Mass Med Society shouldn't trash solo and small practices without considering the data

Solo and small practices in the Ideal Medical Practices project demonstrated willingness and ability to deliver high quality can resulting in improved outcomes, improved experience of care for their patients.  We have published the results in peer reviewed journals.*  Our results compare very favorably to (and often better than) large institutional care settings. 

In extensive work with hundreds of health care improvement teams from all over the US colleagues of mine and I have witnessed with depressing frequency the amazing work of pilot practices in institutional care settings be starved by lack of organizational support.  Large organizations with mixed agenda ("why would we want to hurt our own hospital by avoiding hospitalization or emergency room visits?") often starve effective primary care efforts by flogging their work force to keep up the pace of the hamster wheel.

Why is it that smart people continue to trash the very existence of solo and small practices?  In the most recent Vital Signs from the Massachusetts Medical Society, Tom Walsh states:

In the current ultra-complex health care system, however, cost control is a much more complicated issue. Because of that, large physician groups seem to have the ability to do a better job when it comes to cost-conscious, high-quality care.

I'm presuming that Mr. Walsh is referencing studies that (probably inadvertently) systematically link quality to size and therefor draw the circular conclusion that size = quality. 

The classic example is the current NCQA's PPC-PCMH(tm) tool that equates infrastructure investment with quality.  Folks - their tool is based on an assumption that the infrastructure choices they dictate will lead to quality.  If you buy their assumptions then you might equate their score with quality.  Since infrastructure investment is massively correlated with the size of the organization ( Rittenhouse D, Casalino L, et al.  Measuring The Medical Home Infrastructure In Large Medical Groups Health Affairs 27, no.5 (2008): 1246–1258; 10.1377/hlthaff.27.5.1246 ), we then have the circular argument that size = quality. 

[The evidence that NCQA PPC-PCMH recognition leads to population health improvement over baseline is yet to be demonstrated.  It is quite possible that we have practices with good results who happen to apply for and receive recognition for quality care that is the result of something entirely different that they're doing. Read our open letter to the NCQA.]

Now that we have convinced ourselves with a circular argument we can boldly state that solo and small practices should go away and all care should be delivered in large vertically integrated delivery systems.

We have an all-too-human problem in that people tend to believe in their own models.  What I'd like to see now are the data from large systems that their care systematically outperforms that of solo and small practices when both sides are working on quality.  Our data shows Goliath going down.  This is consistent with the general experience of the public with large institutional care - it frequently fails on the most fundamental attributes of effective care: Poor access, fractured relationships and horrible continuity, complexity, lack of transparency, poor communication and lack of coordination.

Just to be clear: I'm NOT saying that large institutions should go away, I'm saying that statements to the effect that solo and small practices should go away because they can't delivery high quality care are misinformed.  Stop perpetuating the myth.

Given the right tools, meaningful data, and permission to excel, solo and small practices are ready, willing, and able to delivery high quality care.*

• Moore LG, Wasson JH.  The Ideal Medical Practice Model: Maximizing Efficiency, Quality, and the Doctor-Patient Relationship.  Family Practice Management September 2007 pp. 20-2
• Moore LG, Wasson JH, Johnson DJ, Zettek, J.  The Emergence of Ideal Micro Practices for Patient-centered Collaborative Care.  Journal of Ambulatory Care Management July-Sept 2006 Vol 29, No 3, pp. 215-221

• Moore, L. G., & Wasson, J. H. An introduction to technology for patient-centered, collaborative care. Journal of Ambulatory Care Management, July-September 2006  29(3), 195–198.
• Wasson JH, Anders SG, Moore LG, Ho L, et al.  Clinical Mircosystems, Part 2:  Learning from Micro Practices About Providing Patients the Care they Want and Need.  Joint Commission Journal on Quality and Patient Safety, August 2008, 34(8) pp. 445-452.

Comments

[Elatia Harris]

What a wonderful blog!

[Kathleen Patton]

Thank you for speaking up for small practices in Massachusetts.
I hope Dr Mario Motta, the president of the MMS, reads your blog.