Google is not the only innovation coming out of Silicon Valley
Mason Orme, DC, gets to work around 8 a.m. and sees two patients before his working-group huddle. There, he looks at his schedule and talks with an array of other providers about their patients.
He may discuss chronic-pain management with the mental health provider in the practice. Or a primary-care doctor may ask him how to better treat a patient with low-back pain. This wide range of doctors come together daily at Crossover Health Inc., to ensure each patient can see the right provider at the right time. They can do this because of the model Crossover Health created in 2010: They work directly with employers and cut out insurance to create a system tailored specifically to the needs of the workforce.
“It’s amazing that we get to do this; we’re so blessed to be able to pioneer this,” Orme said.
Disrupting an industry
Crossover Health, based in Silicon Valley, was founded by CEO Scott Shreeve, MD, an emergency medicine doctor with firsthand knowledge of how lack of preventive care costs both patients and the system. People coming to the emergency room had problems that were preventable, but left untreated, they became major issues.
Shreeve and others also saw another need in the market — to deliver the care patients need, rather than what an insurance company will pay for, said Daniel Lord, DC, CCSP, physical medicine program manager at Crossover.
The founders had a vision, but didn’t know how to pay for it, or make it work on a large scale. They tried a membership model, but it was very slow moving. Then the idea of employer-funded health care became en vogue.
The idea was appealing to industry disrupters like technology companies in Silicon Valley. While others were pitching more traditional models of care, the Crossover team went to Apple and Facebook and described their idea of what health care should be.
“It really resonated with them at the time and we won their business,” Lord said. “Even though we had no experience, they bought our vision.”
They went from no patients to 30,000 in one location, and to 10,000 at another site. Crossover has since expanded to 20 clinics with two different models. The first is on-site, housed on an employer’s campus. Here, the employer (typically large ones like Facebook) covers the overhead and building costs. The employees can visit the doctors free or pay small copays to offset the cost of the sites.
The other locations are near-site practices. Crossover owns these, usually located within about two miles of four to six smaller employers. The businesses band together and pay a per-member-per-month fee to join. The employers often have other health insurance as well, so they keep copays low to encourage employees to use the site.
Outcome- and patient-focus
Because they don’t have to worry about insurance billing and perpetually ramping up volume, Lord said he’s able to practice closer to the way he learned in chiropractic college.
“If I want to spend an hour talking about how a patient can mitigate pain and give them strategies, I can,” he said. “I worked in an integrated setting before, but it was a fee-for-service model, so we still had to figure out how to do enough to keep the lights on.”
Providers’ behavior changes because they don’t have to deal with insurance, but are paid based on outcomes and patient experience. They can take much more time with each patient. Steven Chang, MD, said his routine office visits are 30 minutes long and a physical or annual well check lasts an hour.
They are also able to tailor each office to meet the client’s needs. For instance, some of their practices have sports medicine doctors on staff because they have a high number of “weekend warriors” as clients. Along with chiropractors and physical therapists, they may have dermatologists, behavioral health providers, health coaches, dieticians, internists and doctors trained in emergency room care.
“The goal is to create a medical home for patients that is truly patient-centered so we can take care of a majority of their primary care needs,” Chang said.
A lesson from the America’s Cup
In 2013, Lord worked as a chiropractor for the America’s Cup team. There he saw the potential for treating patients with an entire care team. Crossover, he said, is the closest kind of practice he’s seen regarding team care.
He calls it sports medicine for the masses. For example, if he doesn’t have a solution for a patient, he can pull a variety of providers in to create a care plan. When treating someone with low-back pain, he can work with a nutritionist to create a meal plan to reduce inflammation and a physical therapist to provide core-strengthening exercises.
Chang considers the Crossover model a “fresh way for primary care providers to practice.” Most of these doctors haven’t worked side-by-side with chiropractors or behavioral health professionals daily. The fully-integrated organization allows him to learn from others. The providers at Crossover don’t have individual offices, but rather work in a large space known as “the bullpen.” This make it easier to communicate and work as a team.
For instance, he didn’t get a lot of nutrition training in medical school, but frequently gets questions from patients in this realm. He can walk over and ask a dietician why everyone is talking about coconut oil, or get a refresher from a chiropractor on the Epley maneuver for a patient with vertigo.
Orme agrees. He has learned a lot from the behavioral health providers about pain science. And he’s changed the way he treats musculoskeletal conditions after working alongside a physical therapist.
“It’s been amazing, and I don’t think a lot of chiropractors consider that,” he said. “That we can collaborate with other providers to excel at the profession. We can do rehab, but they know it extensively, so I have been able to add more tools to my toolbox. That’s the way we should be learning.”
