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The Need for New Models of Primary Care | Scott Shreeve, Co-Founder & CEO, Crossover Health

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In this episode, Cowen’s Health Care Technology analyst Charles Rhyee speaks with Scott Shreeve, MD, Co-Founder and CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery and experience of health care. An emergency medicine physician by training, Scott has spent his career actively building life science technologies that improve the delivery of care and enhance the quality of life. They discuss the problems with primary care today and why we have seen the emergence of new models of primary care in recent years. They speak about how the use of technology can move us from reactive sick-care to proactive well-care. They also discuss the outlook for primary care and the changing role of physicians in delivering care. Press play to listen to their conversation.

Transcript

Speaker 1:                       Welcome to Cowen Insights, a space that brings leading thinkers together to share insights and ideas shaping the world around us. Join us as we converse with the top minds who are influencing our global sectors.

Charles Rhyee:                Hello, my name is Charles Rhyee, Cowen’s Healthcare Technology Analyst, and welcome to the Cowen FutureHealth Podcast. Today’s podcast is part of our monthly series that continues Cowen’s efforts to bring together thought leaders, innovators, and investors, to discuss how the convergence of healthcare, technology, and consumerism is changing the way we look at health, healthcare and the healthcare system.

                                         And today we’re talking about using technology to re-imagine the primary care experience. And joining me today to discuss the topic is Dr. Scott Shreeve, co-founder and CEO of Crossover Health. Scott is an emergency medicine physician by training and has spent his career actively building life science technologies that improve the delivery of care and enhance the quality of life.

                                         Prior to Crossover, Scott was the co-founder of Medsphere Systems Corp, the first open source EHR, as well as a founding member of the Health 2.0 technology and reform movement. Scott, thanks for joining us today.

Scott Shreeve:                 Hey Charles, great to be here. Thanks for having me.

Charles Rhyee:                Excellent. So we want to talk about primary care and all the great things that are occurring right now in the market, but maybe to start, I think most listeners will probably share a similar experience of what it’s like to go see their primary care doc for their annual checkup, sitting around and waiting rooms, getting pushed into a small exam room, and then being seen for maybe five, 10 minutes, and then being kind sent off.

                                         So maybe from your standpoint, what isn’t working right with primary care as it’s traditionally practiced today?

Scott Shreeve:                 Yeah. It’s a great question, and what’s awesome about it is everyone has an experience. Everyone’s got something to say because we’ve all experienced the healthcare system. I got to experience it at 10X speed because I’m an emergency medicine physician, so that is even one more level challenging than the traditional primary care office experience. But what I learned there was because we didn’t have a good safety net, we didn’t have primary care that was accessible, convenient to get to, and affordable, that a lot of people would end up in the emergency department.

                                         And I think if we were to look at primary care, you can go back to all the different root causes, I think even from the very beginning of med school, you’re always kind of taught about how great the medical technology is and getting into all these specialties, and primary care doesn’t receive as much payment, people undervalue prevention generally, and so we kind of wait till things kind of fester up and aren’t taken care of in the right way.

                                         You have whole socioeconomic lifestyle, behavioral, social issues that affect people’s health. And I just think when you start adding all these things up, and then the big dropper for me is how primary care is paid for. And because the way our billing system works and the way that fee-for-service has evolved, you have the result of that. And that’s the short visits, your very abbreviated, single condition interactions with the provider, you don’t have much prevention. In fact, there’s not a code for keeping people healthy.

                                         And so all of these things have evolved as a natural consequence of how we pay for it and what we expect from primary care, and you see that all over the place. And again, I felt like I had a unique view as an emergency medicine physician seeing where primary care really didn’t work when it all came down to it. So that’s kind of my synopsis.

                                         And again, I know everyone shares that view and they’ve had their own experiences, but those are some of the, the root causes.

Charles Rhyee:                Yeah. And so not surprising then, right? We’ve seen a number of attempts over the years to improve the primary care experience, and more recently, companies like Crossover, and others like One Medical, and Oak Street Health. They appear to be gaining the mindshare among consumers and investors as well.

                                         What is it that these new models, primary care do that’s different than what people normally expect?

