The nine-physician practice received recognition last summer as a Level 3 patient-centered medical home from the National Committee for Quality Assurance.
That means the CMOH meets the NCQA's nine standards—including electronic prescribing and physician ordering, care management, patient tracking and monitoring patient compliance—associated with high-value care.
The result: A steady decrease in the practice's chemotherapy patients being referred to the emergency department—from nearly 12% of patients in 2005 to 5% in 2009—and a significant decrease in hospital admissions. In 2009, overall hospital admissions fell by 16%, followed by a 10% reduction in 2010.
Those statistics make Sprandio's practice a test case for the concept of value-based healthcare: Are payers really willing to pay more for quality and efficiency?
So far, only one payer—a Medicaid HMO—has contracted with CMOH for the medical-home services the practice delivers. Unless more payers follow suit, the model is not financially sustainable, Sprandio says.
“If John Sprandio does not succeed in doing this, it is a terrible bellwether for what's going to happen in healthcare in the next few years because he's doing everything right, and he is doing everything” the ACA is calling for, says Alice Gosfield, a Philadelphia healthcare lawyer and former five-term chairman of the NCQA's board.
Sprandio attributes the drop in ED and hospital visits among CMOH patients in part to proactive patient management aided by the practice's administrative assistants, who have been trained as patient navigators to make sure appointments, tests and support services come off without a hitch.
“If a patient doesn't keep her MRI appointment on Monday and we don't get a result on Tuesday, our patient navigator is calling to say, ‘Mrs. Smith, you missed your MRI, and that needs to be rescheduled,' ” Sprandio says.
Patients are educated on how to monitor their health status and call the practice's phone triage line if they suspect a problem. Nurses use symptom management protocols to help most patients manage their symptoms at home. The number of same-day appointments nearly doubled during the first five years as oncologists trained patients to avoid the emergency department. (Sprandio says the number of unscheduled visits appears to be declining this year because the practice has improved its patient education about self-management.)
Perhaps most significant, however, is a standardized approach to managing the side effects of chemotherapy. Preventing dehydration and decreasing diarrhea reduces the number of patients who need emergency or inpatient care, while averting chemotherapy-induced nausea and vomiting decreases the inappropriate use of certain drugs.
All this is possible, Sprandio says, because CMOH uses an enhanced electronic health-record system that allows the physicians to monitor their performance.
“Many of my colleagues say, ‘I'm pretty sure we do what you're doing,' ” he says. “And my response is, ‘Respectfully, I was pretty sure we were too, but we weren't. And you have no idea what you're doing until you start measuring. Only then can you go back and improve your processes of care and thus your performance.' ”
About 1,500 primary-care practices with more than 7,000 clinicians have been recognized as patient-centered medical homes by the NCQA. Sprandio's practice is one of “very few” specialty practices that have received the designation, Peggy Reineking, director of the NCQA's recognition programs, said in an e-mail interview.
And, in fact, the NCQA has no plans to recognize other specialty practices because its medical home program targets primary-care practices. But that doesn't mean the model does not translate to specialists.
About 20 oncologists and practice administrators gathered in Dallas in January to discuss how to follow Sprandio's lead. Ted Okon, executive director of Community Oncology Alliance, says the group hopes to develop a demonstration project that shows government and private payers how the medical home can work for specialists.
“We are focused on this because the idea of the medical home is built around the concept of enhancing the quality of the care to the cancer patient and the value of the care, not only to the patient but to the payer,” he says. “If payers can be shown how the cost of care is being reduced, they are going to be very receptive to that.”