When Danielle Correa, DC, started at her clinic there were 30 people on staff. Now there are more than 100. Working with so many other providers, she said, has helped her learn “how all of the pieces of the puzzle work.”
All the providers at her site host talks and are constantly teaching what they know. She said she’s expanded her skillset in areas from prenatal work to how to better approach postural stresses.
When new providers come to the practice, Chang sees how much they enjoy being able to call in a behavioral health doctor or chiropractor during a visit. Or they can hand the patient off to another doctor for follow-ups on something out of their realm of expertise. The “warm handoff” goes a long way toward comforting a patient who might not be accustomed to seeing a mental health provider or chiropractor, he said.
In the outside community, MDs are often reluctant to refer patients to chiropractors for treatment. Many chiropractors feel like the medical profession is “against them,” Orme said. But that is often just because the doctors don’t understand exactly what chiropractors do.
But primary care doctors don’t want to deal with musculoskeletal issues, he said. Given a trusted outlet, they will send their patients elsewhere. In fact, Orme said about 80 percent of his referrals come from the medical doctors at Crossover. This happens, he said, because he educates them constantly on what he does and “stays in his lane.”
After teaching the doctors in his practice how to treat benign paroxysmal positional vertigo, they now just send all those patients to him.
Correa said most of her patients are unique visitors, but she does get a lot of referrals from her colleagues in acupuncture and physical therapy. Behind that are the other physical medicine providers in her office. She said education is an important component of integrating into the diverse group of providers who normally might not be used to referring to chiropractors. It takes a lot of education and trust among those in the practice.
“We still have to fight a little to be in the mainstream, but we are doing pretty well here,” she said.
Ranking patient experiences
Most of the companies that Crossover works with have their own insurance plans that cover specialty services, emergencies and even other providers in the community. Because of that, Crossover must provide a top-line product to keep patients coming back and employers paying for services.
Lord said after one year working at a new site, about 60-70 percent of the employee populations use Crossover for their primary care services. Their patient experience surveys rank them in the 95th percentile and they have a Net Promoter Score of more than 80 percent (Lord said Kaiser usually ranks in the mid to high 30s).
One cost study they performed compared the opioid prescriptions of their physical therapists and chiropractors with others in the community. They prescribed 10 times fewer opioids and saved $400-600 per patient on back conditions if they were seen first at Crossover as opposed to other providers.
“At the end of the day, when you invest in the right type of primary care, you spend a lot less money on secondary care,” Lord said. “You are not sending as many patients to specialists or imaging or surgeries.”
Lord tracks his patients’ progress using functional outcome measures. These can also be compared to similar measures from community physicians to prove their worth to clients, he said. They also track their patient completion rates — because they discharge patients when they are well.
‘What health care is supposed to be like’
While still in chiropractic college, Orme had to write a business plan and designed one that centered around an integrated health care setting. But when he went into practice, that wasn’t what he found.
It wasn’t until he filled in for other chiropractors at Crossover that he realized this kind of work was possible. When a full-time position opened, he jumped at the chance.
“My mindset is that I’m a team player,” Orme said. “So, when I could work with other providers that aren’t chiropractors I am able to see what health care is supposed to be like.”
What he thinks it’s supposed to be is longer visits with patients. And at Crossover, he can use a wider range of techniques and guide them through a care plan.
“When I could do that and not have to worry about insurance or costs it was very relieving for me and freed me up to do what I want to do,” he said.
Correa likes how Crossover brings greater visibility to chiropractic care and offers her the ability to show how it fits into the overall medical system. She also appreciates the way working with other doctors has helped her understand her limitations.
“I know I don’t have to be someone’s everything,” she said. “I know what other professions would be best suited for different conditions and it allows me to focus on what I do, and do it well.”
Working at an office like Crossover provides additional perks, including a benefit package with health insurance, a 401k plan, and an allowance for continuing education and annual license fee renewals. Correa said they “lack for nothing” when it comes to equipment, technology and training.
Lord appreciates the paid time off, which is negligible in an individual practice. When someone at the office tore his ACL playing basketball, he was able to take three weeks off with disability pay and return afterward.
“You have a better life balance,” Lord said. “We’re not seeing 20-40 patients a day, we’re just seeing 10-12. We just have to focus on being a great chiropractor and are able to make the same, or more, money in the model.”
TAMMY WORTH is a freelance writer based in Kansas City, Mo., specializing in business and health care subjects. She can be contacted at firstname.lastname@example.org.