Primary care private practice will die, will patients benefit?

Having more primary care physicians doesn’t necessarily improve the quality of care.

That may come as a surprise to regular readers of this blog, but that’s one of the findings that came from a recent analysis of the Dartmouth Atlas.

As reported by the WSJ’s Health Blog,

having regular primary-care visits isn’t a guarantee of receiving recommended care. There was “no relationship” between rates of breast cancer screening for women age 67-69 and the amount of primary care care delivered. Nor was there a relationship between rates of blood sugar testing and the amount of primary care delivered…

… primary care is most effective when it’s part of a coordinated effort between specialists and hospitals — and that kind of coordination is hard to come by in many areas. Moreover, quality varies, so visiting a primary-care doc who’s not delivering particularly good care isn’t going to do much in terms of improving health, they write.

It’s an interesting point.

Sheer numbers of primary care doctors are not going to help that much. Having a patient’s care coordinated with specialists in a hospital-based, or integrated, health system amplifies primary care’s positive impact. Furthermore, larger systems can better implement technology like electronic medical records, which smaller, independent practices may have trouble adopting.

Studies like these all perpetuate the trend towards larger health systems.

Early in 2009, I wrote that the days of the independent practitioner were coming to an end:

It is becoming increasingly difficult for doctors not to be supported by a hospital or large integrated health system. With reimbursements declining, many doctors are opting for the relative security of a salary.

Furthermore, joining a large group makes it easier for a doctor to adopt electronic medical records, coordinating care for the chronically ill, or adhering to practice guidelines.

Today, Bryan Vartabedian at 33 Charts cautions against the trend:

Medical practices are just too expensive to run and the services that physicians provide are dangerously undervalued. You do the math. Sure it’s a complicated issue. But the end result is institutionally employed doctors with institutional pay and the risk of institutional service.

He warns that, by treading doctors as an interchangeable commodity, “society will see commodity doctors.”

So, what’s best for patients? The private practice, independent practice physician, or the larger, more impersonal, integrated, or hospital-owned practice?

If you believe the progressively-rooted Dartmouth Atlas, it’s the latter scenario. Despite the objections of physicians and patients who cling onto solo or small practices, that’s the direction we’re headed regardless.

For better or worse.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of, also on FacebookTwitterGoogle+, and LinkedIn.

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  • DCPatient

    It seems to me the study would support the argument for higher quality primary care. You don’t need a hospital or specialist to get your blood sugar tested. While appropriate supports for solo practioners and referral patterns for complex issues needs to be put in place. This study does not support the inevitable conclusion that we need to go to an ACO (hospital centric) over a PCMH (primary care/patient-centric model).

  • family doc

    It won’t die. It will become a niche market for those patients who feel their medical care is not a commodity service that can be delivered by a midlevel in a big institution. These patients will pay for better service by a physician.

    If there are enough of them, primary care physician specialties may even survive in the long run. That will depend upon how much poor service from the government sponsored clinics drives up the demand for independent physicians and how aggressively the reformers move to make private practice untenable.

  • Solomd

    I think there will always be a certain number of patients who will still want to see an independent physician who is able to do what is best for that particular patient, and not be forced to do cookbook medicine because Medicare or the hospital employer demands it. Plus, where will all the less than perfectly compliant patients go? Eventually, patients who refuse to accept every single demand placed upon them by the Borg will need to find a doctor to take care of them after they are booted out of the Borg collective.

    • Mike

      “Plus, where will all the less than perfectly compliant patients go? Eventually, patients who refuse to accept every single demand placed upon them by the Borg will need to find a doctor to take care of them after they are booted out of the Borg collective.”

      That would be me.

  • Margalit Gur-Arie

    “…primary care is most effective when it’s part of a coordinated effort between specialists and hospitals”

    I am not questioning the above statement, but I would like to know what data elements in the actual study point to this conclusion. Or is it just the authors opinion, independent of the study results?
    Perhaps they should perform another study to validate this opinion, before all primary care docs in small private practice are herded into institutions….

    • Primary Care Internist

      I agree. Just because it seems intuitively true, doesn’t mean it necessarily is. E.g., preventive medicine saves money; or prostate cancer screening saves lives.

  • Michael Kirsch, M.D.

    Where do you get better service? At a ‘big box’ home improvement warehouse store, or the family owned hardware store,where the folks know you by name? I hope that my analogy to the medical profession is clear.

  • health services researcher

    The Dartmouth Atlas analysts are advocates masquerading as objective researchers. This widely quoted study is an even greater over-simplification of a complex issue than their interpretation of geographic variation in Medicare expenditures.

    They defined “access” to primary care as a binary variable — whether a beneficiary had 0 or any primary care visits. As usual, they make no adjustment for health status. While having a single primary care visit is a *necessary* indicator of access, it is certainly not an indicator of *sufficient* access for elderly persons with multiple chronic conditions. Therefore, it shouldn’t be surprising that the authors found little relationship between having a primary care visit and the quality indicators for diabetes care.

    In their eagerness to promote their ACO concept, the Dartmouth Atlas has unnecessarily undermined the value of primary care itself.

