THE AUTHORS find that physician-owned practices have lower nonemergent emergency department (ED) rates, lower emergent primary care-treatable ED rates, and lower ambulatory care-sensitive hospitalization rates. They find that higher-revenue practices and practices with a higher ratio of nonphysician clinicians perform poorly on most of these metrics. The effect of electronic health records is ambiguous, lowering preventable ED use but not potentially preventable hospitalizations.

There is reliable evidence that inappropriate ED usage and primary care preventable hospitalizations can be prevented by ready access to a clinic during business hours, by after-hours contact with a provider who knows the patient, and by adequate time to manage problems in the clinic. (Broyles et al., 2000, p. 2070)

The authors could not measure these 3 variables in the MGMA data, but their findings are consistent with that theme. High-revenue clinics are likely high-volume clinics where only a few minutes are allocated per patient. Nonphysician clinicians can assist in care by either processing more bodies through a clinic or improving the quality of care-in high-revenue clinics, it is likely the former.

We have found in a chronically ill pediatric population that a clinic can reduce hospitalizations by more than 50% if it offers open-access appointments half the day and after-hours access to a clinician who knows the patient. But reducing hospitalizations was a specific goal of care and required twice the clinic staffing provided by usual fee-for-service payments-making it a low-revenue clinic. The problem, as most of us know, is that payment for primary care fails to reward the behaviors and investments that keep patients out of the hospital and ED unnecessarily, hence the wide variability in performance on these metrics in this study.

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