Small practices win big on preventing admissions

Size still matters in healthcare — just not to the extent that one might think.

As it turns out, practices run by one or two physicians report 33 percent fewer preventable hospital admission than do practices with 10 to 19 physicians on staff. What’s more, practices with three to nine doctors on board are 27 percent less likely than their larger counterparts to rack up such admissions.

The findings come from a Commonwealth Fund survey of small and midsize primary care practices, published last month in Health Affairs, which analyzed Medicare data on preventable hospital admissions.

Small practices have unmeasured characteristics that may contribute to their lower rates of preventable hospital admissions, the researchers explained. For example, patients in smaller practices may have an easier time getting appointments or reaching their physicians by phone, compared with patients in larger practices. Physicians, their staff, and patients may also know each other better at smaller practices.

The study's conclusions contrast with industry trends toward hospital affiliations and ACO and PCMH involvement, which are commonly hailed as positive steps toward bigger, better, more comprehensive care. The researchers emphasize that policymakers also need to collectively look downward.

“Small practices would benefit from policies enabling them to share resources needed to improve quality of care,” the authors wrote.

The authors also called out payers and the common practice of compensating physicians in smaller facilities at lower rates, noting that the work that the practitioners in these offices are doing to stiffen hospital admissions translates to lower costs for patient care across the industry. 

“To support physicians in smaller practices, policymakers and insurers should consider taking steps to help small practices share resources, like nurse care managers for patients with chronic illness,” the authors wrote.

Of course, hospitals aren't likely to stop absorbing small practices, just as ACOs and PCMHs won't discontinue efforts to recruit in this area. However, the authors advise that  “hospitals and large medical groups … consider preserving the small-practice environment within their organizations,” while independent practice organizations should lend a hand in helping “smaller practices adopt patient-centered medical home processes.”

[See also: What's really behind the ACO boom]

Other key study findings:

  • Practices owned by physicians had significantly lower ambulatory care–sensitive admission rates than those owned by hospitals.
  • The larger practices (10 to 19 physicians) had in place significantly more patient-centered medical home processes — like primary care teams, guideline-based reminders to providers at the point of care, and electronic prescribing — than the smallest practices of one to two physicians, although not more than practices with three to nine physicians. These higher scores were not associated with lower rates of preventable hospital admissions, however.

The study surveyed 1,045 primary care practices with between one and 19 physicians from July 2007 to March 2009. Such results were then correlated with 2008 Medicare claims on ambulatory care–sensitive admissions as defined by the Agency for Healthcare Research and Quality.

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