Post-acute care in skilled nursing facilities (SNFs) is an important sector of U.S. health care. After patients are hospitalized for an illness, they may need rehabilitation in a nursing home before returning to their daily life. In fact, 1 in 5 Medicare beneficiaries are discharged to post-acute care in nursing homes. Traditional Medicare spent $28.5 billion on post-acute care in nursing homes in 2021. Since the federal government pays a generous per diem, it can incentivize SNFs to extend patient stays beyond what is medically helpful. Medicare also institutes a daily co-pay on SNF beneficiaries after day 21, which can unintentionally harm vulnerable patients (e.g., racial/ethnic minorities, poorer patients) if they are discharged prematurely. 

In this context, there’s been a growth of physicians and nurse practitioners who focus their practice on patients in nursing homes, colloquially known as “SNFists.” Since there is no board-certified medical specialty in post-acute care in nursing homes, SNFists are generalist physicians (e.g., internists, family medicine doctors) and advanced practitioners, such as nurse practitioners, who dedicate the majority of their practice to patients in nursing homes. As this practice grew, researchers have puzzled over the SNFists’ role in affecting 30-day rehospitalization rates from nursing homes.

In a new JAMA Network Open study, LDI Senior Fellow Kira Ryskina and colleagues examined the association between nursing homes hiring a SNFist provider and 30-day rehospitalization rates using Medicare data from 2012 to 2019.  

In a cohort of 4,482 nursing homes, researchers compared the rehospitalization rates for facilities that adopted SNFists (treatment group) versus those that did not (control group). During this period, SNFists’ use increased from 13% to 52% within the facilities in the study sample. At the same time, the number of post-acute care admissions in these facilities rose by 14% after SNFist adoption. However, there was no significant change in 30-day rehospitalization rates—a surprising finding.

The policy implications of this study are intriguing. Since nursing homes that used SNFists experienced an increase in post-acute care admissions which are paid for by Medicare, these facilities may be incentivized to hire more clinicians to grow a more profitable side of their business. To quote the authors, “This may be attractive to nursing homes because Medicare payments for post-acute care are more profitable than Medicaid payments for long-term care.” 

The researchers also note that nursing homes with SNFists may have an advantage under value-based payment models that penalize hospitals and nursing homes for sending patients back to the hospital. This is because nursing homes could increase post-acute patient volume while maintaining stable rehospitalization rates.

The article, “Use of Clinicians Who Focus on Nursing Home Care Among U.S. Nursing Homes and Unplanned Rehospitalization,” was published on June 14, 2023 in JAMA Network Open. Authors are Seiyoun Kim, Kira Ryskina, and Hye-Young Jung.


Samuel Schotland

Sam Schotland