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Wednesday Aug 27, 2014

More Than Meets the Eye: Value of Small Practices Shouldn't Be Ignored

For years, we've been hearing about the decline -- even death -- of the small primary care practice, but I'm here to say that obituary is premature, if not flat-out wrong. When a recent study published in Health Affairs touted the value of small practices, I didn't need convincing. I'm a small practice owner and have been for nearly 30 years.

The study found that primary care practices with one or two physicians had one-third as many preventable hospital admissions compared with practices with 10 to 19 physicians. The study also reported that smaller practices achieved their impressive results despite caring for a higher percentage of patients with chronic conditions than larger practices.

© 2014 Texas AFP

My rural, two-physician practice recently achieved Level 3 patient-centered medical home recognition from the National Committee for Quality Assurance.

So how did the small practices in the study manage to have better results regarding preventable admissions (and likely lower costs) than their larger counterparts? The authors point out patients in smaller practices may have closer relationships with their physicians, which might offer greater insight into patients' comprehensive health needs while facilitating ready access to care.

Patient-centered care, which includes enhanced access to care along with other elements, has become a focal point of the movement to improve our health care system in the past decade and, increasingly, is being embraced by small and large practices alike. Large practices, in particular, are likely to benefit from economies of scale that enable them to readily invest in health information technology and other organized care processes recognized as components of the patient-centered medical home (PCMH) model. And indeed, in this study, some of the larger practices appeared to use more such processes than the smaller practices, yet didn't fare as well in keeping patients out of the hospital.

Clearly, there's more to the story.

An abundance of evidence tells us that the PCMH can lower costs and improve outcomes. Just think: How much more could we bolster those outcomes if we combined the efficiencies of a Level 3 PCMH with the strengths and accessibility of a small practice?

Welcome to my small rural practice, which recently achieved Level 3 recognition from the National Committee for Quality Assurance (NCQA).

Regardless of a practice's size, there are hurdles to jump through on the way to PCMH recognition. The process can be overwhelming at the outset, and the AAFP has discussed the need to simplify the process with the NCQA and other such groups.

Although the process can be especially difficult for small practices, which lack the time, capital and resources of larger practices, it can be done. My two-physician practice achieved Level 3 recognition, from start to finish, in two years. We did it by working together with other small practices in our area, combining our efforts and resources.

The key, for me, was taking the process one step at a time, which made it seem more attainable. To that end, the AAFP has created a PCMH Planner to help practices of all sizes transform to the new model; that resource offers a step-by-step guide to follow.

I'm sure many small-practice physicians look at the PCMH checklist and think, "I'm already doing this. I'm already patient-centered."

I was one of those docs. And I was wrong. That's a difficult thing to realize, but my practice is better now than it was two years ago. We've improved vaccination rates, lowered the number of missed screenings and made care more accessible.

I realize now that it's important to be open to change and to always be looking for opportunities to improve. For example, I initially thought a patient portal -- a requirement to achieve the recognition level we did -- would be money wasted, but it's actually changed the way I practice. Giving patients access to their individual records improved the overall quality of our data. I've had patients point out mistakes in their records that were quickly corrected, and I even had one patient point out something we hadn't billed for that we should have. One benefit I had not expected is that my patients who are hearing-impaired now communicate with my office more often and with greater ease through the portal.

For our patients, the quality of care we provide has improved; so what's the payoff for the practice? BlueCross and BlueShield has agreed to a 5 percent payment differential for small practices in the group we are working with if they achieve Level 3 recognition. Four of the practices already are there, and six have Level 2 or Level 3 paperwork pending.

Moreover, my accountable care organization, which also is made up largely of small primary care practices, is in negotiations with two other payers to increase payment for those who have achieved PCMH recognition.

For years, payers marginalized small practices, which lacked the bargaining power of our larger counterparts, leading to more and more employed physicians and fewer and fewer small practices. But if those of us in small practices continue to prove our value, our future may be a lot brighter than anyone anticipated.

As the authors of that recent Health Affairs article noted, "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."

Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.

Comments:

Thank you Dr. Van Winkle for your continued work with the AAFP and the service you provide for your patients in your small practice. I appreciate this blog and you calling attention to the Health Affairs article. My concern is that I feel you error when you lump the concepts of the PCMH into the NCQA certification for the PCMH. Though the tenants of the PCMH are sound, the certification is likely a deviation from and not a path toward better care. Here is a great article (originally from JAMA) showing that NCQA certification does not matter: http://www.ncbi.nlm.nih.gov/pubmed/24570245. As family physicians, we need to focus on the four pillars of primary care--access, continuity, comprehensiveness of care, and coordination, and we need to work hard to improve our patient's confidence in the management of their own diseases. Focusing on policies is nice, but requiring inane policies is a waste of time. Following disease based metrics can be a distraction because disease does not equal ill health and lack of disease does not equal health. Guidelines are nice, but knowing when to deviate from them can be just as important as knowing what they are. Some of this stuff can and should be generalized, but primary care docs need to be measured on the strength of our relationships with our patients, not on the shifting markers of the latest guidelines. We are not mini-specialists and we should not be measured by their standards (note: not because we cannot achieve them but because specialist focus on one thing and we focus on everything). And therein lies the answer to the Health Affairs dilemma. Why do small practices do better even if we do not have as many NCQA PCMH certifications? Because we have greater continuity and strong relationships with our patients, and we can change things quickly to make our practices even better. Focusing on the tenants of primary care is the answer to better primary care. Thanks again for all you do.

Posted by John Brady on September 02, 2014 at 02:02 PM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.