This was an interview with RamaOnHealthcare exploring the future of Primary Care in the US.
BACKGROUND: Crossover is a technology-enabled, national primary health membership service that integrates both online and in person care for self-insured employers and health plans. The company currently serves over 350,000 employees and their families via our onsite, nearsite, and virtual health services.
RAMA ON HEALTHCARE: Welcome, Crossover, to our thought leadership series. Let me start with a direct question. While primary care is rightly seen as the front door to healthcare, what are the top three barriers it faces in delivering on this role?
SCOTT SHREEVE, MD: Thank you for the opportunity to share some thoughts on Crossover. We are certainly passionate about the power of Primary Health to fundamentally transform healthcare delivery.
First, the major challenge facing primary care is the standard business model that rewards fee-for-service volume and transactional medicine, with little accountability for outcomes or engagement. The broader needs of the client (the employer or payer) and the consumer (the patent) are not well aligned, despite a general awareness that a trusted primary care relationship is essential to keeping people healthy and out of the expensive parts of the healthcare system.
Secondly, within the traditional care model, the accepted medium of exchange is the visit. I know there has been a rapid shift to virtual visits because of the pandemic, but in most cases, the visit has simply shifted to a synchronous online setting with the payment model remaining primarily fee-for-service. This results in just treading water with a transactional, time-starved schedule that physicians need to work within in order to keep their financial heads above the water.
Finally, the transactional and compressed nature of primary care encounters have reduced the physician’s tool set to writing scripts, ordering tests, and sending referrals. There is no time or data to delve into the patient’s overall health status and history in order to uncover alternative courses, gaps in care, or anticipate issues before they become major events. The primary care physician’s role has, to be candid, devolved to that of a reactive lead and revenue generator for others. The physician’s practice has become the front door to the rest of healthcare, rather than the front door to health.
RAMA ON HEALTHCARE: Primary care requires a transformative, consumer-centered approach. Ideally, primary care should be easily accessible, affordable, anywhere, anytime, and with a focus on keeping people healthy, promoting health equity, and encompassing social factors. Please comment how you view this disruptive and fundamental shift happening.
SCOTT SHREEVE, MD: As I noted before, the first step is to transition to a fixed-fee payment model that rewards outcomes and achievement, and eliminates the visit as the sole currency of exchange. We believe this involves replacing the idea of a “visit” with something that we call an “Episode of Care.” But it’s more than that. To your point, there are numerous factors in patients’ lives that influence their health status—lifestyle habits, the stresses they face, the absence of a trusted partner to provide the timely and valuable counsel they need, even a lack of access to care. Traditional primary care has done a poor job of addressing social and lifestyle issues that underlie medical conditions presented at visits. At Crossover, we have a very broad view of primary care which to us includes not only physicians and nurses, but also other care services such as physical therapy, chiropractic, acupuncture, health coaching, mental health, and fitness that address all the psycho-social-physical aspects of good health. We created a specific term to describe this expanded view of care: “Primary Health.” We ground Primary Health in comprehensive data, can deliver it through multiple in-person and online channels from Care Teams that are mandated to build trusted relationships with our members, and embed Care Navigation so that we can more effectively manage the referral process end-to-end when sending our members into the secondary care network.
For Crossover, this shift is happening in partnership with activist, self-funded employers, who are frustrated with opaque and ineffective healthcare and are willing to invest more in comprehensive Primary Health. They share our conviction that a strong Primary Health foundation leads to meaningful and objective reductions in overall spend, much higher member satisfaction than patients in the community experience, and improved outcomes. This value-based approach, which we call Commercial Advantage, is the key to a future of care that is based on its ability to keep people healthy and engaged, while simultaneously reducing the burden of costs. The impact is obvious, and the move to the broader universe of payers beyond self-insured employers is becoming both irresistible and inevitable.
RAMA ON HEALTHCARE: The pandemic accelerated the adoption of telehealth but effective remote patient monitoring (RPM) and chronic care management (CCM) are not here yet. What are your views on creating a cohesive environment for day-to-day health management, the play for primary care, and patient engagement?
SCOTT SHREEVE, MD: Your phrase “cohesive environment” is apt. Both patients and payers have already been dealing with an incredibly complex, incoherent delivery ecosystem, and telemedicine simply adds another layer to an already fragmented experience. Most telehealth services deal with a limited number of common, urgent issues and, like other ancillary services the patient may engage in, aren’t connected to the patients’ regular primary care provider, and are not equipped to provide the broad oversight necessary for true CCM or even general health management.
In my view, physicians have largely abdicated their responsibilities in this area, leaving the field open not only to telehealth providers (who partially solve the access issues) but also to vendors of specific CCM point solutions. Yet, in our experience, the member is most likely to engage in beneficial behavior change within a trusted relationship with their provider, not a third-party service. We actually believe the best results can be achieved when their primary care provider can “prescribe” these point solutions as part of a more comprehensive approach to care. When you know your physician or care team is going to be tracking alongside you, those remote devices become a part of the care plan, and the data becomes a continuous stream of information-sharing. That will be the future that I believe wins.
