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.
Could you describe the difference between the new Crossover Platform (XOP) you are building and a traditional Electronic Health Record (EHR)?
The Crossover Platform (XOP) is really about creating a robust communication tool, because at the end of the day, primary care is about conversations and relationships. The other key part of XOP comes out of the understanding that in healthcare you have projects—we have historically called these care plans (a bundle of activities related to each patient). A project starts a certain way, there might be check ins along the way, you might need to add a prescription, or take some other types of action. Think of it as project management based around an issue or a condition, and you manage the project for its entire duration through each ebb, flow, and iteration. If you look at these two factors—communication and project management—and you follow along with what Slack has done for the workplace, you can see what we are up to. Of interest, Slack is primarily synchronous and continues to be one of the sources of inspiration behind what we are building for XOP.
When you start going down this path some interesting things spill out along the way. There are some real efficiencies to be gained. The “episode of care” behind each project allows communication in between what were traditional visits—a lot of care can happen in these “in between” places because there is a lot of life that happens in between physician visits!. Jay had initially made the observation that ongoing communication doesn’t just make the documentation more efficient—the communication is the documentation. There’s tons of research out there that points to how much is lost when talking in person vs. talking synchronously, because when you’re face-to-face so much communication goes unspoken and even more goes unremembered. With the ongoing communication through an episode, you get way more efficiency, as well as more accuracy, because what you’re communicating remains in the record for all to see, access, and review.
One of the advantages of being out of fee-for-service is that I’m also “out” of CPT coding as well. This means I don’t need to document the bullet points dictated by the AMA and payers so that I can get reimbursed according to their whims. Let’s not forget that an EHR is designed to capture documentation in support of billing. It is NOT designed to support the natural clinical workflows, interactions with patients, or the rhythm of what should be a meaningful relationship with your care team. So with XOP, I don’t need to build any of the billing infrastructure; instead I focus on enabling our care model via enhanced communication and effective project management of health conditions. It’s really a communication tool to develop and manage relationships.
What’s the distinction between the care team relationships and the Episode of Care?
I see the relationship as being between the member and the care team. For example, you know that Dr. Patragnoni is your primary physician, but you also know he works as part of a broader care team. That way, if Dr. Patragnoni is ever gone, on vacation, out sick, or not available, another member of the care team that has the same approach, the same principles, and the same information, can help you with whatever your issue might be. It’s not a random physician, it is literally someone on the same care team—the close collaboration effectively creates additional capacity to care for you over a much larger time continuum (after hours, on weekends, holidays, etc.).
We are able to establish these relationships quickly when we have physical centers due to the natural connections that occur when people spend time together. However, we are now going to extend that relationship with you online, which allows you to not just get care when you come in person, but now to also get care online just as easily. We believe the in person + online relationship will be much easier to create and manage than a digital-only relationship.
The challenge really begins where caring for populations that will be purely remote – you never have the opportunity to engage them with health center or interacting in person. So how do we humanize the digital-only relationship right from the start. Part of the humanization is ensuring that we have a good match between members and each of our care teams, which implies that we will employ some forms of regionalization. We don’t think having one big call center in the middle of the country is really helpful, because ultimately our teams will need to know some of the local doctors and understand both the natural networks as well as more traditional contracted networks of specialists . Locating our Care Teams in the same geographies as our members allows us to create scale while also ensuring some level of regional customization as well.
The Episodes of Care are the projects that may pop up. Now, one thing we still have to work on is that episodes are still fairly reactive, meaning that just like in a visit, there is usually some issue that a member has before they initiate care with us. I like to describe our current stance as being “reactively proactive.” We like to try to be as proactive in our care approach as possible, but given the current cultural expectations, there are still many times when individuals only think to engage us if they have an existing health issue. We would like to move toward a place where individuals are reaching out to us first to establish a baseline or well care relationship. We definitely see us heading in the right direction with better and more pervasive communication tools and events.
For a patient, there’s something about the physicality of the visit that tells them, okay, healthcare is now on and then it’s off. This cultural expectation actually gives Digital First care an advantage, because most people understand it as the understand modern life – a continuous conversation rather than a single, finite interaction. Online, we think there’s going to be a greater sense that the care teams are more accessible, more a part of everyday life, with significantly less friction, and where proactive care will first begin to make sense. For example, one of our proactive episodes will be called “Up to Date.” You’re feeling great, but we reach out to you and say it’s time for your yearly “Up to Date” check up. That starts people down a proactive episode just like a routine oil change or a dental check up. We’re not there yet but we’ll have episodes for when you’re sick and when you’re well.
So to summarize, the episodes are the “health” projects, the relationship is with the team, and access to the service should feel like a continuous conversation.
Can you share with us how your care model has responded during the COVID-19 pandemic?
Well, what’s interesting with what we were just talking about is now during COVID-19, you will get to see how the relationships we have with members will be one of our most valuable assets.
When COVID-19 first hit, we immediately set up a clinical task force. We had to quickly get tactical while thinking about the ramifications on the operational side.Do we have enough PPE? Do we keep the centers open? Do we move to remote right away before our teams get impacted? How do we convert to full digital? How do we show our clients that members can retain connections and relationships with care teams, and we can turn on and off the physical as needed, as various waves of the pandemic hit our members? Flexing all of these capabilities also sped up clients’ thinking quite a bit about what digital care actually mean . . . and to be honest, what really is “care” anyway? Clients were still very much thinking in terms of “visits” and we had to shift them away from thinking that these 20-30 minute “meetings” were not going to be the way “care” is delivered in the future. Basically, it took the pandemic to massively accelerate this new paradigm.
