Is it all about service, or quality or cost? Patients, employers and physicians have conflicting notions of what constitutes value, and that could have costly consequences for the $3.3 trillion healthcare sector.
What do we mean when we talk about healthcare "value"?
It depends upon who’s talking.
A survey commissioned by University of Utah Health of 5,031 patients, 687 physicians and 538 employers across the nation found that, while most stakeholders agree that healthcare must deliver "value," it's not clear what that means, or how they’d prioritize the components of cost, service, and quality.
"There is not universal agreement across those three critical voices as to what value constitutes," says Bob Pendleton, U of U Health’s chief medical quality officer. "That is problematic, as we try to work towards a shared vision of what a high-value health system looks like for the country."
For example, when asked to prioritize quality, cost or service as components of value:
88% of physicians ranked quality (defined as the efficiency, effectiveness, safety and outcomes) as the top priority, compared with 62% of patients, and 20% of employers.
43% of employers ranked customer satisfaction, or service, as a top priority of value, compared with 12% of patients, and 7% of physicians.
37% of employers said cost was a top component of value, followed by 26% of patients, and only 5% of physicians.
Pendleton says the responses show that value is nuanced and multi-dimensional.
"We do need to be talking about each of these voices," he says. "Collectively they’re saying that the convenience and accessibility of healthcare is of critical importance to patients, that the cost of healthcare is important to all three players, but especially for patients who have an increasing out-of-pocket burden and employers who continue to pay for rising premiums. The providers have a stronger grounding in the traditional quality outcomes."
As for why agreement on value matters, Pendleton said that it's about setting priorities for a $3.3 trillion sector that consumes nearly 20% of the economy.
"If we don’t have agreement for what we want for that enormous price tag, then it becomes problematic," he says. "We can keep spending more and more on healthcare but if we don’t have clarity on the results we are trying to achieve we are never going to be able to come up with effective and viable solutions."
Answering the question of what constitutes value is even more complex, Pendleton says, because there are no right or wrong answers.
"The truth lies in hearing everyone’s voice," he says. "For example, some people have pushed the notion that value equates to health outcomes over cost. But that notion misses the patient’s perspective, where convenience and accessibility are a critical part of value as well. There is room for an agreed-upon vision."
If no clear-cut understanding of "value" emerges, Pendleton says it becomes just another buzzword, meaning everything and nothing, in a healthcare sector already rife with meaningless jargon.
"Healthcare has become an industry of propaganda," he says. "We are talking about value, which is a buzzword that’s been used to mean whatever the player wants, whether it's an IT support company, a hospital or a doctor’s office. They will use the definition that best benefits them."
"That’s why we did this survey," he says. "We had a pretty strong sense that there was not universal agreement, and if we didn’t start having some data from the voices of these three different players it is hard to have the conversations that move people toward a commonly accepted definition."
The personal records of as many as 24,000 UNC Health patients could be compromised after the theft of a laptop computer at an outpatient dermatology clinic.
UNC Health Care officials are notifying thousands of patients that their personal information could have been compromised with the theft of a laptop computer from an outpatient clinic.
The laptop was taken in an October theft at the UNC Dermatology & Skin Cancer Center in Burlington, NC. UNC Health officials said the laptop contained information about patients seen at the clinic through September 15.
The personal information of about 24,000 people was part of a password-protected database that included patient names, addresses and phone numbers as well as employment status, employer names, patient birthdates and patient social security numbers.
It is not believed that any treatment, diagnosis or prescription records were kept on the computer other than diagnosis codes used for billing purposes, UNC said in a media release.
UNC Health Care acquired Burlington Dermatology in 2015. As part of this transaction, a computer containing patient information at Burlington Dermatology remained onsite at the practice. This was the computer which was stolen, the health system said.
David Behinfar, chief privacy officer at UNC Health Care, said the health system is taking action to better secure patient privacy.
"We have ensured that all remaining computers acquired from, or kept for use by Burlington Dermatology have been properly secured," he said. "UNC Health Care has also implemented process improvements to ensure that future acquisitions of physician practices include a process to properly secure legacy computers and electronic patient information."
The warning to patients includes free credit monitoring protection for one year.
"We want patients to know that UNC Health Care and the UNC Dermatology Center take their obligation to protect patient privacy very seriously," Behinfar said. "We are truly sorry that this incident occurred and sincerely apologize for any concerns it may cause."
