Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents.

Importance: Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care. Objective: To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents. Design, Setting, and Participants: This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023. Exposure: Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually. Main Outcomes and Measures: This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition. Results: Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]). Conclusions and Relevance: This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Physician Turnover in the United States.

BACKGROUND: Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care. OBJECTIVE: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings. DESIGN: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics. SETTING: Traditional Medicare, 2010 to 2020. PARTICIPANTS: Physicians billing traditional Medicare. MEASUREMENTS: Indicators of physician turnover-physicians who stopped practicing and those who moved from one practice to another-and their sum. RESULTS: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019. LIMITATION: Measurement was based on traditional Medicare claims. CONCLUSION: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover. PRIMARY FUNDING SOURCE: The Physicians Foundation Center for the Study of Physician Practice and Leadership.

Implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and outcomes of bariatric surgery.

INTRODUCTION: This study evaluates the performance of bariatric surgery prior to and after the implementation of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). METHODS: The eras prior to (2007-2015) and after (2016-2018) the transition to MBSAQIP were compared for patients, operations and outcomes using adjusted logistic regression estimates. RESULTS: Thirty-day surgical (6%vs.2.9%,p < 0.01) and medical (3.4%vs.1.7%,p < 0.01) complications rates were reduced over the period 2007 through 2018. Th use of sleeve gastrectomy has steadily increased from 2010 to 2018 (14%vs.66.6%,p < 0.01). The proportion of patients who were discharged early continued to rise (9.8%vs.46.9%,p < 0.01) from 2007 to 2018. The MBSAQIP period was associated with reduced odds for 30-day surgical (OR = 0.86,CI = [0.81-0.91]) and medical (OR = 0.81,CI = [0.75-0.88]) complications. Implementation of the MBSAQIP was also predictive of early discharge (OR = 1.93,CI = [1.90-2.00]). CONCLUSION: The type of bariatric procedure, in addition to trends in morbidity and hospital stays, gradually changed from 2007 to 2018. Our findings suggest that outcomes of bariatric operations have improved over the past decade. The MBSAQIP era is associated with lower rates of complications and greater likelihood of early discharge, independent of the procedure type.

US Generalist Physicians and Groups That Focused Practice in a Single Care Setting: 2014-2017.

BACKGROUND: Some generalist physicians whose training prepared them for primary care practice increasingly practice in a facility (eg, hospitals, nursing homes); however, whether this trend was accompanied by a complimentary rise in generalist physicians who focused their practice on office-based care is unknown. OBJECTIVES: Our objective in this study was to examine trends in the prevalence of generalist physicians and physician groups that practice in a single setting. RESEARCH DESIGN: This was a retrospective cross-sectional study of generalist physicians trained in family medicine, internal medicine, or geriatrics. We used 2014-2017 billing data for Medicare fee-for-service beneficiaries to measure the proportion of all patient visits made by physicians in the following care settings: office, outpatient hospital department, inpatient hospital, and other sites. RESULTS: From 2014 to 2017, the proportion of generalist physicians who narrowed their practice to a single setting increased by 6.69% (from 62.80% to 67.00%, p for trend <0.001). In 2017, 4.63% of physician groups included more than 1 type of setting-based physicians. CONCLUSIONS: Generalist physicians treating older adults increasingly narrowed their practice focus to a single type of health care setting. This trend was not accompanied by growth among physician groups that included different types of setting-based physicians. Further evaluation of the consequences of these trends on the fragmentation of primary care delivery across different health care settings and primary care outcomes is needed.

Physician prices and low-value services: evidence from general internal medicine.

OBJECTIVES: To assess the cross-sectional relationship between prices paid to physicians by commercial insurers and the provision of low-value services. STUDY DESIGN: Observational study design using Health Care Cost Institute claims representing 3 large national commercial insurers. METHODS: The main outcome was count of 19 potential low-value services in 2014. The secondary outcome was total spending on the low-value services. Independent variables of interest were price quintiles based on each physician's mean geographically adjusted price of a mid-level office visit, the most commonly billed service by general internal medicine (GIM) physicians. We estimated the association between physician price quintile and provision of low-value services via negative binomial or generalized linear models with adjustments for measure, region, and patient and physician characteristics. RESULTS: This study included 750,452 commercially insured patients attributed to 28,951 GIM physicians. In 2014, the mean geographically adjusted price for physicians in the highest price quintile was $122.6 vs $54.7 for physicians in the lowest quintile ($67.9 difference; 95% CI, $67.5-$68.3). Relative to patients attributed to the lowest-priced physicians, those attributed to the highest-priced physicians received 3.6, or 22.9%, fewer low-value services per 100 patients (95% CI, 2.7-4.7 services per 100 patients). Spending on low-value services attributed to the highest-priced physicians was 10.9% higher ($520 difference per 100 patients; 95% CI, $167-$872). CONCLUSIONS: Commercially insured patients of high-priced physicians received fewer low-value services, although spending on low-value services was higher. More research is needed to understand why high-priced providers deliver fewer low-value services and whether physician prices are correlated with other measures of quality.

Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians.

OBJECTIVE: To identify the perceptions of physicians with expertise in nursing home care on the value of physicians who primarily practice in nursing homes, often referred to as "SNFists," with the goal of enriching our understanding of specialization in nursing home care. DESIGN: Qualitative analysis of semistructured interviews. SETTING AND PARTICIPANTS: Virtual interviews conducted January 18-29, 2021. Participants included 35 physicians across the United States, who currently or previously served as medical directors or attending physicians in nursing homes. METHODS: Interviews were conducted virtually on Zoom and professionally transcribed. Outcomes were themes resulting from thematic analysis. RESULTS: Participants had a mean 19.5 (SD = 11.3) years of experience working in nursing homes; 17 (48.6%) were female; the most common medical specializations were geriatrics (18; 51.4%), family medicine (8; 22.9%), internal medicine (7; 20.0%), physiatry (1; 2.9%), and pulmonology (1; 2.9%). Ten (28.6%) participants were SNFists. We identified 6 themes emphasized by participants: (1) An unclear definition and loose qualifications for SNFists may affect the quality of care; (2) Specific competencies are needed to be a "good SNFist"; (3) SNFists are distinguished by their unique practice approach and often provide services that are unbillable or underreimbursed; (4) SNFists achieve better outcomes, but opinions varied on performance measures; (5) SNFists may contribute to discontinuity of care; (6) SNFists remained in nursing homes during the COVID-19 pandemic. CONCLUSIONS AND IMPLICATIONS: There is a strong consensus among physicians with expertise in nursing home care that SNFists provide higher quality care for residents than other physicians. However, a uniform definition of a SNFist based on competencies in addition to standardized performance measures are needed. Unbillable and underreimbursed services create disincentives to physicians becoming SNFists. Policy makers may consider modifying Medicare reimbursements to incentivize more physicians to specialize in nursing home care.

Strategic use of health information exchange and market share, payer mix, and operating margins.

BACKGROUND: Health information exchange (HIE) capabilities are tied to health care organizations' strategic and business goals. As a technology that connects information from different organizations, HIE may be a source of competitive advantage and a path to improvements in performance. PURPOSE: The aim of the study was to identify the impact of hospitals' use of HIE capabilities on outcomes that may be sensitive to changes in various contracting arrangements and referral patterns arising from improved connectivity. METHODOLOGY: Using a panel of community hospitals in nine states, we examined the association between the number of different data types the hospital could exchange via HIE and changes in market share, payer mix, and operating margin (2010-2014). Regression models that controlled for the number of different data types shared intraorganizationally and other time-varying factors and included both hospital and time fixed effects were used for adjusted estimates of the relationships between changes in HIE capabilities and outcomes. RESULTS: Increasing HIE capability was associated with a 13 percentage point increase in a hospital's discharges that were covered by commercial insurers or Medicare (i.e., payer mix). Conversely, increasing intraorganizational information sharing was associated with a 9.6 percentage point decrease in the percentage of discharges covered by commercial insurers or Medicare. Increasing HIE capability or intraorganizational information sharing was not associated with increased market share nor with operating margin. CONCLUSIONS: Improving information sharing with external organizations may be an approach to support strategic business goals. PRACTICE IMPLICATIONS: Organizations may be served by identifying ways to leverage HIE instead of focusing on intraorganizational exchange capabilities.

Do Skilled Nursing Facilities That Provide More Rehabilitation Therapy Have Lower Rehospitalization Rates?

This study examines whether skilled nursing facilities (SNFs) that consistently provided more rehabilitation therapy than other SNFs had lower 30-day rehospitalization rates. A cross-sectional analysis of 11 866 SNFs in the United States compared 30-day rehospitalization rates of SNFs that consistently provided more rehabilitation therapy to other SNFs using linear regression models. High-billing SNFs were defined as the 10% of SNFs with the highest proportions of Medicare fee-for-service claims that just surpassed the therapy minute threshold for the highest payment category. After controlling for patient and facility characteristics, high-billing SNFs had higher 30-day rehospitalization rates as well as longer median length of stay and greater mean cost per stay. Small reductions in the amount of therapy provided are unlikely to increase 30-day rehospitalization rates in SNFs. This has important consequences for the recently implemented patient-driven payment model, which incentivizes SNFs to provide less rehabilitation therapy.

Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents.

Importance: Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. Objective: To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. Design Setting and Participants: In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity-acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Exposure: Private equity acquisitions of 302 nursing homes between 2013 and 2017. Main Outcomes and Measures: This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care-sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Results: Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity-acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (-0.2 percentage points; 95% CI, -1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, -1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, -0.4 to 1.3 percentage points; P = .30). Conclusions and Relevance: This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.

