Bigger practices may not mean better care for high-needs patients

A larger practice doesn’t translate to better care for patients with multiple conditions, but having greater experience treating high-needs patients just might, according to a study published in the March issue of Health Affairs.

Led by Dori Cross, a PhD candidate at the University of Michigan, the study examined four years of data from commercially insured high-needs patients in Michigan. It tested two ways of predicting how well a practice delivered care to this complicated population: 1) the size of the practice, and 2) its proportion of high-needs patients.

The sample of high-needs patients was split 52-48 between female and males. The average age was 52.6 years old. Type 2 diabetes was present among slightly more than half the sample, with 25 percent having chronic obstructive pulmonary disorder.

Among practices, less than 3 percent were labeled as having a substantial proportion of high-needs patients (categorized as more than 10 percent of its patients) with another 34 percent being classified as having a moderate proportion (between 2 and 10 percent high-needs patients).

On spending, that proportion made a difference. Compared to practices serving fewer high-needs patients, total medical-surgical spending was lower by 12 percent in those moderate practices and 40 percent lower in substantial practices. It appeared to have made a difference in utilization, as well, with moderate and substantial patients having lower odds of any inpatient admissions, 30-day readmissions and a lower number of primary care visits.

Their composite quality score, however, was an average of five points lower for substantial practices.

“These findings are somewhat surprising, given that high-needs patients require more time, resources, and expertise to effectively manage their care,” Cross and her coauthors said. "It may be that practices with a greater proportion of complex patients reach a ‘tipping point’ where they have gained the experience and economies of scale necessary to effectively target care processes to this population’s unique needs."

When judging practices by their size in serving high-needs patients, similarly mixed results were found. Smaller practices, which made up 71 percent of the sample, had lower composite quality scores. On utilization, high-needs patients in smaller practices had higher odds of an emergency department visit and “incurred significantly more primary care visits.”

But on spending, smaller practices performed better: Their total medical-surgical spending on high-needs patients was 7 percent lower and had lower average inpatient and outpatient spending.

To Cross and her coauthors, this calls into questions the conventional wisdom that consolidated, bigger practices can deliver better care to more complex patients.

“Until the evidence is more definitive, it might be valuable for policy makers and payers to consider efforts to support the existing base of small practices. For example, they could offer enhanced resources and technical assistance as small practices navigate the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 and other policies and programs seeking to change care processes,” the study concluded.