In March, UNC Health notified reported a potential breach when the personal information of about 1,300 prenatal patients at two obstetrics clinics were accidentally transmitted to local county health departments.
Hospital spending grew to $1.1 trillion in 2016, representing 32% of overall US healthcare spending, even as expenditure growth for hospital care slowed to 4.7% from 5.7% in 2015.
Healthcare spending in the United States grew by 4.3% to $3.3 trillion, or $10,348 per person, and represented nearly 18% of the national economy in 2016, federal actuaries report.
The new analysis from the Office of the Actuary at the Centers for Medicare and Medicaid Services shows national health spending growth slowed in 2016, when compared to spending increases of 5.1% and 5.8% in 2014 and 2015, respectively.
"The slowdown on overall healthcare spending was broadly based, as spending for the largest categories by payer and by goods and services decelerated," report lead author Micah Hartman said Wednesday in a media availability. "This includes Medicaid, private health insurance, and Medicare, as well as retail prescription drugs, hospital care, and physician and clinical services."
Hartman, a statistician with the Office of the Actuary at CMS, said that he has not seen as broad a deceleration in healthcare spending growth since 2010.
"Basically, we saw two major things happening in 2014 and 2015. We had the enrollment expansion that impacted Medicaid and private health insurance with 10.2 million and 8.7 million people gaining coverage," he said. "In addition, in 2014 and 2015 we saw strong and rapid spending growth in retail prescription drugs."
Those two factors accelerated spending growth more than it had in recent years.
"Following those initial impacts, they started to slow down and were not as strong going into 2016, and that was part of the reason why we saw this slowdown so broadly based," Hartman said. "When you add people to the rolls of Medicaid and private health insurance they are going to be using all types of medical goods and services. When those initial impacts start to wear off, that's when you’re going to see that slowdown that we saw in 2016."
Nonetheless, the share of the economy devoted to healthcare spending edged up to 17.9% in 2016 from 17.7% in 2015, according to the report, which was published online Wednesday by Health Affairs.
And, healthcare spending growth easily outpaced the 2.9% rate of growth for the Gross Domestic Product in 2016.
On a per capita basis, national health spending grew at 3.5%, reaching $10,348 in 2016. Changes in the age and gender mix of the population accounted for a 0.6 percentage point of the growth in per capita health spending. Increases in medical prices accounted for 1.4 percentage points, while growth in the residual use and intensity of healthcare goods and services accounted for the remaining 1.6 percentage points, the report said.
Among the key findings in the report:
Hospital spending hit $1.1 trillion and represented 32% of overall healthcare spending. Hospital care expenditure growth slowed from 5.7% in 2015 to 4.7% in 2016.
The slower growth in hospital spending in 2016 reflected a slower growth of 2.3% in the use and intensity of services, lower than the increase of 3.4% in 2015. That was due to slower enrollment growth, which was partly offset by faster growth in hospital prices, which accelerated slightly from 0.9% in 2015 to 1.2% in 2016.
Physician and clinical services spending slowed from a growth rate of 5.9% in 2015 to 5.4% in 2016, with total physician and clinical services expenditures reaching $664.9 billion, or 20% of overall healthcare spending. Growth in non-price factors such as the use and intensity of services increased 3.8% and accounted for most of the increase in spending in 2016, though at a slower rate than the 4.5% increase in 2015.
The 8.2% spending growth for clinical services nearly doubled the 4.6% growth in spending for physician services for the twelfth consecutive year. Clinical services spending growth was driven primarily by freestanding ambulatory surgical and emergency centers.
In 2014 and 2015, spending increased 5.1% and 5.8%, respectively, as the Affordable Care Act expanded health insurance coverage through Marketplace plans and Medicaid. By 2016, however, the rate of spending growth was more in line with the average annual rate of 4.2% from 2008–15, Hartman said.
Among the major payers, actuaries found that:
Spending growth slowed in 2016 for private health insurance, Medicaid, and Medicare. For private health insurance and Medicaid, the slower growth was influenced by decelerated enrollment growth. Medicare spending slowed because of lower per enrollee growth rates.
Private health insurance reached $1.1 trillion and increased 5.1% in 2016, slower than 6.9% growth in 2015. Private health insurance continued to be the largest payer for health care goods and services in the US in 2016—accounting for just over one-third of total healthcare spending. The notable slowdown in private health insurance spending was mainly driven by slower enrollment growth, slower growth in spending for retail prescription drugs, and a continued shift to high-deductible plans. On a per enrollee basis, private health insurance spending increased 5.1% in 2016, about the same as 2015.
