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 In the past decade, the number of doctors in nursing homes has
dropped as the number of “skilled nursing facility specialists” has
almost doubled, the researchers report in JAMA Internal Medicine.
Whether this trend is a good one isn't clear, the authors write.
“Medicare was created more than 40 years ago around farmers who had
problems with access to hernia care. Now our focus is on frail older
women with chronic illnesses,” said lead author Dr. Joan Teno of the
Cambia Palliative Care Center of Excellence at the University of
Washington in Seattle.
“The patients often have functional impairments and need skilled
help,” she told Reuters Health by phone. Patients also need
coordinated care because for each new chronic illness, they often
meet new doctors and specialists, which can lead to medical errors,
lack of coordination and inefficiency, Teno explained.
“Our current system supports silos of care,” she said. But now
healthcare policy experts are pushing for programs that coordinate
care, provide consistent staffing for older patients and train
nurses for geriatric care.
“What we’re seeing is an emerging set of programs targeting this
older cohort. It’s important to start asking what’s best for the
patient and family instead of the system.”
Teno and colleagues used national Medicare Part B claims from 2007,
2010 and 2014 to identify trends in the numbers of physicians, nurse
practitioners and physician assistants working in nursing homes or
skilled nursing facilities.
The research team found that the proportion of physicians who had
ever billed for care delivered in these facilities fell from 13.7
percent to 9.8 percent. Although the number of physicians classified
as skilled nursing facility specialists rose from 1,496 to 2,225,
that represented an increase from just 0.3 percent of all physicians
to 0.5 percent.
Nurse practitioners and physician assistants classified as nursing
facility specialists nearly doubled in number from 1,678 to 3,074
during the study period, but because more people entered these
professions in general, that did not represent an increase in the
proportions specializing in nursing home care.
The proportion of total billing for care at skilled nursing
facilities by non-doctor specialists rose from 22 percent to 31.5
percent, though this varied by state, the authors note. It reached
nearly 50 percent in Delaware, Hawaii, Tennessee, Connecticut and
Massachusetts.
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“There have been broad concerns at the national level about the
quality of care at nursing homes,” said Dr. Mitchell Katz, director
of the Los Angeles County Health Agency, who wrote an editor’s note
accompanying the study.
“One of the problems is that many nursing homes have no regular
doctors, since it is not a requirement,” he told Reuters Health by
email. “Most nursing home patients have a private doctor who signs
the orders for the nursing care, but it is at an office where they
may not be able to get to the nursing home on a regular basis.”
In an ideal world, primary care doctors would follow their patients
from the office to the hospital and to the nursing home, Katz writes
in the journal.
“Even if we ramped up the training by several factors in medical
schools, we couldn’t meet the need for geriatrics or palliative care
today,” Teno said.
A limitation of the current study is that it doesn’t examine quality
of care. Future research should investigate whether this growing
trend meets the needs of nursing home patients, Katz said.
“My take-home for patients who are frail is to name a good proxy
decision maker who can be your advocate, take careful notes, and
make sure your health care is coordinated,” Teno said. “We’re
keeping our fingers crossed that these new trends will lead to
better quality of care.”
SOURCE: http://bit.ly/2tjxLz9 and http://bit.ly/2uWTC1o JAMA
Internal Medicine, online June 26, 2017.
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