We have already begun to make significant investments in this infrastructure and the data architecture required to aggregate multiple data sources (EHR, Claims, HRAs, etc.) and capture key health metrics. This allows us to leverage the data and metrics to surface clinical insights at the point of care, and have our designated Care Team manage the total cost of care for a defined population. The essential point of difference is that we not only aggregate and analyze the data and identify the risks and care gaps, we’re also the trusted advisors that can deliver the recommendations to our members directly. There is no gap in care when your care team is ensuring those gaps are closed. To us, that’s the very definition of a cohesive environment.
RAMA ON HEALTHCARE: In the US we do not have an ecosystem for data sharing or health management. Do you see wearables/apps as the digital front-door enabling an ecosystem, care continuity, and a more empathetic approach with stronger relationships?
SCOTT SHREEVE, MD: There is no argument that monitoring apps and devices can be incredibly valuable both in helping motivate our members to attain their health goals, and as early warning systems for their Care Teams. However, health monitoring wearables and apps must be seen as part of a broader approach to data-driven individual and population health management. From our perspective, our front door and the core of our relationship and trust-building are not the apps themselves, but the Care Teams that can “prescribe” these apps as discussed previously. We love that our Care Teams build the trust needed to fully engage members in any medium, about virtually any issue, powered by the connected data we collect through encounters, claims and, of course, monitoring devices and apps.
To move beyond the transactional and reactive model of fee-for-service healthcare to one where the focus must be on relationships, prevention, and long-term wellness, we knew a data-rich, population-based model was as important as a fixed-fee compensation model. We’re enabling evidence-based decision-making not only through access to general population data, but also through the data provided by our own expanding national footprint, as we serve the needs of employers and other payers with widely dispersed populations.
RAMA ON HEALTHCARE: What is the role of AI and Machine Learning, enabled by wearables and app data, in enabling “personalized health,” ensuring positive outcomes and saving lives? Can you elaborate on their value to dispersed populations?
SCOTT SHREEVE, MD: We’re firm believers in and adopters of technology that “supercharges” the experience and clinical decision-making. Too often, however, AI is seen as a replacement for traditional decision-making rather than a high-fidelity enhancement to care. To us, AI is simply the tool that hums in the background, making the connections we may not see ourselves. What we find is more relevant is the EI (“Emotional Intelligence”) that needs to serve as the wraparound humanity that allows the “machines” to do their best work. You will always want and need that humanity and human touch for best outcomes.
Based on member’s responses to an annual “Up To Date” Episode of Care, we make recommendations, enroll them in specific care programs, and offer to track along with them. We also connect with them via their preferred devices for simple physiologic metrics like weight, activity, calories, sleep, heart rate, and others that may be relevant to their care. Crossover’s Primary Health model doesn’t just passively track their health journey, we co-create an “annual health strategy” to proactively guide them to their chosen destination.
The monitoring is further enhanced when we can link additional “data sets” such as claims data to their overall health portfolios. These pooled and permissioned data are also bounced against our clinical operating system and its associated care metrics. We can now evaluate “gaps in care,” which represent open care items that should be closed out as part of the “Up To Date” Episode of Care but are now rounded out here. As we begin to aggregate more data we start to get more diagnoses and conditions, and we can begin to effectively use AI tools to monitor these as part of a “condition management” approach. We can now proactively begin to monitor these individuals with known conditions, individually reach out to them, and in partnership, ensure there is a clear plan, active management, and a close connection. And this happens in any channel, at any distance, providing the same level of care oversight to every member of a population.
RAMA ON HEALTHCARE: Where do you see the market for advanced primary care headed in the coming five years and how is Crossover positioned for this future?
SCOTT SHREEVE, MD: There has been plenty of debate in the last many years about the seemingly unstoppable rise in healthcare costs. I think however—finally!—that the pivotal role Primary Health can play in bending the cost curve is being acknowledged. I also think that payers, employers, insurers, and even public health bodies have realized that even the best point solutions need to be positioned within the cohesive environment, as you put it, of advanced primary care, or Primary Health. There are no point solutions available that can plunge the depths, cover the breadth, and engage the masses, while also reducing the complexity and costs like a EI-powered medical group delivering Primary Health.
As the primary care sector is dragged by payer demand out of the fee-for-service paradigm, I believe models like our “Commercial Advantage” will become commonplace, expected, and the standard. There is already demand for transparency and simplicity on the part of employers who are weary not only of the cost, but also the management burden of a Byzantine health ecosystem—and we’re starting to see the same demand from insurers themselves. While we are sometimes seen as healthcare mavericks, I like to think we’re creating the new healthcare mainstream.
Scott Shreeve, MD 