years operating in a business model that is designed to improve quality, improve outcomes, and improve experience for patients.
25:49
And we can measure all three of those things and we demonstrated our ability to do all all those things and we are fully incentivized behind them.
25:55
And now you just like pour AI on that and we can do all those things better and faster.
26:01
Like, yes, more please, yes.
26:01
Um, and until or unless I think others understand that that the way that AI is going to meaningfully change health care services, so I agree with you on drug discovery. Yeah.
26:12
Um, cuz that's their incentive to just bring more things to the market that like actually work, right?
26:18
Like the incentives actually work around that.
26:19
You know, we have a we have a an affordability problem which we need to solve elsewhere.
26:23
Um, but but for the perspective of the drug manufacturers, like their incentives are entirely aligned to make us potentially much, much, much healthier, right?
26:30
And give us the tools to be much healthier.
26:32
I'm so excited about that.
26:34
The services infrastructure is still not built on the right chassis by and large.
26:39
And these folk like we have to move. >> Yes.
26:43
>> And and it it's almost it's almost more imperative now because the tools are so powerful.
26:47
We can do a lot of damage in our existing system if we apply the same tools to that system. So, we got to move.
26:54
>> For for for listeners who are not in US healthcare, I cannot emphasize enough just how much the odds are stacked against you.
27:00
Our friend David Goldhill with Sesame Care, you know, Halley with the work she's done, Halley Tecco we had on the show we work with, and you are just up against immovable forces.
27:09
And it's kind of amazing the scale you've got to.
27:12
I'm I'm wondering whether what your long-term vision is and your kind of legacy might be what you do with value-based care works so well with the population you serve.
27:21
But there's no reason that this couldn't be the model for all of US healthcare.
27:25
This should be the model, right? Value-based care.
27:26
Is is that the long-term goal?
27:29
>> Yes, yes in some ways.
27:29
I mean, look, when we first started, we were, I think, really an N of 1, right?
27:32
Like the first like meaningful venture-backed company to say we're taking on Medicaid, and we're taking like real capital and amazing investors who are not, you know, social impact investors per se, like people we can prove that there's a real hard ROI to doing this.
27:47
Since then, there've been dozens of companies now seeking to sort of follow in our footsteps.
27:53
And that feels like a huge part of our legacy, right?
27:55
Like there's enough for all of us.
27:56
I'm so excited to see, you know, we with there there's conferences now, whole healthcare conferences that are about Medicaid and value-based care.
28:04
I'm like, "Oh my god, this is incredible."
28:05
Um and so that's part of the legacy is to say, "Let's let's spawn more and more and more innovators, including people who used to be City Blockers, right?
28:13
Going out to build their own businesses."
28:15
Like I couldn't be more proud of them and the the legacy that we've spawned there.
28:18
But I do think that um that the system is so unstable in the United States right now.
28:26
Um and, you know, I think like what never waste a good crisis, right?
28:28
We're in crisis right now.
28:29
Like we're we are >> Big cuts coming as well? >> Big cuts coming.
28:32
Um cost trends are completely unsustainable. Consumers are pissed.
28:36
Um and um and the affordability problem um outside of Medicaid where there are no co-pays really um in the in the commercial market, the exchanges market.
28:48
We're seeing I mean, the average family's like insurance bill is $45,000. I mean, it's insane. >> Yeah.
28:57
>> Um, so so we are I think there's just like enough here to catalyze what I hope is like a real meaningful shift. >> Yeah.
29:04
>> And there's been consistent, um, policy tailwinds here, too.
29:09
Doesn't matter what the administration is.
29:10
I'd say over the last decade, every single administration has said, "We must push more value-based care.
29:15
We must push more outcomes-based care.
29:17
Alignment around incentives and outcomes is the way that we have to go."
29:22
And so I think we're seeing more and more of that.
29:25
We're seeing states do the same.
29:25
Um, this is just this is this is this is not a stable situation to be in for the long term.
29:33
>> Let's talk a little bit about the the leader behind the idea.
29:36
Um, I think I'm right in saying that you uh you were born in the US, but then you your family moved to to Africa, um, to Nairobi, and and your parents were working in in sort of, um, the medical world to do with AIDS, right?
29:48
Um, I I I saw something somewhere that the way they raised you and spoke to you as a kid with your siblings kind of made you a leader in some way. Is that right? >> Yeah, I think so.
29:59
I mean, I didn't I didn't sort of appreciate it quite so clearly then cuz it was just you're a kid, it's all normal, but, you know, growing up in Kenya in the '80s and '90s at that sort of height of the AIDS epidemic, um, you know, poverty was everywhere.
30:13
Um, death was everywhere. >> Right.
30:16
>> Um, there was a real fear, I think, about uh for many people about just daily needs for their existence.
30:20
And my sisters and I were raised in a upper-middle-class household.