Scott Shreeve:                 Well, I love the innovation and we need it. We need all comers, all stripes, sizes, shapes of innovation, different segments, different payment models, all these different things all need to be brought together because we need to figure out what’s going to work.

                                         But I do think what’s caught in the attention of certainly, the members or the users of these services, is that they are very focused on specific needs of the populations they serve. If we take One Medical as an example, they were one of the first and pioneers in offering a membership. They had to create a separate thing on top of the existing system to make it palatable, to make it more engaging, to make it useful and valuable to the members. And they’ve done a great job of growing that business in that segment, and raising the profile of what primary care could be.

                                         On the other end of the spectrum, you have folks like Oak Street, which, in the Medicare Advantage space, which I think over the last 15 years, that whole segment has done a great job of educating the market of why primary care is valuable. You can take these very sick, very high cost, challenging patients, wrap them around in a primary care focus model that goes beyond just medical care. You’re getting into delivering meals to homes, delivering medications, social activities, other things that are purpose built to serve that population. And of course in their model, they go at risk.

                                         And so Crossover, it represents yet another kind of evolution and innovation in that we have focused exclusively in the payer space… Excuse me, the employer space. And we are working with large self-insured employers who have employees that they’re paying for, and they’d like to get as much value as possible. And in that, we kind of sit between this great concierge membership-based experience, and then we also deliver these accountable results around cost, quality and the experience.

                                         And so, it’s this kind of nice continuum from no risk to full risk that along that continuum, you’re going to see a lot of different innovative models. In addition to that, each of these models seems to appeal to a different segment. Everything from we are focused on the employers, some are focused just on retail, some that are focused on Medicare, Medicaid populations, some are focused on the LBGTQ population.

                                         And so I do think you’re going to see a wellspring of all these innovations. And what I love about that is we’re in an era where technology is taking its appropriate role as an enabler of the care service, as an extension of the provider. I personally don’t subscribe to the theory that the tech will replace the doctor, but I certainly believe it will augment the doctor, and really increase their capabilities, not just the doctor, but the whole care team.

                                         So what I think you’re seeing in the market, Charles, is a response to those challenges I first laid out. You’re seeing models that now have worked their way around fee-for-service, that have worked their way around limitations in how people can use technology, and how the care models actually work.

                                         And so I welcome all of these. We hope to be carving out our own little path in there, but I think that’s what’s generated all of this innovation, which is more than welcome and absolutely needed.

Charles Rhyee:                Yeah, and I totally agree. Maybe let’s talk more specifically about Crossover. You kind of touched on a little bit there, maybe give us a little bit more of an overview of the business, and a little bit more details on how your model differs from competitors, or how the model itself works?

Scott Shreeve:                 Yeah. So what we’d like to say is Crossover is really trying to create a new category, which we call primary health membership, and what we mean by that, we can kind of break those terms down. So first of all, at our very core, we believe very strongly in primary care and a psychosocial behavioral model of care. And so, again, if you go back to that bio-psychosocial model, it’s addressing all the needs. It’s a comprehensive approach to care.

                                         And so because of that, we focus on prevention, wellness, as well as the actual care. Now, we call it primary health because we move beyond just the primary care physician and the nurse. We also include in our model, physical medicine, behavioral health, health coaching, and care navigation. And the reason we include all of those services is that’s where the need is.

                                         Musculoskeletal has always been a number one or two spend for the employers, and now we’re seeing the emergence or surging of mental health services. COVID just exacerbated that, and that’s been our fastest growing service line. We also are finding that health coaching is incredibly valuable, and the reason why we care about health coaching is we’re trying to lead to behavior change.

                                         Health coaching was traditionally thought of as like a nutrition diet, lost weight kind of thing. We view health coaching as a much broader, impactful scope when you can get to help people make the behavior change that are so hard and at the root of most medical care and spend.

                                         And then finally, we embedded the care navigators into this primary health model, because if you care about total cost of care, then you certainly should care that 85% of the spending is actually happening outside of the walls of primary care. That’s not where the expense is. The expense is out in the secondary care system, and a lot of that is just the coordination, the navigation, and getting people to the right places.

