Transforming Care Delivery for Underserved Populations: Cityblock CEO Iyah Romm on Their Tech-Based Solutions

Iyah Romm - Cityblock

Moderator: Welcome to Conversations on Healthcare, with Mark Masselli and
Margaret Flinter. A s how where we speak to the top thought leaders
in health innovation, health policy, care delivery and the great minds
who are shaping, the healthcare of the futu re. This week Mark and
Margaret speak with Iyah Romm, Founder and CEO of Cityblock
Health, a venture of Sidewalk Labs, a division of Google’s parent
company Alphabet. They are creating a new system of tech - enabled
care delivery that’s addressing care gaps in underserved urban areas.

Lori Robertson also checks in, the Managing Editor of FactCheck.org.
She looks at misstatements spoken about health policy in the public
domain, separating the fake from the facts. And we end with a bright
idea that’s improving health and wellbeing in everyday life. If you
have comments please email us at [email protected] or find
us on Facebook or Twitter , iTunes or wherever you listen to podcast.
And you can also hear us by askin g Alexa to play the program,
Conversations on Healthcare. Now stay tuned for our interview with
Iyah Romm, the CEO of Cityblock Health, on Conversations on
Healthcare.

Mark Masselli : We are speaking today with Iyah Romm, Founder and CEO of
Cityblock Health , an innovative tech - enabled care delivery company
focusing on underserved patients in urban settings. A venture that
was incubated with Alphabets, Sidewalk Labs, prior to that he was
Chief Transformation Office r at the Commonwealth Care Alliance,
driving efforts to improve care delivery in health plan operations. He
was Founding Policy Director at the Healthy Policy Commission a nd
before that he served in the Massachusetts Department of Public
Health working on the state ’ s healthcare reform efforts . Mr. Ro mm
served as an adjunct faculty at Atul Gawande’s, Ariadne Labs and was
named to Modern Healthcare list of Up & Comers. He earned his
Bachelors in Biology at Brandeis, studied medicine at Boston
University. Iyah, welcome to Conversations on Healthcare.

Iya h Romm: Thank you for having me Mark and Margaret. It’s great to be with you
this morning .

Mark Masselli: You have been a healthcare activist since you sought to enter the
medical profession a nd you founded Cityblock because you see health
is the issue of our lifetime a nd that health disparity is the rise of
chronic disease and unsustainable cost have increased poor health
around the country. H e decided that health should be addressed at
the granular level which is in your name, right down to the block
wher e someone lives. What is the tech - enabled approach you have
deployed at Cityblock and how does it address some of these
upstream challenges?

Iyah Romm: I think its important Mark and Margaret first of all let me say about
Cityblock is. We are about 18 mont hs into the best journey of my life

Iyah Romm - Cityblock

certainly professionally, learning about approaches that community
health transformation, technology spread, grassroots organizing
public health and venture capital all alike towards the question of
how do you build a sy stem that’s [inaudible 00:02:50 ] from all of
these disciplines, to improve health and communities all across the
country. Fundamentally , we are a social justice company because we
recognize that [inaudible 00:02:58 ] of our health system including
many of t hose that you have just described, especially for those most
vulnerable among us are unacceptable.

We saw it at Cityblock to build a personalized health system that
serves low er income, individual living in certain neighborhoods, as
they grow as to good he alth. We believe that health happens locally
and so we put each individual we care for, and importantly the
community is the desire of what we do, the care that we deliver is
care that’s designed for who our members are without judgm ent,
wherever they are . O ur approaches we did in the organization that
personalized care can’t be about to one care model or to one toolset,
I heard one of my friend and colleague, Dr. Sachin Jain from CareMore
on your program recently and he similarly described a philosophy and
approach, the idea that we have to build a wide array of tools within
our proverbial took box and the trick to doing this work well is figuring
out in which order to pullout this, and use those tools, to understand
quickly if they are not working. And the n define the right balance
across engagement health outcomes and cost efficacy to ensure that
that algorithm to how you appl y different approaches, teach
individual or community works more effectively , recognizing that any
of these tools, food, transportat ion, social connection, child and elder
care, are largely unknown to the healthcare system.

So what we do is build relationships with our members, we provide
value based and it is wholly capitated care to long - term urban
populations, predominantly those on Medicaid, Medicare and those
who are really eligible for both. We also later focused on the fact that
this week has disproportionally poor quality outcomes, and poor
experience of care despite the fact that the re is disproportionally high
spending. We for ge long - term relationships and bring services to
meet them where they are, be it in our neighborhood hubs, at home,
at work it all has to be local.

