INTRODUCTION

Over 800,000 individuals reside in 28,900 assisted living facilities (ALFs) nationwide.1 ALF residents tend to be medically complex and increasingly depend on services provided in ALFs. ALF residents require assistance with 1.9 activities of daily living on average, over half are age 85 or older, and 71% have some degree of cognitive impairment.2 Little is known about the clinicians who provide care in ALFs. We estimated the prevalence and identified the characteristics of clinicians who provide care in ALFs, including both physicians and advanced practitioners (APs).

METHODS

Part B claims from 2014 through 2017 for a 20% national sample of Medicare fee-for-service beneficiaries were used to identify three categories of clinicians: (1) “ALF specialists” with ≥ 80% of their evaluation and management (E&M) visits in ALFs in a given year; (2) “occasional ALF clinicians” with at least one ALF visit for E&M, but with these visits totaling < 80% of their E&M claims; and (3) “non-ALF clinicians” with no ALF visits for E&M. Clinicians with < 100 Part B claims annually were excluded. E&M visits were identified by Healthcare Common Procedure Coding System codes 99324–99328, 99334–99337 with Place of Service code 13. Other site specialists (e.g., nursing home specialists) have been identified using 90% thresholds for E&M claims,3, 4 but we used 80% due to the relatively small number of ALF specialists. The IQVIA Physician Database, Medicare Data on Provider Practice and Specialty, and Medicare Accountable Care Organization (ACO) Provider file were used to identify additional characteristics of clinicians.

The proportion of clinicians in each category among all clinicians billing Medicare in each year was examined using the Cochrane-Armitage test for trend. Chi-square tests were used for comparisons of clinician characteristics: age (≤ 39, 40–49, 50–59, 60–69, ≥ 70), gender, generalist (internal medicine, family practice, geriatrics, general practice), top 25 medical school graduate,5 foreign trained, ACO participant, practice size based on the number of clinicians (1–9, 10–49, 50–99, ≥ 100), employed by an ALF specialized practice (≥ 80% ALF specialists), and rural location.

RESULTS

The number of ALF specialists increased from 385 in 2014 to 601 in 2017 (56.10%, Ptrend < 0.001; Table 1), including an increase in physicians from 98 to 123 (25.51%) and in APs from 287 to 478 (66.55%). Occasional ALF clinicians increased from 8990 in 2014 to 11,265 in 2017 (25.31%, Ptrend < 0.001); physicians increased from 5602 to 6088 (8.68%) and APs from 3388 to 5177 (52.80%).

Table 1 Prevalence of Assisted Living Specialists and Occasional Assisted Living Clinicians over the Period 2014 through 2017
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The number of E&M visits in ALFs by ALF specialists increased 74.53%, from 90,188 in 2014 to 157,402 in 2017, including increases of 21.81% for physicians and 98.38% for APs (Table 1). For occasional ALF clinicians, the number of these claims increased 56.51%, from 223,130 to 291,828, with increases of 30.79% for physicians and 98.85% for APs.

Compared with non-ALF clinicians, ALF specialists and occasional ALF clinicians were more likely to be female (39.84% vs 78.27% and 56.73%) and in practices of 1 to 9 clinicians (28.21 vs 48.10% and 41.06%), and were less likely to be in rural locations (10.27% vs 3.63% and 9.39%) (Table 2). ALF specialists were less likely to be ACO participants compared with occasional ALF clinicians and non-ALF clinicians (14.39% vs 34.41% and 33.30%) but were more likely to be employed by ALF specialized practices (17.55% vs < 0.10% and < 0.10%).

Table 2 Characteristics of Assisted Living Specialists, Occasional Assisted Living Clinicians, and Non-Assisted Living Clinicians (2014–2017)
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Compared with physicians who were non-AL clinicians, physicians who were ALF specialists and occasional ALF clinicians were more likely to be generalists (27.00% vs 78.67% and 81.41) and foreign trained (24.87% vs 41.29% and 36.98), and were less likely to be top 25 medical school graduates (17.54% vs 10.17% and 11.54%). On average, physicians were older than APs in each of the three categories.

All comparisons of clinician characteristics were statistically significant at the 5% level, though the absolute magnitude of some differences was small.

DISCUSSION

The number of clinicians providing care in ALFs increased rapidly from 2014 to 2017. Growth in E&M visits in ALFs by APs was far greater than the increase for physicians. ALF specialists provided a disproportionate share of these visits, though the vast majority were provided by occasional ALF clinicians. Future study is warranted to determine whether the number of ALF specialists continues to grow and whether they provide higher quality care than occasional ALF clinicians.