Interview with Stephen Ezeji-Okoye, MD (Part 3)

In Part 1 and Part 2 of our conversation, we heard from Stephen Ezeji-Okoye, MD (Chief Medical Officer of Crossover) about his experience at the VA and his first year at Crossover. We now turn our focus to learning about Stephen’s leadership role in helping Crossover respond to the COVID-19 pandemic. We discuss how the company began to prepare, developed response levels, effectively transitioned to virtual care overnight, is guiding employers through testing, tracing, and tracking decision points, and where he sees the pandemic leading us over the next 6-18 months.

When did you first start getting concerned about the Coronavirus?

Like everyone, I started paying attention to news of the outbreak in China in mid-January. My first thoughts were about when it would spread to the US, and what would an outbreak look like? Some of our physicians began sending around email updates at the end of January, and by mid-February when we began hearing of cases in our country (mostly from travelers arriving from China). At that point, we knew it was time to act.

What was Crossover’s initial response to the virus?

We had, arguably, a bit of an advantage in that we could see and learn about what was happening in other countries. To that end, we set up a Clinical Task Force in the first part of March to receive and disseminate information about the Coronavirus to our staff, and share the relevant information with our clients as it came in. 

Not long after that, we expanded the initial Clinical Task Force to include Communication and Client Task Forces that dealt with the increasing volume of requests from both of these areas. These in turn were organized under a “Command Center” framework which allowed rapid, decentralized gathering and processing of information by the Task Forces, but centralized coordination by the Command Center. Finally, we added a Pandemic Task Force to explore rapid deployment of technology, testing and tracing concepts, and other asymmetric opportunities as they were presenting themselves. 

The Command Center proactively established a set of scenarios and response levels to guide our clients on how we would react based on unfolding events. This was extremely effective because it basically created a roadmap for our clients as the situation progressed. We offered up the following response levels to help our teams, our members, and our clients understand what we anticipated might happen and how we would respond. These levels are included below: 

Response Level	Description
Level 1	Business as usual
Level 2	Full in person services but start recommending virtual services
Level 3	Limited in person services and request virtual services
Level 4	Urgent only in person services; require virtual services Initiate the pooling of resources and consolidation of care teams
Level 5	Pull back to remote, limited virtual services only
Level 6	No longer able to provide services

Setting out the levels in this way meant that people could plan, rather than just react, as we moved from physical to virtual to consolidated pools of providers across our market, regional, and national operrations. For example, in Level 4, we knew we would need to coordinate our medical records and create a “Super Practice” (a single practice of pooled providers serving a consolidated pool of patients) that would be able to continue to serve our national clients. Thus far, we have been able to maintain our response level primarily at a modified Level 3 (maintain individual care teams but in a virtual posture), with an occasional drop to Level 4 (pooling of virtual only care team resources) in specific situations. The intent of the planning was to help us create as large an amount of capacity and resilience as possible, even if a local team was taken out (which did occur at one of our centers when 1 provider tested positive and 5 team members were exposed and then quarantined). We are also now prepared for, and capable of, moving clinically, operationally, and technically from Level 4 to Level 5 if ever needed which was not something we had ever contemplated before.  

How you were able to transition from 5% virtual to 95% virtual in 3 weeks?

We didn’t come at this cold. We’ve been moving to a “Digital First” practice with a couple of clients. As an employer, Crossover moved to self-insured this year, launching our own XOP platform to our own employees  – effectively Crossover is now a client of Crossover (nothing like Eating your own Dog Food). We also had the experience from Sherpaa, which had already met the operational challenge of delivering care to pockets of members throughout multiple states (43 to be exact!). So we had the blueprint, and we could extrapolate from our own experience which services could easily be adapted to virtual-only, and which would require more synchronous visits. As an example, we had already gained nearly a year’s worth of experience delivering Behavioral Health virtually, and that proved to be quite valuable during the rapid transition. 

All of the above experience gave us the confidence to further streamline our services appropriately as we broke through the different response levels in rapid succession. For instance, an annual physical remains a standard recommendation, but this service offering was put on hold until we passed through the pandemic. On the other hand, some services that had always been done in person were just as effective when done virtually and asynchronously, so we knew we could quickly transition these. 

What are the long term ramifications of this transition? Do you think care will go back to the way it was before with physical visits? 

No, we wont – and, more importantly, it doesn’t need to. The ending of the pandemic will be a much slower process than most people realize, so a large part of our digital model will stay in place as is for some time. But the urgency of the current situation has pushed the boundaries and challenged assumptions, and I think the view that in person physical visits are the only way to access your care team has changed forever and changed for good.

The feedback we’re getting from our members in their survey responses is that they really appreciate the availability and conveniences of our virtual care. They know right now that they can’t travel to see their doctors, which has forced the transition along, but we are also seeing them realize that they might need to physically see their doctor in the future, post-pandemic. It’s making them think: “What do I need to go in for? Why can’t I do this virtually? What can’t I do virtually?” This now moves us into the territory where people will not just endure, but rather come to expect the convenience and efficiency of virtual primary care. 