The three pillars of our model are community health partners, hire
from the communities in which we serve, w h ere we hire from
empathy, the cost domain for relational skills, these are really th e
quarterbacks of our care team. And then around them we layer and
integrated care team, RN , care manager s , social workers, behavioral
health specialist, both primary care and psychiatric advanced
practitioners and physicians employed and partnered across the
community, to build that integrated environment. Our neighborhood

Iyah Romm - Cityblock

hub serves a primary care clinic, and, in the future, we envision a
variety of ways that each of thes e hubs is customized to the local
community.

F or example , our first [inaudible 00:05:13 ] has a child playing room
w here we can have a visit with one of members at the same time as
that number of children are playing in that room. And then we have a
digita l platform that bind it altogether, really help partners and
educated care team that deliver primary care, behavioral health,
palliative care, alongside services that addressed the social
determinants of health.

Mar garet Flinter : Well I want to share with our listeners this very powerful infographic
you have on your Cityblock website that sort of guess at this issue of
how much things cost, do you use the example of if there was a
hospitalization that cost $10,000. And the comparison to how many
other servi ces could have been provided for that same amount that
would have potentially kept the person out of the hospital . 120
behavioral health visits or 500 hours with a community care worker .
S hare with our listeners how shifting some of the spending to the
pre vention model and to addressing the social determinants of
health, might just lead to better and less costly outcomes.

Iyah Romm : Sure, when you stop and think about it for a moment, an average
hospitalization which is going to shift a little bit market - by - market,
accounts for those per f ours of the community care worker, but also
accounts for significant transportation or one of my favorite statistics,
two and half years at food stamps for family. And we think about the
opportunity for meaning to investmen t of those factors that underline
health of a population, I think it’s very clear that we have opportunity
to reinvest.

So many model vendor in this space has demonstrated and you can
reduce total utilization. Emergency department spending, and
inpatient h ospital spending find in the order of 35% to 40%, even
though with model like ours that can support them out in the
community that can provide wraparound services to help them be
healthy, when you sho w then the emergency department, hospitals
are very good to getting you into their beds. And in the pharmacy side
they ha ve variety of pragmatic factors here that I think are really
important to consider . W e had a member recently who had the
current emergency department utilization, w ho made really smart
choice s, to access the emergency department at the end with every
month, to get a 30 - day based [inaudible 00:07:20 ] because they knew
that the emergency department was lashing that out in the end of
every month. And the reason for that is because they had a $350
copay on that insulin medication.

And so being able to find ways to intervene around the cost of

Iyah Romm - Cityblock

pharmacy services, slides of current and preventable emergency
department spending I think is really powerful. The reasons that
people go to emergency departm ents are largely again fairly
rationale, the people are going for familiarity, it’s a place in care
where they are treated equally with all others because the guiding
principle that drives how people are prioritized in the emergency
department is not insur ance status typically, it is sick or not sick .
That’s virtually the only place in the healthcare system outside of
some of the exceptional community health centers among us, where
people are not judge d for the insurance part that they carry or for the
ways that they addressed or where they live. One of my favorite
recent anecdotes from my members is that she goes for the Wi - Fi and
the air - conditioning in the emergency department. And so for all of
those things there are preventable ways for us to build, tru sting safe
spaces that are available after hours. And even so doing make
relatively incremental investment that drives very significant savings
in the overall total cost of care.

Mark Masselli: So you have adopted this varied approach to improving access. I
wonder if you could talk to our listeners about how you are leveraging
technology and what it looks like in your toolbox that you find
affective.

Iyah Romm: The journey for me of realizing that a common th eme of those
frustrated in family healthcare work ers and the lack of meaningful
tools to engage and communicate with those that we serve [ inaudible
00:08:55 ] . So when I had an opportunity to partner with Sidewalk
Labs, to think about what Cityblock could become with a core infusion
of technology from the outset, I g ot very excited about the
possibilities . So the core of our technology asset common is
appropriate platform for those consumers who tend to be able to
look to be not who they are at low - income, Medicaid recipients, some
of those on Medicare. An d very specifically as we came to pull
together capabilities that I think are fundamentally fairly practical,
their capabilities around communication, cost management. Our
community health partners [inaudible 00:09:27] and can hold them
accountable.

