10 reasons I see only nursing home patients

June 1, 2007

It's more lucrative than you probably think, yet the rewards are more than just monetary. 2006 DOCTORS' WRITING CONTEST -HONORABLE MENTION

What, you don't go to nursing homes? Why not? Takes too long, not reimbursed well enough for your time, not challenging enough, too many phone calls, too depressing? These are some of the complaints I've heard over the years about practicing in long-term care (LTC). They couldn't be further from the truth. I've been in LTC for the last 15 or so years and find it to be an ideal environment to combat many of the problems facing the typical primary care physician today. I feel so strongly about it that I'd like to share some of the reasons why I believe all physicians should be involved in the LTC arena.

1. The population of seniors is growing rapidly. As our baby boomers enter their golden years, they'll need LTC services in ever-increasing numbers. According to The New York Times, the supply of physicians available will not meet the need. ("Geriatrics lags in age of high-tech medicine," The New York Times, Oct. 18, 2006.) This combination of high demand and low supply means lots of opportunity and steady work for properly positioned physicians. These proactive providers will be valuable players as nursing homes and hospitals look to capture this market. This doesn't even count the growing numbers of independent living units that are being built by most large nursing home/skilled nursing facilities. Look around your neighborhood: Do you notice a lot of construction around your older, well-established nursing homes? That's what they're building.

2. Nursing homes are hungry for good doctors. Historically, the LTC setting was for aging doctors who were winding down their practice in anticipation of retirement. Some doctors didn't even consider nursing home work to be real medicine. (I heard this comment from an internist who's in a leadership role in my hometown.) Many of these doctors would just go through the motions, and some gave LTC a bad reputation. This is no longer the case. The typical nursing home and skilled nursing facility (SNF) is being filled with complicated patients needing well-trained physicians to care for them. These patients used to be treated on the inpatient side, but not anymore. Physicians who complete a geriatric fellowship or who are board certified (typically in internal medicine, family practice, or, of course, geriatric medicine) will have a leg up, but there's room for all those truly interested.

4. You don't have to participate in managed care. Yes, it's true. According to CMS and The Competitive Edge from HealthLeaders-InterStudy, the penetration of managed care in the long-term care/geriatric population is far below that of traditional medical care. Even in California, total managed care penetration is only about 65 percent. I wouldn't expect that percentage to increase much in the coming years, since this frail and sickly population is difficult for insurance companies to profit from. Personally, I've never participated in any managed care plan (meaning any capitated or non-fee-for-service product). Can you say that?

5. LTC practice is more predictable than an outpatient practice. In LTC, patients are seen once a month (on average) and as needed. You must show that the visits are medically necessary, but in most cases you can bill for at least 12 visits a year per patient, one of which is an initial, readmit, or annual visit. This visit frequency is much higher than that of your average office outpatient. On the SNF side, most patients are generally sicker and rate at least weekly visits-sometimes more in complicated cases. This provides a steady and predictable patient visit volume with less month-to-month variation, and therefore more business with less stress.