Oncologist-Reformer Pursues Value After Group Rebuff

John Sprandio, MD

Thirteen years ago, John Sprandio, MD, was thriving as the president of a network of 26 oncology practices and 2 academic centers when he hit a roadblock. Sprandio wanted to create a patient-centered medical home (PCMH) with full clinical integration and all the attendant benefits—standardization of treatment, greater efficiency, lower overall costs, happier patients, and leverage to negotiate advantageous agreements with payers. However, no one had the electronic medical records (EMR) system such changes would require and the board could not agree on quality metrics. He soon stepped down from his role as president of the network.

Back at his own practice in Drexel Hill, Pennsylvania, Sprandio started from scratch. Inspired by a paper by Alice Gosfield and James Reinertsen, MD, that outlined practical principles for “doing well by doing good,” Sprandio spent a decade gradually refining his information technology, phone triage, and symptom-management systems to clear the “time-stealers” and “pain points” from physician workflows and give patients easy access to help when they needed it. Over time, his reforms produced striking results.

According to Sprandio’s data, his practice’s chemotherapy patients now average .541 emergency department visits per year, down from 2.6 visits a decade ago and well below the national average of 2 visits per year. Overall hospital admissions have been halved. At the same time, whereas medical home initiatives sometimes require more staffing, his has led to less: his workforce decreased 30% over 6 years—from 8.3 per staff oncologist to 5.6— and his salary overhead fell 14%. In 2012, he estimated his changes were saving insurers $1 million per physician per year (Figures 1,2).

Sprandio projects that wide adoption of his model could cut $8 billion to $16 billion from the nation’s $125 billion in annual cancer spending. He envisions struggling community practices forming independent practice associations to jointly adopt his improvements and find new leases on life. “To be able to reproduce that model across the country is something I find extremely, extremely, extremely exciting,” Sprandio said. “Not only exciting because we can really change the way care is delivered, but we really could scale it.”

“The goal is really clinical integration. You’re banded together and you follow guidelines. You do it all the same way, measure, and adjust. The practices become accountable for their performance. That allows them to negotiate collectively with payers based on their good work. The IPA model is going to essentially save community- based oncology,” he said.

Payers are increasingly recognizing the value of the work done at Sprandio’s 8-physician, 3-office practice. As of last month, 37%of his practice’s patients subscribed to payers who have agreed to alternate payment methods based on his model, and he said a new payer agreement is bringing the figure up to 52% this month. If he is accepted into the Center for Medicaid & Medicare Services’ Oncology Care Model later this year, his participation rate will jump to 88%.

Figure 1. Outcome of Clinical Nurse Triage Phone Calls in 2014^a

n = 4832 clinical phone calls

^aPatients of Consultants in Medical Oncology & Hematology, 2004-2014

Source: Oncology Management Services, Consultants in Medical Oncology & Hematology.

Inspiring an Early Adopter

The medical home model, which typically offers wraparound care to improve patient outcomes, is also slowly expanding into oncology practices nationally. The National Committee for Quality Assurance (NCQA) gave its first oncology PCMH certification to Sprandio’s office in 2010 and launched a patient-centered specialty practice initiative 2 years ago, with 10 oncology practices recognized so far. In 2012, the Centers for Medicare & Medicaid Innovation awarded a $19.8 million grant to test community oncology medical homes in 7 practices in 6 states. In addition, the Community Oncology Alliance launched an accreditation pilot program this year, with 10 practices participating. Aetna, which has an alternate payment agreement with Sprandio, has partnered with providers to set up 14 oncology medical homes.The definition of a medical home can vary. Some models call for practices to add more staff and a broader range of services or require the use of clinical pathways. Sprandio has focused on standardizing procedures, streamlining work flow, creating a customized EMRs system, and better managing the adverse effects of chemotherapy.

Sprandio works to spread his version of the PCMH through his firm, Oncology Medical Services (OMS) of Conshohocken, Pennsylvania. It has consulted with 18 practices in the last few years and is assisting 7 more this year, he said. He has recently been working with 5 providers that are part of a $2-million study funded by the Patient-Centered Outcomes Research Institute (PCORI) and led by NCQA in collaboration with OMS, ASCO, and other organizations.

The providers in the PCORI study include Thomas Jefferson University in Philadelphia. Andrew Chapman, DO, clinical associate professor of medicine and co-director of the Jefferson Senior Adult Oncology Center, said that even before the study, Sprandio’s work with the NCQA inspired Jefferson’s medical oncology department to revamp its processes and obtain its own recognition as a patient-centered specialty practice in December 2013.

