Freedom Edition—Triumph over Tyranny (of the Visit)

When you consider primary care as a “practice” concept, it is so strange to see how the “office visit” became the center of gravity. Beginning with billing codes, which naturally led to payment models, that were then reinforced by performance incentives, and ultimately encoded into “the way it is,” the physical visit with your provider has become not just the primary way, but effectively the only way to engage with your physician. Despite all of the advances in human biology—care models, delivery methods, human collaboration, and enabling technology—the only way to interact (as hard to believe as it is) is by calling an “in person” meeting. 

Think about it. 

What if you were hired by a new company and as part of your employee orientation you were told that “Hey, at our company, when you need to work with someone, you have to set up an in person meeting. We do not use email, messaging, Slack, shared file systems, calendar sharing, photo sharing, project management tools, or any other modern communication collaboration tools at all. In person meetings only.” You protest and ask questions like what if I need a quick answer, have an interesting thought, or just want to share some of my projects? “In person meetings ONLY.” is the dismissive reply. 

In my opinion, this fictional company wouldn’t be around for very long. I don’t think they would be able to build product, attract talent, or succeed in the market. Do you?

Then why do we believe that the patient–physician care model should utilize a singular mode of communication? That this very limited, highly-antiquated, “in person only” mode is the sole “widget” upon which the value doctors create with patients can be compensated? That because of this market distortion, doctors then begin to contort the relationships they have with their patients into bite-sized 7-12 minute increments, which more often than not result in a prescription or a referral, just so they can “move on” to the next hamster wheel experience? If “architecture is destiny,” who thought that building out the entire primary care field based on this payment structure would result in anything but the slipshod experience we have today? The architecture of the third-party reimbursement model has created a world of careless, thoughtless, and I would argue pointless healthcare “shuffling” (ie, activity without achievement). 

At Crossover, we refuse to accept this dystopian future. 

From our perspective, we must break the mental grip and hostage paradigm of the “visit.” In an age of infinite collaboration tools, asynchronous communications, and continuous relationships, why not deploy enabling technologies that would allow a new business model to emerge, and therefore an entire new value network to be created? Why not put all the effort into creating disruptive care paradigms (as opposed to sustaining innovations around experience/efficiencies) that break free of the shackles of “fee for service?” We must increase freedom by introducing direct payment models that reward value over volume, that surface the true cost of care, and that enable meaningful relationships to be developed. In fact, we would be so bold as to say any company that has their architecture based on the fee for service paradigm is in jeopardy. In fact, I often share with people that one of the greatest innovations at Crossover is that we were never designed for (architected), nor did we accept, any fee for service payments in the first place. And that, has made all the difference.

Another point of interest in breaking free from the tyranny of the visit: developing reporting methods for our clients. When we first started in 2011, the easiest thing to measure initially was visits. Despite the simplicity of this metric, we continued to point our clients toward a future where the visit wasn’t the unit of account or metric of value (what is a “visit” anyway?). Instead, we highlighted messaging with members, measurement instruments to show care model improvements (aka FOTO, etc), and programming to impact groups of people, and guided them toward the concept of managing the entire population, rather than just a full schedule. As we got better at showing these other areas of value creation, we realized our schedules were full, therefore our service was highly utilized. Then we started asking questions like, “Are we seeing the right patients? Who are we not seeing that we should be in order to move their health conditions along? Are there any visits on the schedule that we could manage differently than by holding an in person appointment? Can we add convenience along with broader access, and can we shift our members’ paradigm around this as well as our clients?” 

As we began asking these questions, we could feel the shackles loosening, the mindset shifting, and the opportunities for a different payment model surfacing. While we still have a ways to go, we are on the path to Triumph over the Tyranny of the office visit!

Let freedom ring!