In recent years, there has been a steady movement away from small, private practices of physicians into larger group practices. The Affordable Care Act likely is hastening this transition with its encouragement of Accountable Care Organizations. It’s impossible for small or individual practices to meet the requirements of being an ACO, and as more and more reimbursement is tied to metrics associated with them, it’s becoming harder to avoid joining them.
Many are comfortable with this development because they believe in the idea of a “medical home”. Some research has shown that when a personal physician who knows a patient well and can coordinate all aspects of their care, both primary and specialty, then patients do better. It’s much easier to run medical homes out of larger practices that have more resources and practitioners of all types.
A recent study in HSR showed that we might save money through medical homes as well. It examined Medicare Part A and B claims over three years, and looked at how practices designated as NCQA-recognized patient centered medical homes compared to practices which weren’t. They found:
Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.
According to this study, medical home patients were seeing improved quality. Medical home practices had reduced numbers of emergency department visits, with the largest improvements seen where patients were sicker. Not only that, but they saw reductions in total Medicare payments. Medical homes were associated with improved quality and reduced spending.
A more recent study in Health Affairs, however, countered this claim:
Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice size—and other practice characteristics, such as ownership or use of medical home processes—and the quality of care? We conducted a national survey of 1,045 primary care–based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices’ rate of potentially preventable hospital admissions (ambulatory care–sensitive admissions).
This study actively surveyed practices to determine their practice characteristics. Then they used Medicare data to see what their preventable hospital admission rates were. They found that compared to practices with 10-19 physicians, practices with 3-9 physicians had 27% fewer preventable admissions. But practices with only 1-2 physicians had ever fewer, one third fewer preventable admissions. Practices owned by doctors had fewer preventable admissions than those owned by hospitals.
This, of course, contradicts the other study. It would seem to show that moving into larger group practices, and away from single or small practices, might reduce patient quality.
But there are some nuances to these studies worth considering. The first study did not look at practice size, per se. It looked at medical home designation. It’s totally possible for solo practices to become medical homes, and those that were performed better. In fact, if you delve into the tables, it seems that the largest improvements for hospitalizations were seen in solo practices with medical home designation. It also seems that the largest improvements in medical specialist visits were in 2-person practices.
In fact, there seems to be some general agreement that there’s a lot of good outcomes associated with small and solo-practices. Medical homes may lead to better outcomes, but that doesn’t necessarily mean that large ACOs will do just as well.