Has the time come for salaried nursing home physicians?

Quality of care in the nursing home (NH) has received great attention over the past 2 decades. The role of the physician in the quality equation, however, has not been well described. Some commentators have gone so far as to argue that physicians have been marginalized owing to the lack of an evidence base demonstrating the impact of physician care on quality measures, including cost.1 We have postulated that NH quality is related to 3 attributes: physician competence, commitment, and the organizational structure in which the physician practices.2 The theoretical link between physician training, experience, and organization to NH quality is just now garnering empiric support. Increased physician presence in the NH, enhanced nurse-physician communication, and medical director certification have all been shown to improve care. Indeed, the conceptual framework for NH medical staff organization has recently been articulated and linked to quality measures.3e5 Although it is not yet known which specific physician attributes relate to performance, the notion that attending physicians require a unique skill set to manage effectively in the NH setting is being seriously considered. In this vein, the American Medical Directors Association is currently in the process of finalizing a set of competencies specific to NH attending physicians. We previously hypothesized that practice within a closed staff model, formal medical director contractual relationships with the NH, and percentage of total practice time devoted to NH care could be potential drivers of quality. Although research that links these factors to quality is just beginning, we would like to introduce an additional factor. We contend that the method of payment used to reimburse attending physicians is a potential and significant driver of practice patterns and ultimately quality. Studies comparing different payment methods have demonstrated that capitation and salaried models result in enhanced screening and/ or treatment of common chronic conditions when compared with fee for service (FFS).6,7Mostof these studies, however, havebeen limited in their scope, and none have focused specifically on the NH setting. In a2011Cochrane review, entitled “Capitation, salary, fee-for-service and mixed systems of payment: Effects on the behavior of primary care physicians,” therewas no evidence found linking health status or other relatedoutcomesbetween thedifferent payment systems.8 This review also noted that although FFS resulted inmore patient visits, satisfaction