The Vitals - January 2016
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Most Family Physicians Remain in Solo, Small Practices
RICHMOND, VA – Most family physicians are resisting consolidation pressures and remaining in solo and small practices, according to a recent report noting that the trend might not be altogether positive.
A study appearing recently in the Annals of Family Medicine notes that more than half of the 10,888 family physicians who sought board certification in 2013 and completed a demographic survey worked in small and solo practices – 36% in small practices and 15% in solo practices.
Furthermore, according to the Virginia Commonwealth University-led study, small practices were the most likely to be located in a rural setting at 20%. In addition, the study found that small and solo practices were more common among African-American and Hispanic doctors as well as physicians overall who have been in practice more than 30 years.
Results also indicate that physicians were more likely to be working in small practices -- as opposed to solo practices -- if they worked in highly rural areas.
For the survey, practices were split into categories by size:
- solo,
- small (2-5 providers),
- medium (6-20 providers), and
- large (more than 20 providers).
Study authors raised concerns about the types of physicians and communities that are disproportionately affected by practice consolidation, noting that the likelihood of having a care coordinator and medical home certification increased with practice size. They question whether smaller practices are missing out on new payment models that are dependent on medical home certification.
“Large groups benefit from economies of scale, distributing the costs of practice transformation across clinicians. On the revenue side, larger practices have more negotiating power in some markets,” according to the researchers. “Practicing in a larger group may have other benefits, including increased control over work hours, shared resources, access to capital, and greater ability to manage risk. These market forces are fueling a race to get larger, absent any discussion of the consequences or acknowledgment that transformation for a large practice differs radically from that for a small practice.”
The articles called for policies to help small practices profit from economies of scale without sacrificing the benefits of being small.
“Family physicians in solo and small practices comprised the majority among all family physicians seeking board certification and were more likely to work in rural geographies,” study authors concluded. “Extension programs and community health teams have the potential to support transformation within these practices.”
PCPs Often Give In to Patient Requests That Raise Healthcare Expenses
GALVESTON, TX – Are primary care physicians too agreeable with patient requests, even if those increase healthcare expenses?
A study published recently in the American Journal of Managed Care finds that might be the case.
The University of Texas Medical Branch at Galveston study says that more than half of primary care providers reported “unnecessary” referrals to a specialist simply because patients asked them. In addition, many physicians agreed to prescribe brand-name drugs when patients requested them, even when less expensive generics were available.
Background information in the articles notes that 30% of U.S. healthcare expenses each year are believed to be unnecessary. The researchers sought to determine how physicians balance cost-saving expectations when confronted with specific patient requests.
For the study, researchers employed data from a survey of a nationally representative sample of 840 primary care physicians in 2009: 274 in family practice, 257 in internal medicine, and 309 in pediatrics.
The survey reported that, in response to patient requests, 52% of the respondents said they had made what they considered unnecessary referrals for a specialist and 39% prescribed brand-name drugs despite generic alternatives.
Results indicate that family physicians and internal medicine physicians were more likely than pediatricians to respond to those patient requests. Physicians also were more likely to give in to patient requests if they had more interactions with drug/device representatives, more years of clinical experience, treated fewer underinsured patients, and practiced in groups with only one or two physicians.
“PCPs may lack the time to effectively manage patient requests. Therefore, providing physicians with real-time support to effectively manage unnecessary requests can cause desirable outcomes,” study authors wrote. “Certain PCPs (i.e., family and internal medicine physicians) may require additional support to change their response to patient requests for unnecessary medical services. More experienced physicians in solo practices could benefit from guidance on how to appropriately incorporate patient preferences into patient-centered care, without engaging in unnecessary care.”
"Unnecessary medical practices may cause unneeded emotional and financial stress for patients and their loved ones," lead author Sapna Kaul, PhD, added in a University of Texas press release. "Both physician and patient-level strategies are required to limit wastage of medical resources. Efforts to reduce unnecessary practices could include educating physicians about the benefits that result from avoidance of over/under use of medical services and implementing incentives to create a system of value-seeking patients."
Patients with Controlled Diabetes Often Over-Tested, Over-Treated
ROCHESTER, MN – Physicians who too often test patients with type 2 diabetes contribute to over-treatment with hypoglycemic drugs, according to a new study.
The report, published recently in The British Medical Journal (BMJ,) discusses the U.S. trend of over-testing glycated hemoglobin (HbA1c) levels in adult patients with type 2 diabetes.
The study team from the Mayo Clinic argued that over-testing not only adds unnecessary expense and time burden for patients and providers, but it also results in over-treatment, which increases potential health complications.
However, physicians might just be following guidelines as best they can, according to the authors. The study points out that professional societies and regulatory bodies aren’t specific on type 2 diabetes monitoring and treatment protocols. While lower thresholds of testing frequencies often are discussed, the definition of “too much” isn’t offered.
