The number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, although nursing home specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists were advanced practitioners (physician assistants and nurse practitioners) delivering post-acute care. The change in number of nursing home specialists varied significantly by geographic region

Polsky, Daniel

Ryskina, Kira L.

Werner, Rachel M

English

Kosmopolis

University of Pennsylvania
ScholarlyCommons
Research Briefs Leonard Davis Institute of Health Economics
11-28-2017
Physicians and Advanced Practitioners Specializing
in Nursing Home Care, 2012-2015
Kira L. Ryskina
University of Pennsylvania
Daniel Polsky
University of Pennsylvania
Rachel M Werner
University of Pennsylvania
Follow this and additional works at: http://repository.upenn.edu/ldi_researchbriefs
This paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_researchbriefs/32
For more information, please contact repository@pobox.upenn.edu.
Ryskina, Kira L.; Polsky, Daniel; and Werner, Rachel M. Physicians and Advanced Practitioners Specializing in Nursing Home Care,
2012-2015. LDI Research Briefs. 2017; No. 32. https://ldi.upenn.edu/brief/physicians-and-advanced-practitioners-specializing-
nursing-home-care-2012-2015
" >
https://ldi.upenn.edu/brief/physicians-and-advanced-practitioners-specializing-nursing-home-care-2012-2015
Physicians and Advanced Practitioners Specializing in Nursing Home
Care, 2012-2015
Abstract
The number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, although
nursing home specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists were
advanced practitioners (physician assistants and nurse practitioners) delivering post-acute care. The change in
number of nursing home specialists varied significantly by geographic region.
Keywords
Nursing home, nurse practitioner, physician assistant, post-acute care, long term care, Medicare
License
This work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.
This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_researchbriefs/32
THE QUESTION
Over the past decade, hospitalized patients are increasingly cared for by 
clinicians who focus on hospital-based care, such as hospitalists. Although 
increased specialization may improve outcomes by concentrating patient 
care among clinicians who are more familiar with specific processes of care 
and clinical presentations, it may reduce continuity of care with community-
based primary care providers and complicate patients’ transition back to the 
community, for example. Thus, it is important to know whether the trend 
toward setting-specific specialization has spread to nursing homes.
Using Medicare fee-for-service data, Ryskina and colleagues sought to identify 
“nursing home specialists” (clinicians who billed at least 90% of episodes from 
the nursing home) and determine whether their prevalence had changed 
between 2012 and 2015. The authors included both generalist physicians 
and advanced practitioners (nurse practitioners and physician assistants) in 
their analysis. They looked at the type of care provided by these specialists 
(short-term post-acute care vs. residential long-term care) and whether the 
prevalence of nursing home specialists varied by hospital referral region. 
THE FINDINGS
From 2012 through 2015, the number of nursing home specialists increased 
by 33.7% (5,127 to 6,857), while the number of clinicians who provided 
any nursing home care remained relatively stable (33,218 to 33,087, 0.4% 
decrease). As of 2015, nursing home specialists comprised only 21% of all 
generalists billing for nursing home care. 
The mean number of nursing home specialists per 1,000 occupied beds 
increased from 3.35 to 4.58 between 2012 and 2015 (Figure 1). Among 
nursing home specialists, the mean number of physicians per 1,000 
occupied beds increased by 23.4% (1.11 to 1.37), while the mean number of 
advanced practitioners increased by 43.3% (2.24 to 3.21), making advanced 
practitioners the most common type of nursing home specialist. Additionally, 
in 2015, nursing home specialists who focused on post-acute care (2.00 
clinicians/1,000 beds) were most common compared to specialists who 
focused on long-term care (0.90 clinicians/1,000 beds) or a combination of 
both (1.67 clinicians/1,000 beds).
PHYSICIANS AND ADVANCED PRACTITIONERS  
SPECIALIZING IN NURSING HOME CARE, 2012-2015
Kira L. Ryskina, Daniel Polsky, Rachel M. Werner 
JAMA, published November 28, 2017
KEYFINDINGS 
The number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, although nursing home 
specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists were advanced practitioners 
(physician assistants and nurse practitioners) delivering post-acute care. The change in number of nursing home specialists 
varied significantly by geographic region.
DATA  D R I V E N . P O L I C Y  F O C U S E D
BRIEFResearchLDI
Research to Improve the Nation’s Health System   2017 . No. 11
COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDI
FIGURE 1. 
NURSING HOME SPECIALISTS PER 1,000 OCCUPIED BEDS 
(2012-2015)
■  Physicians (per 1,000 beds)         ■  Advanced Practitioners (per 1,000 beds)
 2.24 2.54 2.92 3.21
 1.11 1.22 1.31 1.37
 