Figure 2. Average Yearly Emergency Department Evaluations per Chemotherapy Patienta

^aPatients of Consultants in Medical Oncology & Hematology, 2004-2014

Source: Oncology Management Services, Consultants in Medical Oncology & Hematology.

“John very early on recognized and really pioneered the vision that by incorporating standards of a PCMH, that by implementing those standards in his practice, developing reproducible results, and standardizing processes, he was able to show with data that he was able to lower these costs and improve quality,” Chapman said.

Andrew Chapman, DO

“Once we saw the work Joh n was doing, we then set out as a department to explore becoming a PCMH,” he said. “We went through and redid and rewrote and tried to meet every standard and every element by creating processes, by changing standard operating procedures, by developing any type of workflows to meet those standards.”

As part of the revamp, Jefferson developed a psychosocial assessment form that helps a team of social workers identify patients’ needs, Chapman said. A new tracking system ensures translation services by phone are provided to non-English speakers. The department also has a phone triage system that uses symptom-management maps and a same-day clinic that allows patients to get quick treatment and avoid expensive hospitalization. Chapman said he sees the medical home’s model of comprehensive, continuous care as a crucial tool in creating a medical environment hospitable to the rapidly expanding population of older people at risk of cancer.

“Recognizing the complicated care that oftentimes elders require, because of comorbidities, because of polypharmacy, because of all the things that oftentimes make care for the elderly incredibly complicated, it became very clear to me very early on that having coordinated care is going to be most beneficial to elderly patients who need the social support and these things that are so critical for them to navigate through these complicated treatment plans,” he said.

Jefferson’s involvement in the PCORI study keeps the patient-centered focus at the forefront and contributes to the department’s continued evolution, Chapman said. As part of the study, Sprandio visited Jefferson to make a presentation on his work, and he’s run webinars and spoken at bi-annual day-long workshops attended by all the PCORI providers.

Although the PCORI study has allowed Sprandio to present his idea to more practices, it still falls short of a full implementation of his system. The same is true of the other practices and health systems he’s consulted for or that have approached him about collaborating. Many, for example, do not have symptom treatment algorithms that allow nurses to immediately respond to a patient’s phoned-in complaints without checking with the doctor first, as Sprandio’s practice does. Crucially, none are using IRIS, a software application he commissioned that overlays his EMR.

“We incrementally solved a whole host of issues, which were really pain points for the physician. They were the time-stealers of our day, the interruptions of our day. The lack of consistent data fields being filled, for example,” Sprandio said. “We’re complex medical decision makers; we’re not data inputters. We created this app that reorganizes data. It’s really a foundation for not only the responsibilities of the care team, but it also serves as a template or a foundation for documentation.

“With IRIS, we take the pertinent data, reorganize, and present it. Within a minute, I can know the 5 symptoms that are present that day, I can know where the patient is in their cycles, I can know if their performance status is changing, I can know if I’m palliating their symptoms efficiently,” he said. “If you can give physicians data consistently, they can synthesize that data in minutes.”

Dissemination of his new model remains piecemeal for several reasons. In some cases, practices that OMS has consulted for are too far away, limiting Sprandio and his colleagues to making a 2-day visit and offering recommendations, with little opportunity for follow-up. Many practices cannot afford to redesign their EMRs and existing EMRs are inadequate, he said. With some big health systems, reorganizing their oncology processes may be too large a task for OMS to take on alone. Other organizations, instead of adapting OMS’s ideas, have chosen to “reinvent the wheel,” developing less efficient, less sustainable models that cover fewer patients and creating new software from scratch, Sprandio said.

That’s why he is particularly excited about a project with Capital Blue Cross and 4 practices in the Harrisburg, Pennsylvania, area that launched in June. OMS is leading a PCMH initiative that will involve a high level of standardization and many site visits, he said. The payment model includes staged increases in evaluation and management (E&M) payments based on achievements toward establishing medical homes and shared savings.

It still won’t immediately bring IRIS to the practices, but Sprandio has high hopes that the Harrisburg initiative and the PCORI study will pave the way for a full technology rollout in OMS’s next set of consultations. OMS is also in discussions with a “major technology partner” to build a commercialized version of IRIS, he said. Eventually, Sprandio said, more payers will recognize the benefits to their patients and bottom lines that a highly efficient, highly standardized, technologically advanced PCMH can provide.

“This whole thing is in its infancy in oncology, really. It’s being dictated by payers who want to minimize the level of support they’re providing because they don’t quite get it yet,” he said. “And some payers, like Capital Blue Cross, get it immediately.”