30:24
My parents are both, um, you know, masters-trained professionals.
30:29
My father's a physician, um, worked for an international, um, nonprofit organizations.
30:32
We went to private schools.
30:34
Um, we were expected to achieve academically, for sure.
30:37
Um, but they continually reminded us that we had just got lucky. >> Okay.
30:44
And and my parents were quite like they did not pull their punches, you know, they said like you've done nothing to deserve three meals a day.
30:52
You look around everywhere you see and there are children begging on the streets.
30:56
That could have been you.
30:56
You were fortunate and therefore you have an obligation as we all do to to do something to help make the world better for other people.
31:04
That was very interwoven in my upbringing.
31:07
>> Did they also speak to you like you were you and your you assisted with adults from a >> Yeah, yeah, yeah. Yeah, very much so. Very much so.
31:13
There was it's hard to sort of shield children I think particularly in that environment, right?
31:19
You know, there you know, kids sniffing glue and and and and petrol to just stave away hunger pangs, people starving on the streets, orphans everywhere.
31:31
And I remember actually I was old enough to to to watch TV.
31:33
We had this tiny little black and white TV and I happened to catch a debate at the UN about how to make when antiretroviral drugs were first available, how to make them available to developing countries.
31:48
Because at some point in my childhood the statistics were probably around one in six adults had AIDS and and there was a big debate about this and and I heard somebody come up to the podium and say, well, they can't tell time and their lives are so bad anyway, it doesn't make financial sense to try to make these drugs available to them. >> Wow.
32:08
>> And I remember being like, well, that's me. These are this is what?
32:12
>> [laughter] >> We can say this about people?
32:15
But when you when you sort of as a physician unpack what is happening especially in the United States, we are saying implicitly the same thing about people on Medicaid.
32:28
We're saying they don't deserve the very best health care there is because it's too expensive, because their lives are complicated, because they have mental health challenges, because they have disabilities, because whatever.
32:41
>> [gasps] >> As for every moment that we don't sort of force the application of best practices in the form of not just clinical best practices, but we know that if you are a a person struggling with mental health challenges, that actually getting you housed is the most important next step to getting you healthy >> Yeah.
33:04
>> from a mental health perspective. We know that.
33:05
We know that if you're a senior with diabetes and hypertension and heart failure and you're hungry that feeding you is going to be the next most important intervention to making sure you don't go to the hospital. We know this.
33:18
If we fail to create structures, business models, and clinical models that solve these problems, we are saying implicitly they don't deserve it. >> Right. >> Right?
33:29
It's too expensive, it's too hard, it's too complicated.
33:31
And like I I will never forget the outrage I felt then. I feel it the same.
33:35
It's like the fire in my belly.
33:37
It's a thing that keeps me going.
33:38
It's a thing that like makes me indignant when people say you can't build a business that is successful and scalable and effective in Medicaid.
33:44
Um like this is what venture's about, actually, is taking bets on things.
33:48
So what they don't deserve a bet?
33:52
Like you're not going to bet on us that we could figure this out? We have to.
33:56
>> You you uh you traveled a lot as a kid, right?
33:57
I mean you so you grew up in the US, you saw this extreme poverty and kind of health care administration in in Nairobi.
34:04
You trained in in the NHS in London.
34:07
You've seen a lot of different health care systems, see it work or not work all around the world.
34:10
Do you think that outsider's perspective is is pretty fundamental to having the boldness to come into a very broken US health care system and say, "Hey, there is another way of doing it."
34:21
>> Yeah, you know, I think that there are um many of us actually who do this kind of work have spent time internationally.
34:28
I think there's so much value to that.
34:30
Um I think I think I've been able to take the best of all of the different systems that I've seen and worked in and try to bring that to Cityblock and to trying to bring that to the US.
34:39
And so, you know, growing up going to medical school in the UK was like what an incredible experience.
34:44
Um you know, this is I know the NHS has its challenges.
34:48
I certainly am not the best person to opine on them.
34:49
But um but the principle behind um making healthcare available and accessible to folks at the point of need irrespective of their ability to pay and the the sort of passion with which I think British people still to this day hold that principle I think is really inspiring and it and it engendered a different kind of care model.
35:09
You know, I did home visits as a medical student to postpartum women.
35:12
You know, the idea that you should have a baby and then a week later like bundle yourself up in your little newborn and take them to the clinic.
35:20
It's like, why are we doing that? >> Yeah.
35:22
>> Um you know, basic things again that we know work um or just sort of how things are done here.
35:26
Um in Africa and in India, I spent time with community health workers who are not clinically trained folks um who are from the communities they serve, have a lot of trust inbuilt and a lot of cultural understanding um and I saw them go door-to-door and get people to tell them things that they wouldn't have told their doctors.
35:45
Um I watched them uh diagnose actually and in in in many parts of the world, community health workers are actually able to diagnose simple things like pneumonia um and prescribe for them, malaria and prescribe for them.
