qotd: Smaller primary care practices have lower rates of preventable admissions

Health Affairs
August 13, 2014 (online)
Small Primary Care Physician Practices Have Low Rates Of Preventable
Hospital Admissions
By Lawrence P. Casalino, Michael F. Pesko, Andrew M. Ryan, Jayme L.
Mendelsohn, Kennon R. Copeland, Patricia Pamela Ramsay, Xuming Sun,
Diane R. Rittenhouse and Stephen M. Shortell

The Affordable Care Act and initiatives by private health insurance
companies are driving major changes in the ownership of physician
practices, the incentives practices face to improve the care they
provide, and the processes practices use to improve care. Many practices
are consolidating into larger medical groups. Many others are shifting
from physician ownership to hospital ownership. Practices are
increasingly subjected to pay-for-performance and public reporting
programs and are being encouraged to implement processes used in
patient-centered medical homes.

Ambulatory care–sensitive admissions are defined by the Agency for
Healthcare Research and Quality (AHRQ) as admissions for conditions such
as congestive heart failure for which good primary care may prevent
admission.

In our large national study of small and medium-size primary care–based
practices, practices with 1–2 physicians had ambulatory care–sensitive
admission rates that were 33 percent lower than those of the largest
small practices (having 10–19 physicians). Practices with 3–9 physicians
also had rates that were lower than the rates for the largest small
practices, although slightly higher than the rates for practices with
1–2 physicians. These findings were unexpected, since small practices
presumably have fewer resources to hire staff to help them implement
systematic processes to improve the care they provide. Larger practices
did have higher patient-centered medical home scores than the practices
with 1–2 physicians (though not higher than those with 3–9 physicians)
and so appear to use more such processes, but these higher scores were
not associated with lower ambulatory care–sensitive admission rates in
multivariate analyses.

It is possible that small practices have characteristics that are not
easily measured but result in important outcomes, such as fewer
ambulatory care–sensitive admissions. For example, there is evidence
that patients in smaller practices are better able to get appointments
when they want them and better able to reach their physician via
telephone, compared to larger practices. It is also possible that
physicians, patients, and staff know each other better in small
practices, and that these closer connections result in fewer avoidable
admissions.

We cannot fully exclude the possibility that the largest practices,
which had a somewhat higher percentage of specialists, had patients who
were sicker and, therefore, more likely to have an ambulatory
care–sensitive admission. However, we controlled for the percentage of
specialists in practices and for patients' demographic characteristics
and comorbidities, and we found that the smallest practices cared for a
significantly higher percentage of dual-eligible patients and for
patients with more comorbidities.

Physician-owned practices had lower ambulatory care–sensitive admission
rates than hospital-owned practices in both bivariate and multivariate
analyses—approximately 13 percent lower in multivariate analysis.

Hospital ownership would be expected to result in a lower ambulatory
care–sensitive admission rate if hospitals provided additional resources
to practices to hire staff and implement systematic processes to improve
care. In fact, consistent with prior studies, we found that
hospital-owned practices used more patient-centered medical home
processes than physician-owned practices. But these practices
nevertheless had higher ambulatory care–sensitive admission rates.
Hospital acquisition of a practice might disrupt longstanding referral
relationships between the practice's physicians and specialists outside
the practice and might lead to other changes that result in worse
performance by the practice and higher ambulatory care–sensitive
admission rates.

We did not find an association between the ambulatory care–sensitive
admission rate and the use of patient-centered medical home processes or
between that rate and pay-for-performance or public reporting
incentives. Prior research has resulted in inconsistent findings
regarding the relationship between patient-centered medical homes and
physician practice performance and between incentives and physician
practice performance.

Physicians in small practices have no negotiating leverage with health
insurers, so insurers typically pay them much lower rates for their
services than they pay to physicians who practice in larger groups or
are employed by hospitals. This policy might be penny wise and pound
foolish if it drives small practices out of existence and if further
research confirms that small practices have lower ambulatory
care–sensitive admission rates, and possibly lower overall costs for
patients' care, than larger groups.

Small practices have many obvious disadvantages. It would be a mistake
to romanticize them. 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.

http://content.healthaffairs.org/content/early/2014/08/08/hlthaff.2014.0434.abstract

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Comment by Don McCanne

It is believed that consolidation of the health care delivery system
through the formation of larger groups of physicians and through
hospital ownership of physician practices is anti-competitive and drives
up health care spending, especially through non-competitive pricing.
Nevertheless this consolidation is being encouraged under the assumption
that closer integration of the health care delivery system will improve
processes and outcomes, one rapidly expanding model being accountable
care organizations. This important study casts doubt on this concept.

One important measure of the quality of care being provided is
ambulatory care-sensitive admissions - admissions that can be prevented
through good primary care. This study shows that small primary care
practices had lower preventable admission rates than did larger
practices. Further, although larger practices did have higher
patient-centered medical home scores, the scores were not associated
with lower ambulatory care–sensitive admission rates. Also,
hospital-owned practices used more patient-centered medical home
processes than physician-owned practices, yet these hospital-owned
practices had higher ambulatory care–sensitive admission rates. Neither
pay-for-performance nor public reporting incentives improved the rate of
ambulatory care-sensitive admissions.

The policy and political communities are pushing innovations such as
more closely integrated groups through consolidation and accountable
care organizations, pay-for-performance, and patient-centered medical
homes, when there is sparse evidence that these measures will improve
quality or reduce costs. On the other hand, studies such as this
demonstrate that traditional Marcus Welby, MD-type primary care
practices serve us very well (as long as they do see more than one
patient a week).

Patients have better access through a long standing relationship with a
health care professional they know and trust and who knows and respects
them, while receiving their care at a lower cost. Although this
traditional model is now being threatened, a single payer system would
revitalize it as long as it serves patients well.