                                         So primary health is really descriptive of that comprehensive, integrated, coordinated team of people that are taking care of you. And at Crossover, you don’t just get a random doctor or provider every time you have an issue, it’s that same care team. You’re building a relationship, and it’s really the currency that we transact in is trust. And we really want to build trusted relationships over time.

                                         Now, the reason we use the word membership as well, is membership implies that you belong to something. This isn’t some transactional, “I’m in and out, I’m gone.” This is something where someone’s got your back. You’re developing a relationship with someone and a care team because they’re going to take longitudinal care of you.

                                         And so that’s why Crossover isn’t just there for sick care, we do a fabulous job of that. We’re also there just for your health. So we engage people proactively in screenings, prevention, social determinants of health, and we have a rich set of programming that allows our members to learn about all these different issues from the experts that are also their providers. And so we really create a community, a way to engage the members in their own health and set their own strategies for the year.

                                         Now, membership has two swords. One of that is obviously, to the patients who we call members, but also, the employers who are involved in these models really feel the same way. They feel like they belong to something too. And in fact, they do it, they belong to a connected system of care that spans all 50 States and so forth. And so there’s a lot of value between the clients who joined Crossover, who are sharing knowledge and experiences between each other.

                                         So primary health membership is the category, but at the root of that is just basic good, fundamental blocking and tackling primary care based on trust.

Charles Rhyee:                That makes a lot of sense. Maybe talk then about how you enable that? You talked before, where you view technology as an enabler to deliver service, not to replace the physician. Talk about the role of technology then with Crossover in delivering your services?

Scott Shreeve:                 Yeah, absolutely. And this is fundamental and foundational to, I think these next generation care models, is we view technology, just as you said, Charles, as an enabler and an extender, and a coordinator, and an integrator of what the care team actually does. So let me kind of break some of that down.

                                         So we use a third-party electronic health record as our base kind of layer for documentation, and some of the things that we need to do to submit claims to insurance companies. We don’t build them, but we do submit claims for a complete record. But everything we do to engage the member is software that we have written ourselves. And this is how you sign up, how you schedule, how you message, how you ask for refills, how you get surveyed, how you pay your bills. All of that is a technology layer that we built because we felt we had to be connected to the member. That was a huge part of the way we engage them and stay connected with them.

                                         But again, it’s not just the connection that’s important. We also need a lot of intelligence about each member to add value to the care. So in partnership with our employers, we get access to claims data. And with that claims data, we put that into our enterprise data warehouse. We apply all the rules and logistics to that, and out spits what we call the care insights. Those insights are pumped right to our care teams who are accountable for the outcomes of the patients that they are responsible for. And then they share those information and insights directly with the patients, through that same connection that we already had.

                                         So that technology stack and that ability to do that is typically not available to the primary care teams because they don’t have access to the data. They haven’t been able to invest in these enterprise data warehouse or set up the intelligence generators, and that’s really challenging. And so now, the other part about that tech is not only we’re connected to the members, but our care teams are connected to each other as well.

                                         And so that’s really important because our care model relies on a care team. So how you do these handoffs, how you make sure that people are being followed up on, how you track and trend the population you’re responsible for. So when our providers show up in the morning and they have their huddles, they’re reviewing their case loads for the day, but more important than who’s coming in or who we’re interacting with that day, is who are we not interacting with that day?

                                         And that’s where the tech really enables my care team to go after the people that they should be interacting with. Those who might have care gaps, those who might have needs or follow-ups that are necessary to keep them engaged. And I think that’s really the role of technology to be a fascinating extender. It’s a force multiplier of how we provide the care.

Charles Rhyee:                And you made an interesting point there. In some ways, you talked before going beyond sick care. What you’re describing though, in many ways, when we’re looking at patients who are not seeing, it sounds like there’s an element of being proactive…

Scott Shreeve:                 Yeah.

Charles Rhyee:                [crosstalk] Reaching out to the patients.

Scott Shreeve:                 This is my biggest thing that I want people to understand about these models, right? We’re not sitting around waiting to see who shows up and is sick, right? What we’re doing is we’re really a health monitoring service for the population. So when we go into one of our clients, everyone who’s eligible for the service and with the patient’s permission, we’ll monitor the health of that population.

