Sometimes, I just can’t restrain myself. After a particularly frustrating encounter with a specific opportunity the following letter just poured out. I want to be clear, I fully respect that we are not the right partner nor solution for every situation . . . that is not where this comes from. However, just seeing the missed opportunity by those who currently sit at the helm of the large payers is traumatizing. The lip service paid to innovation and “creating something new” cannot be reconciled against the cognitive dissonance of the deeply entrenched incumbent that will not and cannot innovate. Ever. Period.
Dear [Consulting Firm] ,
Thank you for taking the time to share the feedback from [Insurance Payer]. As I mentioned, we are disappointed that the conversation won’t move forward, as we felt a strong connection to the opportunity to partner with you and [Insurance Payer] in creating and delivering a new model of primary care.
I did want to clear up several misconceptions I caught in our brief feedback session that you were kind enough to share:
- Crossover has a home-grown EHR.
- This is inaccurate. We use Elation, which is an award-winning ambulatory EHR based in Silicon Valley. We selected Elation after a rigorous process, vetting both their ease of use by a comprehensive primary care team, as well as functionality to integrate with health systems, insurance payers, and our employer clients. We also selected them for their flexibility to add new capabilities for population management, care gap reminders, and other data analysis.
- We wrote our own patient engagement software, which rides on top of the core EHR. Our patients engage with this for scheduling, reviewing health trends, reviewing results, requesting med refills, getting health information, making payments, and completing surveys. This platform has been vetted at [#1 Most Valuable Company], [#2], [#5], [#30], and other leading firms, whose own employees have battle-tested our software in over 1.5M visits over the last 10 years.
- We also leverage Health Catalyst as our underlying data analytics partner, and use their full “data operating system” capabilities in managing our own health information, as well as the claims data shared with us by our employer clients. We are able to analyze our own health outcomes to objectively demonstrate the impact we are having.
- We have a team of six data scientists who are actively managing our reporting, outcomes, and analytics that go into managing our populations. We feel we have become quite able to effectively demonstrate the value of our care model, including its impact on cost, quality, and experience.
- We believe all of the above is material and should be understood by both [Consulting Company] and [Insurance Payer].
- Crossover is nascent in managing populations.
- This is an accurate statement from the perspective of an insurance company. It is inaccurate from the perspective of a medical group.
- We have been managing the health and wellness of our populations including managing screening rates, vaccination rates, and basic health metrics (BP, Cholesterol, and related metabolic syndrome symptoms) since our inception. This IS what we do every single day, all day, and we plan to continue to innovate, and do this even better in the future.
- We are adding a new Care Management service line where we will have dedicated nurses and coaches focused on proactively managing panels of patients with specific conditions. This will augment and formalize the work that our current care teams are already doing. It will also transition our practice from reacting to member demand, to instead proactively shaping the demand, by seeing the right members who need us the most.
- We added Care Navigation to our core care model in 2017 and have been able to reap the rewards of strong steerage since the program opened. We have been able to achieve more than 85% referral completion rates to our curate network after inception of this program which has been incredibly effective in increasing satisfaction, compliance, and information capture, while significantly lowering costs.
- Given our confidence with our experience to date, we have begun to sign up for our first risk-based contracts this year.
- Crossover isn’t flexible on its financial model (no Fee For Service).
- This is accurate. We do not believe that Fee for Service is an appropriate mechanism from which to reimburse primary care or any other care for that matter.
- We believe that primary care should be paid to manage basic health conditions, that we should be paid to manage disease burden in a population, and there should be fees at risk based on basic and enhanced performance.
- We also believe, that in our roles as fiduciaries for the members, we should be involved in guiding care in the secondary care system. We believe that our care navigators have an essential role to play in steering our members in the most costly, complex, and confusing part of their care journey to the right providers for required care. And most importantly, we believe that as a medical group, we have a role to play in knowing the cost, quality, and outcomes achieved by the secondary care network, in order to independently make decisions about where the best value can be achieved.
- We believe that a PEPM / PMPM model creates an effective operating budget from which we can creatively manage the cost of care. We believe paying for value is just that—paying for the things that really move the cost needle. We are willing to bank on the shared savings of our model with innovative payers who understand the foundational role of primary care in controlling downstream secondary care spending.
- The intangibles and the inevitables. We didn’t have time to talk about our experience platform, our brand strategy, facility design, details of our care model, how we manage populations, or our member technology. We didn’t get to talk about how we can scale from 1,000 members to 25,000; from 1,000 square foot to 25,000 square foot facilities; our national scope including the ability to practice in 45 states; the digital health program integration we are implementing with our client partners; how we regularly achieve >90 NPS, huge satisfaction scores, and why 70% of people who use the service consider us their medical home; or why Fortune 50 companies regularly select us to replace their other vendors when they are serious about scale, performance, outcomes, and an exceptional experience. But, hey, all of these intangibles and inevitables would have been spreadsheeted out of any formal RFP process, and likely would not have made it to the client anyway.
We really enjoyed meeting [Initiative Leader] but do not envy his situation. Trying to hold together a business model that is dependent on a network of providers he does not control, on members he cannot reach, and on a payment system that does not have a future, will certainly be challenging. I am sure there are medical groups who are comfortable operating within the current system, and attempting to solve the long-standing problems, using the same tired tools and same old solutions. Unfortunately, we are not one of them. We will continue to innovate outside the traditional system, with payers willing to pay for something different, using non-standard technology, new types of care tools, and integrated, collaborative teams that achieve objectively exceptional results.
We wish you every success in this endeavor!