Residents of nursing homes (NHs) comprise a medically complex and vulnerable population with many persons experiencing multiple comorbid conditions, frailty, and advanced dementia. Health care professionals such as physicians, nurse practitioners (NPs), and physician assistants (PAs) play an important role in managing their care. An Office of Inspector General Report1 noted that specialization of health care professionals in NH care could potentially improve care through increased presence of health care professionals in NHs, enhanced knowledge in the care of patients with medically complex conditions, and better understanding of the regulatory environment. On the contrary, specialization in 1 setting of care could result in increased fragmentation of care, giving rise to concerns about medical errors and lack of care coordination. Little empirical research is available about the number of clinicians who primarily practice in NHs or the proportion of NH care delivered by these clinicians.2 Using national Medicare Part B claims from 2007, 2010, and 2014, we characterized temporal trends in the number of physicians, NPs, and PAs concentrating their practice in the NH or skilled nursing facility (SNF) setting (ie, SNFists), the fraction of all NH and SNF claims generated by SNFists, and state variation in this phenomenon in 2014.
The Medicare Part B Carrier File includes Evaluation and Management codes based on common sites of service: the nursing home, outpatient office, hospital, emergency department, a patient’s home, and assisted living, custodial care facilities. Using Evaluation and Management codes from 20% of all Medicare Part B Carrier file claims from 2007, 2010, and 2014, we identified all physicians, NPs, and PAs who billed more than 90% of all their visits in the NH setting. The 90% threshold is consistent with a prior study of hospitalist care in the United States3; in a sensitivity analysis, we relaxed this threshold to 50%. Temporal trend comparisons for 2007, 2010, and 2014 were performed using variance-weighted least squares. We further characterized, in each state, the fraction of all outpatient visits in NHs that were accounted for by SNFists. An institutional review board waiver was obtained from Brown University.
Between 2007 and 2014, the proportion of physicians ever billing in an NH decreased from 13.7% to 9.8% (test of trend, P < .001) while the number of physicians classified as SNFists increased by 48.2% (1496 vs 2225), increasing from 0.34% to 0.49% of all physicians (Table). The number of NPs or PAs classified as SNFists nearly doubled (1678 vs 3074). The proportion of NPs and PAs classified as SNFists remained stable because of increasing numbers of these clinicians. The proportion of all Evaluation and Management bills for care in an NH or SNF submitted by clinicians classified as SNFists increased from 11.6% to 14.3% among physicians (test of trend, P < .001) and from 10.4% to 17.2% among NPs and PAs (test of trend, P < .001). Between 2007 and 2014, the proportion of total SNF billing accounted for by SNFist clinicians increased from 22.0% to 31.5% (test of trend, P < .001). The SNFists’ proportion of total NH billing varied by state, amounting to nearly 50% in Delaware, Hawaii, Tennessee, Connecticut, and Massachusetts. In a sensitivity analysis using a threshold of more than 50% of visits in the SNF, the number of physician SNFists increased from 2551 to 3529 and the number of NP or PA SNFists increased from 3267 to 5477.
The care of frail and medically complex NH residents is increasingly performed by NPs and PAs who focus nearly exclusively in this site of care. In some states, SNFists accounted for nearly half of the total billing in the NH setting of care. Future research is needed to understand how this specialization of care affects not only care delivery but the overall experience of frail, elderly patients.
Corresponding Author: Joan M. Teno, MD, MS, Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Box 359765, Pat Steel Bldg, 401 Broadway, Ste 5123.1198104, Seattle, WA 98122 (email@example.com).
Accepted for Publication: April 2, 2017.
Published Online: July 10, 2017. doi:10.1001/jamainternmed.2017.2136
Author Contributions: Drs Teno and Gozalo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Teno, Gozalo, Trivedi, Mitchell, Bunker, Mor.
Acquisition, analysis, or interpretation of data: Teno, Gozalo, Bunker, Mor.
Drafting of the manuscript: Teno, Bunker.
Critical revision of the manuscript for important intellectual content: Teno, Gozalo, Trivedi, Mitchell, Mor.
Statistical analysis: Teno, Gozalo.
Obtained funding: Teno, Mor.
Administrative, technical, or material support: Teno, Gozalo, Bunker, Mor.
Supervision: Teno, Gozalo, Mor.
Conflict of Interest Disclosures: Dr Trivedi reports consulting fees to edit the Merck Manual. Dr Mor chairs the Independent Quality Committee for HCRManorCare, Inc, a nursing home chain, for which he receives compensation, and also serves as chair of a Scientific Advisory Committee for navHealth, a postacute care service organization, for which he also receives compensation. No other disclosures are reported.
Funding/Support: This research was funded by National Institute on Aging grant P01 AG027296-06A1, Changing Long-Term Care in America: Policies, Markets, Strategies and Outcomes.
Role of the Funder/Sponsor: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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