Room for specialists
While Lee has focused on primary care redesign, Consultants in Medical Oncology and Hematology, an eight-physician oncology group in Drexel Hill, Pa., believes it has found a model of care that can be rolled out to other oncology practices. The strides made by CMOH's leader, John Sprandio, MD, FACP, focus on both improving care for patients and building a payment infrastructure for specialty physicians that can survive the transition from volume to value.
In 2003, Sprandio started building the Oncology Patient-Centered Medical Home® after being struck by what Alice Gosfield and James Reinertsen, MD, wrote in a 48-page white paper titled Doing Well By Doing Good: Improving the Business Case for Quality, which looked critically at barriers that prevented physicians from delivering consistent care.
"In that paper there was a list that details the barriers that physicians face on their way to becoming more accountable for the quality of care delivered. These barriers also happen to be significant physician time-stealers, things like utilizing an EMR that doesn't really match workflow or processes of care, communication and documentation burdens, the lack of coordination systems, etc.," says Sprandio. "All those things were really clear after reading the article, probably a dozen times."
On a mission to reduce variability and—like Lee's vision for One Medical Group, become more efficient—Sprandio began working in earnest to identify where work could be standardized among the three CMOH sites. He focused first on getting physicians to manage symptoms in the same way so that CMOH's nurses were giving consistent advice to patients who called the telephone triage system, which was designed to allow immediate patient access to clinical information and advice.
"There was a lot of variation in terms of how we managed symptoms as a practice," says Sprandio. Dr. A handled delayed chemotherapy-induced nausea different than Drs. B, C, and D. Another important goal was to try to minimize clinically irrelevant physician activity and to give physicians consistent data and have them not just be able to respond to it, but hold them accountable for responding to it."
The solution, he says, was basic communication. The physicians discussed why they liked one approach to managing symptoms over another until they finally came to a consensus on managing specific, predictable symptoms related to chemotherapy and complications of disease.
"We embraced the Dr. Brent James/Intermountain Healthcare philosophy that it rarely matters that you get symptom management strategies perfect the first time, but you have to start a process of doing things the same across your organization and then measuring the outcome and making changes based on the success or failure of those efforts," he says.
Sprandio helped physicians maintain the clinical standards they chose with a robust EMR system that he says created efficiency by getting rid of data that was irrelevant and integrating a documentation template that prompted physicians to facilitate communication with patients and referring physicians.
Once that variation in data and diagnosis was eliminated, Sprandio worked on getting physicians to improve their documentation turnaround time, which in 2006 was "abysmal."
"It was three, three-and-a-half, four weeks," he says. "We improved it to a couple of weeks in 2009–2010. After we inserted Dragon dictation into our software overlay, we're down to a day-and-a-half. That's where we are right now."
The documentation improvement, process standardization, and EMR system (along with the custom software that supplemented it), added up to fewer variations in care and the realization that CMOH was basically a PCMH.
"We turned around in 2008 after we did all this, and it was clear to us that we met or exceeded the NCQA criteria for PCMH recognition," he explains. CMOH did earn Level 3 PCMH status in 2010. Sprandio is also pursuing a new NCQA Patient-Centered Specialty Practice recognition program that aims to identify specialty practices as meeting the same stringent requirements as those that cover primary care.
Sprandio's efforts in standardizing the way symptoms are managed with the centralized phone triage system has led to an increase in the number of cases that can be handled over the phone with a nurse. In 2006, Sprandio says, 77% of all symptom-related calls were effectively managed at home; in 2012 it rose to 85%.
ED evaluations per chemotherapy patient per year have also steadily declined from 2.6 visits in 2004 to 0.82 in 2011.
Sprandio attributes the decline in ED evaluations to the physician-led care teams that engage the patients early by asking them to call the telephone triage line as soon as they suspect a problem. He also directly credits the improvement to the quick document turnaround time by physicians.
"It provides up-to-date clinical information to our triage nurses with detailed information regarding current patient-specific symptom management recommendations," he says.
CMOH's initiative to work toward better outcomes at a better value have caught the attention of payers who are willing to test specialty-based APMs. Sprandio says CMOH now has three APM contracts, in total, with Keystone First, a Pennsylvania Medicaid managed health program; Aetna; and Independence Blue Cross. All three are pay-for-performance contracts, and among them Sprandio says 54% of his patients are now covered by APMs compared to about 15% a year ago.
But for Sprandio, the desire to pioneer a way that rewards value over volume is really rooted in figuring out a way to give his patients consistently good care.
"This was all driven by the fact that I wanted patient X, Y, or Z, who was initially referred to me to get the same level of attention, same process of care, same symptom management that I would have given them if I were seeing them. And there was a tremendous amount of variability. Anybody who says, 'There's five doctors or there's 20 doctors and we all do things pretty much the same,' they're delusional. They're completely delusional. If you want to drive quality, you have to create an environment where consistency is a default mode."
This article appears in the April 2014 issue of HealthLeaders magazine.