“Very early in my career, I realized that seeing 20 patients a day in clinic or 16 patients a day on the inpatient hospital unit where I was admitting and discharging people with complex needs wasn't going to be fulfilling, and it probably wasn't going to change the trajectory of anyone's life meaningfully in a way that felt scalable. 

So, I took an unusual career choice to go work at a health plan because I wanted to see scale. I was also really interested to understand how we pay for healthcare and how that influences the care that people get and the experiences that they have.” 

“We had the opportunity to come to New York to build Cityblock, really on the notion that we could take what we'd learned from a health plan and expand that to scale, addressing the needs of Medicaid and dually eligible populations. To do this, we needed a ton of capital, we needed the best possible talent, we needed a bigger platform to play in, so that we could do something that would change health outcomes for people for a long time to come.” 

“We went there very certain that we wanted to build a company for Medicaid. We also went there knowing that most investors would look at us and say, “that's bonkers.” There had been no scaled venture-backed companies serving Medicaid populations because it's too hard. Those people are too complex, the margins are too thin, reimbursements are too low, churn is too high. However, the folks at Sidewalk had no prejudice about this. They weren't like the seasoned healthcare person who can tell you 50 reasons why your idea will fail before you even open your mouth. And that created space for real dialogue.

In addition, they offered us space, access to technology, technologists, and capital.”

As for how the team knew it was time to leave Sidewalk? That was a bit less clear.

“There’s a version of the story that's like, “And then we knew, and the metrics were hit, etc.” The reality is we were just figuring it out as we went along. It was messy because everything's messy.”   

“I cannot overstate how dramatic and profound those first days of the pandemic were for us…You combine the physical and existential risk that people felt…It was tough…But I think one of the decisions we made was that were going to continue to see our members in person to the extent that we could, because we knew that's what they needed.

While we did a lot of work on digital tools and we really ramped up our virtual care, we still had a commitment to seeing our members in person. And that led us to build a whole new capability that now is the backbone of our 24/7 clinical response capability and what we call our mobile integrated care team that helps to avoid ED visits and acute utilization across all of our markets today.

…We grew dramatically during the pandemic, but we had to pivot our whole business model, our whole clinical model, to accommodate that growth.”

“We felt those shifts not only in the number of employees, but also in the number of markets we operated in. 

What does it mean for employee number 20 to no longer be in every meeting when you become a team of 200? What does it mean when someone who joined as an early employee has been doing a phenomenal job has to accept that they're going to get a new boss who's going to lead the function that they used to lead because they no longer have the skills to take it to that next level? What happens when you go through your first downsizing, where you have to close a market, where you have to make really tough choices, to say goodbye to folks that you brought into the company and have given so much? 

There are so many firsts that you go through when you build a company and every single one leaves lessons and also changes, sometimes imperceptibly, but sometimes really meaningfully, the trajectory of the business.”   

“When you walk in the door for that first conversation, if the person you're pitching to doesn't put down their laptop or phone, look you in the eyes and say, “Yes, that is a problem I have today and I would like to work with you to solve that” – then you’re not talking to the right problem. 

Unfortunately, a lot of these MCOs, while they may have 15 problems, they're only going to work on two max at once. So if you're not in the top two problems that day, that week, that quarter, it's gonna be very hard to get that next conversation.

And so the question I always ask when folks say, “Oh, it's so hard to get that first contract” is, well, did you have a hard time getting in the door?”

“I think because when we started our business, there was so much inherent skepticism about if you can make money in Medicaid that we knew we had to figure out how to make money from the start…There was no way we would get a pass having grown a big business with lots of top line revenue and no path to profitability…So the bar always felt a little bit different. 

I think it's a good thing that we're in an environment where business fundamentals are required, and I think it will force more discipline in how companies grow. I think the one place where it gets challenging is that in healthcare, particularly healthcare services…businesses are inherently capital intensive and require scale in order to achieve unit economics that make sense.

…I think there were some decisions we would make differently, like marginally. But actually, I don't think it would have profoundly changed our trajectory.”

