Physicians and Advanced Practitioners Specializing in Nursing Home Care, 2012-2015
Kira L. Ryskina, Daniel Polsky, Rachel M. Werner
JAMA, published November 28, 2017
Key Findings: The number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, although nursing home specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists were advanced practitioners (physician assistants and nurse practitioners) delivering post-acute care. The change in number of nursing home specialists varied significantly by geographic region.
Over the past decade, hospitalized patients are increasingly cared for by clinicians who focus on hospital-based care, such as hospitalists. Although increased specialization may improve outcomes by concentrating patient care among clinicians who are more familiar with specific processes of care and clinical presentations, it may reduce continuity of care with community-based primary care providers and complicate patients’ transition back to the community, for example. Thus, it is important to know whether the trend toward setting-specific specialization has spread to nursing homes.
Using Medicare fee-for-service data, Ryskina and colleagues sought to identify “nursing home specialists” (clinicians who billed at least 90% of episodes from the nursing home) and determine whether their prevalence had changed between 2012 and 2015. The authors included both generalist physicians and advanced practitioners (nurse practitioners and physician assistants) in their analysis. They looked at the type of care provided by these specialists (short-term post-acute care vs. residential long-term care) and whether the prevalence of nursing home specialists varied by hospital referral region.
From 2012 through 2015, the number of nursing home specialists increased by 33.7% (5,127 to 6,857), while the number of clinicians who provided any nursing home care remained relatively stable (33,218 to 33,087, 0.4% decrease). As of 2015, nursing home specialists comprised only 21% of all generalists billing for nursing home care.
The mean number of nursing home specialists per 1,000 occupied beds increased from 3.35 to 4.58 between 2012 and 2015 (Figure 1). Among nursing home specialists, the mean number of physicians per 1,000 occupied beds increased by 23.4% (1.11 to 1.37), while the mean number of advanced practitioners increased by 43.3% (2.24 to 3.21), making advanced practitioners the most common type of nursing home specialist. Additionally, in 2015, nursing home specialists who focused on post-acute care (2.00 clinicians/1,000 beds) were most common compared to specialists who focused on long-term care (0.90 clinicians/1,000 beds) or a combination of both (1.67 clinicians/1,000 beds).
The change in the number of nursing home specialists varied significantly by hospital referral region (HRR). While 240 HRRs (79%) had an increase in the number of nursing home specialists per occupied bed, 61 HRRs (20%) had a decrease (Figure 2). The median change across HRRs was a 33.8% increase (interquartile range, 3.8% to 80.7%).
In 2014, 1.7 million fee-for-service Medicare beneficiaries received care in 15,000 skilled nursing facilities, at a cost to Medicare of $28.6 billion. Nursing home care is costly and quality is variable, by many measures such as rehospitalization. While nursing home specialists make up a relatively small share of all nursing home clinicians, their effect on the quality of patient care may be considerable because they provide a large proportion of the visits. However, regional variation in the adoption of nursing home specialists indicates a lack of consensus regarding specialization. Whether increased access to nursing home specialists improves health outcomes or leads to adverse consequences (e.g., due to worsened care fragmentation) requires further investigation.
The authors used Provider Utilization Files, which contain all Part B Medicare fee-for-service billings, to identify generalist physicians (internal medicine, general practice, or family medicine) and advanced practitioners (nurse practitioners and physician assistants) who provided nursing home-based care from 2012 to 2015. Clinicians who billed at least 90% of episodes from the nursing home were defined as nursing home specialists (a definition analogous to the one used to define hospitalists). Visits were subcategorized into post-acute care and long-term care using place of service codes.
The authors used the Long-Term Care Focus database to calculate the mean number of occupied Medicare-certified beds per year in each hospital referral region (HRR). The number of clinicians was then aggregated at the HRR level based on their billing zip code and reported per 1,000 occupied beds.
One limitation of the study was the lack of data from individuals not covered by Medicare fee-for-service, such as Medicare Advantage patients.
Kira L. Ryskina, MD, MS is an Assistant Professor of Medicine in the Division of General Internal Medicine at the Perelman School of Medicine at the University of Pennsylvania. Her research aims to elucidate non-clinical factors that systematically influence physician practice of high- vs. low-value care. Her recent work explored the relationship between clinicians’ experiences during training and generic prescribing. Dr. Ryskina is the recipient of a Career Development Award from the NIA to study physician specialization in nursing home care as a potential mechanism to improve the outcomes of patients receiving post-acute care in nursing homes. Dr. Ryskina completed clinical training in internal medicine and primary care at New York Presbyterian – Weill Cornell. She treats hospitalized patients at the Penn Presbyterian Medical Center in Philadelphia.
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