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Small Practices Face Big Challenges

Elyas Bakhtiari, for HealthLeaders Media, December 10, 2009

In Atul Gawande's latest piece in The New Yorker, the physician-author compares the current pilot-project approach to reforming healthcare with efforts in the early 1900s to improve agricultural production. Farmers at the time were struggling with analogous problems—spiraling costs, a lack of "comparative effectiveness research," poor quality rating mechanisms, and industry fragmentation—and only began to see improvements after government-initiated pilot programs spurred innovation.

Gawande, who was named one of HealthLeaders' 20 People Who Make Healthcare Better this year, offers long-term and clear-eyed hope amidst a lot of short-term nay saying and pessimism about the future of healthcare.

But his analogy may not be very reassuring to one segment of physicians. A consequence of agricultural progress that Gawande briefly glosses over is the near extinction of the small family farmer. If healthcare follows a similar path, does the solo or small physician practice face the same fate?

Before the transformation of agriculture, the industry presented a similar economic challenge as healthcare does today. Forty percent of a family's income went to paying for food and almost half the American workforce worked in agriculture, many on small farms. Scientific and technological advancements, as well as evidence-based efficiencies, cut spending to 24% of income and 20% of the workforce by 1930, Gawande explains. Today it only accounts for 8% of income and 2% of the labor force.

Consolidation of farms and the rise of big agribusiness played a major role in that. Small farmers increasingly had trouble purchasing necessary new equipment and keeping up with productivity gains made by larger operations with more capital to invest.

Sound familiar?

It's no secret that, even with the reimbursement bonuses in the HITECH Act, solo and small physician practices face a steeper climb when purchasing and implementing electronic health records than larger groups.

A new study published in the Journal of the American Medical Association highlights yet another small-practice struggle: Nearly 65% of primary-care physicians work in practices that are too small to draw meaningful conclusions about the quality of care they provide based on Medicare data. Even aggregating data over a 3-year period for each physician group failed to produce large enough sample sizes for half of the groups with fewer than six physicians.

Don Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement, offered some suggestions to improve data collection without compromising the size and autonomy of practices, such as pooling data from all payers and surveying patients about their experiences.

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