There is plenty of room for small independent practices, says Harvard health policy expert and internist Michael McWilliams — and too much emphasis on downside risk. “I don’t know what that really gets us. It requires scale and some degree of consolidation,” he says. Evidence shows that the most effective payment model in terms of savings thus far is the Medicare Shared Savings Program, which is essentially devoid of downside risk. “With the right regulations in place, the right models, there is no reason why a smaller practice can’t be in a one-sided contract and make inroads.”
Griffin Myers, Chief Medical Officer for Oak Street Health, somewhat disagrees, pointing to the problem with romanticizing small independent practices. “[When] we say that medicine is so hard and it’s technical and it’s like rocket science, and it requires all this training, but then at the same time, I can do it and I can have a family member be my accountant and still do it — that doesn’t make sense to me,” he says. “It’s very hard to do something really well meaningfully, consistently, if it’s hard, and do it by yourself without a team.” Small practices don’t necessarily have the infrastructure or resources to measure “all of the things that we know matter.”
It depends on what we mean by small, adds McWilliams. The literature suggests that after a dozen or so physicians, practices have plenty of room for scale without hospital integration, as well as the capabilities for measurement and taking on risk.
From the NEJM Catalyst event Navigating Payment Reform for Providers, Payers, and Pharma, held at Harvard Business School, November 2, 2017.