Interview with Karoline Hilu, MD (Part 1)

Karoline Hilu, MD is Chief Strategy Officer at Crossover Health. She joined us five years ago, after time spent in healthcare policy, corporate strategy, and finance. Karoline has been at the heart of Crossover’s growth and transformation into a different kind of care provider. In this first post, she provides some insights into her thoughts on primary care, her unique background, and wisdom culled from mentors in her life that have led her—you might say it was inevitable—to Crossover. 

What’s your background and how did you come to Crossover?

I’m originally from Poland. When I think back to that time, I remember a few critical moments which have shaped my belief system, whether I wanted them to or not. I lived in a system that was set up as a socialist environment but in which everyone knew that Communist party members greatly benefited. I remember my family members being involved in underground Jesuit organizations, which were strictly prohibited by the state, and paying the price. I recall standing in reparation lines set up by the Germans for the victims of the Holocaust, people whose pain was visceral to me even at that young age. I watched my father write his PhD on toilet paper when store shortages were pervasive. I remember his despair when he had to hand over iodine to Party members during Chernobyl while the rest of the country was unaware and walked the streets in May Day (Polish independence) celebrations. That was the  final straw for him—he left for a visit to Canada and never returned. My mother and I followed with backpacks on a similar visit a few years later. I remember standing outside the Polish Embassy in Toronto waiting for the Berlin Wall to fall. It is my deep belief that inefficient and perverse systems like those I literally escaped from must fall—and will fall. 

However, I also remember moments of pure comedy as we adjusted to our new reality in Canada. My parents held a strong position that the iconic Barbie Dolls, which conveyed women’s value as physical attractiveness, were worse than narcotics. I was constantly reminded that I could—and should—do anything a man could do. (But, no, playing competitive soccer was for boys only and involved wearing shorts in public.) You could just hear the misplaced, hilarious dialogue of Eddie Murphy’s character in Coming to America playing in the background.

Although, while I balanced the seriousness of my upbringing in Poland, and the lighter, new life we were building in Canada, it became clear to me that immigration is a state of nothing. You are unseen (ideally), have almost nothing, and have very limited choices. You realize that the tangible things you had in the past are irrelevant and that you can make it through almost anything. If you are lucky, as I was, somewhere along the way, someone will help you. The most basic things—a bag of clothes outside your door, a job, any advice—will set you on a new path. I’ve received all of these things and I am determined to pay it forward. 

There were many people who have helped shape me and my career including: Professor Charis Thompson, now at the London School of Economics, precepted my undergrad thesis on the tension between intellectual and economic production and reproduction, and has remained a mentor over the past 20+ years; Jim Walter MD, who ran the Emergency Department at the University of Chicago, and taught me how to make lightning fast choices and run a team like a family; the guys at HLM Venture Partners, especially Peter Grua and Russ Ray, who hired me for a summer internship, making the bet to hire a woman when many firms were not, and gave me some of the best career advice I’ve ever gotten to boot. They suggested that as a woman, I should do what is least expected of me and go into investment banking. As jarring as that advice was, somehow I knew it was right—and to date, both Peter and Russ have been there for me at every critical moment of my career. I also have to mention Cormac Miller, Chief Product Officer at the Advisory Board, who treated me with refreshing, radical candor and  involved me in talent moves far above my paygrade. All of these mentors taught me that merit-based equity, revolutionary transparency, and being part of a true team—not just having a seat at the table, but a voice!—are mandates of the only type of work worth doing. I have applied these ideals to every single person we have hired, invested in, and promoted at Crossover. People are everything. 

Many years after first meeting him, it was my mentor Peter Grua who called me and said, “I spoke to a team, and when I spoke to them, I felt like I was talking to you.” And with that, he introduced me to Crossover Health. I already had a coveted job with a wonderful boss, but I knew within five minutes that I would take any role at Crossover. 

What was the compelling reason for joining?

The single reason that I joined Crossover was that this is a team I respect and trust. Peter called it right. When I joined, Crossover was a nascent asset with so many possible pivot points. In my corporate strategy role prior to Crossover, I ran point on primary care strategy for large provider organizations and I worked up all the different direct primary care players. Two things caught my eye about Crossover: almost no one knew about the company, yet Crossover provided care for Apple and Facebook—which was intergalactic. And the second was my thesis (which few at the Advisory Board agreed with), which stated that while everyone was betting on the Medicare Advantage space, the space was too crowded, most companies were using the same broken methodologies, and that ultimately, it would fail because of the psychosocial complexity of the population. In my mind, the right place for rapid innovation was the self-funded employer space.

One of the fundamentals that we were (and still are) aligned around at Crossover was the thesis: how do you use this incredible employer-funded, consumer-centric, primary care asset as your key lever to control healthcare trend? About a year after I came onboard, Facebook was willing to speak on the national stage at the NBGH National Conference and say, “Because of Crossover, we’ve reduced total trend by 30% on a risk adjusted basis.” This was a huge milestone for us . . . and the rest is history!

What are the challenges facing primary care?

In spite of how I loved provider organizations and academic medical centers, I knew (and they knew) that they would not solve the population health problem. Why? Three basic reasons:  1) the wrong payment model, 2) the lack of philosophical alignment between providers and administration, and 3) the lack of underlying technology. 

These are the three categorical issues we’ve very intentionally addressed at Crossover from Day 1 because we were effectively creating our own system of health. First, we’re directly contracting with employers in a capitated model, with absolute alignment around longitudinal patient outcomes, not around the number of visits. Secondly, with the exception of Nate Murray (who we consider a doc because he took three weeks of sports medicine in high school), the rest of the initial leadership team consisted of clinicians. We share a love of patient care, in contrast to the business-run companies where there’s a philosophical disconnect between those making the business decisions and those providing patient care. And, then there’s our tech platform that we are so proud of and that could be a company in and of itself. It is a distinctive asset—a tech platform built by clinicians for clinically-oriented processes because we don’t have the requirement (let’s call it a distaste at best) for visit-based, fee-for-service billing. Those factors together—a new payment model, shared clinical vision, and underlying tech—are the key market differentiators and value levers of our model.

If you’ve met our Chief Medical Officer, Stephen Ezeji-Okoye, MD and our VP of Practice Management Sally Larwood, RN, then you knew in a heartbeat that the only reason you should be in our organization is because you love clinical care, and you deeply believe that not only does the current system need to go, but that we are the ones poised to do make that dream a reality. Stephen and Sally just drip these beliefs, and their evangelism is compelling—and refreshing—relative to the traditional suits running clinical practices. 

The second part of our conversation with Karoline addresses the impact of COVID-19 on our members, our providers, and how healthcare is being transformed in these times, and then looks into our future as we come out on the other side of the pandemic.