Over the years, we have had the privilege of working with some of the greatest companies, brands, and corporate innovators in the world. I have learned so much from them, about them, and most importantly, about how they approach their work. Each company, like every individual, is unique with different beliefs, cultures, values, and how they get work done. But as with all very successful products or companies, they do certain things in a consistent way that differentiates them through the clear articulation of their value, their positioning, and how they can help you achieve something in your life. In all cases, they have been able to effectively define themselves relative to others in the market and convince you (based on a number of factors) why their product or service is the right one for you. This clarity around definitions, about the one simple thing they do to help you, has been a big driver of their success.
At Crossover, we feel we are at the advent of a new era of medicine, care, health, wellness and vitality. These are all very different terms with individual meanings. I feel that words really matter, and how things are defined is critically important. I’m always surprised when a word I feel is clearly defined one way, is understood in a different way by someone else. I have occasionally introduced new terms well (as in an effective way), but I have also experienced the slog of trying to explain terms by going through multiple rounds of clarifications, retracing concepts, and the frustration of slogging through more attempts to explain, reiterate, and restate while still not always landing in the right comprehension zone. My best success has been not just when people can articulate it for themselves, but when they can teach it to others. I really believe there is something to that old residency training adage of “See One, Do One, Teach One.” This is my attempt to help you “See” what I believe is the future of health.
With the above as context, I am going to use a series of posts aimed at definitions the meanings behind what we see as the future of health, and the broad set of services that create the foundation of what we have defined at Crossover as “Primary Health”1. I am doing this because we are finding it critical to define what we do relative to others, to establish the unique value proposition of our care model relative to the market, and to correctly define terms that are broadly used but narrowly understood. I am going to take on the notion of telemedicine, telehealth, virtual care, remote monitoring, and other forms of remote health delivery. I will tackle synchronous versus asynchronous, transactional versus relationship, and continuous versus episodic care. I want to describe how urgent care definitely fulfills a need, but that this convenience cannot achieve the population-level health outcomes that continuous care can. And, of course, I just can’t resist taking some shots at financial models that encourage fee-for-service, transactional medicine, and activity based billing over achievement based payments. My goal is to have these posts stand alone as distinct explanations, but also to have them hang together and create a continuum towards what we consider the future of health. And, in the end, if my own team can use this as the standard by which we use terms and communicate, I will consider this a success. If others can also use this as a reference to advance our industry…I will consider that a bonus.
So let’s get started by defining the unique set of services that Crossover provides. We have a very broad view of traditional “Primary Care”2 which to us includes not only the physicians and the nurses, but also other care services that we believe combine to create the foundation of good health. These “other” care services can be delivered in the outpatient or ambulatory setting and include physical therapy, chiropractic, acupuncture, health coaching, behavioral health, and fitness. In some settings, we add optometry and even some specialties like pediatrics, psychiatry, allergy, dermatology, and dentistry. This more expanded, integrated, and coordinated care delivery creates a very robust, yet flexible care model. We have gone much further than just bringin the providers together under one roof (what we would call “parallel play”), and instead they literally work together in caring for our patients (true “cooperative play”). Our Primary Health care model is further fueled by the significant investments we have made to “supercharge” our comprehensive care approach. Through a technology infrastructure and data architecture that allows us to aggregate multiple data sources (EHR, Claims, HRAs, etc) and capture key health metrics, we can surface the data and metrics as clinical insights at the point of care, and have our designated care team manage the total cost of care for a defined population. Historically, this has been referred to as “advanced primary care” and in our world, we apply the same modifying term, calling it “Advanced Primary Health.”3
All of our providers practice in “Care Teams”4—groups which provide care for defined populations and work together in an integrated, coordinated, and comprehensive way to achieve stated health outcome goals. These Care Teams are literally accountable to, and for, their members, and are allowed, and expected, to innovate using a variety of technology, programs, and services to increase the health of their “Members.”5 We use the term “Member” explicitly to convey that we have, and seek to maintain, a relationship, that the care model is not transactional but relational, and that we are here to provide continuous comprehensive care versus episodic urgent care.
