About 10% of patients discharged from a hospital to a skilled nursing facility are not getting a visit from a doctor for a medical assessment, and researchers from one Ivy League school are wondering whether Medicare needs to change its policies to close that gap.
Currently, Medicare requires only that SNF patients be seen by a doctor or other advanced practitioner within 30 days. But given the increased acuity and medical complexity of patients sent to nursing facilities, experts say that requirement may be too liberal.
University of Pennsylvania researchers noted that, based on a sample of almost 2.4 million fee-for-service Medicare beneficiaries, about 10.4% did not receive such a visit from a doctor for a medical assessment during their stay. Almost 28% of those patients without visits were readmitted to a hospital within 30 days and more than 14% died — both twice the rate of those who did have at least one visit, according to their study, published Monday in Health Affairs.
“The biggest surprise for me was the difference in outcomes for patients who were seen compared to those who were not,” Kira Ryskina, M.D., lead author and an assistant professor at the Perelman School of Medicine, told McKnight’s. “We know this population has pretty high rates of readmission and mortality, but I think that the differences were higher than what I would have expected.”
On the flipside, more than 71% of patients were visited by a physician or other advanced practitioners for a medical assessment in the first four days. Penn researchers found “considerable” variation in days to the first visit, which were often fueled by local practice patterns, rather than the patient’s clinical needs. For instance, rural SNFs had a much higher percentage of stays with no doctor visit (23.7%) when compared to their urban counterparts (7.6%).
Patient characteristics also played a part. Those who had a longer hospital length of stay, or experienced more critical-care stays in the prior year, were slightly more likely to have a SNF visit, compared to those without.
Reasons for this missing assessment from a doctor include a lack of evidence-based triage protocols for evaluating recently admitted SNF patients, inadequate training of direct care staff, and physicians who are reluctant to practice in SNFs, among other factors, according to past research.
“It’s been hard to get those clinicians to practice in the nursing home. There are obviously financial disincentives and there just hasn’t been as much support, so in my experience working with the administrators, they have a hard time getting the assessments done or patients evaluated quickly enough, because there are no physicians available 24/7, or there isn’t coverage,” Ryskina said.
Researchers pondered whether further incentives are needed to encourage doctors to practice in SNFs, and to ensure that medical assessments are performed for every patient.
“As patients discharged from hospitals to SNFs for post-acute care tend to be increasingly more medically complex, they may require timely physician assessment that is not incentivized by current regulatory or payment policies,” authors wrote.
