In an unassuming office beside Delaware County Memorial Hospital, oncologist John Sprandio has been trying for years to revolutionize community cancer care.
He's not shy about saying he thinks he has done it. Or that it has been surprisingly hard to get insurers to reward him for doing what they say they want: giving good care while preventing hospital stays or trips to the emergency room - changes that lower costs for insurers and taxpayers.
Most insurance contracts for specialists still reward doctors for volume of care rather than efficiency, although some contracts now include pay-for-performance incentives. Sprandio concedes that his obsessive focus on efficiency, end-of-life planning (that led patients to choose less chemotherapy), and preventing emergencies has lowered revenue.
His practice, Consultants in Medical Oncology and Hematology (COMH), is only now persuading insurers to pay differently, allowing the group's eight oncologists to share in the savings they're creating.
"We expected a payer response three years ago," he said. He says the leaner payments have made the practice more efficient. He remains hopeful. "My philosophy all along," he said, "has been that, at some point, somebody's going to pay for value."
Keystone First, a Medicaid managed-care plan affiliated with Independence Blue Cross, gave Sprandio's group a special, performance-based contract in September 2010. Aetna followed in July. Sprandio says he hopes to have a better contract with IBC this year.
Alice Gosfield, a health-care lawyer who represents Sprandio and is a fan of the changes he has made - he says one of her papers inspired him to start - said it was hard for insurers to pay doctors in a "nonstandardized" way.
Still, she said, "he has done exactly what the payers say they want. Payers have to step up."
In 2010, Sprandio's group became the first and only oncology practice to become a Level III Patient-Centered Medical Home accredited by the National Committee for Quality Assurance. This is a type of well-coordinated care that has been championed by many health-policy leaders and insurers. COMH is now among 10 area groups seeking a new type of accreditation for patient-centered specialty practices. Sprandio has spoken widely about his practices and written about it in medical journals. He has also consulted with others who want to try his ideas.
In a 2012 journal article, he estimated that his changes saved insurers $1 million per physician per year. He says ER evaluations have fallen from 2.6 per chemotherapy patient per year in 2004 to 0.785 last year. Hospital admissions for chemo patients fell more than 50 percent between 2007 and 2012.
"I think, certainly among oncologists, among everyone, he's at the cutting edge of trying to redesign a practice to try to deliver higher-quality care at lower cost," said Ezekiel Emanuel, chair of the department of medical ethics and health policy at Penn Medicine.
He said he was working with Sprandio to confirm that his group was achieving the savings he claimed. Emanuel said Sprandio had been caught in a "misalignment" between what insurers have said they wanted and old fee-for-service payment methods that "do not reward value at all."
Sprandio, a stocky 58-year-old with a mostly gray beard and barely gray, dark-brown hair, has a rare combination of abilities.
He is warm, attentive, and reassuring with patients. When a longtime patient with metastatic cancer complained of arm pain last week, Sprandio instantly found the worst spot in the patient's shoulder, then gently left his hand on the man's back while they talked.
"Did you eat breakfast?" he asked another. When a patient balked at getting chemo because her partner wouldn't be home, he pressed her a little, quickly saw her point, and urged her to make an appointment this week instead.
His patients can easily miss that he is also deeply wonky about the way his office is organized, so steeped in the acronym-laced language of health policy that he has a hard time describing what he has done in terms the rest of us would understand. It's tough for him to resist showing the data slides stored in his MacBook Air. The man has memorized quotes from Don Berwick, the former administrator of the Centers for Medicare and Medicaid Services.
Sprandio, the sole shareholder of the practice, started his sweeping changes in 2004.
He had an electronic medical record created for the office so doctors can see all of a patient's pertinent information on one scrollable page before entering the exam room. The doctors can order prescriptions and lab tests via laptops and share their findings with patients' other doctors. The system requires so little effort doctors can make eye contact with patients and input their notes in minutes after an exam.
The practice uses guidelines established by oncology leaders, with the goal of standardizing care as much as possible.
Patients are more likely to notice other things. Conversations about how patients are doing and what kind of care they want at the end of life are built into the care. Sprandio said patients were able to handle the truth. "No one's ever run out of my office because I told them they're not in a curative situation," he said.
Before patients leave a visit, a navigator helps them make any other appointments they need, whether it's for a PET scan or a cardiologist. The staff follows up to make sure patients got the care they needed.
Michelle Rosado of Clifton Heights, who has cancer in her esophagus and uterus, says it has made her life much easier to have someone else make her appointments. Plus, she'd have trouble keeping them straight without help. "I have a good memory," she said, "but ever since this started, I've been foggy."
The practice also assigns a nurse to answer patients' questions every day. This "symptom" line gets about 4,800 calls a year, and Sprandio says it has helped lower emergency visits and admissions by dealing with problems when they're small.
He tells patients to call no matter how tiny the problem and to call early so the practice can squeeze them in that day.
"We tell people to have a really low threshold to call," Sprandio said. "Don't try to figure it out. It's not your job. It's our job."
Josephine Rowell, 79, of Drexel Hill, has been a patient of Sprandio's for 20 years. She has had lymphoma, breast, and thyroid cancer. She was in last week for chemo for the lymphoma. She calls when she has a cold.
"It's very efficient," she said of the office. "They do everything for you. . . . I never saw an office like that. . . . I don't have a bad thing to say about them."