Parallel to the tactical, operational, and client management pieces of our day to day operations, we had to figure out how to really make it all work during the conditions imposed by the pandemic. This was us basically trying to make sense out of all the data, figure out what primary care’s role in the pandemic should be, and determine what could we be doing as an organization to have maximum impact for our members and our clients. Our early data showed we could have the biggest impact with triaging and navigating for our members. Asking, “Are you one of our highest risk or sickest members?” If not, then we will manage you in a different way and ensure you are not clogging up the hospitals, which are focused on managing those with respiratory failure, other diseases, or simply those individuals who have nowhere else to go. Keeping our care digital meant that we could expand capacity, continue to stay connected, and ensure that we didn’t infect more people. Effectively, we viewed our role as being a key pressure relief valve to the system as a whole.
So how are you guys now helping employers get “Back to Campus”?
The final thing, and we—like everyone else—don’t have a definitive answer for yet, is how we get our clients’ people back to work. This involves looking at the latest data on serologic testing to see if there is immunity, who is high-risk and who is not, and coming up with a plan for each of our clients that is ultra-flexible, including screening to guide employers on when it is safe to return back to campus, as well as when we can reopen health centers again. Our clients are actively turning to us for these answers. We’re staying as up-to-date as possible, and placing, for instance, bets on serological testing as one of the variables that will allow people to get back to work. We are stirring several pots right now, and we see a lot of opportunity to increase our value in the weeks and months ahead given who we work with, how we are working, and the issues our national medical group can uniquely solve.
The furthest we’re going to look forward is a mid-term view. If you look at the ends of the spectrum—from staying sheltered at home in an economic standstill all the way to the other end when we will have an effective vaccine with 75% herd immunity—we are trying to stay reasonable and practical. We want to find solutions that can work for employers trying to get back to campus, and for our employees who want to get back to normal life. Getting back to normalcy won’t be a straight line—instead we’re preparing to adapt as things ebb and flow over the next 18-24 months. Maybe there won’t be an effective vaccine, or the virus mutates year to year, or we find we just don’t mount a big immunity response, just like the related cold virus. We have to be ready for all these scenarios and have flexible solutions that can improvise, adapt, and overcome in any scenario.
What will be the long term impact of COVID-19 on primary care?
There are a couple of categories of change. I’ll start with the things that aren’t patient-facing. And some of these are “I’m hoping…” for observation as well.
First, the state licensing requirements have been ridiculous roadblocks preventing care from being provided nationally. Pneumonia doesn’t change because of a state boundary, and people need access to doctors wherever they are. Thankfully, this has been largely—though not completely—wiped away because states have recognized that they can radically increase the care capacity by – temporarily at least – removing these barriers. I hope these positive changes stay.
Second, the HIPAA privacy regulations have also gotten in the way. These were really geared to physical records, and most people don’t think these rules have been appropriately applied to the digital space. If I don’t have a patient’s full medical history online, I’m really limited. So many of these rules are so arcane, and the financial system—which has equally sensitive data—has certainly figured out multiple different ways to handle the secure sharing of information across all kinds of platforms. There is just no excuse to not get this done for healthcare in 2020.
Third, on the patient and social side of things, I’m hoping that the digital experience is seen as more than just telemedicine. We have been saying #beyondtelemedicine in our internal and social media conversations. Giving people access to a primary care team, online as well as in person, can not only build great care relationships but also be meaningful in “steering” people to the services they need in the “secondary care” market. This steerage is particularly relevant now because it means guiding people to avoid hospitals and care aggregation spaces where they increase the risk of infection.
I’m shocked at what we’ve considered “essential” during the shutdown, and how little we valued these things before—everything from food sales to primary care. I hope as we come out on the other side of this, we value and invest in these things more. We’ll see something like this pandemic again, and we shouldn’t wait until it’s broken, or until we have to deal with national lockdowns to take action. We need to have the infrastructure in place and make the right investments in what people—now more than ever—understand is truly essential. Having the infrastructure of digital care in place right now has been really great, and as people get even more used to it in the future, it will continue to pay dividends in not only navigating COVID-20 or the next pandemic, but also diabetes, cancer, chronic diseases, or other future health calamities.
What’s the end game in the next few years?
When we started the company, people asked us, “What’s the end game?” We said we didn’t know, we just knew there were a lot of things we needed to fix. I know that at some point there will be some type of exit—whether that be through new private equity investors, someone acquiring the company, or perhaps the company going public. To be candid, a lot of that line of thinking is directly out of my and the other founders’ control, but the one thing that is in our control is the ability to continue to innovate, execute, and bring forward our vision so that more and more people can see it. We have always found that continuing to solve the hard problems allows us to also stay one step ahead—we can see and consider options, rather than worrying about what might come next.
If you weren’t at Crossover, what would you be doing?
If I wasn’t at Crossover, I’d be trying to join Crossover! As a provider, healthcare has let me down. It was supposed to be so much more, and I will continue to fight and fix and deliver care the way I would want it to be for my own family. So, after this experience at Crossover, I will never be able to go back to the way things were. I will now always be swinging the hammer to innovate some new part of care delivery. I can’t unsee what I now can see clearly as the future of care.
You know, as ambitious as I have been and as the company’s goals are—and after a decade of blood, sweat, and tears—there has always been a part of me ever since medical school that wanted to travel the world surfing. It’s so funny, because I actually went out and did the complete opposite by working 100 hours per week for 10 years. But, just as there have been so many remarkable twists and turns on this journey, there would be nothing greater than at least having the option of doing exactly that. Nothing like a little “Inevitable” to put an exclamation point on this journey.
Many thanks to Peter Heywood (one of our long-standing brand advisors and business consultants) who helped conduct these interviews.
Scott Shreeve, MD 