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 2014a
n = 4832 clinical phone calls
aPatients of Consultants in Medical Oncology & Hematology, 2004-2014
Source: Oncology Management Services, Consultants in Medical Oncology & Hematology.
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.
Inspiring an Early Adopter
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.