Medicare spending hit $672.1 billion, accounting for 20% of total healthcare expenditures. Spending for the program grew at 3.6% in 2016—slowing from 4.8% growth in 2015—while enrollment growth was stable. Spending growth per Medicare enrollee increased at a slower rate in 2016 (0.8%) than in 2015 (2.1%). Physician and clinical services and prescription drug spending growth slowed, while Medicare hospital care spending remained relatively stable in 2015 and 2016.
Medicaid expenditures reached $565.5 billion in 2016, accounting for 17% of total national health expenditures. Medicaid spending increased 3.9% in 2016, much slower than the rates in 2015 and 2014 (9.5% and 11.5%, respectively), both of which were due to the initial impacts of ACA’s expansion of Medicaid eligibility.
On a per enrollee basis, Medicaid spending increased 0.9% compared to 4.5% in 2015, which reflects increased efforts by states to control costs, a decline in supplemental payments to hospitals, and a decrease in per enrollee costs for newly eligible adults. Medicaid goods and services—with the exception of nursing care facilities and continuing care retirement communities—experienced decelerating growth in 2016.
Retail prescription drugs expenditures reached $328.6 billion and represented 10% of overall health spending. Growth in spending for retail prescription drugs increased 1.3% percent in 2016, following much stronger growth rates in 2014 and 2015 (12.4% and 8.9%, respectively).
Hartman attributed the deceleration in 2016 to a decline in spending for drugs used to treat hepatitis C, the introduction of fewer new drugs, and slower growth in prices for both brand-name and generic drugs. Despite large fluctuations in growth rates over the past several years, the 10% share of national health spending is similar to the share in 2009.
Pine Creek Medical Center's alleged enticements in exchange for physician referrals included magazine, radio, television, and pay-per-click ads, billboards, website upgrades, brochures, and business cards.
A Dallas-based, physician-owned hospital will pay $7.5 million to resolve whistleblower claims that it violated the False Claims Act by providing marketing services for physicians in exchange for surgical referrals, the Department of Justice announced.
Federal prosecutors said that Pine Creek Medical Center ran an illegal kickback scheme between 2009 and 2014 that would pay for marketing and advertising services for physicians. In return, the physicians would refer their patients, including Medicare and TRICARE beneficiaries, to Pine Creek.
HealthLeaders Media's request for comment from Pine Creek officials was not answered.
Among other things, Pine Creek allegedly paid for advertisements on behalf of the physicians in a number of local and regional publications. Pine Creek also allegedly paid for radio and television advertising, pay-per-click advertising campaigns, billboards, website upgrades, brochures, and business cards, as well as other forms of marketing to induce physicians to refer patients to Pine Creek for medical services.
"Healthcare providers that attempt to profit from illegal kickbacks will be held accountable," Principal U.S. Deputy Assistant Attorney General Chad A. Readler said in a media release. "Improper financial incentives can distort medical decision making and drive up healthcare costs for federal health care programs and their beneficiaries."
Pine Creek will enter into a corporate integrity agreement with the Department of Health and Human Services Office of Inspector General, which requires the hospital to take up internal compliance reforms for the next five years.
"Hospitals that try to boost their profits by paying kickbacks to physicians will instead pay for their improper conduct," said Special Agent in Charge C.J. Porter, with OIG's Dallas Region. "We will continue to investigate such illegal business arrangements that undermine impartial medical judgment."
Whistleblowers Suzanne Scott and Savannah Sogar, former employees of Pine Creek’s marketing department, will receive more than $1.1 million from the settlement.
New research suggests that Medicare’s pay-for-performance measures, including the Merit-based Incentive Payment System, unfairly penalize providers who serve older, sicker, poorer patients.
A study recently found that Medicare's Value-based Payment Modifier program inadvertently shifted money away from physicians who treated sicker, poorer patients to pay for bonuses that rewarded practices treating richer, healthier populations.
Study lead author Eric Roberts, an assistant professor of health policy and management at the University of Pittsburgh Graduate School of Public Health, says that if changes aren’t made, value-based payment models will continue to shortchange the poor.
Roberts spoke with HealthLeaders Media about his findings. The following is a lightly edited transcript.