“The way that my job has shifted is that I spend my energy differently because the things that would have stretched me a year ago no longer do. For some of them I've hired people to take on. Others, I've seen enough reps that I can make the decision that much more quickly. For others, we put in place processes that require us to just fully take offline. And so I'm spending my time differently on new problems. 

…You go from the early days of figuring out is there even a thing that anyone's interested in? Then you go to, well, is there a product that a customer wants to buy? Will a health plan pick up what I'm putting down? Can I enter into the contract? Can I replicate that contract? 

And then you get into the phase of, can I actually execute on the thing I said I was going to do? How do I close the PowerPoint to reality gap that all of us face in the startup space? You can spend a long time closing that gap because the reality of what it takes to get as good at execution as you need to be to scale a business that's serving patients in any way, shape or form is a lot of debt you enter into by virtue of even signing your first contract.”

“Yeah, I think a lot about this, and I think we've had a lot of learnings here. There have been moments in the business, and I'll be transparent, where we didn't always get it right. 

We spend a lot of time on our values and instilling our values…We start large meetings, company wide meetings, our monthly business reviews, with a voice of the member story that reminds us of what we're doing and why. 

…I think the place where we were slower than I would have liked to build was then you have to codify that in processes, you need to build this stuff so that it is in the fabric of the company. For example, talent reviews – what do you think about performance management and performance reviews?

…We do regular employee engagement surveys. We take that feedback really seriously. I read every single comment that comes through personally. And then as leaders, we model how the rest of the organization shows up.

This was a very personal learning – you can say all you want to say, but how you interact speaks volumes. When we as leaders are not self aware, when we're tired, when we're stressed, when we transmit that stress and that fatigue, even if we say, oh, we care about the mission and we care about the values, we're projecting something different.”

“I think that the healthiest thing that a person can do when they're founding a company is to figure out how to divorce yourself from the things that you accomplish, in terms of your internal sense of self worth and what personal success is. So, for me, success is, do I get up every day and try as hard as I possibly can to live in accordance with my values – to do something meaningful and to treat people the way that I think everyone ought to be treated? Do I show up for myself, for my family, the things I believe in and do I work really hard for something that's meaningful. That's it.

And it seems small compared to having a business and having 1,000 employees and 100,000 members to serve. But it helps me because there are some days when I make mistakes. There are days when we don't hit the mark. And it would be very easy for that to feel like a personal failure. 

It becomes a success if you can take that, introspect, reflect, and get up and do better the next time and compel the people around you to get up and do better next time.” 

“The reality is, whether you are a Cityblock member in Crown Heights, New York, or in Fort Wayne, Indiana, or in Chicago, Illinois, you need somebody to find you, who cares about you, who sounds like you, comes from your community, who is able to engender your trust, who is able to figure out what's going on for you and your health needs. And you probably need better primary care or more access to it, better mental health or more access to it and support in accessing social services. And so that's the kind of the core chassis of our care model, but the deployment of it actually looks very similar from market to market. 

What looks different is the ‘who’. We hire people from the communities we serve who will reflect the demographics and the lived experiences of the communities we serve. 

On the social services and network side, we build bespoke partnerships in every community. But again, we're all humans. We need food, we need a safe place to sleep, we need social support, we need transportation to our doctor's appointments, and we need a source of income. Those are the same needs. We just have to meet them slightly differently depending on where we are in the market.”

“There certainly are nuances, but I think what helps with our business model is that we do not bill fee for service. So, if the rate card looks different in Minnesota from New York, it actually doesn't impact us that much. We're working directly with a managed care plan, with a health plan, and negotiating a fixed rate, a total PMPM for the full population. So we're taking full cap risk that is tied to the total cost of care for that population.

We do have to grapple with different risk adjustment methodologies, provider networks are different, some of the social benefits that are covered or not covered vary from state to state. Licensure is a big deal, scope of practice, things like that are different from state to state. But, the underlying economics of a business actually looks remarkably consistent given how heterogeneous Medicaid can be.”