Patients with high health care needs enrolled in Michigan primary care practices that treat a large proportion of such patients had lower health care costs, fewer hospital admissions, and fewer emergency department visits than those enrolled in practices serving smaller proportions of high-need patients. Small practices—those with one or two physicians—exhibited lower overall spending for high-risk patients, though not lower utilization of services, compared with larger practices.
The Big Picture
The finding that practices with a large proportion of high-need patients had lower levels of spending was surprising given that these patients require more time, resources, and expertise to manage their conditions effectively. The authors suggest that practices treating more high-need patients might have structural advantages over other practices or specific approaches developed over time that position them to provide better care. “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,” they write. As to why smaller practices and practices with more high-need patients had lower quality-of-care scores, the authors posit that the quality measures may have been targeted toward adherence to best care practices for healthy patients or those with only one health condition rather than capture the distinct care needs of more complex patients.
The study’s results have important policy implications. Efforts to direct high-need patients to specialized sites of care that serve a high proportion of these patients have shown early promise and could be bolstered with support from policymakers and payers. In addition, there is a consistent trend toward consolidation of primary care to large practices, but these results and others affirm the value of smaller practices. Policymakers should find ways to support and preserve small primary care practices across the country.