And th en very specifically we hired on for our team the folks who
think about product expertise that really fundamentally focus on
beautiful user - friendly design. When I put in front of the senior
Alphabet leadership, screenshots from some of the leading electro nic
health records that are charging 100 and millions of populating the
dollars in the market today, they laughed and thought I was joking.
And so the opportunity to build simple, easy - to - use tools with those
foremost goal of maximizing the value team and interactions
anywhere between our care team members, those that we care for.
And some of these stuff just isn't that effective to be frank, figuring

Iyah Romm - Cityblock

out staff deployment models, figuring out workf low management,
how do you communicate across teams in seam less ways. And
importantly how do you capture all of this, for example the ability to
ask family members or caregivers of our members that we are caring
for, directly in to [inaudible 00:10:18 ] full budget of the care team.

And what we heard from our membe rs, was a real desire to be able to
provide [inaudible 00:10:24 ] to each of the, father, mother, brother,
sister and caregiver, whoever that was. The other thing that we have
gotten is text messaging, one of the tools that we have built is the
way to pull all of our text messaging content, which is a primary form,
I think the compliant communication between our members and their
care teams into a common database that directly feeds the record so
that we can escalate chronically where somebody is expecting t o be
sick, to a clinician member of the care team is providing oversight.
And then underneath it all, we have built you know Integrated
Telehealth and a variety of really interesting clinical decision support
tools, very specifically built it [inaudible 00 :11:02 ] . The work on
technology here is about asking very simple questions and building
very simple solutions.

Margaret Flinter: W hen I think about what you are doing, in essence you have what I
would call in some ways a select population of universal insu red
people. In fact we think about the challenges that are out there right
now, preexisting conditions could fall, essential benefits could fall,
then the story that you told of the patients who had the $350 copay,
they lived by the millions . A re you looki ng at a strategy to make your
model work to embrace those individuals as well, talk with us a
minute about that ?

Iyah Romm: Fundamentally I believe that if you build the system that is oriented
towards Medicare or those who are commercially insured, you ar e
going to not force yourself to build systems that address factors that
are fairly unique to the low est income populations among us. And so
it is easy to build and to not deeply engage in the comprehensive
needs of social factors in populations that are n ot a Med icaid. F or us
that was an important one from the outset. What enforced us to do
was build a toolkit that was fully inclusive of all of the needs with
those populations. And then importantly also I believe that it’s itself
an opportunity for convers ations about how you start to serve other
populations -- .

So I should note that our first partnerships in New York with
EmblemHealth , stretches across virtually all of the ir lines of business.
But also when you are working for example on Crown Heights,
Bro oklyn which is wh ere our first s ite is, there are variety of folks who
are living on the bubble of eligibility for those programs, who are
struggling with the sam e challenges of poverty. And in many ways,

Iyah Romm - Cityblock

some of the social practice challenges around those populations are
even more challenging to wrestle with, the individual that you
referenced with the copay is a great example of this, so that is not a
challenge that a Medicaid beneficiary w ould face in the same way, but
it is a unique challenge to a certa in type and kind of insurance.

Another example of where this manifest s is on some of the social
factor, so you know ac cess to Food support may not be there in the
same way for folks who are on individual markets, for example. And
importantly part of our mo del is focused on trying to care for whole
household. And so on a given Cityblock, there maybe household living
side - by - side that stretch across line s of business as we think about
them in insurance [inaudible 00:13:28 ] . But frankly in a given
household th ere are also individuals that stretch across th ose lines.
S o we are built around the notion that we can care for whole family
units and whole households. Medicaid is an important core
component to this and it’s an important identity, but fundamentally
as you say, this is about car ing for people actual population.

Mark Masselli: We are speaking today with Iyah Romm, Founder and CEO of
Cityblock Health, an innovative tech - enabled care delivery company
focused on underserved patients in urban setting a ventur e of
Alphabets, Sidewalk Labs. Iyah, I think you may be in the vanguard of
this trend of nontraditional companies leveraging their market power
to create new pathways in the last couple of months at Amazon,
Berkshire Hathaway and JPMorgan Chase also launch ed the
innovation , b ut I wonder if you could pull the thread for us on how
close you are to scaling this model, maybe also just paint this picture
of what a national model of what you are contemplating might look
like ?