HLM: Why did you do this study?
Roberts: We wanted to take a critical look at the implications of this earlier iteration of pay for performance for physicians, quality of care and spending which were the key outcomes that CMS used to judge physicians, and implications for how practices were paid and whether payment adjustments in the Value-based Payment Modifier really reflected differences in the value of care delivered by different practices or unmeasured differences in the characteristics of patients served.
This has big implications for whether physicians who are treating sicker and poorer patients are going to be treated fairly in payment models like the Value-based Payment Modifier and MIPS, and whether they will have the appropriate resources to address the needs of disadvantaged patients as Medicare continues to implement value-based purchasing initiatives.
It’s very hard to distinguish what is variation in provider quality, who are good and bad providers, from differences in the patients that they serve. Value-based Payment Modifiers and MIPS are one example where the case mix adjustment is particularly inadequate and may contribute over time to healthcare disparities.
HLM: What did you conclude?
Roberts: Our article very clearly crystalizes this argument that, with value-based purchasing models, policymakers need to think carefully about incentives and unintended outcomes to ensure that the goals of the policy are being achieved while the policy itself is not being undercut by the fact that providers serving sicker poorer patients are more likely to be penalized provided that risk adjustment is inadequate.
Risk adjustment is usually inadequate in these programs, in part, because it is difficult to measure the differences in complexity of patients across providers. We need to take a careful look at how incentives in these programs are structured and how performance is assessed in order to create the right incentives to improve value and outcomes for the most vulnerable patients.
HLM: How does this imbalance in risk adjustment manifest itself?
Roberts: If you look in the measures specifications that CMS puts out to evaluate provider performance under the Value-based Payment Modifier, there is a glaring inconsistency across the patient characteristics used to risk adjust outcomes.
For example, one of the key performance measures to assess practice quality in the value modifier is hospital admissions for ambulatory care sensitive conditions. CMS only adjusts that measure for the age and sex of beneficiaries, whereas it is quite conceivable that disabled patients, poorer patients, patients with long-term clinical comorbidities are at higher risk of admission, but those are not taken into account.
Other measures in the program are just adjusted for different sets of patient characteristics. This inconsistency in how risk adjustment is applied across performance measures, and the parsimony of the adjustment which doesn’t account for many relevant patient factors, is concerning.
HLM: How do you fix it?
Roberts: We would suggest that adjusting for observable clinical and socioeconomic characteristics of patients is advisable to mitigate any unintended consequences of this program for providers who serve more of these patients.
It is impossible from a practical standpoint to capture all differences among patients that may be relevant predictors of healthcare use and spending that we would want to distinguish provider performance from differences in patient mix. No amount of risk adjustment is going to completely mitigate the problem we have identified in the value modifier, where practices that serve sicker poorer patients in ways that we don’t measure well are going to get penalized.
In addition to better risk adjustment for clinical and social factors that we can observe, policymakers may want to consider primary care case management fees akin to what have been used in the comprehensive primary care model that CMS has, which would be risk adjusted so that providers who serve sicker poorer patients would receive a higher per member per month case management fee to help address some of those complex needs of patients that are not being adequately accounted for.
HLM: Are value-based payments fundamentally flawed because they do not adequately reflect patient mix?
Roberts: I would agree that it is a fundamental flaw. The principle which is that big payers like Medicare should be pushing the system toward a value-based system and not a fee-for-service system is well intentioned, but the execution is wanting. We don’t think many of those limitations are corrected in the MIPS.
Any efforts to promote value-based payment needs to be accompanied with other correctives to ensure that providers are correctly incentivized to improve value and not disadvantaged for treating poorer and sicker patients.
HLM: What other corrective actions do you recommend?
Roberts: Promoting competition among healthcare providers. There is substantial literature that suggests that provider consolidation is not associated with better patient outcomes, may be associated with worse outcomes, and certainly drives up healthcare costs, the opposite of the goal that policy makers are intending to achieve with value-based purchasing. So there is a certain amount of market-based activity that is needed to achieve the goals of value-based payments.
HLM: What other problems do you see with MIPS?
Roberts: MIPS retains the budget neutrality provision but includes more bonuses and penalties. More provider groups will be eligible for bonuses and penalties because they use a more continuous scoring system as opposed to a system where practices have to be above or below discreet thresholds to get payment adjustments.
