For some researchers, small physician groups are the source of many of the quality issues in health care. But a new study in Health Affairs suggests this attitude may be wrong. (HA Article) Small practices have been under assault, with continued consolidation into larger health systems and incredible burdens from regulatory requirements. The study indicates we may not be doing ourselves any favors by extincting the small practice. The researchers looked at potentially avoidable hospital admissions; ones that would suggest poor primary care. The practices surveyed had primary care providers, cardiologists, pulmonologists and endocrinologists, who usually render most of the care for patients with four major chronic illnesses–asthma, diabetes, depression and congestive heart failure. About 1045 practices were included in the research. Fifty-five percent of the practices were 1-2 physicians, 40% had 3-9 doctors and 5% had 10-19 doctors. Hospitals owned about 17% of these practices. Almost all had little risk for hospital expenses and slightly over half had no pay-for-performance exposure. About a quarter had a least some processes related to a patient-centered medical home.
In regard to Medicare beneficiaries, in unadjusted analyses, the 1-2 doctor practices had ambulatory-care sensitive admissions of 5.1 per hundred beneficiaries, 3-9 member ones had a rate of 4.3 and the 10-19 ones were at 6.1. When adjusted the smallest practices had a rate of 4.3 compared to 6.5 for 10-19 practices. Hospital-owned practices had higher rates than physician-owned ones, 6.4 to 4.3 unadjusted, 5.3 versus 4.6 adjusted. The use of PCMH processes, the presence of pay-for-performance and hospital cost risk were all unassociated with rates of admission. Despite the fact the larger practices presumably had greater resources for improving the quality of care, their performance on this basic measure is worse, suggesting that financial pressures to generate revenue may be at work. It may also be that small practices, where interaction between all staff is likely to be better, may inherently coordinate care more effectively. The study also finds little effect of highly promoted initiatives like pay-for-performance and PCMH.