Iyah Romm: Sure, for us we are pretty open and pretty humble about where we
are sta g e wise. We are an early company that is humbled it got the
attention that we have got ten, because then we are trying to tackle
fundamentally a very hard set of problems, in a way that is both
methodical about how we learn and iterate and improve, but also
there is tremendous [inaudible 00:14:50 ] across the country. One of
th e things that motivated me in coming to do this work, was the fact
that many of the models that we could all articulate on this
conversatio n, fundamentally have not scaled at the level that a large
technology company would for example [inaudible 00:15:07 ] scale . If
y ou add up all of the lines under management of companies that look
like us and are variations on the team and the space, it stil l numbers
in the hundreds of -- . And when we think about that compared with
the profound opportunity and also this question of how you crack
them at the being able to do this on much larger scale, I think i t’ s very
important.

Iyah Romm - Cityblock

When we think about growth on models like this, I don’t know yet to
be totally honest, what it looks like in terms of release some play
books or care models or how you think about product izing from value
technology as we think about large growth. But what I do know is that
the answer c an’t be buildings 3000 clinics across the country. We all
know healthcare has plenty of books in order as it is, what it has to be
is finding ways for the model to scale across the chassis of existing
infrastructure all across the country. And thinking abo ut ways that we
can build models that flex and hyperlocate in a way that it is heavily
rigorous .

W e focus a lot of our time [inaudible 00:16:04] we spend a lot of our
time in technology thinking about, how do you build a system that
using Advanced Analytic s capabilities and using the technology
infrastructure that we have fundamentally rebuil t a n d how you
manage a practice like this. We talk all the time for example about
clinical guidelines, but there has never been a randomized control
trial of how do we think about administering med s for somebody who
ha s diabetes, who is also streak homeless and [inaudible 00:16:30]
and eats out of the trashcan. That is not how we think about clinical
evidence, it’s not how we think about care model evidence.

S o part of o ur foundational bet is that by building insight driven
capabilities that allow us to learn very quickly, allows us to
understand how we even ask these questions of our members very
quickly and [inaudible 00:16:48] them to local context that we can
think ab out real opportunities to scale. Our model in Brooklyn I think
is a pretty interesting one as a first outset, this is something that I
think is not largely known about us, but our practices in Brooklyn are
actually collocated inside of an existing primary care of practice group
and managed care physicians of New York. It has been very
interesting partner for us, because fundamentally where patients
have a meaningful trusted relationship with the provider, we have no
interest in breaking that. I think it’s t he wrong conversation to say, in
order to get access to a new model of care you marginalize vulnerable
person, have to make a different choice about what you actually care.
Instead we have to build systems that wrap these models inclusion
around folks whoe ver they are, by meaningful chunk of the
population that we care for in New York, our members actually have a
primary care provider that belongs to a different medical group. W e
have a very close partnership with th ose medical groups to ensure
that we are collaborating effectively and managing care together.

Margaret Flinter: We have been speaking today with Iyah Romm, Founder and CEO of
Cityblock Health, an innovative tech - enabled care delivery company
that’s focused on underserved patients in urban settin gs. It’s a
venture of Alphabet, Sidewalk Labs and you can learn more about
their work by going to www.cityblock.com or follow them on Twitter

Iyah Romm - Cityblock

@cityblockhealth or at @iyahromm, that’s I - Y - A - H R - O - M - M on
Twitter. Iyah , thank you so much for your dedication to innovation in
healthcare , to your focus on underserved populations and for joining
us on Conversations on Healthcare, today.

Iyah Romm: Thank you for the conversations, I enjoyed it very much .

[Music]

Mark Massell i: At Conversations on Healthcare, we want our audience to be truly in
the know when it comes to the facts about healthcare reform and
policy, Lori Robertson is an award - winning journalist and Managing
Editor of FactCheck.org, a non - partisan, nonprofit con sumer advocate
for voters that aim to reduce the level of deception in U.S. politics.
Lori, what have you got for us this week?

Lori Robertson: The Democratic Senators have repeatedly claimed that Supreme
Court nominee Brett Kavanaugh’s history shows he wo uld be a danger
on the court to the Affordable Care Act. For instance, Senate Minority
Leader Chuck Schumer said in late August that Kavanaugh “has
written opinions skeptical of our healthcare laws .” The Democrats
point primarily to a case called Seven - Sky v. Holder which came
before the U.S. Court of Appeals for the District of Columbia Circuit
for Kavanaugh as a J udge in 2011. The Appeals Court rejected this
challenge to the ACAs individual mandate which requires most people
to have insurance or pay a pen alty. Kavanaugh dissented but his
objection concern ed the jurisdiction of the court, not the
constitutionality of the healthcare laws.