There is more potential for adjustments that may enhance incentives for quality improvement to some extent, but practices subjected to MIPS are given greater leeway to choose their performance measures so they can pick the test questions they are scored on. Ultimately, this opens the door for gaming the system and doesn’t necessarily produced a balanced set of measures across which all practices are assessed for quality.
That may weaken incentives or focus providers on the wrong quality measures rather than on the ones that are most salient for patients. On balance we don’t think there is a net improvement in the design of the MIPS vis-a-vis, the value-based payment modifier.
Study authors say the nation’s largest insurance companies should be required to offer coverage in ACA marketplaces in the same geographic areas where they participate in Medicaid and Medicare.
Medicare and Medicaid accounted for 59% of healthcare revenues reported by the nation's five largest commercial health insurance companies in 2016, according to a study released Monday in Health Affairs.
The $213.1 billion collected byUnitedHealthCare, Anthem, Aetna, Cigna, Humana last year is more than double the $92.5 billion the five insurance giants collected when the Affordable Care Act was passed in 2010, according to the study, which was funded by the Commonwealth Fund.
Cathy Schoen, lead author of the study and a senior scholar at the New York Academy of Medicine, said the insurers have pulled out of state ACA marketplaces, even as they continue to enroll people in non-ACA government-sponsored coverage in those same states.
Schoen said policymakers should require insurers offer coverage in the marketplaces if they participate in Medicaid and Medicare in the same geographic area. Nevada and New York have such requirements for Medicaid plans.
"Many states' ACA marketplaces are facing uncertainty about insurer participation and have fewer choices for consumers, as some insurers have left the markets," Schoen said in a media release accompanying the study.
"At the same time, some of these companies have thrived from growth in public coverage in those same states. Requiring insurers that participate in Medicaid and Medicare to offer marketplace coverage could help shore up those state markets," she said.
The study finds that, following the ACA’s passage, the number of enrollees with public coverage grew faster than the number with private coverage in all five companies.
Between 2010 and 2016, Medicaid and Medicare enrollment in the five companies doubled, from 12.8 million to 25.5 million; Medicaid enrollment increased from 7 million to 15 million. Collectively, the five insurers participate in 31 state Medicaid programs and in at least some regions of most states.
Kristine Grow, spokeswoman for America's Health Insurance Plans, said the insurance industry "continues to recommend policy solutions to ensure affordability and choice in the individual market."
"Regardless of the uncertainty of the past year, insurance providers worked hard with state leaders to ensure that every American who buys their own coverage has a plan available for them on the exchange for 2018," Grow said.
"The best way to encourage health plans to participate in future years is to ensure the individual market is stable, so that plans can offer Americans coverage options they value and find affordable," she said.
The study also found that:
The top five commercial carriers enroll 43% of the country’s insured population, or 125 million people.
Membership in the five companies grew by a total of 23 million people from 2010 to 2016. That increase was more than double the increase for the five years leading up to passage of the ACA (2005–2010).
"These findings are an important reminder that despite reporting losses in the Affordable Care Act marketplaces, the nation’s biggest insurance companies generated substantial revenues thanks to Medicare and Medicaid," said Commonwealth Fund President David Blumenthal, MD.
"This growing dependence on taxpayer-funded insurance programs suggests there are opportunities to improve access to health care and stabilize insurance markets if insurers that participate in these programs also offer plans in the ACA marketplaces," he said.
The revised outlook from Moody's comes amid a larger-than-expected drop in cash flow this year and the ongoing uncertainty regarding federal healthcare policy for public and not-for-profit hospitals.
Moody's Investors Service has downgraded from stable to negative its 2018 outlook for the not-for-profit hospital sector based on an expected drop in operating cash flow.
"Operating cash flow declined at a more rapid pace than expected in 2017, and we expect continued contraction of 2%-4% through 2018," said Eva Bogaty, a Moody's vice president.
"The cash flow spike from insurance expansion under the Affordable Care Act in 2014 and 2015 has largely worn off, but cash flow has not stabilized as expected because of a low revenue and high expense growth environment," Bogaty said.
In a briefing released Monday, Moody's said hospital revenue growth is slowing and is expected to remain slightly above medical inflation, which declined to a low of 1.6% in September. Hospitals can't translate volume growth into stronger revenue growth because of the lower reimbursement rate increases across all insurance providers and higher expense growth.
