Bigger practice, better quality? Practice size not the complete answer

Large physician groups have long had a head start on solo and small practices in the medical marketplace because they can negotiate better health plan contracts. Now, a rising tide of evidence indicates that size also confers a quality advantage.

Researchers admit that the medical literature emerging on the relationship between group size and quality is far from a slam dunk. They argue, however, that bigger physician groups can pool capital to pay for electronic medical records systems and other quality initiatives that help them more reliably deliver guideline-based care.

On the opposite end of the spectrum, a small but growing movement of doctors is experimenting with a leaner model of medicine that they say improves the financial viability of solo and small-group practice and, most importantly, improves patient care.

While medical skill may vary among individual physicians, an overriding question is the extent to which the system in which doctors practice can improve the odds that their patients will receive the right care at the right time. Is a system of giant, integrated medical groups the right path for medicine's future, or can the traditional small practice be redesigned for the era of quality measurement?

Trying to understand the connection between the practice structure and patient outcomes is "the Holy Grail of studies of physicians and quality," according to a December 2006 Annals of Internal Medicine editorial authored by Lawrence P. Casalino, MD, PhD.

"If it were convincingly shown that larger groups do a lot better, you'd want patients and physicians to know that," said Dr. Casalino, associate professor of health studies at the University of Chicago.

Recent investigations have found that size may make a difference on certain quality aspects:

• Medicare patients with myocardial infarction that solo physicians treat are more likely to die than patients cared for in other settings, according to a study in the January/February issue of Health Affairs. Patients of solo physicians also are least likely to receive cardiac catheterization or percutaneous transluminal coronary angioplasty, the study found.
• Groups with 50-plus physicians are more likely than solo physicians to generate or have access to data on their own quality of care, said a May/June 2005 Health Affairs study.
• The bigger a physician group is, the more likely it is to offer health promotion and smoking-cessation programs, according to studies that Sara B. McMenamin, PhD, MPH, and colleagues at the University of California, Berkeley, published in 2003 and 2004.
• Doctors in solo or two-physician practices are less likely to deliver appropriate preventive services such as hemoglobin A1c testing, mammograms and influenza vaccinations, a July 27, 2005, Journal of the American Medical Association study found.

The new research is beginning to show a "consistent relationship" between larger, integrated physician groups and performance on process-oriented quality metrics, said Stephen M. Shortell, PhD, MPH, dean of the UC Berkeley School of Public Health.

"It is different from a year or two ago, when the evidence was much weaker," he said.

The argument for bigger practices

These results are not an accident, said Don Fisher, PhD, president and CEO of the American Medical Group Assn., which represents large multispecialty practices such as Geisinger Health Systems, the Cleveland Clinic and the Kaiser Permanente Medical Groups.

"If you're in solo practice, nobody ever sees what you do to patients," Dr. Fisher said. "I call that the private practice of medicine. When you get into a larger group and have medical records, all of a sudden you have the public practice of medicine. You have peer pressure to do the right thing rather than just improve your W-2 at the end of the year."

Large, multispecialty groups ought to be "the preeminent form of care in the United States," Dr. Fisher said.

Albert W. Fisk, MD, is medical director of the Everett Clinic in Washington. The 250-physician medical group is about 25 miles north of Seattle and has received several awards for its quality and patient-safety initiatives. Dr. Fisk said the clinic leverages its size to invest in EMRs, develop disease registries for common chronic conditions and efficiently remind both patients and physicians about preventive services.

"We have a number of people whose primary job is quality improvement. You can't do that if you have a three-physician office," said Dr. Fisk, a member of the AMGA's board of directors.

"Being big doesn't necessarily mean quality's better, that's for sure," he added. "It depends on what your mission is, what your core values are, and whether you can execute. We do have the advantage over smaller, disorganized practices in that we can put resources to it."

Making sure that patients receive guideline-based care is not a matter of medical skill, but systemic improvement. And larger groups may have the advantage on that score, said the University of Chicago's Dr. Casalino.

Some say smaller is the way to go

The way to help solo and small-group doctors measure up on quality, said L. Gordon Moore, MD, is to think outside the box when organizing their practices. Or, perhaps, to shrink the box.

Dr. Moore, a solo family physician and assistant professor of family medicine at the University of Rochester School of Medicine and Dentistry in New York, said physicians should operate super-lean practices and leverage new technologies to improve patient care. So far, about 100 physicians have adopted his Ideal Medical Practices model, which calls on doctors to cut overhead such as office space and ancillary staff, while increasing investments in relatively affordable EMRs and using a free online patient survey tool available at HowsYourHealth.org.

Practices participating in a demonstration project have scored better than the national average of all practice sizes on How's Your Health measurements of accessibility, efficiency, continuity, patient education, chronic disease management and patient collaboration, said John H. Wasson, MD. Dr. Wasson, assistant professor of community and family medicine at Dartmouth Medical School in Hanover, N.H., maintains the HowsYourHealth.org database.

John Brady, MD, left a six-physician practice after reading about Ideal Medical Practices in the journal Family Practice Management in 2002. The Newport News, Va., family physician employs only one full-time nurse, answers the phone himself, and said that thanks to low overhead, he nets $130,000 a year while seeing fewer than 15 patients a day.

"I can tell you without hesitation that the quality of medicine that I'm practicing is head and shoulders above what I've ever been able to do before," Dr. Brady said. "I'm free to actually think."

He added that going micro means fewer gaps in care.

"It is possible in a large clinic to provide really good quality care," Dr. Brady said. "The challenge is getting really good communication amongst all the different clinicians. If the communication isn't there, it starts to fail. Here, it's just me and my nurse. If something falls through the cracks, it's either her fault or mine. Nobody else can be blamed for it."

Jury still out

There are very real constraints to the newly emerging evidence on group size and quality, experts say. As with most quality measurement, results are often based on health plan claims data that may present an inaccurate picture of real-world practice. Also, good information about physician group size is hard to come by. And there are elements of quality that researchers do not yet have a reliable way to measure.

"The quality measures we have are quite limited in most cases," Dr. Casalino said. "There is no question about whether large practices that can invest in it and hire staff to make sure they score well are likely to have higher Pap smear rates than people in small practices. But when you get to things that are perhaps harder to measure, like diagnostic skill, then we don't really know anything about how group size might affect that."

Researchers are looking to go beyond whether larger groups are more likely to have EMRs, fund quality initiatives or score better on process-oriented metrics. For example, Berkeley's Dr. Shortell is studying whether physician group size may be linked to improved patient outcomes such as hospitalizations and complications. "I can't make a definitive statement that larger groups absolutely provide the best medicine in America. ... There is growing evidence they do some things better. Think about the explosion of medical knowledge and the financial incentives -- how can the solo docs keep up? We need to work on how to get them to be part of virtual organizations, at least, that give them the advantages that folks like Kaiser have," he said.