The study advises that for adult patients who are not using insulin, have stable glycemic control within the recommended targets, and have no history of severe hypoglycemia or hyperglycemia, checking once or twice a year is sufficient.
The prevalence in practice is much higher, however, according to study results. Using de-identified administrative, pharmacy, and laboratory data from the OptumLabs Data Warehouse (OLDW) from 2001 to 2011, the researchers examined a national cohort of 31,545 non-pregnant adults with controlled noninsulin-treated type 2 diabetes. Slightly more than half of them achieved and maintained the recommended less than 7% HbA1c level and were tested three or four times a year, while 6% were tested five or more times.
Excessive testing increased the odds of over-treatment with one or more drugs, despite normal HbA1c levels. Specifically, compared with guideline-recommended testing, excessive testing was associated with treatment intensification by an odds ratio of 1.35.
"Our findings are concerning, especially as we focus more on improving the value of care we deliver to our patients -- not only ensuring maximal benefit, but also being mindful of waste, patient burden, and healthcare costs," lead investigator Rozalina McCoy, MD, a Mayo Clinic primary care physician and endocrinologist, explained in a press release. "As providers, we must be ever vigilant to provide the right testing and treatment to our patients at the right times -- both for their well-being and to ensure the best value in the healthcare we provide."
According to study authors, potential reasons for more frequent testing include:
- clinical uncertainty;
- misunderstanding of the nature of the test – i.e., not realizing that HbA1c represents a three-month average of glycemic control;
- a misplaced desire for more comprehensive care;
- fragmentation of care;
- efforts to meet regulatory demands such as a performance metrics; or
- internal performance tracking.
The study also found that patients receiving bundled testing, such as cholesterol, creatinine, and HbA1c tests in the same day, were less likely to be over-tested.
Should Regular Colorectal Cancer Screening Begin Earlier Than Age 50?
ANN ARBOR, MI – Are patients screened early enough for colorectal cancer?
In a recent analysis of U.S. data, one in seven colorectal patients was found to be younger than 50 years old, the recommended age to begin screening.
Furthermore, according to the study published early online in the journal Cancer, younger patients were more likely to be diagnosed with advanced stage disease. However, they also received more aggressive therapy and lived longer without a cancer recurrence.
While colorectal cancer usually is considered a disease of the elderly, the proportion of cases in younger individuals is on the rise. That’s why a study team, led by Samantha Hendren, MD, MPH, of the University of Michigan, conducted a population-based retrospective review of the nationally representative Surveillance, Epidemiology, and End Results registry, specifically looking at information on patients diagnosed with colorectal cancer in the United States from 1998 to 2011.
Of 258,024 colorectal patients, 37,847 -- nearly 15% -- were younger than 50 years old, the age at which routine screening begins in the United States. Earlier screening wouldn’t be out of line with other cancers: Study authors pointed out that breast cancer screening often begins at age 40 even though fewer than 5% of invasive breast cancers occur in women younger than that age.
“These findings suggest the need for improved risk assessment and screening decisions for younger adults,” study authors wrote.
Results indicated that young colorectal patients were more likely to be diagnosed with regional or distant disease, more serious forms of cancer leading to more aggressive treatment. In fact, 72% of younger patients compared to 62% of older patients received surgical therapy for their primary tumor, and 53% of younger patients had radiation therapy compared to 48% of older patients.
In fact, colorectal cancer patients who were younger than 50 years of age lived slightly longer without a cancer recurrence, even though they tended to have more advanced disease when they were diagnosed. The five-year cancer-specific survival for younger patients was 95.1% vs. 91.9% for patients 50 and older for localized disease, 76% vs. 70.3% for regional disease, and 21.3% vs. 14.1% for distant disease, respectively.
"This study is really a wake-up call to the medical community that a relatively large number of colorectal cancers are occurring in people under 50. In a practical sense, this means that we should look out for warning signs of colorectal cancer such as anemia, a dramatic change in the size or frequency of bowel movements, and dark blood or blood mixed with the stool in bowel movements," Hendren said in a Wiley press release. "Also, people with a positive family history for colorectal cancer (in first-degree relatives, such as parents or siblings) and some others who are at higher risk should begin screening earlier than 50. This is already recommended, but we don't think this is happening consistently, and this is something we need to optimize."
UPCOMING [LIVE] WEBINARS
New Pharmacy & Medication Standards: the CMS CoPs
Live: January 28 Credits: 2 CE
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Advance Care Planning Payments and Standards
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The IMPACT Act and its effect on Discharge Planning Standards
Live: February 8 Credits: 1.5 CE
Safe Opioid Use: Meeting the CMS CoP Hospital Requirements
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Violence Prevention in Healthcare: OSHA Requirements
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Grievances and Complaints: Compliance with CMS, TJC & DNV Standards
Live: March 7 Credits: 1.5 CE
