The Distribution of Intervals Between Visits as a Basis for Assessing and Regulating Physician Services in Nursing Homes

We propose a new indicator of responsiveness of physician care in nursing homes: the distribution of intervals between physician visits. Current reimbursement and certification practices work to contain costs and assure minimum quality by influencing the intervals between visits. Data from a comparative study of 2 systems of medical care in nursing homes reveal marked differences in the interval distributions of the 2 systems. The system operating under current reimbursement procedures had interval distributions more concentrated around the minimum reimbursable interval. We interpret this concentration as a sign that the reimbursement procedure makes care less responsive to randomly occurring acute episodes by discouraging brief intervals. The interval distributions also document the impact of Medicaid certification standards on longer intervals. A mathematical model of intervals between visits is developed and used to estimate the interval distribution which would obtain in the absence of current reimbursement and certification procedures. This model also describes the distribution of intervals between physician (and dentist) services to noninstitutionalized individuals. These results suggest that such a model might be used in a system of "stochastic regulation" of physician services which would allow physicians greater freedom to respond to patient needs while still permitting public payors to oversee service provision.