                                         So Charles, if you were one of our patients, I would be able to tell you where you stand on over 40 different clinical metrics. And if you were out of balance on any of those, with your permission, which I already got as you signed up for the service, I would be reaching out to you to say, “Hey, Charles, let’s follow up on these two things.”

                                         And normally, when you get that call from the insurance company, you have no relationship with, you’re like, “Who are you and how do you know this? And I’m not talking to you,” click, or message wise. In our case, it’s like, “Oh, this is my care team who’s doing what I asked them to do to follow up with me.” And so this becomes this proactive care. We’re actively closing down all these gaps, helping people set a strategy for the year.

                                         And what ends up happening is for the first time ever, our employers are starting to see, “Oh, you’re actually monitoring the health of my population.” And what’s going to happen is over time, as people continue to get more and more instrumented up, they’re wearing their watches, their Fitbits, whatever they have, their sleep things, their beds tell me how well they slept, they’re stepping on the scale every day. All these different things are just information that’s being gathered, and where should it go?

                                         And what we’re saying is it should come back to that trusted medical group. The doctor doesn’t need to know that you took 10,000 steps a day, but your health coach might. And so someone on your care team is going to be following up with you. And so this idea of active health monitoring of populations is really what we do.

                                         And again, this is why the virtual care model is 1.0, I think have limitations because you’re not connected with them. There’s no ongoing relationship. Who’s going to track and trend with you? And that’s what Crossover is signing up for. And that’s why we think these models, these primary health membership concepts are really so powerful. It’s really how we think healthcare should be.

Charles Rhyee:                And it seems to me, this is what with technology can enable in healthcare. I think most providers would say, “We would love to be able to be more proactive in delivering care but there were limitations in the ability to do it.”

Scott Shreeve:                 Absolutely. Listen, if your business model requires you to see 35 patients in seven minute increments, you cannot be proactive. There’s no thoughtfulness in a model like that, versus, you’re responsible for the same number of people, but now you’re like, “Hey, who do I need to see today? And I have a care team now that can be interacting with patients. So I’d get rid of the things that don’t…” Remember, I’m coming from an emergency medicine viewpoint, which is 70% of these people don’t need to be here today, right?

                                         Let’s make sure we get them taken care of, and from a primary care perspective, who is here today that I can take care of because there certainly are urgent needs, but who is not here today that I should be taking care of? And that’s really the flip in mentality that starts all the way back to how you get paid because if I’m not paid to do any prevention, then I’m not doing any prevention.

                                         It’s like the dentist who hands out candy, right? We’ve been doing that for years. It’s like I don’t want to be generating bills that way. I want to be responsible for outcomes, not for activity. So what we say is reward achievement, not activity. And that’s where I think these models, move, and technology allows you to be proactive.

                                         If I didn’t have that data, I’m just flying blind. But with that data, I know that I’ve got 32 diabetics that I need to be keeping close track of. I have technology that does that, and I have a care team set up that my nurse is reaching out to them.

                                         And then also, my health coach is involved in the behavior change that’s needed because at the end of the day, if my patients could do most of the things, we might wipe out another 30% to 40% of the situations that they have just because they’re taking accountability for themselves.

Charles Rhyee:                Yeah. And you talked about being paid for outcomes and not activity. It kind of brings to mind the model that you often talk about, commercial advantage.

Scott Shreeve:                 Yes.

Charles Rhyee:                Maybe kind of talk about that a little bit and [crosstalk]?

Scott Shreeve:                 I think it’s a great term and I’ll set the stage this way. So over the last 20 years, everyone is seeing people are very worried about Medicare spending and all this stuff. We’ve talked about value-based contracting, all of these different things. And over the last 15 years, we’ve started to have a nice body of evidence that starts to show that a lot of the models around Medicare Advantage are starting to have some outcome results and some impact.

