We recently spoke with Dan Lord, Crossover’s Medical Director for the Central Region, about his decade-long journey to and through Crossover. In Part 1, he touched on his background and the key initiatives he has been leading. In Part 2, he digs into the creation of the Guild infrastructure and the value of measurement-based care as implemented across Crossover’s national operations.
When you moved to a leadership role at Crossover, you were instrumental in the formation of the Guilds at Crossover. What are “Guilds” and how did they come about?
I remember Scott sending me an article on the “tribes and guilds” that Spotify had been using to help build a culture and share information at scale. A Guild is a specialized group that organizes around their craft—in our case, our “craft” is our various clinical disciplines. So we had all of our primary care physicians, all of our nurses, all of our physical medicine practitioners (PT, Chiro, Acu), and all of our mental health providers—all of whom not only practice in their integrated care teams at their respective health centers, but also practiced together by promoting clinical excellence, deploying best practices, and innovating within and outside of Crossover. It became a badge of honor to belong to a Guild, where you could practice your craft, with fellow artisans who could appreciate your skill and push you as well. I was tapped to help lead Physical Medicine and then later asked to lead all of the Guilds as we began to scale. Seeing the Guild program grow and mature during my tenure at Crossover has been a real highlight.
What have you seen as the benefit of this Guild mentality in the organization? As the company has grown, how have the Guilds changed?
It directly impacts our ability to deliver leading outcomes for our members. If you’re a physical therapist and you have a question about a challenging case, you have an amazing team of experts at your fingertips to get second opinions or ask about different approaches to care. We can continuously improve our standards, implement new technology, iterate quickly, and share new information across all Guild members. In our Guilds, you’re able to bounce your ideas off everyone, and this happens all the time. Because we enable direct communication and meetings with everyone in the Guild, we are building relationships and a culture where collaboration is much more natural. It’s how our providers want to deliver care.
As we’ve grown, so the tactics and the way that we’ve organized guild communication have changed. Throughout the country, there’s more tiered and standardized communication during distributed huddles, at both regional and market levels.
What is the Guild Quality Operating System (gqOS) and what does it mean for Crossover?
Most people are generally familiar with the measures that we typically see in primary care—things like screenings, preventions, social determinants of health, health equity, and related disparity questions. However, there has been much less work done to develop similar or equivalent measures for the other disciplines that form such an integral part of the Crossover model. The “Guild Quality Operating System,” which we shortened to the more catchy “gqOS,” enables us to look at the health of our entire care model, as well as all of its individual service lines and associated providers which form the basis of our guild structure. What is great is that the architecture of the system allows us to scroll up and down—from individual provider, to individual health center, to market, to region, and at the enterprise level. It allows us to look at access and understand if we need to add more appointments, add more people, or create more efficiency in our practice. Digging down further, it means something different for each stakeholder. For providers, it’s how we enable and assess measurement-based care (we use feedback about each member’s progress and their therapeutic alliance to guide their treatment). Every Crossover provider creates their goals each year; those goals are based on gqOS metrics and tied to their performance bonuses.
What kind of metrics is a provider measured against?
There are participation, completion, and efficiency rates for each of our service lines and their associated health outcomes in the gqOS. For example, in physical medicine, participation means what percentage of people who came in had an initial survey to assess their functional level. Completion rate means how many people completed care, verified by a final survey to measure the change and function from start to finish. Efficiency assesses what percentage of members who came in had a statistically significant improvement within six weeks. You can see a real world example of this in our “Measuring our Way to Well” report on how we implement this for behavioral health.
I’ll refer to our old nemesis, fee for service. In that payment model, you are just measuring volume, or number of visits. Now we’re saying “do we actually fix people when we see them and is there a measurable improvement?” We can set a target such as 65% of members having a specified improvement within a time frame. Providers will also set goals related to therapeutic alliance or “goodness of fit” and related practice experience areas like panel size as well.
Each of the guilds will set its own goals with data in mind, and then we go to work to measure these over time. Of course, we want to make these reachable goals, hence the reason behind our benchmark being set at 65% rather than 100%. We know there’s a certain percentage of people that you don’t even need to measure, for example, someone who comes in needing advice about their posture in one visit. Or maybe you need to refer them out because it’s not a good member for you. Measurement-based care provides a firm and objective background in which we can evaluate practice performance while allowing a balance of the softer skills that make the experience of delivering care a great one. Basically, this is the way that both the science and the art of medicine can come together.
It’s clear the measures are going to remind any provider in any Guild to pay attention to the relationship as well as the outcomes. To your knowledge, does anyone else practice this way?
