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Oncologist Blazes Trail Toward Bundling

 |  By jfellows@healthleadersmedia.com  
   February 06, 2014

The head of a multi-physician oncology practice and patient-centered medical home explains how his practice is "capable of signing any payment methodology that any payer could dream up."

The transition from volume-based care to value-based care is churning up anxiety about revenue and reimbursements among many physician leaders.

John Sprandio, MD, FACP, is not one of them.

Sprandio, founder and leader of Consultants in Medical Oncology and Hematology (CMOH), believes his three-location, eight-physician oncology practice in Drexel Hill, PA., is ready.

"I feel that we are prepared to respond to any changes in the payment system… I have no preference," says Sprandio. "We're capable of signing any payment methodology that any payer could dream up. I am not kidding."

Sprandio's confidence stems from years of fine-tuning the physician workflow at his practice to establish efficiencies for the doctors and reduce variability for the patients. His confidence also comes from CMOH's status as the first oncology practice to be certified as a Level 3 patient-centered medical home by the National Committee for Quality Assurance.

That certification came in 2010, and was sort of incidental. Sprandio says he was not working toward PCHM status, rather he was working toward the goal of giving his patients consistently good care.

"The heart of what we did, and the heart of this model, is really taking a critical look at the physician work environment and overcoming some of the barriers that we face as physicians on our way to becoming more accountable for quality and consistency of care and cost."

The work that led to gaining PCMH certification began in 2003 after Sprandio and others in the practice took to heart a 48-page white paper by Alice Gosfield and Jim Reinertsen MD, titled, Doing Well by Doing Good. It was a critical look at what Sprandio calls physician "time stealers" that prevented delivering consistent care.

"Variation is so common in healthcare delivery," he says, citing communication and documentation burdens as part of the reason for disparities among physicians, as well as systems that lack coordination, measurement, and outcome targets. "Anybody who says, 'There's five doctors or there's 20 doctors and we all do things pretty much the same,' they're delusional."

Instituting Standards
Getting physicians to start acting in a coordinated fashion may seem counterintuitive to the "art" of practicing medicine. But Sprandio is a strong believer in giving patients, especially cancer patients who are very sick and scared, a level of care they can trust.

"That desire, to get more consistent care, had a tremendous, tremendous impact on our processes of care and our workflow," says Sprandio.

In the beginning, he says the goal was to minimize "clinically irrelevant" physician activity. For example, instead of having a patient tell both a nurse and a physician what their symptoms are, thereby repeating information and wasting time, Sprandio began having an oncology nurse grade a patients' symptoms based on toxicity.

One Team
That information was put into a progress note template so that the physician could be accountable for addressing the symptoms the patient articulated. Additionally, the management of those symptoms was also standardized because the protocols were agreed upon by the whole practice.

"It is one team," says Sprandio, explaining that even though there are eight physicians at his practice, they function as one entity. "The team works the same. There's no variation. There's no, 'Doctor so-and-so likes the nurses to do this and not do that,' we wanted standardization."

By instituting a robust EMR system with a custom software overlay to mirror the physician work environment, Sprandio was able to reduce the variation of many aspects of physicians' interactions, but it's not something he glosses over or cites as a determining factor in the success of where CMOH is today in terms of efficiency. Documentation is important, but it's "just one part" of consistent patient care. The real key, he says, is a physician-led care team committed to the same goal.

Sprandio says he tackled the process of standardizing workflows by prioritizing what was most important.

The telephone triage system for managing predictable and common symptoms was a work in progress for 15 years. Now, it is centralized in one practice location, and has netted some real success in reducing ER visits by helping patients manage symptoms at home. In 2006, 77.2% of all symptom related calls were managed at home. By 2012, that percentage grew to 85%, with only 4.1% getting referred to the ER.

Engaged Patients
Part of the success of the triage system is due to engaging patients in their care early and often. At Sprandio's practice, it begins with telling the patient on the first visit that CMOH is always the first point of contact.

"If they think they might have a symptom, whether it's on a potential symptom list or not, they call us," he says. "This is said multiple times by three sets of people: the orientation folks, the nursing staff, and the physicians."

CMOH also orders every test so patients do not have to worry about scheduling or tracking it to completion.

Another key factor to reducing variability was getting physicians to complete their documentation more quickly. The EHR and custom software overlay solved some of barriers to increasing turnaround time, which Sprandio says is now down to a day and a half. That's down considerably from 2006 when he says it was taking 20+ days to get doctors to turnaround their documentation on a patient.

But, Sprandio is quick to say that his organization's model of care is not an easy path to the question of how to transition into a reimbursement model that isn't fee-for-service. He believes strongly in the PCMH standards. While CMOH was the first oncology practice to achieve PCHM Level 3 certification, Sprandio says his practice is now working toward a NCQA certification developed in 2013 for specialty practices, Patient-Centered Specialty Practice Recognition.

Sprandio is also part of a consortium of healthcare leaders examining a national approach to bundling cancer care. He's already participating in an alternative payment method with one insurer, and hopes more insurers decide to offer the same.

"We [CMOH] have what we call an oncology PCMH with Aetna and there's a shared savings component," says Sprandio. "I would maintain that oncology bundling of any kind really requires the foundation or insertion of PCMH standards as a safety net to make sure that patients are advised in the right way."

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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