                                         And I think you’re starting to see some public entities, Oak Street being one, and there’re several others that are like them that are close behind. But what they’re doing is they’re saying, “Listen, I can take the sickest, most challenging patients. I’m going to surround them with a care model. And that care model is fine tuned to their needs, which is polypharmacy, multiple admissions to the hospital, issues at home and access, and all these things. I’m going to fix all those problems, but I’m not going to fix them in a medical way. I’m going to look at them holistically. And I’m going to send a driver to your house to get your blood pressure. Because I know if I do that, you’re not going to show up in the ER, and they can just do the math and see where they say that.”

                                         So they’ve purpose-built these things and they get great outcomes. And so Medicare Advantage now has about 35% of all Medicare patients are enrolled in one of those plans, which is fantastic. And as we looked at that, we said, “Wow. Listen, here’s a prototype of what we’re trying to do in the commercial space.” So I work with self-insured employers, which by definition implies people who are probably age 20 to 65. These are people generally healthy enough to work.

                                         And so I have a different population and sometimes we get criticized for that but I’m like, “Hey, we can’t boil the ocean. We’re going to take care of this segment, and we’re going to do a great job.” But what we do is we say, “For this group, let’s purpose-built our services, our care, our care models, our technology to serve their needs.” And when you do that and then simultaneously, “Let’s get paid a different way, and then let’s get rewarded for the outcomes we achieve. Let’s create a commercial advantage plan for our employers.”

                                         And so that’s what we really love about this, is we deliver concierge level experience, a whole range of services, we get high engagement, and then we’re accountable for the outcomes. And that creates this commercial advantage for the employers who are paying for the care.

                                         We like that term because people generally can kind of get it. They understand that we take some forms of risks. We’re not all the way at total risk, and we’re not all the way at fee-for-service. We’re somewhere in the middle, which provides some nice segmentation. But I do think the employers who want value-based care, they want great access, they want great outcomes, and they want a great experience. We can deliver that, that’s what we do and we do it at scale.

Charles Rhyee:                And maybe talk about then the growth you’ve seen? I guess another way to frame it is what percent of the market is ready for this kind of healthcare delivery?

Scott Shreeve:                 I think you’re hitting on something because not everyone is ready for this. Much to our chagrin, some people just want to solve the problem of access. Like, “Hey, what’s quick, easy, convenient? Let’s get a solution in place and I’m good. I’m good until next year.” And we find that those aren’t really our clients, right?

                                         Our clients are people that are fed up with that and they want something more organized. They want more accountability and they really want to go deep. And they’ve realized that you can’t impact healthcare costs if you don’t change healthcare delivery.

                                         And so what we’re seeing the growth is coming from is a group of employers we call health activist employers. These are people that are paying a growing, ever and growing amount of money each year to healthcare. They don’t feel like they’re getting value and they’re willing to put in the time and effort to fix it.

                                         And when I say time and effort, what I mean is they’re willing to dive in and to directly contract with a group, a medical group is going to come in and start to change the health care delivery. They have to set up the outcomes that they’re expecting and to pay for them in a different way. Sometimes they have to pay for facilities to have the services delivered in, or to offer them virtually.

                                         So there’s work on the side of the human resource leader and the company to make this decision, but when they go direct, they can actually get this. And so what we’re seeing is once you’re about 2,500 people and you’re self-insured, you’re feeling the pain of this and you’re starting to be motivated.

                                         And so a lot of the bigger companies who are self-insured, they’re like, “This is so getting out of control, it’s impacting our bottom line. Let’s go after this.” And what’s so funny or interesting, Charles, is the companies we work with, they are innovators in their own field. They know how to manage supply chains and to drive the cost, and deliver great products.

                                         And they’re just turning their sights to healthcare saying, “You know what? I’m not going to tolerate an 8% to 10% to 12% increase in my healthcare costs every year, year after year, after year. I’m going to get after it and figure this out,” and they’re starting to really get involved with direct contracting, expecting more and putting the onus on providers like Crossover, “Deliver these results. I’m happy to pay you differently and separately, but I expect results.”

                                         And I think you’re going to see more and more of that over the years. And so there’s just a growing momentum of employers who are looking for these models. And then our job is to make it really simple to acquire and to implement. And it used to be that it would take you six to nine, to 12 months to build out a facility. Well, we can do that now in four to five months. And it also used to take us that length of time, but now I can turn people on to the virtual service in a matter of two to four weeks, and get people up and running right away, and get this kind of care going.

                                         And so we’ve really tried to compress those timelines, but we’ve seen the growth. I think you’ve seen it in our numbers in some of our announcements, and it’s a great time to be in the segment as people have really recognized that primary care, it’s like Justin’s song, Bringing Sexy Back. It’s all the rage now, Crossover Health, primary care. People think it’s great again so I love it.

Charles Rhyee:                You talk about these larger companies becoming more like these health care activists.

Scott Shreeve:                 Yeah.

Charles Rhyee:                Obviously, more recently, we’ve had an example, Amazon, Berkshire, JP Morgan trying to really take that next step, and then eventually kind of pulling back here.

Scott Shreeve:                 Yeah.

Charles Rhyee:                What were the challenges you think they probably faced as they kind of looked at this healthcare issue?

Scott Shreeve:                 Well, here’s the thing, and again, because we see these big announcements. You think about that partnership of these three mega companies, all incredible innovators. I just think it speaks to how hard this is. It is not easy, it is no joke. You’ve got to be committed, you’ve got to be long-term, and I think as you try to bring three different visions together, I think they found that, that was challenging. But I applaud the effort.

                                         Listen, people might point to that and say, “That was a failure.” I would say, you know what? That was an awesome effort. We need 50 more of those and then we’ll finally get it. So I applaud the effort, but I do think it’s extremely challenging. You have to be extremely committed. And at the end of the day, you’ve got to be willing to put your money where your mouth is.

                                         And what I mean by that is that if you really believe in a new health system, if you really want value-based care, then you’ve got to pay for a foundation of primary health in a different way. And you’ve got to go after the network, and you’ve got to spend money in your network in an effective way. And at the end of the day, you’ve got to play the long game with helping people change their behaviors. Because at the end of the day, 70% of what we’re talking about is chronic conditions that could be altered by behavioral modification.

                                         And so I think not every employer wants to do that. They’re busy, they’re competing for their lives and their own markets, and their own business, and then to turn and spend a lot of time on healthcare. But I can tell you that those who make that investment, the yield, not only on the direct healthcare cost savings, but in the productivity, in the reputation, in the differentiation of that company, is significant as it becomes a part of their culture.

Charles Rhyee:                You made an interesting comment just now, being able to tackle the network. It kind of speaks really to the systemic nature of how our healthcare system is set up. It’s really set up for specialist care and referrals into a specialist network where, to your point before, most of the cost actually is. [crosstalk].

                                         So if we think about the market for primary care, what do you think it looks like in five years? And how do we change them, that structure that incentivizes health versus [crosstalk]?

Scott Shreeve:                 Well, the first thing, you know you’ve got a problem where there’s not a single code that I can bill when someone’s healthy, zero. So what do you do? I just take care of sickness all day. Well, I’m not a technician. I should be a thoughtful strategist for the patients I work with.

                                         And I think a much better analogy than our current kind of sick care model is the financial services model. If you think about asset management that you partner with someone who sits down, reviews your assets, you make a plan, you prepare, you make investments, and someone keeps you accountable for those outcomes.

                                         I think your health is your most important asset, and without that asset, none of the other assets matter, but let’s take an asset approach to health. So let’s think about your health. So where are you, Charles, in your baseline health? What should you be investing in this year? Where are you trying to go and grow your health? And how can we increase it over time, and who’s keeping you accountable?

                                         And much like in putting money away for your IRA or future, this is that kind of a mentality. How do I convince someone who doesn’t have a need today that they should be making some investments? And so this is where I think this really needs to go, is that you start thinking about your health in terms of your wealth, manage it like an asset.

                                         So get involved with people who can help you set a baseline, be involved in programming that actually makes some investments in some decisions that you’re doing, and then stay connected with an advisor who can help you keep accountable. And I really think that’s where this is going.

                                         So I don’t know if that answered the question, but I just think that paradigm shift is really… It’s the same thing. It’s the whole reason for Health 2.0 to exist. Health 1.0 is all based around the provider, it’s very reactive, I get paid for doing things, and I think Healthcare 2.0 needs to all be about… it’s really about the member, it’s about proactive care. It’s about staying in front of these things ,and it’s getting paid for outcomes.