Kavanaugh wrote that the court shouldn’t have heard the case
because the Anti - Injunction Act s aid, “A tax must be assesse d and
collected before a suit e against it could be decided. And the individual
mandate didn’t go into effect until the 2014 tax year. ” The Federalist,
a conservative publication published opposing views on it, one
commentator said Kavanaugh’s dissent was a “roadmap to save
Obamacare” w hile another said that was “nonsense” .

A law professor and expert on healthcare, also wrote that Kavanaugh
didn’t show a strong opposition to the healthcare law in that case or a
second case that Democrats have also cited. Tha t case Sissel v. HHS in
2015, question ed whether the Affordable Care Act was
unconstitutional because it violated the Origination Clause of the
constitution which says that legislation that raises revenue must
originate in the House of Representative. The Appeals Court rejected
a request that the full court hear the case, saying “The purpose of the
ACA was to overhaul the National Healthcare System, not to raise
revenue.” Kavanaugh dissented saying the ACA was indeed a revenue
raising bill, but he said it c omplied with the Origination Clause , he
said, he would grant a rehearing of the case, but he went on to argue

Iyah Romm - Cityblock

that the court should rule for the government. And that’s my
factcheck for this week, I am Lori Robertson, Managing Editor of
FactChecks.org.

Marg aret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you
would like checked, email us at www.chcradio.com , we will have
FactCheck.org’s Lori Robertson, check it out for you, here on
Conversations on Healthcare.

[Music]

M ar garet Flinter : Each week C onversations highlights a bright idea about how to make
wel lness a part of our communities and everyday lives. Tens of
millions of people around the world have conditions that make it
impossible for them to speak on their own, requiring them to adapt to
a computerized voice box for communicating. Perhaps the most well -
known of these folks is the physicist Stephen Hawking.

Stephen Hawking: I would have thought it was fairly obvious what I meant.

Margaret Flinter: The problem is that sound of Hawking’s speaking through his voice
box is the same voice sound say that a 10 - year - old girl with a
neurologic disorder might be forced to use as well, because there just
haven't been many voice options on the market.

Rupal Patel : In the U.S. alone there are 2.5 million Americans who are unable to
speak and many of whom, use comp uterized devices to communicate.

Margaret Flinter: At a recent TED Talks, speech researcher and innovator Dr. Rupal
Patel shared a program she has launched that can change that reality,
VocalID.

Rupal Patel: I thought there had to be a way to reverse engin eer a voice from
whatever little is left over. So we decided to do exactly that. We set
out to create custom crafted voices that captured the ir unique vocal
identities.

Margaret Flinter: Creating a voice bank of donor voices that will allow voices to be
in dividualized for each unique patient, seeking to communicate
through an electronic voicebox.

Rupal Patel: Why don’t we take the source from the person we want the voice to
sound like and borrow the filter from someone about the same age
and size, because t hey can articulate speech and then mix them,
because when we mix them, we can get a voice that a s clear as our
surrogate talker and is as similar in identity to our target talker, i t’ s
that simple.

Margaret Flinter: Since this popular TED Talk, 16,000 peop le have signed up to be voice

Iyah Romm - Cityblock

donors at the Human Voicebank Initiative . S o volunteers like this little
girl will read a series of simple phrases over a several hour period.

Female: Things happened in Paris . I love to sleep . T he sky is blue without
cloud.

M argaret Flinter: And then those phrases are matched with the voice footprint of the
patient being provided for.

Female: This voice is only for me . I can’t wait to use my new voice with my
friend.

Margaret Flinter: Such speech synthesis will give that perso n the dignity of a speaking
voice that is as closely match to their own identity as possible. To take
that dream from the lab into the real world, Dr. Patel who is a
Professor of Computer Engineering at Northeastern University has
launched the website www.vocalid.com .

Rupal Patel: I imagine a whole world of surrogate donors from all walks of life,
different ages coming together to give people voices that are as
colorful as their personalities.

Margaret Flinter: And wit h the bank of voice donors now building around the world, Dr.
Patel expects that patients with conditions ranging from Muscular
Dystrophy to Lou Gehrig's disease or stroke will one day be given the
chance to communicate in a voice made just for the m. T he H uman
Voicebank Initiative matching vocal donors with millions of people
who seek to authentically communicate with friends and family and a
voice that most closely matches what would be their own, now that’s
a bright idea.

Mark Masselli: You have been list ening to Conversations on Healthcare, I am Mark
Masselli.

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Peace and health.

Moderator: Conversations on Healthcare is recorded at WESU at Wesleyan
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