Medscape Medical News, 2014-08-19
Despite common assumptions that larger practices offer better care, a new study finds that those with 1 to 2 physicians had 33% fewer preventable hospital admissions than practices with 10 to 19 physicians. Practices with 3 to 9 physicians had 27% fewer admissions.
In addition, physician-owned practices had fewer preventable admissions than hospital-owned practices. The study is believed to be the first of its kind in the United States.
Authors of the study, published online in August in Health Affairs, suggest smaller practices may offer advantages such as more immediate appointments, easier telephone access to physicians, and closer ties among patients, physicians, and staff, which may lead to better outcomes. Those qualities should be considered in an environment that encourages and rewards consolidation, they said.
Using data from the National Study of Small and Medium-Sized Physician Practices, Lawrence P. Casalino, MD, PhD, from the Department of Healthcare Policy and Research at Weill Cornell Medical College in New York City, and colleagues surveyed 1045 primary care practices with 1 to 19 physicians from July 2007 to March 2009. The survey included questions about ownership, patient demographics, the processes the practices use to improve care, and any incentives they received to improve quality and lower costs.
Practices were eligible if at least 60% of their physicians were adult primary care providers, cardiologists, endocrinologists, and pulmonologists. Those specialties were singled out because they encompass ongoing care for patients with asthma, congestive heart failure, diabetes, and depression.
The authors linked the survey data to 2008 Medicare claims on ambulatory care–sensitive admissions, defined as admissions for conditions such as congestive heart failure that good primary care could have prevented. Those admissions totaled 3.9 million in US hospitals in 2010 and cost $31.9 billion. The authors note that as many as 40% of the admissions may have been preventable.
Most Office Physicians Are in Small Practices
The authors also said their data put into question the trend of insurers paying lower rates to physicians in smaller practices, which lack the numbers needed for bargaining power. Instead, they suggest policymakers and payers should help small practices share resources, such as nurse care managers for chronically ill patients.
“Our results suggest that the common assumption that bigger is better should not be accepted without question, at least in practices of nineteen or fewer physicians,” the authors write.
They said there may be advantages for hospitals and large practices acquiring smaller groups to try to preserve the small-practice environment while providing the resources to help them thrive.
“Small practices have many obvious disadvantages. It would be a mistake to romanticize them,” they write. “But it might be an even greater mistake to ignore them, and the lessons that might be learned from them, as larger and larger provider organizations clash to gain advantageous positions in the new world of payment and delivery system changes catalyzed by health care reform.”
The authors cite estimates that 83.2% of office-based physicians in the United States are in practices of 10 or fewer physicians: 38.6% of the practices have 1 to 2 physicians, 26.4% have 3 to 5 physicians, and 18.2% have 6 to 10 physicians.
Further research on why smaller practices have fewer preventable admissions will be important as medical models head toward acquisitions, mergers, and hospital employment of physicians, the authors conclude.
This research was supported by the Commonwealth Fund, and the Robert Wood Johnson Foundation provided support for the National Survey of Small and Medium-Sized Physician Practices. Dr. Casalino serves on the American Hospital Association Committee on Research and on the boards of the American Medical Group Association Foundation and the Hospital Research and Educational Trust. A coauthor serves on the advisory boards of Centene, the Thedacare Center for Healthcare Value, and the Kaiser Permanente Institute for Health Policy.