John Sprandio, MD
Five years ago, Capital BlueCross, a health insurer in Pennsylvania, asked community oncology practices in its network what kind of reimbursement model they would like to try as they worked to stay financially viable and independent. After rejecting the idea of a clinical pathways program, the practices expressed interest in specialty medical homes, particularly the patient-centered model pioneered by John Sprandio, MD, in the Philadelphia area.
Sprandio spent years standardizing care, streamlining workflows, and improving the electronic medical record (EMR) system at his oncology practice, resulting in fewer hospitalizations and substantial cost savings. Starting in 2015, the insurance company asked Sprandio and his consulting firm, Oncology Management Services (OMS), to bring his model to 4 of its network practices.
In July, Capital BlueCross received the first batch of practice-performance data, covering the second half of 2016. Thanks to reductions in emergency department visits and hospital admissions, the financial results were “really positive,” said Denise Harr, MD, senior medical director of Capital BlueCross. Patients’ total medical costs over 6 months were down 5.2% compared with a previous baseline period, and pharmacy costs dropped 13.9%. Even with incentive payments that practices received along the way, the effort has already achieved savings, Harr said. Measures of care quality did not improve as much, but both the insurer and the practices expect to see more positive results in the first half of 2017. “I’m hearing the practices say that this increased support they’ve received from John Sprandio and his team really helped them to feel like they’re impacting our patients’ lives in a different way and a better way,” Harr said. “They’re doing something different, and it’s measurable.”
Two of the 4 practices are in CMS’ Oncology Care Model (OCM), which was influenced by Sprandio’s work and resembles his model in many ways. Under his team’s guidance, the practices created or expanded phone triage systems to better manage patients’ symptoms, improved processes and technology for collecting and analyzing data, and made other changes required by the OCM. “We are very thankful for the experience of being in the Capital BlueCross pilot, because we really feel it prepared us to be successful in the OCM,” said Azlynn Swartz, MHA, BSN, RN, OCN, executive director of Andrews and Patel Hematology/ Oncology in Camp Hill, Pennsylvania. “They really worked with us to make the changes we needed to make. Other practices, I think, are struggling. They’re where we were 2 years ago.”
The pilot kicked off in July 2015, with the practices filling out questionnaires to guide Sprandio’s recommendations, Harr said. His team held webinars, visited sites to observe workflows, developed individualized blueprints, established timetables, and suggested technology improvements. To help fund infrastructure upgrades and hiring, Capital BlueCross reimbursed the practices for meeting a series of participation milestones over the program’s first year.
In one part of the transformation process, the practices developed symptom-management maps to guide nurses’ phone conversations with patients experiencing adverse effects from drugs. Swartz said OMS provided a template for decision-making paths, which a clinical group at Andrews and Patel modified based on their beliefs about the best responses. This standardization leads to individualized management of patient issues, avoiding automatic emergency department visits and unnecessary interruption of busy physicians, she said.
“What we’re working on now is using that phone call as a launching point for continued proactive telephone calls to the patient to say, ‘We talked about this yesterday. How are you today?’” Swartz said. “We’ve come up with a way to utilize the EMR to form a queue that a nurse will look at each day and make outbound calls based on people who have had recent symptoms.”
The practice staff is also focusing on improving the often-complicated task of tracking different aspects of patient care to make sure no steps are missed. For example, Andrews and Patel wanted to track whether it had received radiology reports doctors had ordered. The EMR did not easily allow that, so the practice built in a button that would attach a radiology test to a patient’s chart, Swartz said. Now a report can be run to show all the tests received— provided staffers didn’t forget to click the button.