Hospital-Based Practices Do Worse than Physician-Owned Ones

When it comes to higher usage of low-value CT Scans, MRIs and x-ray imaging along with increased specialty referrals, ownership and location of primary care practices appear to matter. So says a new study published in JAMA Internal Medicine which further concludes the following:

“Ultimately, these results raise general concerns about the provision of low-value care at hospital-associated primary care practices. Because almost one-third of health spending is considered potentially wasteful, our findings have important implications for policymakers, health care practice leaders, and clinicians, who have an interest in providing the highest-quality care at the lowest per capita cost.”

As I have written previously, the highest-quality care is not only a moral and ethical priority but provides a superior long-term financial benefit. Doing things correctly in the best interest of the patient the first time around prevents an unnecessary cascade of potential untoward events including but not limited to avoidable patient harm and escalating monetary expenditures. Misguided or superfluous testing can prompt excessive radiation exposure to invasive, even irreversible procedures to adverse drug events, to name a few. Anxiety and stress can also be a consequence. 

Sadly, much focus and attention or protocol and administrative decisions get redirected toward short-term, band-aid cost-cutting which results in penny-wise, pound foolish policy. As reimbursements declined, the trend was to see more patients. Ever-expanding patient volumes results in less time spent with providers as well as pushing non-doctors beyond the scope of their training. Diminishing time spent with patients means not acquiring the most thorough and comprehensive medical history and physical examination. These are essential pieces to the diagnostic puzzle. So, what transpires when the clinician’s ability to clarify a patient’s picture gets curtailed? More testing and specialty referrals. 

Care of the highest quality especially in the primary care realm necessitates reducing patient volumes and maintaining as much continuity in care giving as possible. To review additional data that supports this assertion, read Unhealthiest Reality of Obamacare: Lack of Doctor Choice, To Survive The Hospital, Make Sure Your Heart Stops On A Weekday, and Will More Nursing and Optometrists Lead to Erosion of Patient-Centered Medicine?

Unfortunately, as physicians in hospital systems are typically salaried they can be subject to perverse incentives while integrated health systems also tend toward pricier care without any apparent benefit. (1) Due to the evidence demonstrating increasing rates of low-value care, using high precision equipment for common conditions is on the rise. (2) Hence, why these researchers opted to study the association of hospital ownership and location with the provision of low-value medical care.

The authors compared “low-value service use after primary care visits at hospital-based outpatient practices from January 1, 1997, to December 31, 2011, vs community-based office practices and at hospital-owned vs physician-owned community-based office practices from January 1, 1997, to December 31, 2013. Results were…stratified by symptom acuity and whether a generalist (eg general internist or family practitioner) was the patient’s primary care provider (PCP). This study used nationally representative data…Participants were patients seen with 3 common primary care conditions, namely, upper respiratory tract infection, back pain, and headache.” (3)

A summary of their findings

  • 31,162 visits for the 3 common conditions were identified (reflecting estimated 739 million US primary care visits 1997-2013)
  • Patients at hospital-based practices were often younger than community-based (mean age, 44.5 vs 49.1) and had greater discontinuity of care (saw PCP 52.7% of time vs 81.9% at community-based)—this lack of provider continuity yielded greater low-value care mostly in the hospital-based settings
  • Antibiotic use was consistent between settings, but hospital-based visits had more orders for imaging studies across the spectrum (e.g. CT to MRI to X-ray) and with 19% specialty referrals compared to 7.6% in community-based
  • Hospital-owned and physician-owned community-based practices demonstrated similar patterns except hospital owned had greater volume of specialty referrals
  • Non-PCP visits plus hospital-based environments produced greater frequency of low-value services
  • The researchers site prior studies in support of continuity of care as metric to deliver higher-value healthcare (with respect to lowering costs, amping up preventive care, reducing emergency room visits and hospital admissions as well as mortality rates).

Appreciating that they did not assess all forms of low-value care, the study team conveyed their limitations and efforts to focus on the more straightforward—not complex—outcomes that are mainly or relatively universally viewed as low-quality care. That said, through their work it was determined the community-based patients had higher verifiable rates of co-morbidities, making them even more complicated—and yet they received higher value care.

Whether it be enhanced ease of access to specialists and imaging technology, the location and discontinuity of hospital-based or owned ambulatory services impact quality. The “why” is likely a combination of influencing factors. Lower quality negatively affects well-being and outcomes, thereby raising costs. 

It is time to put high quality into the discussion with the same vigor and level of import as access. Actual patient-centered care -- and not mere lip service -- saves lives and money. Win-win.



(1) (2) (3) Mafi JN, Wee CC, Davis RB, Landon BE. Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States. JAMA Intern Med. Published online April 10, 2017. doi:10.1001/jamainternmed.2017.0410