                                         And so you can see that shift and people want to pay for that. People want to try to strive for that kind of model and move to something new. And I just think you’re seeing employers, payers, and others moving towards these models. And I think there’s enough of us that are out there doing this, that I think you could see a pretty big trend, which I think speaks to the investments, and investor community really paying attention to this area.

Charles Rhyee:                What you’re speaking of sounds very much like value-based care, value-based care models.

Scott Shreeve:                 Yeah.

Charles Rhyee:                And to that point, yeah we’re seeing this trend, but you would think it would be moving much faster than it is. And clearly, I think for many providers though, it seems like it’s a hard transition for them, right? They’ve got one foot in the fee-for-service world. They’ve got some payers trying to come at them with value-based models. [crosstalk] keep the lights on, right?

Scott Shreeve:                 Well, here’s the bottom line. I think you have family members who are in medicine, but again, I’m an ER doctor. I’m taught to hyper tasks which is I can do 10 things at once. But when you think about a provider is in his office, he’s got 50 different health plans. He or she has no idea who’s on which health plan, they just walk in the room and take care of whatever’s there. They’re not treating them any differently. So the fact that they’re in some value-based plan, I think is a joke.

                                         And so, what we do is you’ve got to be a 100% all in on this stuff. And what I like is the idea that our providers have made a choice, it’s a career decision, they join us. We employ everyone in the company. It’s a culture of care, it’s an approach. And everyone we take care of is in that model. I’m not dealing with multiple different models that treat different people different ways. And it’s just so easy.

                                         There’s a great phrase by Steven Pressfield, he talked about turning pro, “When you turn pro, your life gets easy.” When my providers aren’t worrying about billing 55 different codes for everything, they’re just focused on the member, there’s one payment model, it’s all consistent.

                                         Now, I also recognize that, that’s a little bit of a fantasy where one of the things that I like about where we started with the employers is it was like a safe harbor of innovation. I didn’t have any rules of insurance. I didn’t have any other problems. I could just go in and innovate and get the model.

                                         Now that we’re at scale, we’re starting to go back to the payers and say, “Hey, you’ve been talking about value-based care for a long time. We’re actually doing it, and you can pay us in a different way, and we will produce the outcomes you want.” And so that’s why, again, using the language of commercial advantage, a lot of these payers have had a lot of success with Medicare Advantage and now they just want to apply it to the commercial space.

                                         And so, I do think value-based care is hard. It’s not so easy, and I think you can’t be fractured in trying to do four different things at once, there’s no accountability. And so this is why we love… We use a phrase in our company, “Designated care team for a defined population.” All the providers know what the game is. They know how to play together. They’re going to work together to take care of this defined set of people. They get to know them over time, build a relationship, and they know they’re accountable for those people. That’s how we’re going to get there.

                                         You can’t be have no accountability. You can’t be in the buffet line every night and expecting to lose weight. That’s just not how it works. You’ve got to have some direction and some management. This goes back to my other point, Charles, is that you cannot control healthcare costs unless you can control healthcare delivery. The way we try to do that in the ’90s, if you remember, was this capitation model, which had a lot of good elements to it, but it was the compulsion aspect of it that limited it.

                                         Now with technology 25 years later, I can make you feel like… Well, you are in control, but I can now add technology to provide the recommendations and the guidance that feels complimentary, as opposed to compulsory. And that’s really where I think this goes because when our care navigators are steering you, you could still go to any doctor you want, but chances are, you don’t know all 10 cardiologists, and you’re going to take our recommendation 95% of the time. And we’re going to send you to the two value-based people.

                                         And remember, value is not cheap, it is not price. Value is the outcome you get for the price you pay. And that equation is really important because the numerator and denominator both have to play together to get you what you want. And so we are value-focused and we’ll get you to the right people.

                                         But I think you can see how all the parts of the model, you don’t just show up and say, “I like value-based care,” and it happens. It is blood, sweat, and tears to make this thing come together. But when it does, it is beautiful.

