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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