Last week the AMA urged CMS to consider a number of issues that stand between solo/small practices and participation in Accountable Care Organizations.
It is an excellent letter and points out policy issues that systematically block small practice involvement in quality improvement and the kind of collaborative activity deemed necessary to achieve the outcomes we all want.
Create explicit safe harbors from antitrust enforcement and waivers of the Civil Monetary Penalty statute, the Anti-Kickback statute and the Ethics in Patient Referrals (Stark) statute so that small, independent physician practices can work with each other and collaborate with hospitals and other providers to deliver coordinated care for both Medicare beneficiaries and commercially-insured patients. Currently, all of these laws and associated guidelines favor hospital-based systems with employed physicians, yet the best way to preserve opportunities for appropriate competition in health care and choice for patients is to enable physicians to form ACOs in ways that enable them to continue practicing independently of hospitals and large health systems.
78% of primary care practices are small (fewer than 5 providers), and 62% are solo.* The national strategy for improving health care delivery must include this significant part of the health care workforce.
Solo and small practices need a stronger voice in the process of improving health care delivery. In addition to the excellent AMA recommendations let me make one or two additions:
- Increase representation of independent solo and small practice primary care practices at CMS meetings addressing delivery system redesign.
- In addition to the typical top-down approach, set aside part of the Center for Medicare and Medicaid Innovation funding to test bottom-up innovations with networks of primary care practices with emphasis on small and independent primary care practices. Leadership for the CMMI and major positions in CMS are often culled from the ranks of large organizations, perpetuating the systematic big-system bias inherent in US health care.
Big systems are not inherently bad but the systematic exclusion of small practices must stop.
*Hing E, Burt CW. Office-based medical practices: methods and estimates from the national ambulatory medical care survey. Adv Data 2007;12(383):1-15.