Charles Rhyee:                And you talk often, we’ve talked often about a care teams and coordinated care here. Where do you see the role of the doctor then in the future?

Scott Shreeve:                 Great question. So I was a quarterback in college, and so I got to experience what that’s like. And what I realized is while the quarterback gets a lot of the recognition and the accolades and so forth, he is worthless without his lineman. He’s worthless without his receivers and his kicker, and the punter and everyone else on the team.

                                         And so I do think the physician has a unique role to play as the healthcare strategist. They should be setting the strategy for every individual patient. They should be setting the strategy for the care team and how they’re managing the population.

                                         However, that quarterback needs a lineman, needs a receiver, needs a running back, needs a punter, needs a kicker, and that team needs to come together to work. And as you know from team sports, you can have a superstar quarterback in a really crappy team, and you can have an average team that is just exceptional. And I think the team-based care is a phenomenal approach to delivering outcomes to the members.

                                         Here’s a little secret that you wouldn’t know unless you’re on the inside, it is also phenomenal for the providers. They love to practice in a team-based environment. They love to learn from each other. They love being accountable if you give them the tools to actually impact the outcome.

                                         So we have enjoyed very high retention. We’ve enjoyed a lot of great collaboration between the team members and a lot of satisfaction because they do work in care teams together trying to achieve a very targeted goal.

Charles Rhyee:                That’s great, and I wanted to maybe round it out here with a last question on sort of the outlook. Obviously, a lot of excitement here, it sounds like Crossover is doing great and there’s a lot of innovation happening in the market.

Scott Shreeve:                 Yeah.

Charles Rhyee:                Is the market ready for all this innovation? Is there enough capacity, you think, to support all these types of new models emerging?

Scott Shreeve:                 Yeah. Well, a couple of things. First of all, I just thank you for the nice comments. As an entrepreneur and founder, you kind of feel like you’re walking through the desert for 10 years. And then finally, there’s a little drink of water at the oasis, and we’re finally getting to that oasis moment if you will, for our own company, which is great.

                                         But I also think that with all the innovation which is fantastic, and what I always say is bring it all because we need to solve… This a $4,000,000,000 problem for our country. And so we need that innovation, but the innovation, the underside of the innovation is it is incredibly confusing and complicated, and so many point solutions, and so forth.

                                         So now having reached the oasis and the awakening of all the possibilities here, I do think you have to get to some kind of great consolidation. We can’t have all these 85 different things, because if you think about it from the employer perspective, they’re trying to weave together and architect this thing, and they’ve got 82 mental health solutions and 55 musculoskeletals and a bunch of care navigation stuff, who is going to last through this stuff together? Who is going to organize this? Who’s going to coordinate this.

                                         And there’s a couple of models out there that are emerging, and maybe ways to do that. Maybe you organize it around the navigators, that’s a great place because they’re connected to the patients guiding, steering them. Maybe there’s a technology kind of a focus, and so you integrate a lot of these things.

                                         And we present a third option, which I think is a little biased, but I think it’s the right option. I think you go to the most trusted entity and system, which I think is the medical group. And I think you make the medical group more capable than it’s ever been before. This is where the technology comes in. You arm your providers, to the hilt, with technology that allows them to be more capable to force multiply, to have more influence, to have more insight, to have more outreach.

                                         You are in that group because they are the most trusted entity, and then you hold them accountable for the outcomes, and they can organize that. Why isn’t the doctor prescribing the digital health solutions that should happen? Why is it that care team accountable for getting these great point solutions to integrate and organize into their own care pathways? That is the solution that we think has the most long-term viability and the most power.

                                         So we want to give the employer segment and payers the opportunity to organize around a next generation medical group that is more capable than it’s ever been before, leveraging technology to enable a whole new experience, and then delivering outsize results. That is what we hope is the answer for the future.

Charles Rhyee:                And I think with that, that’s a perfect ending. So Scott, thanks so much for joining me today. Really enjoyed it, really look forward to seeing all the progress you guys make going down the road. And thank you everyone for listening to this episode.

Speaker 1:                       Thanks for joining us. Stay tuned for the next episode of Cowen Insights.


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