Rich Patragnoni, MD is one of the three co-founders of Crossover Health, alongside Scott Shreeve, MD and Nate Murray. He trained and practiced as an Internal Medicine physician for about a decade before his impatience and frustration with the primary care system led him to embark on the adventure that is Crossover Health. In Part 1, we learned about Rich’s role in the founding of the company. In Part 2, Rich talks about how the company grew and the inevitable pivot to a Digital First medical group.
You started as Chief Medical Officer at Crossover, but what’s your role now?
Starting out, I was initially the clinical guy. Scott was the higher level guy, and I got down to ground level. Nate was in the middle, and there was lots of overlap between us, with all of us covering various aspects of how we’d attack the problem. There was a nice balance between the three of us. Since all of us were basically living together for 12-15 hours a day in the beginning, they soon realized I was a little fanatical about the details of how our model would work clinically.
This kind of forced me into “operations” and how the processes would work, like how a member would literally “check in” to an appointment. As part of that effort, I was introduced to—and spent thousands of hours with—Scott’s brother Steve Shreeve, as we developed our own proprietary software. We needed the member check in process to work in a very specific way—far beyond anything any other electronic health record software was doing—and this would then apply to every aspect of the member journey (payment, surveys, results reporting, etc.). So at the beginning, I was clinical, operations, and the detailed product guy working with the software development “team”.
As we started to get a bit bigger, I found myself, as is common, leaning more and more toward the bigger picture of how the clinical “machine” needed to work. As the operations load grew with more and more clinics, we had to ask, “How do we scale what had worked in 1 clinic now that we are operating 10 clinics?” This caused me to dive even deeper into Clinical Operations, and work with a larger and larger team of nurses, other service providers, hosts, new sites, and new methods of care delivery. About 3-4 years ago, that set of challenges gave way to ask, “Well, now that we have 10 clinics, how do we scale to 100?”. What probably initiated the biggest jump for my role personally is when we began to hire process people who could solve these challenges at this level of scale.
As we started bringing in a lot more experienced people, Mark Nelson, our current CFO who had come over to us from Vizio, said something that really resonated with me. He noted that at Vizio they had a group of people working on “today’s stuff” and then they had a few people working on the “tomorrow stuff.” That clicked for me because it made me realize what I really loved doing—I am definitely a Zero to One guy.
Fully 90% of Crossover was, and is, working on supporting scalable, consistent processes. For example, we brought in Stephen Ezeji-Okoye, MD (See his interview Part 1, Part 2, and Part 3) to serve as Chief Medical Officer running our now national medical group. We said to Stephen, “Hey, we need you to help us run and manage a national medical group.” and he said, “No problem, that’s what I do.” His background and experience aligns perfectly with this role, and he knows what needs to be done to run an organization at this size and scale. We also hired Joe Ennesser, our new VP of Operations (See his interviews Part 1 and Part 2), and we also said to him, “Joe, we need to build 100 stores.” and he said “No problem, that’s what I do.” These people were put into place to create necessary infrastructure in order to scale the current incarnation of the product, which when they were hired, was mostly physical with some online. So as of last summer, with these roles in place to handle “today’s stuff,” I began to slide over and work on “tomorrow’s problems,” as well as keep an eye on what’s out there in the future.
As a side note, as you can imagine, the challenges of trying to have a singular company with a today team and a tomorrow team and all the swirls that inevitably surround a growing company (adding people, process, and protocols) can create some organizational “growing pains” and we have certainly lived through that ourselves. We’re not that big of a company, but still, how do we continue to create and think differently when most of the organization is built specifically to stamp out what we’ve been doing for the past eight years?
What is unique about XO’s culture that can address this challenge and help build on its success?
The corporate practice of medicine requires us to be a professional medical corporation run by physicians, separate from its associated management company. And the death knell to every medical group is typically its management company. The structure of these partnerships is usually, and unfortunately, organized in a way that inevitably leads to conflict. The management group says, “Hey, medical group, we need to optimize our finances and you’re going to need to provide your care this way.” Then, the medical group turns around and says “No, you have never seen a patient, you don’t know what you are talking about, and I am going to do it this way.” So, one of the key architectural designs we made was to have clinician leadership of our management company, and to first and foremost be a medical group.
