More Docs Are Becoming 'Nursing Home Specialists'

John Commins, November 29, 2017

More than one-in-five physicians and advanced practitioners who practice in nursing homes specialize in nursing home care, and the trend suggests the rise of a significant new specialty in medical practice.

The number of doctors and advance practitioners in the United States who focus on nursing home care rose by more than a third between 2012 and 2015, according to a study this week in JAMA.

"We don’t know how this trend will play out in the long term, but nursing home specialists have the potential to change the way health care is delivered in this setting," said study lead author Kira L. Ryskina, MD, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine.

Ryskina and colleagues used a Medicare database to analyze all Part B Medicare fee-for-service billings by generalist physicians, nurse practitioners, and physician assistants who provided nursing home based care during 2012-2015. "Nursing-home specialists" were defined as those clinicians billing at least 90% of episodes from a nursing home.

The number of these specialists rose from 5,127 in 2012 to 6,857 in 2015, a jump of 34%. Adjusted for the patient population this rise was even greater: from 3.35 nursing home specialists per 1,000 occupied beds to 4.58, an increase of 37%. During the same period, the overall number of clinicians billing from nursing homes was almost unchanged (33,218 to 33,087).

About 80% of hospital referral regions saw rises in nursing home specialists per bed, while 20% saw declines. "The variation in adoption of specialists indicates a lack of consensus regarding the benefits of specialization," Ryskina said.

Nursing home specialists made up about 21% of all nursing home clinicians in 2015, so the results may mark the earliest phase of a trend towards nursing home specialization. "The impact of that trend on patient care may already be considerable, though, because specialists provide a disproportionate share of the care," Ryskina said, adding that how this change will affect patient outcomes or care remains to be seen.

"On one hand, clinicians who practice in the nursing home exclusively could improve patient outcomes and reduce costs by leveraging expertise in nursing home processes of care, for example," she said. "But, concentrating patient care among nursing home specialists could also mean that patients are no longer seen by their primary care providers, who traditionally follow patients for years and across care settings."

Concerns over care quality have prompted the Centers for Medicare and Medicaid Services to propose a number of reforms as well as penalties for low-quality care in nursing homes. The nursing home industry may now be adapting to this stricter regulatory environment by employing physicians who specialize in nursing home care.

"Twenty years ago, the Hospitalist movement started in the same way, wherein hospitals were under pressure to reduce costs, and readmissions," Ryskina said. "We might be seeing the beginnings of a similar trend in nursing home care."

John Commins

John Commins is a senior editor at HealthLeaders Media.

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