 2012 2013 2014 2015
5
4
3
2
1
0
LEAD AUTHOR
KIRA L. RYSKINA, MD, MS 
Kira L. Ryskina, MD, MS is an Assistant Professor of Medicine in the Division of General Internal Medicine at the Perelman 
School of Medicine at the University of Pennsylvania. Her research aims to elucidate non-clinical factors that systematically 
influence physician practice of high- vs. low-value care. Her recent work explored the relationship between clinicians’ 
experiences during training and generic prescribing. Dr. Ryskina is the recipient of a Career Development Award from the NIA 
to study physician specialization in nursing home care as a potential mechanism to improve the outcomes of patients receiving 
post-acute care in nursing homes. Dr. Ryskina completed clinical training in internal medicine and primary care at New York 
Presbyterian – Weill Cornell. She treats hospitalized patients at the Penn Presbyterian Medical Center in Philadelphia.
BRIEFResearchLDI
FIGURE 2. 
RELATIVE PERCENT CHANGE IN THE NUMBER OF NURSING HOME SPECIALISTS PER 1000 
MEDICARE-CERTIFIED, OCCUPIED BEDS BY HOSPITAL REFERRAL REGION, 2012-2015a
The change in the number of nursing home specialists varied significantly by 
hospital referral region (HRR). While 240 HRRs (79%) had an increase in the 
number of nursing home specialists per occupied bed, 61 HRRs (20%) had a 
decrease (Figure 2). The median change across HRRs was a 33.8% increase 
(interquartile range, 3.8% to 80.7%).
THE IMPLICATIONS
In 2014, 1.7 million fee-for-service Medicare beneficiaries received care in 
15,000 skilled nursing facilities, at a cost to Medicare of $28.6 billion. Nursing 
home care is costly and quality is variable, by many measures such as 
rehospitalization. While nursing home specialists make up a relatively small 
share of all nursing home clinicians, their effect on the quality of patient care 
may be considerable because they provide a large proportion of the visits. 
However, regional variation in the adoption of nursing home specialists 
indicates a lack of consensus regarding specialization. Whether increased 
access to nursing home specialists improves health outcomes or leads to 
adverse consequences (e.g., due to worsened care fragmentation) requires 
further investigation. 
THE STUDY
The authors used Provider Utilization 
Files, which contain all Part B Medicare 
fee-for-service billings, to identify 
generalist physicians (internal medicine, 
general practice, or family medicine) 
and advanced practitioners (nurse 
practitioners and physician assistants) 
who provided nursing home-based 
care from 2012 to 2015. Clinicians who 
billed at least 90% of episodes from the 
nursing home were defined as nursing 
home specialists (a definition analogous 
to the one used to define hospitalists). 
Visits were subcategorized into post-
acute care and long-term care using 
place of service codes.
The authors used the Long-Term Care 
Focus database to calculate the mean 
number of occupied Medicare-certified 
beds per year in each hospital referral 
region (HRR). The number of clinicians 
was then aggregated at the HRR level based on their billing zip code and 
reported per 1,000 occupied beds. 
One limitation of the study was the lack of data from individuals not covered 
by Medicare fee-for-service, such as Medicare Advantage patients.
Kira L. Ryskina, Daniel Polsky, Rachel M. Werner. Physicians and 
Advanced Practitioners Specializing in Nursing Home Care, 2012-
2015. JAMA. 2017;318(20):2040–2042. doi:10.1001/jama.2017.13378
LDI Research Briefs are produced by LDI’s policy team.  
For more information please contact Janet Weiner at  
weinerja@pennmedicine.upenn.edu.
a Adjusted for 
region occupancy.


