Why Smaller May Be Better

Despite the assumption that larger practices provide better healthcare, a new study in Health Affairs found smaller practices had fewer preventable hospital admissions.

In a national survey of 1,045 primary care-based practices with 19 or fewer physicians, Lawrence Casalino, MD, PhD, MPH, and colleagues found practices with just one or 2 physicians had 33% fewer preventable admissions compared to practices with 10 to 19 physicians. Practices with 3 to 7 physicians had 27% fewer preventable admissions.

Physician-owned practices also performed better than hospital-owned ones, according to the data.

"That's important because right now hospitals are rapidly employing more and more physicians," Casalino, the study's principle investigator and a professor at Weill Cornell Medical College, said in a statement. "It's happening very fast and changing the landscape of practice, so finding that hospital-owned physician practices did not perform as well should be interesting to physicians, patients, hospital executives, and policymakers."

The researchers used Medicare data to calculate practices’ rate of potentially preventable hospital admissions.

Although hospital-owned and large practices have more resources available to them, these practices lagged, possibly because size and ownership cause the smaller care-sensitive admission rate, the authors suggested.

"It's possible that there are closer connections among patients, physicians, and staff in smaller practices," said Dr. Casalino, the Livingston Farrand Professor of Public Health and a professor in the Department of Healthcare Policy and Research at Weill Cornell. "It may also be that it is easier for patients to reach their physician by phone and to be seen the same day, if necessary, in smaller practices."

However, the study did not include any practices with more than 19 physicians. Casalino pointed out that the small practices in this study might not perform better than very large medical groups or very large hospital-owned groups.

“In an era when healthcare reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures — such as independent practice associations — that may make it possible for small practices to share resources that are useful for improving the quality of care,” the authors wrote in conclusion.