I think it’s a lot like what happened in banking. Before the ATM, we were at the mercy of the bank tellers and their banking hours. Later, we didn’t need to go into the branches because of those interesting tube deposit systems. Still later, the ATM was introduced and was another leap forward in convenience and access. Now we are in a time where it is expected that 90% of banking can be—and should be—conducted online (did you ever think the bank would become a cafe?). We check balances, pay bills, take photographs of deposits, and send money seamlessly—all virtually—with an actual in person visit to the bank every once in a while to handle some issue. The pandemic has accelerated a similar realization around healthcare.

Maintaining a Digital First model is obviously going to impact things like reimbursement, but it truly enables convenience and efficiencies, so the demand will continue. With Digital First, we can effectively care for more lives, more efficiently, and its relevance will outlive the pandemic. We have an incredible opportunity to ensure that a Digital First model is seen as the core of efficient healthcare, not an adjunct to existing practices. We should also anticipate the Virtualist as becoming a new general medical specialty at some point as well. 

How have you guided employers through this challenging time? 

First, through the work of our various Task Forces doing an entirely new body of work, we have used the Command Center to keep them informed of our planning, strategy, and several broader issues. Secondly, we have made them aware of the necessity and the resilience of our model. Digital First allows us to continue to operate. It protects our staff which ensures our availability, enabling us to better protect their employees .Longer term, as we return to less restricted behavior, I think this experience will have exposed the limitations of the in-person-only approach to clients. Having gone through the pandemic, clients will expect a more robust and resilient approach as a result of seeing how this model can address the gaps in care for all employees, not just those close to a center. Finally, Employers understand that not all services can be delivered in these times, and that we are using our platform to provide the necessary pandemic-focused care virtually. 

What do you mean when you say you offer employers a Chief Medical Officer “as a Service”?

Our Chief Medical Officer as a service provides a consultant who assists with analysis of, responses to, and implementation of plans, that addresses health care needs and challenges faced by our clients.  This service can help clients determine what steps they need to take to minimize risk to their employees as well as how to leverage Crossover, and/or other medical offerings, to design and deploy a comprehensive pandemic strategy. This encompasses planning to ensure that COVID-19 and non COVID-19 health care needs are met. As well as screening, surveillance and risk mitigation strategies, including testing, treatment and return to work evaluations.

What do you anticipate will be the process of restarting the country again? 

We really need an effective vaccine in order to return to any sort of “normal”—and I don’t think that will be for 18 months. Thus, the re-opening of our country (and our own business) will be phased, and will require a bit of trial and error as we look out for a resurgence of infections. It has to be done carefully so we don’t have to retrace, given the progress we have seen flattening the curve. In Crossover’s case, I see us bringing back a quarter or a third of our workforce at the start, while maintaining social distancing, instituting strong environmental controls, wearing masks, etc. Beyond the development of a vaccine, the big issue looming for all employers is testing. We need testing at scale, not just within our organization and for our members / clients, but for the whole country. Testing is absolutely critical to spot trends and narrow the window of opportunity for a resurgence.

How is Crossover navigating the return to work issues with employers?

Everyone wants to get back to work, and our role is to help employees re-enter work spaces safely and effectively. We want and plan to be an active partner in ensuring safety, through symptom surveillance, rapid testing (if someone shows signs), prescribing appropriate quarantines, remotely monitoring our members, and helping them return to pre-COVID-19 health.  

When it’s feasible, we want to offer serological immunity screening, for those who have been infected and are now well again, as a possible way of identifying employees who can return safely. As well, we plan to help with triaging of employees, for example, identifying those employees whose presence will help the business the most. As we move forward, we’re going to help with mass testing, outdoor testing, testing from home, and virtual guidance for those quarantined—it’s all about remaining in contact, which our model enables. 

In addition, we’re going to play a role in state or county level contact tracing efforts by identifying at-risk or infected employees. We recently learned a lot about community-level handling of infectious disease testing through a measles outbreak in our region, where we had to step in to do community level tracing for a couple of counties. The outdoor testing procedure we did also taught us a great deal about the need for appropriate protocols and how to operationalize these services at scale. 

How is the provider staff coping?

They’re holding up well. They were all involved from the beginning in following along with the planning of our response, and looking for what could happen next. We communicate on a regular basis (Surf Advisories, Surf Reports, etc.), have conducted webinars on best practices (Client Council Webinars, Virtual Virtuoso’s sharing techniques, etc.), and held focus groups to uncover our own employee concerns. We’ve also expanded benefits such as sick leave, not only for any illness they may get, but also time off to care for their sick loved ones. And we’ve had many people help build our flexibility and resilience through a series of remote projects that help not only now, but will position the company for success in the future (standard care pathways, workflow revisions, question sets, etc.). It has been a collective journey and one that has been incredibly accelerated by the pandemic.

Many thanks to Peter Heywood (one of our long-standing brand advisors and business consultants) who helped conduct these interviews.