35:58
They're much cheaper and actually much more effective.
36:00
And so, coming to the US and saying, well, hang on a second, we still have this operating model for healthcare that is, you know, it's it's an ivory tower, it's the doctor in the white coat behind the desk and you come to us and we convey, you know, a few minutes of insight and maybe a prescription.
36:16
We lay hands and we go and no one else really has a role to play here and certainly we're not leaving our ivory tower to go see people.
36:24
Um it really really antithetical to how I had seen healthcare work even in countries that had fewer resources.
36:32
There was so much to learn and so much good to take from that.
36:35
>> [snorts] >> When you were talking about the the NHS, the UK NHS there, I saw a kind of warm glow in your eyes.
36:39
Um, this is a very could be a very long discussion, but in a in a nutshell, if you had to choose the very broken UK healthcare system as is today or the very broken US healthcare system as is today, which would you go for? >> Oh yay, yay. That is a tricky one.
36:53
Um, >> [sighs and gasps] >> choose it for what purpose?
36:57
For myself as a patient or for, you know, it would like for what purpose? For society?
37:01
Like >> on behalf of all Britons or all Americans.
37:05
[laughter] >> Oh my god, this is such a fun question.
37:08
>> Which would you give them?
37:10
>> Again, I have to ask a clarifying question because if you have resources in America, there's no better place to be. Yeah. Right?
37:16
Like if you can pay, you can buy the best healthcare on the planet. >> Right.
37:20
>> Um, if you cannot, I'd much rather be in the UK. >> Okay. Yeah. Yeah. That is a great answer. >> So, pick your poison.
37:29
>> I would go I would I would give you exactly the same answer.
37:31
>> It's it's not a fair one, right?
37:33
>> [laughter] >> Um, we ask all of our guests uh to sort of choose three photographs that will kind of define the wisdom they've picked up along the way.
37:39
You you've given us one in a way which was this video uh that you saw, this TB thing you saw of this kind of outrageous statement by the UN about, you know, why bother giving Africans treatment for for for AIDS. So, that can be one. >> Mhm. >> We can take that one.
37:55
What would the other two be?
37:57
>> You know, we actually do we do member stories, which is our sort of way of reminding ourselves of what we're doing um every all hands.
38:04
So, we do monthly sort of all company all hands and um and we interview patients talking about their experience with Cityblock and we talk to their care team members and we sort of produce it and share it internally.
38:16
Um, and there There one recently of a of a of a woman talking about her experience actually postpartum.
38:26
Um she she was She was pregnant. She got connected to us.
38:30
We were her care provider.
38:31
We connected her to food resources because they didn't have sufficient um food.
38:37
We supported her through the pregnancy.
38:39
And postpartum when she developed symptoms that as it turned out would become preeclampsia, which is quite a can be a It's a life-threatening condition for women in pregnancy.
38:47
Um she developed leg swelling and had some symptoms and she called us and we immediately recognized that she needed to go to the hospital.
38:56
Um and and ultimately the care she received there saved her life.
38:59
But um that one really stuck with me because there's an element underneath um the experience for Medicaid patients and particularly for sort of underserved patients of not being heard.
39:12
And when you look at the the literature around maternal deaths in the United States again has some of the highest rates of maternal mortality um for a developed country.
39:21
Um often the stories you hear from families are she said she wasn't feeling well and she called in and they told her it was okay and she was dismissed or she was sent away.
39:33
Um and and so the ability to say that we can provide care at scale >> Yeah.
39:38
>> that is tech-driven, like deeply tech-driven, high quality, lower cost, but also has that really human element of of listening >> Yeah.
39:49
>> and being held and cared for, to me that's what I strive for every day, right?
39:53
And so that that story really really um warmed something inside me and um and just like renews my passion for what we do. >> I love that. Final one in 30 seconds. >> Oh my gosh.
40:04
Um I'm so busy thinking about this one.
40:07
I think probably dinner table and as a kid, you know, like I think that um uh at the time as I said it was it was unremarkable as how I grew up, but we had these very very spirited dinner table conversations in my household yeah that were about mission and purpose and who we want to be in the world and many of those I think shaped who I am today.
40:27
>> I think that's so great cuz when we look at entrepreneurs at John, often we're looking for kind of what drove them in childhood to go on and be this obsessive founder who never gives up and often it can be these quite traumatic things that have, you know, something went wrong in childhood that means they're always trying to show the world whatever.
40:40
This is an example of childhood really shaping a an amazing entrepreneur but just a wonderfully positive way I think so fantastic wonderful place to end.
40:48
Toyin, thank you so much for sharing your giant idea. >> Thank you so much. Thanks for having me. This is really fun.
40:54
>> If you like that episode, you might enjoy our conversation with Halle Tecco where we talked more about the broken US healthcare system and how to fix it.