The healthcare status quo for Medicaid and other underserved patients frequently leaves them in the lurch, said Cityblock Health CEO and cofounder Dr. Toyin Ajayi.

They may have infrequent access to the medical system, hampered by transportation issues or the need to take time off work. Doctors' offices can be busy, and they may not have enough time to address concerns. Meanwhile, racial and ethnic minorities and LGBT patients more often report discrimination or disrespect, pushing them away from providers. So patients end up in the emergency room when their health problem becomes severe.

Ajayi said Cityblock's value-based care model — which includes primary care, mental healthcare and assistance addressing social needs — incentivizes them to find patients who need support and figure out how to address all their health needs. 

She sat down with MobiHealthNews to discuss why it can be challenging to deliver care to the Medicaid population and how Cityblock approaches expansion into new markets. 

MobiHealthNews: It seems like there's a clear opportunity in healthcare when patients are going to the emergency room first for care. That's very expensive and not efficient. I know Cityblock is pretty well funded, but do you think that digital health generally has really taken advantage of the opportunities in this space, particularly with the Medicaid population?

Dr. Toyin Ajayi: No, I think you've seen that, right? Historically, we founded the company about five and a half years ago. And at the time, there were very, very few venture-backed, digitally enabled companies focused on the Medicaid population. When we launched the company, there was just so much resourcing and attention and talent focused on improving care access and experiences for people who already had resources, who are privately insured, who were digitally savvy, who sat at the top of the life expectancy curve based on their demographics and their income. 

We saw a real opportunity to say, "Well, let's focus on bringing all of these tools and focus them on people who need it the most, and people who are so often left behind." That was a pretty radical and novel idea when we launched the company, and we've remained one of the sort of largest companies in this space really focused on marginalized and underserved communities. It's not that there's a dearth of funding. And certainly it's not a dearth of talented people to do this work. It's just hard. 

MHN: What are some of the things that you find that have been most difficult when building your business?

Ajayi: Everything about company building is hard. So I don't want to dismiss that. It's hard to get it right. We're caring for a population with very heterogeneous needs. We talk about Medicaid, but there are lots of different reasons why people are on Medicaid and folks have different needs. This is not a homogenous population by any means. And so, in order to be successful in delivering outcomes for our populations whom we serve, we have to be really good at a number of things. 

We've got to be really good at engagement and relationship building and trust building. We've got to be really good at providing excellent chronic disease management and primary care in the home, preventive care in the home. We've got to be really good at engaging and taking care of people who struggle with mental health and substance use. We've got to be great at managing care transitions into and outside of the hospital. We've got to be great at taking care of pregnant moms and in the perinatal and postpartum phase. And the list goes on.

That's a business model complexity and a clinical complexity that few businesses really have, because they're managing a much more circumscribed population. But we think it's so important to recognize that people can't be disaggregated. This mental health company is for your brain and your emotions. And then there's the diabetes company and the cardiovascular disease company. Actually, we're humans, we're all integrated, everything talks to each other. 

And to ask people to navigate these complex and siloed solutions for their health needs is asking too much, particularly for folks who are really struggling with complex physical health and behavioral health and social challenges.

MHN: Cityblock recently expanded into Indiana with a partnership with MDwise. You noted how different the Medicaid population is, and that there are a lot of different needs there. How do you think about which states to expand into?

Ajayi: First of all, we're really excited about the partnership with MDwise. They've been just an incredible partner there. We're totally mission-aligned and super committed to serving the state and serving it really well. We are excited to grow the business because we just see so many opportunities to bring better care to communities that really need it and to individuals who have often been left behind. So that is a strategic priority for us, and we'll continue to do that. 

We look for communities where we know there's real need, where there's physical health, behavioral health and social challenges that a population is facing, where there's a significant penetration of managed care, and specifically managed Medicaid and dually eligible programs. And where there is a policy landscape that supports the integration of physical and behavioral care and social care services into a cogent, coherent benefit design for people. Those are the kind of core criteria for us that can really guide our desire and our decisions to move into a market.

MHN: How often do you consider partnerships like that when you're considering expansion?

Ajayi: We always enter a new market with partners. So we partner with managed care organizations that have financial risk for populations, because they're the insurer for the populations, either Medicaid or dually eligible individuals. We help them figure out who their highest risk populations are and then take on accountability for providing the care. That's always our market entry strategy. 

Once we're in there, we also partner with community-based organizations, with primary care practices and other supports within the community to make sure that we really understand the needs of the community and that we're supportive of addressing those needs. 

Health is local; that's one of our one of our favorite slogans. And that means we need to tailor the model to ensure that we are specifically addressing the needs of the communities we serve all the way from, what's the right language to use to describe what we do and who we are? Who are the teams that we hire? We hire people from the communities we serve. What are the social priorities that we ought to focus on to ensure that we're addressing the needs of the population? All of those things are customized and tailored to specific markets in which we operate.