  • Elizabeth Rowe, Ph.D

    This article seems to be supportive of the trend of the buying of physician practices by hospitals as well as the development of the ACO’s as a good thing for patients and doctors, and suggests it could save the healthcare system money as well. I could not disagree more on all three points:

    1. The real reason that so many doctors are selling out to hospitals is that the reimbursement rates for office visits and other outpatient services have purposely been cut so that independent doctors and physician groups are forced out of business. As hospital employees their services are “loss leaders” to bring in business for the testing facilities and operating rooms, and restricting patient choice to captive specialists and services.
    2. Reimbursement fees for tests and many other outpatient services are much higher when done in hospital facilities, compared to in free standing out patient facilities, thus driving up the healthcare costs overall as more and more doctors are in hospital systems and thus refer only to in-hospital facilities.
    3. The new “accountable care” organization is just a reprisal of the HMO model, where patients have no choice of doctors, or, once having chosen a primary care doctor, no choice of specialist referrals. This is based on the ludicrous premise that all doctors are alike.
    4. Doctors who have a boss, who is a business executive primarily interested in profits, are in an ethical bind when they are subject to 4 above, where they have no choice of specialists or testing facilities to refer patients to.
    5. The hospital self-referral issue, when hospital employees are incentivized to keep the operating rooms and test facilities filled, is only going to be magnified as the consolidation increases.

    1. Incentivize organizations, such as free standing non-hospital affiliated out patient facilities and doctors, to keep patients out of the hospital, by referring to the lower reimbursed outpatient testing facilities, and keeping patients healthy.
    2. Make hospital systems no longer exempt from the Stark law on self-referral. They should be required to give each patient a list of alternative specialists and testing facilities whenever a test or referral is ordered, as is the case now for doctor owned facilities.
    3. Stop the excess payments to hospitals for testing (sometime 3 times more) that can be done at an outpatient facility.
    4. Go ahead and reimburse hospitals adequately for the things that must be done in a hospital, so they don’t have to go out and buy all these loss-leading physicians to pump their testing facilities.

    • gzuckier

      Hmmm. Your post calls to mind the model of many other services, where the wisest course of action is to find somebody who only does the diagnosis/analysis/thinking part, entirely separate from the person who actually does the fixing; otherwise every person who comes in with a question discovers that whatever is being sold is exactly what will fix that problem.

  • jsmith

    Personal anecdote: I have worked for 2 large health systems in my 21 year career, Kaiser in northern California, and a system in Minnesota that will remain un-named. These were professionally intolerable situations for me: No control, responsible to business types, etc, etc. You all have heard the stories.
    Kevin could very well be right that more or less forced integration into large systems is the future, but it is a future that I hope not to be a part of, one that I will avoid as long as I can (retirement is in about 15 years). I suspect there are many others of my generation that feel the same way. Maybe the younger docs will bear servitude better.
    So here we are, between the devil of low reimbursement and hassles of solo or small group practice, and the deep blue sea of commoditized corporate primary care. It doesn’t take a Cassandra to predict shortages.

    • gzuckier

      Maybe this is a good time to point out that in Canada, with the dreaded Compulsory Socialist Health Care, a much higher percentage of doctors are in individual practice.

  • Davis Liu, MD

    The primary care doctors I work with at Kaiser Permanente Northern California are quite happy to have an EMR available with real-time medical information 24/7, a competitive salary, and to work with a group of collegial colleagues (both primary care and specialty care). Integrated healthcare organizations don’t have to provide impersonal care, but can deliver more personal care as we have more information available at our fingertips. JD Power’s 2010 survey affirms this –
    Now we aren’t for everyone. This is why primary care will survive as solo practice doctors with low overhead or others, who are entrepreneurs, who setup virtually integrated with technology – The first year medical students I train are excited to see a different primary care than the one that currently exists. All of these are the best chances for our specialty to survive.

  • Steven Reznick MD FACP

    I think it is unfair to characterize large groups as impersonal and delivering cookie cutter medicine . It is equally unfair to characterize small private practices as inefficient and not delivering care according to guidelines. There are outstanding practitioners and empathetic physicians in both settings just like there are physicians who fall below the bell shaped curves in both settings.
    We need to identify the gems in all settings and promote and encourage what works. Different approaches may work in different locales and different settings. As long as we are providing access and striving towards Best Practice Quality measures being achieved we are moving in the right direction. Some practitioners may love the large group setting while others need a small private setting. As long as they work and achieve goals set for the specialty there should be no reason to pit one against the other.

  • Michael Kirsch, M.D.

    @Steve, of course, you are correct. However, in general, I believe that a private business has a higher level of customer service. I have certainly observed this in our own profession, and many of my patients have validated it. For the first 10 yrs of my career I was employed. During the past 10 years, I have been in private practice. So, I have a reasonable perspective on the issue.

  • Beth Haynes, MD

    shouldn’t the question be, what delivery system would patients choose in a level playing field?

    The PPACA and its subsequent regulations are purposefully designed to end independent private practice and herd physicians into employee status.

    And if you don’t believe that, you haven’t been reading what Sebelius, DeParle, and Berwick are writing.

  • Janet Still FNP-BC

    Studies are by nature limited in what they can quantify (to those making contention with the scope of the study and/or its conclusions). Naturally this study is imperfect but it does imply further studies to be made.
    Between the lines, the study omits that there are as many options for patients as their are minds to conceive the options. As we speak, forward thinking entrepreurs are cooking up new arenas in which to put the management of health care into the hands of “the people” using social networking foundations.
    We, as providers, do ourselves a diservice to limit our concepts of self/profession to the current and plainly limited caregiving modalities. I urge us to take the data gathered in these studies and integrate data into knowledge and skills for the future….if our desire and goal is truly to address the needs of our society, then we must adapt and continually grow into the contemporary as well as into the quickly approaching technological future.

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