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Primary Care and Behavioral Health Practice Size: The Challenge for Health Care Reform

Bauer, Mark S. MD*; Leader, Deane MBA; Un, Hyong MD; Lai, Zongshan MPH; Kilbourne, Amy M. PhD

doi: 10.1097/MLR.0b013e31825f2864
Original Articles

Introduction: We investigated the size profile of US primary care and behavioral health physician practices since size may impact the ability to institute care management processes (CMPs) that can enhance care quality.

Method: We utilized 2009 claims data from a nationwide commercial insurer to estimate practice size by linking providers by tax identification number. We determined the proportion of primary care physicians, psychiatrists, and behavioral health providers practicing in venues of >20 providers per practice (the lower bound for current CMP practice surveys).

Results: Among primary care physicians (n=350,350), only 2.1% of practices consisted of >20 providers. Among behavioral health practitioners (n=146,992) and psychiatrists (n=44,449), 1.3% and 1.0% of practices, respectively, had >20 providers. Sensitivity analysis excluding single-physician practices as “secondary” confirmed findings, with primary care and psychiatrist practices of >20 providers comprising, respectively, only 19.4% and 8.8% of practices (difference: P<0.0001). In secondary analyses, bipolar disorder was used as a tracer condition to estimate practice census for a high-complexity, high-cost behavioral health condition; only 1.3–18 patients per practice had claims for this condition.

Conclusions: The tax identification number method for estimating practice size has strengths and limitations that complement those of survey methods. The proportion of practices below the lower bound of prior CMP studies is substantial, and care models and policies will need to address the needs of such practices and their patients. Achieving a critical mass of patients for disorder-specific CMPs will require coordination across multiple small practices.

*Department of Psychiatry, Harvard Medical School & the Center for Organization, Leadership, & Management Research (COLMR), VA Boston Healthcare System, Boston, MA

Aetna Behavioral Health, Aetna Inc., Blue Bell, PA

Department of Psychiatry, University of Michigan & VA Ann Arbor HSR&D Center of Excellence, Ann Arbor, MI

Supported in part by NIMH Grant R-01-MH079994 (AMK) as well as the VA Health Services Research and Development Center of Excellence, The Center for Organization, Leadership, & Management Research (COLMR) (MSB).

The authors declare no conflict of interest.

Reprints: Mark S. Bauer, MD, Department of Psychiatry, Harvard Medical School & the Center for Organization, Leadership, & Management Research (COLMR), VA Boston Healthcare System-152 M, 150 South Huntington Avenue, Boston, MA 02130. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.