Practice Trends and Characteristics of US Hospitalists From 2012 to 2018.

This cohort study uses Medicare data to assess trends and characteristics among hospitalists who shift practice to settings outside of the hospital.

Medical Care Delivery in U.S. Nursing Homes: Current and Future Practice.

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape.

Comparative Performance of Private Equity-Owned US Nursing Homes During the COVID-19 Pandemic.

Importance: It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic. Objective: To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes. Design, Setting, and Participants: This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics. Exposure: Nursing home ownership status. Main Outcomes and Measures: Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages. Results: Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, -69.2 to -1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% (14.8 percentage points; 95% CI, 6.5 to 23.0 percentage points; P < .001), respectively, more likely to have at least a 1-week supply of N95 masks than PE-owned nursing homes. They were 24.3% (21.3 percentage points; 95% CI, 11.8 to 30.8 percentage points; P < .001), 30.7% (27.0 percentage points; 95% CI, 17.7 to 36.2 percentage points; P < .001), and 29.2% (25.7 percentage points; 95% CI, 16.1 to 35.3 percentage points; P < .001) more likely to have a 1-week supply of medical gowns than PE-owned nursing homes. Government nursing homes were more likely to have a shortage of nurses (6.9 percentage points; 95% CI, 0.0 to 13.9 percentage points; P = .049) than PE-owned nursing homes. Conclusions and Relevance: In this cross-sectional study, PE-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring.

The patient-driven payment model: addressing perverse incentives, creating new ones.

The Patient-Driven Payment Model addresses perverse incentives in Medicare's previous payment system for skilled nursing facilities, but it includes new incentives that may be problematic.

Developing an actionable patient taxonomy to understand and characterize high-cost Medicare patients.

BACKGROUND: Improving care for high-cost patients requires a better understanding of their characteristics and the ability to effectively target interventions. We developed an actionable taxonomy with clinically meaningful patient categories for high-cost Medicare patients-those in the top 10% of total costs. METHODS: A cross-sectional study of a Medicare fee-for-service (FFS) patient cohort in the New York metropolitan area. We merged claims and neighborhood social determinants of health data to map patients into actionable categories. RESULTS: Among 428,024 Medicare FFS patients, we mapped the 42,802 high-cost patients into ten overlapping categories, including: multiple chronic conditions, seriously ill, frail, serious mental illness, single condition with high pharmacy cost, chronic pain, end-stage renal disease (ESRD), single high-cost chronic condition, opioid use disorder, and socially vulnerable. Most high-cost patients had multiple chronic conditions (97.4%), followed by serious illness (53.7%) and frailty (48.9%). Patients with ESRD, who were seriously ill, and who were frail were more likely to be high-cost compared to patients in other categories. 72.7% of high-cost patients fell into multiple categories. CONCLUSIONS: High-cost patients are highly heterogeneous. A patient taxonomy incorporating medical, behavioral, and social characteristics may help providers better understand their characteristics and health needs. IMPLICATIONS: Mapping high-cost patients into clinically meaningful and actionable categories that incorporate medical, behavioral, and social factors could help health systems target interventions. Integrated approaches, including medical care, behavioral health, and social services may be needed to effectively and efficiently care for high-cost patients.

Health systems' use of enterprise health information exchange vs single electronic health record vendor environments and unplanned readmissions.

OBJECTIVE: Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions. MATERIALS AND METHODS: The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor. RESULTS: Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant. CONCLUSION: Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.

The associations between query-based and directed health information exchange with potentially avoidable use of health care services.

OBJECTIVE: To quantify the impact of two approaches (directed and query-based) to health information exchange (HIE) on potentially avoidable use of health care services. DATA SOURCES/STUDY SETTING: Data on ambulatory care providers' adoption of HIE were merged with Medicare fee-for-service claims from 2008 to 2014. Providers were from 13 counties in New York served by the Rochester Regional Health Information Organization (RHIO). STUDY DESIGN: Linear regression models with provider and year fixed effects were used to estimate changes in the probability of utilization outcomes for Medicare beneficiaries attributed to providers adopting directed and/or query-based HIE compared with beneficiaries attributed to providers who had not adopted HIE. DATA COLLECTION: Providers' HIE adoption status was determined through Rochester RHIO registration records. RHIO and claims data were linked via National Provider Identifiers. PRINCIPAL FINDINGS: Query-based HIE adoption was associated with a 0.2 percentage point reduction in the probability of an ambulatory care sensitive hospitalization and a 1.1 percentage point decrease in the likelihood of an unplanned readmission. Directed HIE adoption was not associated with any outcome. CONCLUSIONS: The Centers for Medicare & Medicaid Services' (CMS) EHR certification criteria includes requirements for directed HIE, but not query-based HIE. Pending further research, certification criteria should place equal weight on facilitating query-based and directed exchange.