California Hospital Group Seeks to Coordinate Care - WSJ.com
This article gets right at the crux of an interesting issue in health care and health reform: what are the costs/benefits of aggregating physicians? It would seem obvious that larger groups would be able to achieve better efficiency and thus improve quality and reduce costs. Indeed there are studies that link increasing size of the physician group to increased quality of care, but there is a flaw in this logic that deserves our attention.
I'm bringing up this WSJ article to point out some interesting risks that might flow from the notion that 'bigger is better' in health care. Health care is about people not institutions. Institutions are self-perpetuating organizations and have agendas that might not coincide with the best interest of the people they purport to serve.
I quote from a report written by Laura Tollen (of the Kaiser Permanente Institute for Health Policy) for the Commonwealth fund. This report is representative of the studies of the issue of size of group and quality. It has a number of interesting and nuanced findings. Tollen's conclusion in the executive summary:
Today, the state of that evidence is not great, but it is good enough to be intriguing and to prompt further study.
Too many of our policy discussions devolve to sound bites and ignore important nuance. Right now one can wander the virtual halls of health policy folks and hear all sorts of talk about how we have to get doctors to join Accountable Care Organizations centered around hospitals. Why? Well the literature clearly supports that as the approach to improve quality and reduce costs.
Hold on a minute!
Tollen's very well reasoned analysis of the literature (done by a person steeped in the culture of huge vertically integrated delivery systems) say no such thing. In fact she notes that there is no clear understanding of links between organizational attributes and quality:
Until a better understanding is reached of how specific organizational attributes contribute to systemness, however, policymakers should strive to create an environment that rewards quality itself (rather than tying incentives to organizational attributes).
The Ideal Medical Practices project worked with volunteer solo and small practices. We demonstrated that solo and small practices were able to measure and improve the quality of care. We published results in peer reviewed journals. The work has been cited by others. The popular press has picked up the more titillating aspects (though sometimes missing more important points).
The important point is that small and solo practices are able to deliver high quality care. With results better than a system with a robust quality improvement arm, we question the notion that bigger is better.
Further muddying the notion that big is better we as a nation have a wealth of negative experience with institutional delivery of care: it is often cold and distant, inhumane, lacking in dignity and respect, inflexible, unresponsive to individual needs, and very very expensive.
Many health delivery systems organized around hospitals appear to be more interested in maintaining market share and driving revenue than they are about quality of care. This bold statement comes from repeated experience of watching front line office practices teams receive little or no support for quality improvement if that improvement would lead to reduced emergency room or hospital use.
"We can't continue our primary care improvement project because it results in fewer people going to the hospital, and we receive our funding from the hospital."
The first time I heard this response I was shocked, but over the past decade that shock has worn off due to repeated experience.
I do not mean to imply that big is necessarily bad. Kaiser, Group Health, Geisinger and others all demonstrate high quality big organizations. I do mean to state that big might be bad or good and small might be good or bad. Size is not the issue. Quality is the issue.
I want to state clearly that policy makers must stop supporting and repeating the notion that big is necessarily good and that we have to get rid of small practices. I like the idea of practices working collaboratively to improve outcomes for their individual and collective patients. Let's continue the work we've done in the Ideal Medical Practices project and enroll solo and small practices in high quality groups that support them in improvement.
As Tollen concludes:
Until a better understanding is reached of how specific organizational attributes contribute to systemness, however, policymakers should strive to create an environment that rewards quality itself (rather than tying incentives to organizational attributes). [emphasis added]
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