Because of this shift in the balance of power, toward the medical group perspective, it very much feels like a sea change for clinicians as they join Crossover. However, this change isn’t intended to be that we built some concierge practice catering to the needs of the physicians; rather, our physicians are intended to lead care teams, based on high clinical and experience outcomes. This is real work—there isn’t an easy way out, and this isn’t the way to slow down during your last few years of practice. When you leave residency you’ve got such limited choices as I had experienced first-hand in my own career—join Kaiser, join a big group, join a small group, or work in urgent care. Culturally, we started looking for care team members who wanted to do something fundamentally different—they love medicine but they also can’t stand its current incarnation. We aren’t looking for shift workers, fill-in part-timers, or career lookie-loos. We want people committed to being part of the next generation of care. And, ironically, this approach of looking for people committed to a career change proved to be the second huge cultural differentiator for us.
Who is the ideal doctor for us? We look for someone with 5-15 years of experience, because we need a balance of enough relevant experience to really inspire member confidence, but not so much that they are a Zombie Doctor jaded by the system. The ideal candidate is kind of like a well toasted but not burnt dinner roll, still warm and fluffy in the middle but a bit crusty on the outside. When these ideal people get in here, they see that we genuinely want to change the whole primary care delivery landscape, and they really want to be part of that mission. Our approach really resonates with the people who join us—everyone at Crossover is mission-driven by design.
It’s funny that we almost overdid it, with this culture of being fearless, trying to design everything, all of our values—sometimes it can become and feel like quite a lot. But that idea of the medical group leading really set the tone for who we are, which is so different from our “competitors” who are really businesses that happen to provide medical care. And the people who come here see the difference—we all really want to fix it.
That passion is consistent across both the care delivery and the medical support functions of the company. It applies to Scott, Nate, and me as founders, just as much as it applies to our Hosts, our Nurses, and every care provider in between. This chain of passion has to be real and authentic, and it needs to run up and down the organization. Even our Hosts, which we believe have one of the most critical roles in the company as the first and last face that each member sees, need to share in this same belief because every interaction can be positively or negatively impacted by anyone on our care team.
What do you attribute past successes to, and what principles do you think will guide your future success as a company?
Remember what I said about the Speed of Trust? Imagine three people, Nate, Scott, and me, being able to work together so closely for ten years. It’s extreme trust. It doesn’t mean we always agree or get along, or that we never argue at high volume; it’s that none of us ever need to be right but that we all agree we will battle until we get to the right answer. This is a small distinction with a big difference. Getting to the right answer is really a fight to the truth, and if the guys at the “top” are striving so hard to find the right answer, then I better be doing everything I can as a member of the org to get the answer right as well. This now has become a cultural norm and people really latch on to the concept.
How is the company transitioning to become a Digital First company?
People, even inside XO, have not quite completely wrapped their heads or their hearts fully around what it means to be a Digital First company. They hear what we are saying, and they can see where we are trying to go, but in the actual execution I can understand how we are still in the mindset of a “video visit.” This is challenging but logical—everything that everyone knows and sees is effectively turning the in person visit into an online replica. The much heavier cultural, process, and technical lift is getting people to shift their vision from what is practical with the digital capabilities applied to current visits, to what is now fundamentally possible.
We didn’t start off by saying we needed a physical center, we started by saying people needed a way to better engage with their own health. We weren’t going to be fee-for-service, we weren’t going to get paid to do stuff. We wanted our members to experience, “This is how I live my everyday life, my health advisors are accessible whenever and wherever I need, and my entire care team is available online just as easily as they are in person.” When you stack what people really want, you don’t land on “build a health center.” Rather, the health center becomes just one of several channels that members can use to access services that allow them to better manage their health. We started with physical centers because it somehow seemed easier to have something you could see and touch. We’re not retail like Apple, but it was the same kind of thing—our physical centers helped people understand our model and culture because they gave them an opportunity to see and feel it themselves. Once they walked in, it was always, “Oh, now I see what you mean” and “Now, I get what you are all about.”