Physicians and Advanced Practitioners Specializing in Nursing Home Care, 2012-2015

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsResearch Briefs Leonard Davis Institute of Health Economics11-28-2017Physicians and Advanced Practitioners Specializingin Nursing Home Care, 2012-2015Kira L. RyskinaUniversity of PennsylvaniaDaniel PolskyUniversity of PennsylvaniaRachel M WernerUniversity of PennsylvaniaFollow this and additional works at: http://repository.upenn.edu/ldi_researchbriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_researchbriefs/32For more information, please contact repository@pobox.upenn.edu.Ryskina, Kira L.; Polsky, Daniel; and Werner, Rachel M. Physicians and Advanced Practitioners Specializing in Nursing Home Care,2012-2015. LDI Research Briefs. 2017; No. 32. https://ldi.upenn.edu/brief/physicians-and-advanced-practitioners-specializing-nursing-home-care-2012-2015" >https://ldi.upenn.edu/brief/physicians-and-advanced-practitioners-specializing-nursing-home-care-2012-2015Physicians and Advanced Practitioners Specializing in Nursing HomeCare, 2012-2015AbstractThe number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, althoughnursing home specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists wereadvanced practitioners (physician assistants and nurse practitioners) delivering post-acute care. The change innumber of nursing home specialists varied significantly by geographic region.KeywordsNursing home, nurse practitioner, physician assistant, post-acute care, long term care, MedicareLicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_researchbriefs/32THE QUESTIONOver the past decade, hospitalized patients are increasingly cared for by clinicians who focus on hospital-based care, such as hospitalists. Although increased specialization may improve outcomes by concentrating patient care among clinicians who are more familiar with specific processes of care and clinical presentations, it may reduce continuity of care with community-based primary care providers and complicate patients’ transition back to the community, for example. Thus, it is important to know whether the trend toward setting-specific specialization has spread to nursing homes.Using Medicare fee-for-service data, Ryskina and colleagues sought to identify “nursing home specialists” (clinicians who billed at least 90% of episodes from the nursing home) and determine whether their prevalence had changed between 2012 and 2015. The authors included both generalist physicians and advanced practitioners (nurse practitioners and physician assistants) in their analysis. They looked at the type of care provided by these specialists (short-term post-acute care vs. residential long-term care) and whether the prevalence of nursing home specialists varied by hospital referral region. THE FINDINGSFrom 2012 through 2015, the number of nursing home specialists increased by 33.7% (5,127 to 6,857), while the number of clinicians who provided any nursing home care remained relatively stable (33,218 to 33,087, 0.4% decrease). As of 2015, nursing home specialists comprised only 21% of all generalists billing for nursing home care. The mean number of nursing home specialists per 1,000 occupied beds increased from 3.35 to 4.58 between 2012 and 2015 (Figure 1). Among nursing home specialists, the mean number of physicians per 1,000 occupied beds increased by 23.4% (1.11 to 1.37), while the mean number of advanced practitioners increased by 43.3% (2.24 to 3.21), making advanced practitioners the most common type of nursing home specialist. Additionally, in 2015, nursing home specialists who focused on post-acute care (2.00 clinicians/1,000 beds) were most common compared to specialists who focused on long-term care (0.90 clinicians/1,000 beds) or a combination of both (1.67 clinicians/1,000 beds).PHYSICIANS AND ADVANCED PRACTITIONERS  SPECIALIZING IN NURSING HOME CARE, 2012-2015Kira L. Ryskina, Daniel Polsky, Rachel M. Werner JAMA, published November 28, 2017KEYFINDINGS The number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, although nursing home specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists were advanced practitioners (physician assistants and nurse practitioners) delivering post-acute