The tip of the iceberg: A call to improve medical director presence, time, and training in US nursing facilities

Abstract

The 1974 federal requirement that skilled nursing facilities provide a physician medical director was partly a response to an investigation of a 1970 salmonella outbreak in a nursing facility.¹ In 1987, the Omnibus Budget Reconciliation Act (OBRA) expanded the requirements to include a medical director in residential as well as skilled portions of nursing facilities. Forty-two CFR 483.70(g) Medical director and Appendix PP of the State Operations Manual for F-Tag 841 Responsibilities of Medical Director outline the expectations for medical direction in nursing homes. The federal regulations state that the medical director is responsible for implementing resident care policies and coordinating medical care in the facility. Reporting of medical direction hours is now required through the federal Staffing Data Submission Payroll-Based Journal (PBJ) system.²

Goldwein et al.³ provide excellent service through their descriptive study, which looks at the PBJ data on medical director hours. Their finding that more than a third of US nursing facilities report zero medical director time represents a wake-up call for enforcement of the federal mandate for medical direction. Surprisingly, they report that surveyors rarely cite deficiencies related to medical direction. This article should trigger a reevaluation of how CMS and state surveyors use the available PBJ data as part of the survey process.

Goldwein et al.³ use mean medical director minutes per day (MPD) to compare among different facility sizes. They then evaluated the facility's MPD by ownership type and found that government-owned facilities had significantly more medical director time. There was little difference between nonprofit and for-profit facilities. The analysis found considerable state-to-state variation with the majority of facilities in four states reporting no medical direction time at all. This raises serious questions about the adequate enforcement of reporting requirements including the CMS PBJ Policy mandate that the reported medical director data be auditable and verifiable.² Goldwein et al.³ recognize this problem by identifying the primary limitation of their study, which is the accuracy of the medical direction data. These findings of variability and significant numbers of facilities reporting no hours could reflect an alarming failure to have meaningful medical direction, inaccurate documentation of time, or a combination of the two. It is imperative that state surveyors and CMS step up and enforce current reporting regulations to improve the quality of this data.

The CMS “Nursing Home Compare” website (https://www.medicare.gov/nursinghomecompare) is a resource available for consumers to readily access pertinent information about competing nursing facilities to make an informed decision about which nursing facility would best suit them. In addition to an overall rating, it provides information on health inspections, quality measures, and staffing. The staffing data include registered nurse hours, LPN/LVN hours, nurse aide hours, and physical therapist staff hours. There is no information on the hours of participation by the medical director on the Nursing Home Compare website. In 2022, the Nursing Home Disclosure Act (HR 8832) was introduced to mandate reporting of medical director hours on the Nursing Home Compare website, but that bill was not enacted. Given the critical role of medical directors in developing, implementing, and monitoring facility policies, quality improvement, medical staff coordination, and staff education, it is reasonable to provide consumers with accurate information about the medical direction time provided to a facility. Should medical direction time be reported on CMS Nursing Home Compare, it would be essential for the data to be valid and accurate.

A further consideration is that the CMS star rating system used on the CMS Nursing Home Compare website may add to the challenge of locating a medical director if the facility is low-rated or flagged for concerns. Understanding the qualities and challenges of facilities that do not report medical director time is imperative to guide the recruitment of medical directors for facilities that may already be struggling.

As we strive to use accountability through citations to enforce the federal mandate for medical director presence in the nursing facility, we must also seek to understand the root cause of the problem. In addition to possible inaccuracy of data reporting, the impact of physician shortage and decreasing numbers of physicians seeing nursing facility patients⁴ should also be considered. The nursing facility's location can impact access to a medical director as well. Underserved areas such as rural or urban sites may struggle to find a physician at all, much less a physician with adequate time for the medical director's duties.

Goldwein et al.³ advocate to establish a requirement for medical director certification. We know that some physicians practicing in nursing facilities have minimal training in nursing home care and would benefit from a medical director who has been adequately trained through medical director certification.⁴ Further, medical director certification has been shown to correlate with better quality of care in nursing facilities.⁵ A mandate for certification is ideal, but is it achievable for all facilities, particularly in rural or underserved areas?

Past efforts to improve geriatric education have made strides, but opportunities exist at all levels of medical training to enhance understanding of and care for people in nursing facilities. Family medicine training requires 2 years of continuity care in nursing facilities, but there is no similar requirement for internal medicine training. It has been established that internal medicine residents need to be sufficiently trained in nursing home care.⁶ Improving education in medical schools as well as postgraduate programs is necessary to provide the physicians needed for nursing home care and subsequently to serve as medical directors.⁶

To evaluate the root causes of medical director absence, the impact of staffing shortages beyond physicians should be considered. Recruitment and retention of trained staff is imperative to the success of any medical director and may impact the recruitment of a medical director to begin with.

Goldwein et al.³ report that most facilities with medical directors record approximately one-half day of medical director engagement weekly regardless of facility size. This suggests the current status quo, but does not suggest a standard as there is no evidence that this limited time is sufficient to improve patient outcomes. Future studies should strive to establish evidence-based standards for medical director time.

In addition to enforcement of federal regulations, CMS could consider creative strategies to encourage adherence to federal regulations for medical director time. Possible measures include giving financial incentives to those facilities that report verifiable medical director time and developing quality indicators around medical directorship.

In summary, Goldwein et al.³ report on medical director presence and time, not quality. Future studies should include measures of the quality of medical direction provided to nursing facilities. While this study provides clear evidence of a gaping opportunity to improve medical directorship time in nursing facilities, it is only the tip of the iceberg.

Denise Zwahlen and Jay Luxenberg served as reviewers for the original article. They collaborated to provide the editorial statement.

Both authors have no conflicts of interest to report.

There are no sponsors to report.