With the increased premium placed on preventing rehospitalizations from skilled nursing facilities, timely interventions from a doctor can potentially make a major difference.
Between 2012 and 2014, about 10.4% of residents did not see a physician at all during their time in the skilled nursing facility, according to a study published Monday in the journal Health Affairs, leading to notably worse outcomes. Of the residents who didn’t see a doctor at all, 27.9% were readmitted to the hospital, and 14.2% died within 30 days; among those who did receive a physician visit, those numbers were 14.3% and 7.2%, respectively.
“Overall, these findings suggest that missing and delayed medical care occurs during a time when patients are discharged from an acute care hospital to post-acute care in a SNF and are particularly vulnerable to poor outcomes,” the study authors — led by Kira Ryskina, an assistant of professor of medicine at the University of Pennsylvania — wrote in their findings.
Even among the group of residents that did receive attention from a physician or other type of advanced practitioner — including nurse practitioners and physician assistants — the authors found substantial variation in the timing of the initial assessment. Under Medicare rules, residents only need to receive a visit within 30 days of admission, and while the majority of residents were seen on the first two days of their SNF stays, some wait weeks to see a doctor.
While the outcomes gap doesn’t necessarily imply that a doctor visit directly lowers the risk for rehospitalization, the results add to an already solid body of evidence that timely attention by physicians can have a direct impact on the statistic — and, by extension, an operator’s bottom line.
Under the SNF Value-Based Purchasing (VBP) initiative, for instance, providers automatically lose 2% of their Medicare reimbursements, which they can win back by improving their readmission stats. The first round of penalties and bonuses revealed that 73% of providers would see some sort of cut, and though the penalties could be minimal, other payers such as Medicare Advantage have placed an increased emphasis on cutting hospital transfers from SNFs.
In response, a variety of tech companies have developed and deployed telehealth systems designed to provide physician interventions in nursing homes. Third Eye Health, for instance, allows frontline caregivers at SNFs to videoconference with physicians, with some operators able to reduce readmissions from 20% to the low teens as a result. Call9, another platform that provides remote access to physicians and emergency medical technicians, claims that individual facilities have been able to prevent 70% of hospital admissions through the use of its technology.
But support for telehealth from the Centers for Medicare & Medicaid Services (CMS) remains in its infancy, with Medicare currently covering the cost of remote visits at rural nursing homes only. The study authors noted that under the current structure, physicians themselves may not have sufficient incentives to focus on residents in nursing homes.
“First, physicians have historically been reluctant to practice in SNFs, citing poor reimbursement, greater exposure to malpractice litigation, and other concerns,” they wrote. “Furthermore, physicians who practice in SNFs report discrepancies between optimal versus actual visit time for SNF patients, which suggests that the time allotted to SNF visits may be inadequate for this high-need population.”
Ryskina and the coauthors point to current financial incentives for physicians to provide services after a patient is discharged, noting that while relatively rare, those reimbursement codes are linked with better patient outcomes and lower overall Medicare spending.
“An analogous approach could represent one potential lever to encourage prompt assessment of SNF patients,” they concluded.