Small Practices Successfully Preventing Readmissions! by Steven Mussey MD


We have two doctors in our Internal Medicine Practice.

That’s it!


We don’t have any “physician extenders.”  We each cover our own calls, unless one of us is out of the country or on a plane.  We enjoy our lives and we believe we do a good job.

For years, I listened to leaders in the American College of Physicians (ACP) ramble adoringly about the “Patient Centered Medical Home (PCMH). “

I grumbled.

The requirements to officially create such an entity really require a larger group.  The necessary checklist of requirements is daunting.

My message has been, instead: Our group of two doctors creates a “Patient Centered Medical Home, “ better than any concoction from the National Committee for Quality Assurance (NCQA).

Yet, it is clear the Affordable Care Act (ACA) and the NCQA is doing its best to crush little groups like us.

Finally, however, our value is getting noticed:

Bottom lines:

  • Solo or partner practices had 33% fewer hospital re-admissions than bigger groups.
  • Smaller practices do the things that should actually be happening in a “medical home.”  Unfortunately, the “medical home” is simply checking boxes without improving care.
  • Financial incentives do not reduce readmission rates.
  • Smaller practices are actually succeeding in providing an integrated care experience for the patient.

Yet everyone wants to kill us off and make us join a mega-group or organization.

“We’re dinosaurs… and I like it!” I shout after leaving a typical healthcare meeting.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  9 comments for “Small Practices Successfully Preventing Readmissions! by Steven Mussey MD

  1. Mary Helen Morrow, MD
    March 23, 2015 at 11:13 pm

    The additional way they try to go after us (for low re-admission or admission rates) is to complain about our low admit rates and make us get colleagues to “vouch for us”. …or give us the option to relinquish privileges… 🙁

  2. Spring Texan
    March 19, 2015 at 12:54 pm

    Very cool! My family doctor too belongs to a small, excellent medical practice and yes I worry about their survival and do NOT want to switch to any alternative. Keep on keeping on.

    • Doug Farrago
      March 19, 2015 at 1:47 pm

      They would be extinct with a single payer govt plan. You can’t have it both ways. Idiot.

  3. Perry
    March 13, 2015 at 11:09 am

    The policy wonks, administrators and politicians are wedded to the alphabet soup physicians now have to contend with. They are convinced the salvation of the American patient comes with governmental and institutional interference. The so-called ACO just places yet another layer between patient and physician. The PCMH concept is probably reasonable for some locations and conditions but is not practical for many small physician practices.
    Corporate medicine and the weight of clunky regulations and ideas will surely sink the small practice.

  4. David Caughell MD
    March 13, 2015 at 10:53 am


    Bully SteveO !

    I teach residents for a day during their rotations, it is kinda like a museum experience for them. I spend the entire time encouraging them that they can do this if the want to. Don’t sell your soul to an MBA because you think you have to. You can explain the Loop of Henle for crying out loud. The hump is that they do not seem to have the desire to experience the type of practice driven by duty and responsibility to the patient. One that is based in a true doctor patient relationship rather than the patient – insurance company relationship,, or the patient – practice relationship or what ever seems to be the strongest driving force in at the time. They need the opportunity to see a practice that provides the medical home without check-boxes.


  5. Sheryl
    March 13, 2015 at 10:43 am

    I’m a nurse practitioner in a physician-owned practice in a rural community in Oklahoma. We’ve been in the community for 27 years. We do it all ourselves; billing, payroll, IT, etc. The residency program in a larger community sends their residents to us for a day of “Practice Management”. The first thing the doctor tells them is “Welcome, I’m Jurassic Doc”…it is nice to know that all of us dinosaurs aren’t extinct.

  6. JRDO
    March 13, 2015 at 8:49 am

    When I worked at ABC Megahealth my coworkers and I always had the sense that the patients belonged to ABC. Now that I am in a two physician private practice, my coworkers and i all feel a much deeper sense of responsibility to our patients. My mantra for years now has been, “In healthcare, bigger is not better”.

  7. drhockey
    March 13, 2015 at 8:10 am

    It is always nice to have data supporting what intuitively is obvious.

    My take on reading the referenced article: You can have poor quality small groups, but large groups diminish the good quality doctors in it for the bureaucratic reasons stated by the study’s author.

    Or, as my high school music teacher said, “The orchestra is only as good as its worst player.”

    • Steve O'
      March 13, 2015 at 8:33 am

      I’ve got to call you out, Dr. H., on your using American Business Principles – the very ones touted by Jack Welch, a former auto CEO. These principles made Detroit what it is today – the land of hope and wealth. [NOT]
      The fallacy is, you put a bullet through the head of the slowest sled dog, and the team will go faster. If you repeat it enough, you are stuck looking for the Big-Box sled-dog store in the vast and trackless wilderness. Or go to HR. I’d rather freeze to death, myself.
      Remember, the “worst” doctor in the group has had 5,000 practice hours of SOME sort of experience. A REAL management group would focus on trying to bring the worst doctor to their best productivity, not just a round to the ol’ foramen magnum on Friday Afternoon.
      And how do we measure the “worst” doctor in the group? Press Gainey? Number of unchecked boxes of the required checkbox system? How? Unshined shoes? This system of management says that diminished productivity – say, after a painful divorce – leads to culling of the weak from the herd. Now, that’s humanity fer ya!
      That approach inevitably leads to prizing the mediocre – the silent not-failing middle of the herd. That is what Corporate Medicine and megagroups select for – the unobtrusively dull.
      DPS – its greatest danger as well as its revolutionary principle – is the idea that the care of the patient is solely measured by the CARE OF THE PATIENT – a revolutionary idea from 1927 JAMA (see Dr. Peabody’s essay).
      The world of medicine is being terminated by the thirtysomething MBA psychopaths who think that management is reading the monthly Excel spreadsheet, and racking the .45 to weed out the losers.
      The IOM publication “To Err Is Human” of 16 years ago – for those few who have read it – know that failures in medicine are almost always SYSTEMS failures, not PERSONNEL failures. The PEOPLE are caring, but the SYSTEM hurts them. But this arcane secret was deeply encrypted in the document using an ingenious method – the American attention span rarely exceeds 15 seconds, so nobody read or understood the damn thing. And then they turned it into the healthcare equivalent of Hitler’s Enabling Acts – temporary measures to stem the emergency, trust us, they said.

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