Steven Chang, MD, is a veteran of Crossover Health, having started as a practicing physician in the onsite health center at Applied Materials in 2013. His arc at the company reflects not only his innate skills as a physician, but also provides a lens into the increasing complexity of Crossover as we have significantly expanded from a Silicon Valley startup to a growing national network that manages the health of entire populations.
Can you share with us your Crossover “Origin Story”?
I’m a Midwesterner, having grown up in Ames, Iowa, home of Iowa State University. After high school I left for the East Coast and studied public health at Johns Hopkins in Baltimore. Following a short stint at the National Institutes of Health, I completed medical school at McGill University in Montreal.
I didn’t know much about Montreal initially, but it’s now one of my favorite North American cities. It’s so vibrant, culturally interesting, and very European in its aesthetics and people. It was a great experience but as the climate kept getting colder the further I moved up the East Coast, I decided it was due time to go someplace warmer, so I ended up coming to California and starting residency training at the Stanford-O’Connor Family Medicine program.
Instead of going the traditional route – straight into practice – I first worked at a startup company which was later acquired by Walmart and became Walmart Labs. I was an analyst for the startup, wrote a daily blog called The Daily Dose, and helped support their health website. It was a valuable experience, but realizing that my true calling was still medicine, I completed my training at UC Davis, got board certified in family medicine, spent three years at One Medical before joining Crossover in 2013 where I’ve been ever since.
Crossover was still very small and very early at that time. What helped you make the leap?
At McGill I was exposed to Canada’s single-payer healthcare system and coming back to the US, I found myself stuck in the trenches of healthcare, doing a lot of documentation for insurance companies that did not provide any benefit to the patients. What sold me on Crossover was that I felt that I could take a chance and work in the employer-sponsored healthcare space. This opportunity would let me take part in creating unique and creative strategies to enhance health outcomes in an environment that was much less constrained than the traditional fee-for-service world. I was really passionate about being a part of the change that is so desperately needed in primary care.
You literally started at the Applied Materials (AMAT) health center in Santa Clara. What were some of the interesting aspects of that experience?
You’re right, I started as the medical director at AMAT pre-launch and was there through the opening years. What stood out for me during my tenure was the uniqueness of their employee population and the willingness of their benefits team to engage with us on strategies to improve the health of their employees. The AMAT employees I interacted with were superbly intelligent and highly data driven. It was probably the first time I had multiple patients come in with Excel spreadsheets of all this self-quantified data. But, despite having all of this data, many of them still didn’t engage with healthcare even though they suspected that something was wrong. Almost always they waited until some seminal event happened and prompted them to show up for an urgent visit.
In primary care, we emphasize prevention. But how do we engage with our patients to get them to see the value of prevention? This is so fundamental to the care we provide at Crossover – working to empower every individual to understand how to live their best health, and to establish trusted relationships with us – their care team – in order to be able to successfully do that.
How did you engage with members like these? How did you create the relationships?
It was a lot of education, wanting to be a guide for them, and ultimately letting them make the decisions that were right for them. And mirroring their approach, I often shared data, clinical resources, and my knowledge base so that I could take the time to work with them as a trusted partner on their wellness journey.
What was your transition to take on more of the program development for Primary Care?
I had been at the AMAT health center for more than three years when an opportunity came up to do program management work for the greater Crossover organization. This meant an opportunity to set clinical policy, participate in medical group governance and clinical operations, and to serve as a representative voice of our physicians. So, not wanting to decline an opportunity to acquire new skills, I transitioned to this management role while still seeing patients at our onsite health center at Apple.
What are your key program management responsibilities that you led and what have you learned from that experience?
My current role is the Primary Care Program Director. At Crossover, primary care is one of five key components in our interdisciplinary Primary Health model that also includes mental health, physical medicine, health coaching, and care navigation. Of course, I’m not the single person manning our primary care program. It’s a large and complex program and it obviously takes a village, but I get to have a say in how the program is managed, how we standardize care, as well as the overall program direction. One of my core duties is to ensure standardization of operations and clinical practice across the company, which ultimately leads to a consistently high level of care delivery, member satisfaction, and great health outcomes.
I love what I do because it’s challenging and it keeps me on my toes. In a rapidly growing company, constant iteration is required in order to scale. A great example is our response to the ongoing COVID-19 pandemic, during which I’ve spent countless hours digesting clinical data and guidance, interpreting it in the context of our company’s needs, and then writing and rolling out the guidelines and policies that support sound clinical practice and operations.
How do you integrate standards yet still provide for the individuality of each physician?
I try to strike a balance. We want providers to have autonomy, but at the same time, we must follow the most up-to-date practice guidelines and care standards. So, for example, it may be up to the provider to decide which specific medication is best for their patient, but with our evidence-based recommendations in hand to guide them.
In our integrated approach, we leverage all of our service lines in the management of the member. One of the things that Crossover providers learn shortly after joining us is they’re not siloed. We’ve made sure that our primary care providers are not just physicians working in a room by themselves; but that they are collaborators in a team which, ultimately, is to their advantage and to the member’s benefit.
That raises an interesting point. Your practice standards obviously incorporate processes for involving other types of providers, and I assume, how to work best with them. How does this work in practice?
All of our service lines (we call them “guilds”) have evidence-based care pathways and guidelines which they follow. We are deliberate in incorporating inter-guild referrals to take advantage of our integrated care model. A very common practice is for our physicians to refer patients with low back pain to one of our physical medicine providers because we want patients to get back to activity as quickly as possible and be active in their healing practice. We don’t want to simply prescribe medication, as that can simply be a bandaid. So, we refer the patient to physical therapy, chiro, and/ or acupuncture as part of our recommended care pathway.
One of the first things that providers do when they onboard at Crossover is meet with their team members so they can start to understand their team’s skill sets and how they can work cooperatively. During medical training, we seldom work right alongside other types of providers, so it’s an eye opening and learning experience for some new providers to go through. Some providers will even participate in their patient’s chiro or PT visit to see first hand the treatment process. And I think this kind of experience contributes to our physician retention rate, which is around 95%.
How does the new Guild Quality Operating System (gqOS) tie into how you maintain standards?
The gqOS is an example of our outcomes based, data-driven approach. In its simplest sense it’s a metrics dashboard which enables our providers to gauge their performance on the care standards that we’ve set. Once a care standard is set by our medical group, we work with our tech team to determine how to track the associated metrics. We build in the technology workflows that will allow us to gather data to see if we’re meeting our care standards, which is then fed into the gqOS for each provider to access. It provides the ultimate level of accountability for the members in our care.
Please see the continuation of the interview in Part 2 where we learn about several other key initiatives Steven has been playing a lead role in, as he brings a systems-driven approach to all that Crossover does.