According to The National Ambulatory Medical Care Survey (2007), 78% of primary care practices in the US have five or fewer providers and 62.9% of all medical practices are solo and account for 35.8% of all office visits.*
The number and percent of solo practices has been declining over time and some cheer this trend as there is some evidence that large organizations are more likely to have quality improvement infrastructure** and are better able to afford to participate in multi-day and expensive improvement seminars.
But killing off solo and small practices might make sense only if solo and small practices are incapable of delivering the kind of high quality care our country needs. To cut off such a large part of our primary care workforce we ought to have iron clad evidence. So far the evidence is far from iron clad and there is some evidence that solo and small practices are quite capable of delivering high quality care.***
The Rittenhouse study** demonstrates the circular logic used (not by Rittenhouse) to bash solo and small practices. Defining quality in ways biased to favor very large organizations will lead one to the conclusion that large organizations are able to demonstrate quality.
A lot of medical practice quality improvement is currently delivered in large venues where as many as 200 participants learn new content and process improvement from experts in two day meetings, several times per year. These meetings can be costly to run and it is very difficult for solo and small practices to close up shop to participate in two day meetings.
The NCQA defines quality as being able to spend many tens of hours filling out forms and taking screen shots to prove the capability of health information technology. A large organization can do this once for all providers, solo practices have to do this for themselves at a monstrously larger cost per MD per submission. [If it costs a hypothetical $2500 in time and fees to submit, a 100 MD group spends $25/MD, a solo doc spends $2500/MD.] So the deck is stacked against solo and small practices.
We must explode the myth that solo and small practices are unable or unwilling to participate in quality improvement and reporting. The Ideal Medical Practices project work predominantly with solo and small practices and easily recruited more than 100 volunteers. Solo and small practices participated in the AAFP's TransforMED project.
At issue is the mode of practice engagement. The Ideal Medical Practices project recruited via online listservs, provided online content and supported improvement work through conference calls. Participants did not have to leave their practices and had no costs other than getting on the calls.
Organizers of medical home or ACO demonstrations, other organization interested in supporting improved health care delivery, improved outcomes, and reduced unnecessary costs could do the following:
- Set threshold for participation to include all practices, not just large groups and organizations.
- Require for instance that solo practices make up 62% of practices in improvement projects.
- Use quality improvement processes that work as well with solo and small practices as with large groups.
- A significant amount (if not all) technical assistance can be provided through conference calls thus minimizing the opportunity costs to the practices as well as the cost of practice support.
- Provide online resources and tool sets.
- Make measurement and reporting less onerous and more accessible.
- Use quality data sets that always have sufficient denominators at the individual provider level.
- Use reasonable proxies for quality that can be measured through aggregate patient experience of care, thus minimizing the practice burden of measurement.
This is a choice. We can't afford to write off this much of our primary care workforce. The IMP project demonstrated one path of inclusion. This can be done.
* 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.
** 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
***Moore LG, Wasson JH. The Ideal Medical Practice Model: Maximizing Efficiency, Quality, and the Doctor-Patient Relationship. Family Practice Management September 2007 pp. 20-24.