Should you see nursing home patients?

With more than 1.5 million patients currently residing in about 17,000 nursing homes, and with aging Baby Boomers likely to boost that population over the next few decades, nursing home care should be an attractive market for primary care physicians.

And for many, it is. Since most nursing home patients must be seen at least once a month, they represent a steady source of supplemental income. Jeffrey Kagan agrees. An internist in Newington, CT, Kagan and his partner currently see about 325 nursing home patients-who represent about 15 percent of their practice. Together the two doctors and their NP cover nine facilities; at two of them, Kagan is also medical director. One of the three makes nursing home rounds three mornings each week.

Kagan says he enjoys his nursing home practice because it gives his elderly patients continuity of care-something he feels has become increasingly rare these days. "We still see them the old-fashioned way," he notes, "in their homes, at the hospital, and then at the nursing home."

Paul Williams, an FP in Harrisburg, PA, finds his nursing home practice enjoyable as well as profitable. He currently sees about 20 patients at several facilities, usually in the evenings or on weekends. "Because I see the same patients every month," he says, "it's a dependable source of revenue that helps stabilize my cash flow."

Despite such arguments, many doctors have given up or cut back on nursing home care. In addition to low reimbursement and liability risks, they cite a variety of other reasons: too many phone calls, too much paperwork, too many regulations, commuting and scheduling problems, difficulty arranging call coverage, and unrealistic expectations or unreasonable demands by patients' families.

We spoke to doctors on both sides of the fence about the pros and cons of nursing home practice. Here's what they told us.

Reimbursement: Is it really inadequate? "When I started out in practice, I would do almost anything for an income," recalls Jeff Schultz, an FP in Baltimore. But like many physicians, he discovered that the reimbursements he received for nursing home visits simply didn't pay enough to justify the time and effort involved. Another doctor who gave up nursing homes complains that he was making less per hour for those visits than a home health nurse makes.

Frederic Porcase Jr., an FP in Jacksonville, FL, stopped seeing nursing home patients after his group's administrator told him he was losing money on them: "His data showed that for every dollar I made at the nursing homes, I lost three dollars in the office. It just didn't make economic sense."

Still, plenty of doctors feel that nursing home reimbursements, though relatively low, are worth the effort. Richard Waltman, an FP in Tacoma, WA, says one problem is that many physicians don't charge enough. (See "Coding Consult: Homing in on nursing home codes," Aug. 9, 2002, available at http://www.memag.com/memag/article/articleDetail.jsp?id=117359). "Some doctors seem almost embarrassed to charge for nursing home visits," he says. "That reinforces the notion that these patients are somehow less important than the ones they see in their office or the hospital."

To support those codes, however, doctors should carefully document the visits and other contacts with the patients, their families, the nursing home staff, and other physicians.

Many doctors supplement their nursing home income by serving as part-time medical directors at one or more facilities. Members of the American Medical Directors Association, mostly internists and FPs, typically work six to 10 hours a month at each facility, earning an average of $130 an hour.