It sure seems that way.
A perspective piece in the NEJM talks about “innovations” like telephone medicine, communicating by e-mail, physician-nurse teamlets, group visits, and part-time schedules, all designed to reduce primary care burnout.
All the cited examples were large physician groups, which pretty much ignores 90 percent of the doctors in practice today.
The ideas that work in a Mayo or Kaiser setting can’t realistically be applied in solo or small-group practices, which accounts for the majority of physician environments nationwide.
Moreso, these “innovative” practices are still facing recruiting difficulties. Jaan Sidorov observes that “if large group practices, nurse teaming, scheduling know-how, remote care communications and group visits are all that cool, then why are young physicians not flocking to [these] large group practices?”
topics: practice, primary care
{ 4 comments… read them below or add one }
What about Jay Parkinson MD (http://www.jayparkinsonmd.com/). He is innovating in a “solo” PCP with some success.
The reason innovations only work in large practices is due to the economies of scale needed for some of these costly innovations. As I mention in my blog post today, our 25-30 provider practice has 4 full time equivalents that do nothing but referral forms. Similarly, we use a robust electronic medical record (Touchworks by Allscripts) that a small group practice could simply not afford. However, as Dr. Bonis points out, Jay Parkinson is a solo MD who has done many of these innovations. He is able to do this because his patients pay out-of-pocket, and these fees cover the administrative and technical costs of these innovations.
Innovations can happen in small group practices if and only if reimbursements increase for primary care, administrative burden (referral forms) is diminished and/or reimbursed, and costly technologies (EMR) are made affordable for the individual or small group practice
Of course.
Large practices often get direct subsidies from the feds, higher payments from the commercial payers, and indirect subsidies from ancillary services that regulations make difficult for small practices. They have extra cash reserves and cash flows to survive failed or partly successful innovations.
They can afford to pull people from their larger staffs away from patient care to sit around meetings and attend conferences. Naturally, the innovations they come up with are geared to large practices with lots of staff.
This is not an argument for big practices. Most small practices are very efficient and get good value from each health care dollar, otherwise they wouldn’t survive in the brutal economics of primary care. Many have skilled managers or physicians leading them. Unfortunately, the current payment and regulatory environment heavily favors big practices.
Hopefully, if cash based primary care isn’t strangled by regulators, small efficient practices can offer a good alternative to patients and have enough success in that niche to develop innovations of their own.
Anon 9:30>>>>Large practices often get direct subsidies from the feds, higher payments from the commercial payers, and indirect subsidies from ancillary services that regulations make difficult for small practices. They have extra cash reserves and cash flows to survive failed or partly successful innovations.
Exactly. The "efficiency" is their ability to extract higher payment for the same service. Sounds like my hospital-based primary care group.
They get enhanced payment from the government payors, critical access designation and all that. I suppose I could get it too, if I chose to hire that NP. I never could figure out why you needed NP's as a condition of critical access designation. Sounds like a jobs program for the NP's.
The Mafia is more efficient than traditional business when you consider the extra cash that Guido extracts from the payors.