care. The change in number of nursing home specialists varied significantly by geographic region.DATA  D R I V E N . P O L I C Y  F O C U S E DBRIEFResearchLDIResearch to Improve the Nation’s Health System   2017 . No. 11COLONIAL PENN CENTER   |   3641 LOCUST WALK   |   PHILADELPHIA, PA 19104-6218   |   LDI.UPENN.EDU   |   P: 215-898-5611   |   F: 215-898-0229   |    @PENNLDIFIGURE 1. NURSING HOME SPECIALISTS PER 1,000 OCCUPIED BEDS (2012-2015)■  Physicians (per 1,000 beds)         ■  Advanced Practitioners (per 1,000 beds) 2.24 2.54 2.92 3.21 1.11 1.22 1.31 1.37  2012 2013 2014 2015543210LEAD AUTHORKIRA L. RYSKINA, MD, MS Kira L. Ryskina, MD, MS is an Assistant Professor of Medicine in the Division of General Internal Medicine at the Perelman School of Medicine at the University of Pennsylvania. Her research aims to elucidate non-clinical factors that systematically influence physician practice of high- vs. low-value care. Her recent work explored the relationship between clinicians’ experiences during training and generic prescribing. Dr. Ryskina is the recipient of a Career Development Award from the NIA to study physician specialization in nursing home care as a potential mechanism to improve the outcomes of patients receiving post-acute care in nursing homes. Dr. Ryskina completed clinical training in internal medicine and primary care at New York Presbyterian – Weill Cornell. She treats hospitalized patients at the Penn Presbyterian Medical Center in Philadelphia.BRIEFResearchLDIFIGURE 2. RELATIVE PERCENT CHANGE IN THE NUMBER OF NURSING HOME SPECIALISTS PER 1000 MEDICARE-CERTIFIED, OCCUPIED BEDS BY HOSPITAL REFERRAL REGION, 2012-2015aThe change in the number of nursing home specialists varied significantly by hospital referral region (HRR). While 240 HRRs (79%) had an increase in the number of nursing home specialists per occupied bed, 61 HRRs (20%) had a decrease (Figure 2). The median change across HRRs was a 33.8% increase (interquartile range, 3.8% to 80.7%).THE IMPLICATIONSIn 2014, 1.7 million fee-for-service Medicare beneficiaries received care in 15,000 skilled nursing facilities, at a cost to Medicare of $28.6 billion. Nursing home care is costly and quality is variable, by many measures such as rehospitalization. While nursing home specialists make up a relatively small share of all nursing home clinicians, their effect on the quality of patient care may be considerable because they provide a large proportion of the visits. However, regional variation in the adoption of nursing home specialists indicates a lack of consensus regarding specialization. Whether increased access to nursing home specialists improves health outcomes or leads to adverse consequences (e.g., due to worsened care fragmentation) requires further investigation. THE STUDYThe authors used Provider Utilization Files, which contain all Part B Medicare fee-for-service billings, to identify generalist physicians (internal medicine, general practice, or family medicine) and advanced practitioners (nurse practitioners and physician assistants) who provided nursing home-based care from 2012 to 2015. Clinicians who billed at least 90% of episodes from the nursing home were defined as nursing home specialists (a definition analogous to the one used to define hospitalists). Visits were subcategorized into post-acute care and long-term care using place of service codes.The authors used the Long-Term Care Focus database to calculate the mean number of occupied Medicare-certified beds per year in each hospital referral region (HRR). The number of clinicians was then aggregated at the HRR level based on their billing zip code and reported per 1,000 occupied beds. One limitation of the study was the lack of data from individuals not covered by Medicare fee-for-service, such as Medicare Advantage patients.Kira L. Ryskina, Daniel Polsky, Rachel M. Werner. Physicians and Advanced Practitioners Specializing in Nursing Home Care, 2012-2015. JAMA. 2017;318(20):2040–2042. doi:10.1001/jama.2017.13378LDI Research Briefs are produced by LDI’s policy team.  For more information please contact Janet Weiner at  weinerja@pennmedicine.upenn.edu.a Adjusted for region occupancy.

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