The impact of practice size on readmission rates
There is a general assumption that large primary care practices perform better than smaller, independent offices. These groups have more resources, often ones provided by hospitals that own the groups.
To test this theory, a study led by researchers at Weill Cornell Medical College surveyed small- and medium-sized primary care practices to compare the number of preventable hospital admissions of the groups' patients.
Contrary to popular notions, the study authors found that the smaller practices had markedly fewer preventable hospital admissions. Groups with up to two physicians had 33% fewer ambulatory care-sensitive admissions than practices with 10 to 19 doctors. Those with three to nine physicians had 27% fewer than the larger groups.
"For decades, we have looked at practice size because it's something we can count," said Anne-Marie Audet, vice president for delivery system reform for the Commonwealth Fund, which funded the study. "It has become a proxy of quality and now we are recognizing that practice size is no longer a measurement of anything."
The study looked at more than 1,000 primary care practices between July 2007 and March 2009. The patient information was compared with Medicare claims on their hospital admissions.
The study also found that medical home implementation and ownership status affected admissions. The larger practices had about 5% more patient-centered medical home processes in place than the smallest ones. And hospital-owned groups had 6% more than private practices.
But medical home implementation did not reduce admissions. Larger groups had more admissions and physician-owned groups had significantly lower admissions than did practices owned by hospitals.
In looking at accountable care organizations, Audet said other researchers have found that physician-owned groups tend to be more successful at reducing institutional care because their incentives are aligned with reducing costs and avoiding higher-priced care. Hospital-led ACOs, on the other hand, have to change their entire business model to treat admissions as something that is not revenue-generating.
Reid Blackwelder, president of the American Academy of Family Physicians, said it could be the "middle steps" that larger practices have to take, along with the lack of connection to the community, that may be causing an increased number of hospitals admissions.
Blackwelder now works in a large group, but when he was in a small practice in a small town, there was a different relationship with his patients and community. For instance, it would not be unusual to have someone call his office and say they had seen one of his patients in the grocery store and they didn't look well. His nurse would then call the patient to see if they were sick and tell him or her to come in that day for an appointment.
"That is the ultimate patient-centered approach," he said. "The study recognizes the power of relationships that individual and small practices have with their communities and I do believe there really is power in that."
The study authors and Blackwelder suggest that larger and hospital-owned groups keep the aspects of small practices that are effective. These may include smaller patient panels, fewer middle steps for processes when possible, targeting care toward patients with high needs, increased access outside of normal office hours, easier access to physicians and appointments and better overall communication with patients.
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- The Commonwealth Fund Small Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions