OIG Medical Director Report "Disappointing"

by Susan M. Pettey, JD, MPA

The Office of the Inspector General (OIG) of the Department of Health and Human Services recently released its long-awaited report on the role of medical directors in nursing facilities (www.oig.hhs.gov; OEI-06-99-00300). But although the OIG identified respondents' expectations of medical directors, it failed to make any recommendations regarding that role.

The OIG noted that the role of the medical director "is largely undefined by CMS, except in the broadest sense of resident care and clinical policies and coordination of medical care." Moreover, "(n)o regulatory guidance exists on how medical directors are to accomplish these charges, nor is there any specific activity requirements for a medical director's direct, ongoing clinical interaction or any related quality-specific activities, with patients and nursing home staff."

Given the lack of specificity in the law, OIG decided on a survey to ascertain nursing homes' expectations of medical directors. The OIG sought in its report to identify the functions reported by medical directors that are expected of them by nursing homes, whether those functions should be the responsibility of the medical director, and whether the medical director has the authority from the nursing home to perform the function. The study also sought to identify the time medical directors spend in meeting these functions, and their self-reported credential status.

Performance Expectations

To prepare its report, OIG surveyed medical directors in seven sampled states (CA, ME, NY, OH, SD, TN, TX) that account for approximately 30% of all certified nursing facility beds. In one-fourth of the homes sampled, they also surveyed administrators, directors of nursing, and attending physicians. A total of 119 medical directors responded to the survey.

Medical directors reported on four key areas that contain many functions they are expected to perform.

Quality Ninety-seven percent of medical directors reported that their participation in quality improvement is important to their leadership role in establishing and maintaining quality care. In nursing homes,medical directors are expected to:

• Review and revise existing medical and clinical policies, and encourage quality of care.
• Review and analyze quality indicators for potential areas of concern, and perform quality-improvement activities.
• Develop medical care policies and procedures.
• Confirm that patients' problems identified by nursing staff are adequately addressed.

While these activities were identified as those "expected" of a medical director, a slightly larger number of respondents indicated that they believed that medical directors "should" be performing these activities.

Unfortunately, the report does not hone in on the difference between activities that medical directors reported they should perform and those they are expected to perform. Such responses could reflect a sense by medical directors that they are underutilized or less involved in quality improvement than they feel they should be. Nor does the report probe the information that 81% of medical directors feel they should serve as patients' medical advocates, yet only 64% report that this is expected of them by the nursing facility. It would have been useful for OIG to have considered what may be preventing some medical directors from serving as medical advocates for their patients.

Patient Services Professional interactions with attending physicians, nursing staff, and consultant pharmacists about concerns related to patient care are often expected of medical directors and are seen as important. The vast majority of medical directors are expected to:

• Intervene with the attending physician when concerns are raised about patient care.
• Review consultant pharmacists' drug regimen reports.
• Interact with nursing staff, providing medical advice and guidance and discussing patient care.
• Ensure appropriateness of services and treatment.
• Monitor appropriate patient care by attending physicians.

In addition, 72% of medical directors are expected to perform attending physician duties. Although regulations do not require any direct involvement between the medical director and consultant pharmacist, 65% of medical directors report meeting with consultant pharmacists on a quarterly basis.

Significantly larger numbers of respondents indicated that medical directors should be performing activities in the patient-services area than reported that they were actually expected to perform such services.

Residents' Rights Sixty percent to 69% of medical directors reported that ensuring residents' rights (such as appropriate drug regimens, ensuring treatment choices, confirming appropriate restraint usage, supporting patients' involvement in care planning, and honoring end-of-life decisions) is expected of them by nursing homes. Nearly 80% felt that these were activities that medical directors should perform. The report noted that 89% of respondents reported attempting to ensure that facilities have provided patients or their families with specific information about end-of-life issues, including the availability of hospice care.

Administration It is clear that nursing facilities expect their medical directors to provide medical expertise to respond to regulatory agency survey concerns. That activity received one of the highest scores of the survey for both expectations by the facility (94%) and perception as an appropriate activity (96%). The focus on responding to survey concerns echoes a common complaint of many medical directors--namely, that they are perceived as more important in reactively addressing survey concerns than in proactively promoting quality care. Approximately one-half to two-thirds of medical directors participate in specific aspects of the survey process (45% participate in exit interviews and 47% participate in writing plans of correction).

The report noted that medical directors are expected to serve as a liaison among medical staff, nursing staff, and administration. Medical directors are also expected to stay abreast of regulatory and medical treatment changes, and to a lesser extent, promote employee health.

Other Activities Several other activities were infrequently identified, such as ensuring sufficient staffing to meet all patients' needs, ensuring appropriate supplies for patients' needs, verifying sanitary storage and preparation of food, confirming adequate lighting levels, and ensuring availability of patients' prior medical records and advance directives at the time of admission. Again, for these activities, more respondents indicted that medical directors should be performing these activities than that they were expectations of nursing facilities.

"In general, medical directors report that they have the authority from the nursing homes to perform many of the functions," although in many instances, fewer respondents believed that they had the authority to perform certain activities than believed that medical directors should perform those activities.

Of particular note is that a majority of respondents felt they had less authority to: verify qualifications of attending physicians (62%); verify qualifications of consultants (54%); ensure appropriate care by nurse practitioners and physician assistants (65%); or develop performance indicators for attending physicians (57%).

A minority of respondents (27%) indicated that medical directors should encourage sufficient staffing to meet patient needs, but only 10% believed that they had the required authority.

Time Involved

The overwhelming majority of medical directors (86%) reported spending eight hours or less per week at the sampled facilities in their medical director capacity. The OIG concluded that "the amount of time spent on their nursing home role may allow them to complete work already scheduled and for which they are held directly accountable, such as certain paperwork related to patient care or participation in committees."

The report did not detect a significant trend toward full-time medical directors, with 70% of medical directors reporting that less than 10% of their practice is devoted to their medical-director role. Only 7% stated that more than 33% of their practice is devoted to medical-director responsibilities.

The report noted that 54% of medical directors serve as attending physicians in the facilities in which they serve as medical directors.

In addition to the time spent in the nursing facility, telephone calls serve as a primary method of communication between medical directors and nursing staff. "Research supports that much of the medical care delivered in nursing homes occurs as a result of telephone calls, except for the regulatory need for 60-day certification of medical necessity."

Training

The OIG report points out that current regulations require that the medical director be a physician, but not that he or she be licensed to practice. However, 92% of responding medical directors reported that they are licensed as medical practitioners in their states.

Medical directors typically come from a professional background of family practice (44%) or internal medicine (47%). Of those medical directors from other fields, the majority reported receiving medical school residency training in family practice or internal medicine.

Twenty-two percent reported that they specialized in geriatrics in medical school, 30% reported having a "certificate of added qualifications" in geriatrics, and 4% reported completing a geriatric fellowship.

Medical directors displayed a strong support for continuing education, with 48% completing continuing education, credited yearly in programs relating to geriatrics, gerontology, or long-term care. Participation in local or regional professional groups seemed somewhat important, with 39% reporting membership in their state-affiliated chapter of the American Medical Directors Association (AMDA). Twenty-five percent reported that there are currently certified or recertified by the AMDA Medical Director certification program. Two percent reported working toward AMDA certification, and 3% reported that they were formerly certified by AMDA, but their certification had lapsed.

Missed Opportunities

The OIG report clearly missed an opportunity to probe the reasons that more medical directors felt they should be involved in identified activities than were expected to by nursing facilities. The report should have also probed perceptions of authority to perform medical-director responsibilities to ascertain the basis for situations in which fewer medical directors perceive they have the authority to perform certain activities, versus those who believe that the medical director should be performing those activities.

The issue of authority is surely critical in describing the role of the medical director, as well as assessing the possible need for changes in the role. The report offers no conclusions regarding whether the role of the medical director should be strengthened, but merely notes that "CMS will find the...information useful as it continues to work with [representatives of the nursing home industry, patient advocacy organizations, and physician-related organizations] in establishing, clarifying, and enhancing the medical director's role."

Steven Levenson, MD, CMD, Chair of Caring's Editorial Board commented that "the report was mainly descriptive, and didn't call very much upon the work that those of us have done in the field to clarify these roles and functions. It didn't refer much to specific aspects of AMDA's identification of medical-director roles or functions. It didn't do much to define the true scope of authority in issues such as quality oversight. It did confirm what AMDA has already found, but so what?"

AMDA met several times with OIG staff and provided a detailed review of the survey instrument, suggesting that it might not get at the core issue of authority. AMDA Executive Director Lorraine Tarnove said that "the survey did not go far enough to ask the questions that would indicate the root causes of the difference between expectations and authority. The survey simply did not go far enough to be able to make recommendations. This is particularly disappointing since at the beginning of this endeavor, all agreed that such a survey would have the potential of providing further clarification that would give the medical directors the authority needed to fulfill their role. The study shows that the medical directors understand their role and want to fulfill it, but don't have the support or affirmation from the administrator."

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