For us, the early successes had to be translated to larger and larger audiences as the opportunities we were pursuing grew in size, scale, and complexity. How could we bring the same attention to detail we applied to our physical care model when we transitioned online into the brave, new digital world? Would the same design tenets, the same culture differentiators, and similar workflows allow us to achieve the same type of results? And, in making this technology and cultural shift, did we also have the right financial model to support the transition as well?
For example, how do you get paid for this new model of care delivery—messaging, structured question sets, and surrounding the patient with ongoing care throughout the full cycle of care—when there is no visit? What CPT codes would I apply when I am taking care of 2-3 related but different things? When does it start and when does the episode end? As we started working through all these questions, we just kept coming back to the same thing—how happy we were to never have been beholden to the traditional fee-for-service system. In fact, our transformation to virtual is probably more enabled by our financial relationships than anything else, and working directly with our self-funded employers as the most innovative payer is really starting to yield transformational dividends.
We also anticipate that the care model will continue to evolve rapidly. We still see a need for dedicated care teams who know you personally, and care will still need to be comprehensive, integrated, and coordinated. But it can’t just be medical, or limited to urgent care, it has to include physical medicine, behavioral health, and care coordination—and it will need to surround the member 24/7. Ultimately, we will need to learn how to create that same sense of confidence and security that the members get when they come to a physical center – but now create this when the interaction is Digital First or digital only. That is where we are focusing our efforts now.
What are the key elements that will help Crossover really get the Digital First transition right?
Let’s face it, short of COVID-19, no one does video visits for most of their interactions. Sure, you can video chat with your kids or aunt, or message internally within a company, but it’s not the standard business-to-customer move. We had someone who was thinking of joining us and he said, “Yeah, I have an accountant who I’ve never actually seen. He does all my stuff, we communicate through chat, but I don’t call him my virtual accountant, he’s just my accountant.” Exactly.
For some reason in healthcare, that example of the accountant didn’t translate. Because of COVID-19, we went right from synchronous in person visits to synchronous virtual visits. Jay Parkinson, MD, who joined us as Chief Designer in February 2019 (see his interviews Part 1 and Part 2), is right when he says there’s no other industry that says, “Hey, I’m going to jump online and interact with a stranger on a video visit.” That doesn’t happen anywhere else, and it’s not the path we’re choosing either.
To be honest, some of our current clients brought on the push to digital only. They said, “We love what you did with the onsite, you solved the problem with our smaller offices with the nearsite, now what can you do for all of my remote employees?” We struggled a bit with this. Even from the beginning we didn’t want video visits, but then, what did we want? And that’s where Jay and his company Sherpaa brought their technology into the mix. When you talk to Jay about what he accomplished, you won’t hear him talk about technology until you are like 30 minutes into the conversation. Jay pretty much says all the same things we do about the components of a great experience. What he means by that is not the overused idea of experience as entertainment but simply creating access to a care team that knows me, who’s accessible, and who’s not a stranger. You have to meet me where I am, not where healthcare is, and he built tools that look and act like those that we all use in everyday life, to accomplish what we are trying to do digitally. That really resonated with us because it looked a lot like what we had done (minus the physical buildings) and we were fortunate to bring Jay into the company to jumpstart and accelerate our Digital First approach.
There are, of course, some very technical challenges to continue to solve with Digital First like, “How can I monitor you remotely? Can I get labs to your home? How can I do more for your care in this new way?” We have made a lot of progress, and we are seeing clear opportunities to increase our member communications in a way that allows us to do even more with this new approach to care. In the fee-for-service model, we wouldn’t look at any of these innovations because we would be waiting for administrative set pricing from the government to “tell us” which innovations are valuable, and which are not. Again, this is why we love working with self-insured employers as payers—they truly value these innovations, these efficiencies, and the cost and experience advantages we can bring with this care model.
In Part 3, Rich speaks to the qualities of the online experience, the nature of relationships, and how Crossover is addressing the challenges of COVID-19.
Scott Shreeve, MD 
Have you integrated other specialties such as orthopedics and podiatry?