More doctors are becoming 'nursing home specialists'

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 new study published today in JAMA from researchers at the Perelman School of Medicine at the University of Pennsylvania. Of all physicians and advance practitioners who do any work in nursing homes, 21 percent now specialize in nursing home care. The authors say the trend suggests the rise of a significant new specialty in medical practice, though how it will affect patient outcomes and continuity of care is yet to be seen.

"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, MS, an assistant professor at the Perelman School of Medicine, adding that how exactly the 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. 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."

There are presently more than 15,000 nursing homes in the U.S., with a total capacity of nearly 1.7 million beds. But, the quality of health care in these facilities varies considerably. Research has shown, for example, that in 2014 the rate of avoidable hospitalizations for the worst-performing nursing homes was high (14 percent) and also was nearly double the rate (8 percent) for the best-performing nursing homes. In addition, costs of nursing home care are high and account for 75 percent of regional variation in Medicare costs, for example.

Concerns over care quality have prompted the federal government's Centers for Medicare and Medicaid Services (CMS) 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.

"Hospitals in recent years have sought to improve care by concentrating it among 'hospitalist' physicians who focus on treating hospitalized patients," Ryskina said. "Twenty years ago, the Hospitalist movement started in the same way, wherein hospitals were under pressure to reduce costs, and readmissions. We might be seeing the beginnings of a similar trend in nursing home care."

In the study, 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 percent 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 33.7 percent. Adjusted for the patient population this rise was even greater: from 3.35 nursing home specialists per 1,000 occupied beds to 4.58 (+36.7 percent). During the same period, the overall number of clinicians billing from nursing homes was almost unchanged (33,218 to 33,087).

The data indicated some regional variation from the overall trend. About 80 percent of U.S. hospital referral regions saw rises in nursing home specialists per bed, while 20 percent 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 only about 21 percent 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 whether the increase in specialized care will improve outcomes or disrupt the continuum of care is an issue that requires ongoing study.