AAFP Questions Claims That Health Care Reform Will Reduce Role of Solo, Small Practices

September 15, 2010 04:35 pm James Arvantes

The AAFP has sent a letter to the White House regarding an article in the Annals of Internal Medicine written by top White House officials that gives the impression that health care reform will accelerate the establishment of larger group practices at the expense of solo and small physician group practices.

"As many as 25 percent of family physicians serve their patients in either a solo or two-physician practice," says AAFP President Lori Heim, M.D., of Vass, N.C., in response to a recently published article(www.annals.org) in the Annals of Internal Medicine that was written by Nancy-Ann DeParle, M.D.; Ezekiel Emanuel, M.D.; and Robert Kocher, M.D. "These practices flourish all over the country, in rural communities and in city neighborhoods," Heim adds.

She also notes that solo and small group practices provide up-to-date medical care and, via information and communication systems, help ensure that patients can find the community resources "that will allow them to manage their chronic diseases and prevent them in the first place."

Heim sent the letter after a personal discussion with DeParle, who is the director of the White House Office of Health Reform. The other authors of the article, Emanuel and Kocher, respectively, are a health policy adviser at the White House Office of Management and Budget and a former special assistant for health care to the president.

The article the three wrote covers the opportunities and challenges posed by the recent health care reform legislation, including in the delivery of health care services. For example, the article notes that "the economic forces put in motion by the (health care reform) act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups."

The authors also contend that the health care system will evolve into one or two forms, which will be organized around hospitals or around physician groups. "Only hospitals or health plans can afford to make the necessary investments in information technology and management skills," say the authors.

In the letter from the AAFP, Heim questions the article's implications. "It is the article's abstract that caused the greatest concern to those of us who believe that high-quality health care can be -- and is being -- delivered to patients, often in rural and underserved areas, by family physicians practicing alone or with a few other physician and health professional colleagues," says Heim.

She also points out that the models of care listed in the Annals of Internal Medicine article can work equally well in small-practice settings. For example, the article cites accountable care organizations, or ACOs, and the patient-centered medical home, or PCMH, as examples of models that can work within larger physician groups. But, in the AAFP letter, Heim says, "An ACO can serve as a vehicle for disparate small physician groups, such as within a virtual integrated organization, to share some assets and support some community resources needed to coordinate care and help prevent disease."

Likewise, a PCMH can work very well in a small-practice setting, says Heim. "Indeed, physicians in a solo, small- or medium-sized practice do provide the important team-based primary care and preventive health services and chronic disease management called for in the health reform legislation."

If one of the preeminent goals of health care reform is to transform the practice of health care delivery to reduce duplication and fragmentation of service and to focus on integrating care, says Heim, physicians in all group sizes can do that.

"We need not eliminate the variety of practices that make health care delivery most effective in different settings," she says. "We will continue to need small and medium-sized practices, and we should give these physicians the assistance they need to participate fully in our nation's renewed emphasis on primary care."

After her conversation with DeParle, Heim told AAFP News Now that she is convinced the White House is "very supportive of small practices." She believes that the true intent of the article was to emphasize that all practices -- large and small -- have to move toward improving quality and care coordination.

According to AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho, the Academy will continue to work to ensure that the role of small and solo practices is not forgotten, marginalized or overlooked in the nation's health care system.

"In fact, these practices must be enhanced," Epperly told AAFP News Now. "America must have small practices if we are going to be successful with health care reform. These practices are critical to many locations -- rural America, suburban America, urban America and inner-city America."

Epperly and other AAFP leaders have met and discussed health care issues with DeParle, Emanuel and Kocher during the past few years, and they are convinced that the article represents more of an oversight than an actual attempt to devalue the contributions of small physician practices.

"I think that in writing this, (the authors) were pointing specifically to larger group practice successes and inadvertently left out mentioning the value of small-practice successes," said Epperly. "I think is it more of an oversight than a purposeful direction they are trying to insinuate."