I think people do bits and pieces of this approach. You can read all about this in the literature and see case studies of this at academic centers where value-based care models were born. There are pockets of mental health systems that practice this way, but I don’t think I’ve ever seen any group combine an integrated model and an outcomes-based payment model with measurement-based care. And the reason why you don’t really see this is that it typically comes back to incentives. Moving away from a fee-for-service approach gives you the leverage to enable a care model like Crossover, which is now even better when informed by our gqOS.
Of interest, this approach also allows us to attract a certain type of provider who is burned out from the fee-for-service treadmill and is excited about practicing in a value-based care model instead. Practicing measurement-based care is all about the patient and best enables relationship building with members. Providers who are successful at Crossover are all in on having full access to our program data on the gqOS which provides full transparency and a continuous improvement environment.
How do the Guilds help maintain the unique culture at Crossover?
It’s tough out there in healthcare, even at Crossover. The Guilds are at the center of the connection our providers have with both our company and the mission. It’s actually pretty brilliant that Scott got our Guilds going so early on. We’ve been crafting this for years now—I think if we tried to start it today, it wouldn’t be the same. It wouldn’t be as organic or genuine. You can really see this in some of the standards and measurements we have introduced, including how they get rolled out, adjusted and adopted, and then improved over time. It has been a very effective dissemination and standardization approach within the organization, and something unique to Crossover.
There continues to be a lot of talk in healthcare about evidence-based care. How does measurement-based care differ from this?
Measurement-based care is a much more specific and rigorous term. Evidence-based care is used very broadly and it’s always been a squishy term, because if you asked ten people to define it, you’d get 10 different answers. Generally, all healthcare companies in our space—a medical group, a point solution, any digital health company—can say they practice evidence-based care. If you have gone through the process to become an accredited medical group, you have to practice evidence-based care, so it turns out it’s not a very high bar to meet given it simply means that you follow basic practice guidelines.
However, measurement-based care includes direct feedback from the member and measures the impact of treatment in real time. Providers then use that information proactively to help them optimize care. It’s more than simply following general care guidelines for a member and their condition. It includes using data and insights with the patient to set goals and expectations for treatment. In addition to specific functional outcome measures, we track the therapeutic alliance developed with each patient to ensure a strong relationship is achieved throughout care. The relationship between patient and provider has a direct correlation to the outcome of care, as well as engagement in our program. Crucially, measurement-based care cannot be achieved in mainstream fee-for-service environments. It has been possible for us because Crossover’s payment model incentivizes providers to deliver high value vs high volume, and gives them the time and space required to practice in this way.
For example, when you engage with physical therapists or chiropractors in the community, you’re going to get a certain amount of visits, modalities, and services based on what’s billable to the insurance company. There is no measurement, no feedback, and no objective way to follow the progress in the relationship. The billing codes dictate both the type of care rendered as well as how frequently it is provided. So, if your physical therapist or chiropractor is authorized to see you 12 times, the recommendation will be that you have 12 visits—whether you need them or not.
When a member comes into Crossover, we design our treatment plan based on their goals, track progress throughout, and make adjustments to care in order to be as efficient and effective as possible. It’s always amazing what happens when members feel like they are not just following along but actually having an impact on their own time to recovery, given that they are measuring and following along in the progress of their own treatment.
How does the progress toward clinical goals get impacted by you also measuring “therapeutic alliance”? Can you also describe that for our readers?
Therapeutic alliance is defined as a collaborative relationship between a member and therapist in the common effort to resolve the member’s health issue. This includes not only agreeing to goals of treatment, but also on the approach, meaning the specific steps that will be taken to achieve the goal and the positive, reciprocal relationship that develops in the course of treatment. This has been fairly well-studied and determined to be an indicator of not only a great member experience but more importantly, having a therapeutic alliance delivers the best health outcomes.
Crossover implements this in a very common sense way by first evaluating the nature of the health situation, attempting to predict or project where the individual is now and where the specific goals of treatment will take them over what time period, and measuring how the member feels about both the plan and the support from the therapist. So, our members are asked things like, “Do you understand and agree with your treatment plan?” and “Are you aligned with your provider?” This creates a lot of value when built directly into the care model itself, as well as every visit in which we engage our members. What we love about this is the intertwining of our member engagement strategy directly into our care model design. And, you just don’t see this type of seamless integration today. So proud to have Crossover leading the way in care delivery innovation!
Many thanks to Peter Heywood (our long-standing brand advisor and business consultant partner) who helped conduct these interviews. Please read Peter’s other Crossover Leader Series Interviews.
Scott Shreeve, MD 