#22 - Where does health care end?

How to make money by improving the social determinants of health

Welcome to Create The Customer, a weekly newsletter discussing the business of healthcare. I’m Isaac Krasny, a healthcare BD guy and strategist. If you find this interesting, consider subscribing. If you already subscribe, consider sharing with your friends, colleagues, and household pets. Tell me what I got wrong on twitter or via email.


I’ve expended many pixels lately discussing the merits of value-based care. When placed into a primary-care setting, value-based care is a potent incentive for providing the right care at the right time, and can even work to control downstream costs. 

One of the most compelling aspects of value-based care is that it no longer allows payment (read: health plans) to govern how care is delivered. Providers get a fixed amount to care for their patients, and they can keep those people healthy in whichever ways they discover to be most effective. As opposed to the terrible triangle that kills innovation, this value-based paradigm allows innovation to flourish. Primary care practices can engage in rapid, disciplined experimentation without worrying about billing codes and reimbursement. 

Once primary care is unshackled from the bounds of traditional fee-for-service, the composition of the primary care practice is able to morph into whatever is best at delivering value. If the goal is to keep patients healthy through diet and exercise, help them manage their chronic conditions, and act as their navigators and medical allies when they need secondary and tertiary care, it calls the question of whether the primary care model that has evolved around fee-for-service is still the best one to achieve these goals. 

Cityblock Health is pushing the boundaries of what can be considered primary care. 

Spun out of Alphabet’s Sidewalk Labs, Cityblock Health was founded to bring healthcare services to high-need, low-income urban populations. It does this by operating almost as a hybrid primary care, community service organization. Founder Iyah Romm discusses Cityblock’s model in his post announcing the company: 

Our “clinics” — which we call Neighborhood Health Hubs — are designed as visible, physical meeting spaces where health and community converge. Caregivers, members, and local organizations will use these Hubs to engage with each other and address the many factors that affect health at the local level. Where possible, our Hubs will be built within existing, trusted spaces operated by our partners. Our workforce will be hired from the communities we serve, adding jobs and contributing to the economic well-being of the community as a whole. This approach will promote a truly collaborative, team-based environment.

Cityblock is taking a view of primary care that doesn’t start with a patient’s health history form in the waiting room. They want to be fully integrated in the communities they serve. Much like the barbers I wrote about a couple weeks ago, who offered blood pressure screenings and guidance, Cityblock aims to first be members of the community, and then use that platform as a means for delivering health services. 

Study after study shows how crucial the social determinants of health are to a population’s well-being. Romm notes earlier in his post, “Zip codes are better predictors of health outcomes than biology.” One study cited by Health Affairs shows: 

Within a population of nearly 10,000 people in Oregon with unstable housing, the provision of affordable housing decreased Medicaid expenditures by 12 percent. At the same time, use of outpatient primary care increased by 20 percent and emergency department use declined by 18 percent for this group.

Cityblock, by weaving itself into the fabric of the neighborhood, will be in an optimal position to effect these social aspects of healthcare and improve outcomes across the board.

By virtue of being in value-based contracts, Cityblock stands to gain financially by improving those outcomes. While ostensibly a health care company, they can work on helping patients find and maintain affordable housing, take them shopping for nutritious foods, and even help them find good jobs; all of which are likely to reduce unnecessary utilization, and improve overall health. 

The health care world, and specifically policymakers, should be watching Cityblock to see if they can experiment their way into a model for improving healthcare outcomes by dealing with the health factors that are largely exogenous to the system. If they are successful, not only should the model be replicated, but we should look for ways beyond value-based care to promote innovation in our ailing health system.