To further emphasize this, our unit of measurement is not an individual “Visit,”6 but rather a discrete “Episode of Care (EoC).”7 I have written extensively about the EoC in the past (here, here, and here), but it is an important enough concept to return to again. In the new age of multichannel and multimodal care delivery (see the next post), the entire notion of a visit starts to lose its meaning as well as its utility. By the way, what is a visit anyway? Is it only the work that I do in person? Is it the phone call follow up with the physician to whom I referred you to? Is it the work the care navigator does to source and schedule your appointment and follow up with the results? Is it the after hours message I send you to calm your fears about a change in your status? Is my expertise only valuable when I am in person, or is it even more valuable when it’s asynchronous because I can be more thoughtful in my reply?
We believe that in the next advent, care will best be grouped into an EoC, and that we should measure the asynchronous as well as synchronous interactions that occur during the active period of managing a health condition. Clearly, not all conditions fit neatly into an EoC (particularly chronic conditions or ongoing programs of care), but there are certain ways to handle those as well (by purchasing defined units of care at monthly or annual increments). The EoC bundles the concepts of time, labor, outcomes, and value into an aggregate fee that serves as a discrete form of capitation (and provides innovation incentive with the “care budget” created for the condition). The EoC is an organizing principle, a unit of account for clinical care rendered, and measure of value of care received (given that we can measure outcomes at the EoC level). We also believe it eliminates fee-for-service perversions and both ensures and encourages care team innovation and a focus on outcomes.
These definitions must be understood by clients seeking to purchase our services, as well as seeking to understand the difference in orientation, philosophy, care model, health outcomes, and most importantly the “Value”8 (outcome/costs) we deliver relative to other care models and competitors in the market. Having now laid the basic foundation of Primary Health, let’s move on to better understand how it is delivered.
DEFINITIONS:
- Primary Health – a comprehensive, integrated, and coordinated care delivery model that includes multiple disciplines working as a designated care team managing the health outcomes of a defined population.
- Primary Care – a set of services that provides definitive care to the undifferentiated patient at the point of first contact and takes continuing responsibility for the patient’s comprehensive care. This care may include preventive, acute, and chronic care.
- Advanced Primary Health – an “advanced” form of Primary Health that includes a population focus in managing a defined population of members. This involves the creation of an enterprise data warehouse, the use of standard care pathways, and a set of metrics universally applied to the care model across all disciplines such that health outcomes (along cost, quality, experience, and practice operations) can be measured, reported, and improved.
- Care Teams – a designated group of care providers and support staff who provide care for a defined group of patients. Care teams are responsible for the health outcomes of their defined populations and use a variety of technology, programs, and services to achieve their stated health outcome goals.
- Members – an eligible employee or dependent who has created an account on Crossover’s member technology and has received health services from the Care Team.
- Visit – traditionally defined as a single, synchronous, in person visit with a provider for the purposes of receiving care. This is a clinical “meeting” where a patient presents to a provider seeking guidance on a care matter. Historically, this was the only channel available to patients seeking profession medical advice.
- Episode of Care – is an organizing method for care delivery that includes all the “interactions” between a member and their care team around a specific health issue. The issue can be preventive, acute, or chronic and may involve multiple members of the care team. Crossover uses Episodes as an organizing principle, a unit of account for clinical care, and a measure of value.
- Value – is an express term that intends to describe the outcome achieved for the cost expended. In a world with scarcity, some outcomes which would be fantastic to achieve come at too high of a cost. Therefore, the term “value” captures an implied ratio of the value achieved relative to the cost required to achieve it and the associated calculus of choice and tradeoffs faced by decision makers.
Scott Shreeve, MD 
6 comments on “Primary Health is…an emerging health model”