In addition, rising exposure to governmental payers will dampen revenue growth for the foreseeable future due to a rapidly aging population and low reimbursement rates. Medicare and Medicaid, represent 60% of gross patient revenue in 2017, Moody's said.
Key drivers of expense growth include rising labor costs, driven by an acute nursing shortage and ongoing physician and medical specialist hiring. Technology costs are also rising as systems are upgraded and IT staff is needed for training and maintenance. While the ACA’s arrival heralded a drop in bad debt from 2014-16, bad debt rebounded in 2017 and will continue to grow at a rate of 6%-7% in 2018, Bogaty said.
"Rising copays and use of high deductible plans will increase bad debt for both expansion and non-expansion states," she said.
In the near-term, uncertainty regarding federal healthcare policy will have a marginal fiscal impact on NFP hospitals. Bogaty said ambiguity surrounding the ACA does affect the planning and modelling of long-term strategies, while recent federal tax proposals will add to rising costs for hospitals.
The outlook could be revised to stable if operating cash flow resumes growth of 0%-4%. A change to positive could result from expectations of accelerated operating cash flow growth of more than 4% after inflation, Moody's said.
Research shows opioid use on the last day in the hospital is the strongest predictor for determining how many opioid pills surgical patients would use once they got home.
Vigilant prescribing guidelines for surgeons could reduce by as much as 40% the number of opioid pills prescribed after operations, and still meet patients’ pain management needs, according to research published in the Journal of the American College of Surgeons.
“We specifically looked at the number of opioid pills that surgical inpatients took the day before discharge from the hospital, and we found that this number was the strongest predictor of how many opioid pills the patients would use after discharge,” said study lead author Richard J. Barth Jr., MD, a general surgeon at Dartmouth Hitchcock Medical Center in Lebanon, NH.
The researchers recommend following schedule for post-discharge prescription based on the number of opioid pills taken the day before discharge: No pills for patients who took no opioids the day before they left the hospital; 15 pills for those who took one-to-three pills the day before; and 30 pills for those who took four-or-more pills on their last day in the hospital.
Using phone calls and questionnaires, the study tracked 333 hospital inpatients discharged to home after six types of general surgery: bariatric procedures; operations on the stomach, liver, and pancreas; ventral hernia repair; and colon operations.
“This guideline was true for multiple different operations,” Barth said. “It didn’t matter whether someone had a colon operation, liver procedure or hernia repair; no matter what type of general surgery operation they had, this association held throughout all procedures studied. So the beauty of this finding is that one guideline would apply for multiple different surgical procedures.”
While 85% of patients were prescribed opioids after they went home, only 38% of the pills were taken. Age also influenced patient opioid use. Patients younger than age 60 averaged about 13 pills after discharge while those 60 and older averaged four pills.
The study also looked at why a small fraction of patients took more opioids than the new guidelines called for. “Over half of them were taking opioids for non-pain-related reasons, such as to sleep better, or because they felt they should take all the pills the physician prescribed and other various and sundry reasons,” Barth said.
Starting salaries of non-academic physicians in hospital/IDS-owned practices follow suit, with first-year candidates earning up to $86,000 more than their academic counterparts.
Specialty care physicians in non-academic hospitals make $122,795 more per year, on average, than their full-time, fully clinical colleagues in academic systems, according to a new survey from the Medical Group Management Association.
Under those same parameters, MGMA also found that primary care physicians in academic systems earn $57,129 less.
In addition to general salary differentials, starting salaries differences loom large. New hires, who are first year post-residency or fellowship, earned more starting out in a non-academic setting than an academic setting across the board, MGMA said.
The greatest difference was seen in primary care where the difference can be upwards of $86,000 more in hospital systems or private practice than in academic settings.
MGMA’s Physician Compensation and Production Survey compared nationwide data from more than 120,000 providers across more than 6,600 groups of various practice types.
The academic subset represents more than 17,400 providers in over 437 organizations, compared to non-academic data representing more than 96,000 providers in more than 5,000 organizations.
The survey also found that:
Specialty care, non-academic physicians report 1,200 more work Relative Value Units per year than academic physicians, namely due to academic providers reporting less billable clinical time than non-academic providers.
Specialty care physicians who are full-time, fully clinical reported earning a base compensation of $67,290 more than those physicians who were 67% or more research.
Primary care physicians who were full time, yet mostly research, reported making $9,556 more in base compensation than those physicians who were full time yet mostly clinical.
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."
