Small Primary Care Practices Shine in National Study

Research Compares Hospital Admission Rates for Small Versus Large Practices

August 20, 2014 05:26 pm Sheri Porter

Small-practice primary care physicians -- a description that includes thousands of family physicians nationwide -- may have a secret ingredient or two that helps keep their patients out of the hospital. That's the headline news from a study recently published online(content.healthaffairs.org) ahead of print in Health Affairs.

AAFP President-elect Robert Wergin, M.D., empathizes with a patient he's taken care of for many years in his small family medicine clinic in Milford, Neb.; it's that kind of practice and those types of relationships that researchers point to in a study that compares hospital admission rates for small versus large primary care practices.

Specifically, the authors of "Small Primary Care Physician Practices Have Low Rates of Preventable Hospital Admissions" found that practices with one to two physicians had 33 percent fewer preventable hospital admissions compared with practices with 10 to 19 physicians; practices with three to nine physicians had 27 percent fewer admissions.

Andrew Ryan, Ph.D., M.S., an associate professor of health care research and policy at Weill Cornell Medical College in New York, talked with AAFP News about the research and its unexpected findings.

"The smaller practices in our sample, once we controlled for other characteristics, had significantly lower rates of ambulatory care-sensitive admissions," said Ryan. He added that the research team was surprised by what they found because of long-standing and widespread presumptions that larger practices provide better care.

"There are these economies of scale in larger practices that mean they can have more health information technology and more organized care processes such as nurse care managers," said Ryan. "And so, we were surprised (by the finding of fewer hospital admissions among smaller practices), because it looked like from the evidence that some of the larger practices actually do better in these indicators of patient management," he added.

Story Highlights
  • New research shows that small primary care practices have lower rates of preventable hospital admissions than larger practices.
  • Researchers noted that long-standing assumptions have held that larger medical practices provide better care -- in part, because they have more resources.
  • Study authors suggest that small practices could have hard-to-measures perks such as better physician/patient relationships that contribute to their ability to keep patients healthy.

But could it be that these small practices have something large practices don't? That's the big question, according to Ryan.

"They could have better relationships with their patients; for instance, patients could have better access to physicians through phone calls and other means that might not be the case in larger practices, and that's one of the things that we speculate could be driving these results," said Ryan.

Indeed, in their discussion, researchers pointed to evidence that patients in smaller practices have an easier time snagging appointments when they need them. "It is also possible that physicians, patients and staff know each other better in small practices and that these closer connections results in fewer avoidable admissions," the authors observed.

"Our results suggest that the common assumption that bigger is better should not be accepted without question," they added.

It's important to note that the Agency for Healthcare Research and Quality defines ambulatory care-sensitive admissions as those for certain conditions -- such as congestive heart failure -- for which good primary care could prevent hospitalization. The researchers pointed out that nearly 4 million such adult admissions to U.S. hospitals in 2010 came with a price tag of nearly $32 billion.

They also estimated that nearly 40 percent of those 2010 admissions could have been avoided.

With that much money at stake, is it possible that these study results could turn heads and open new windows of opportunity for physicians in small-practice arrangements?

Is Your Small Practice Thriving?

AAFP News is interested in talking with family physicians in small practices -- particularly those in solo or two-physician shops -- to tap into some of those unique features that likely contribute to the ability of so many of them to keep patients out of the hospital.

So whether it's strong personal connections to patients, an easy-to-access appointment desk, welcoming staff or something else a little more elusive, we want to hear your stories.

Please contact AAFP News Senior Editor Sheri Porter at sporter@aafp.org for more about this project.

"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 physicians who practice in larger groups or are employed by hospitals," wrote the authors.

"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 possible lower overall costs for patients' care, than larger groups," they added.

Study Methods, Additional Finding

Researchers used data from the National Study of Small and Medium-Sized Practices (NSSMSP) -- conducted between July 2007 and March 2009 -- to analyze the association between hospital admission rates and key characteristics of practices that included size, ownership, processes used to improve care and external incentives offered to improve quality and control costs.

Authors used the private IMS Healthcare Organizational Services database to create the population from which they sampled practices for their research. Ultimately, researchers analyzed data from 1,045 practices and cross-linked that data to Medicare claims data to match patients to practices.

Practices were classified as physician-owned or hospital-owned and grouped by size according to the number of physicians in the practice: one to two, three to nine, or 10 to 19.

In addition to the key findings already mentioned, researchers also noted that physician-owned practices had a lower ambulatory care-sensitive hospital admission rate (4.3 per hundred patients per year) than did hospital-owned practices (6.4 per hundred patients).

Next Steps

Ryan called for additional research, however, before making broad inferences about the quality of care provided by small versus large medical practices.

"Much of our existing evidence comes from research done in large academic medical practices, and those are very different from small-practice settings," said Ryan.

If new evidence shows that the health care system is moving in the wrong direction, then that evidence should be put in front of policymakers and other health care stakeholders, Ryan added. The small-practice experience and the "unique benefits to practicing in that environment" need to be acknowledged, he said.

Research authors noted that hospital leaders and large medical groups that absorb physician practices would do well to consider the advantages to preserving the small-practice environment within their organizations "while providing resources to help small practices proactively improve care for their populations of patients."

"Small practices have many obvious disadvantages," the authors concluded. "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 delivery system changes catalyzed by health care reform."


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