More than one-third of US nursing homes did not have a medical director onsite during the first quarter of 2023, according to new study findings, which were strongly rebuffed by the head of the Post-Acute and Long-Term Care Medical Association.
However, the report itself stated that nursing homes may have misreported Payroll-Based Journal data, which is the same conclusion reached by Rajeev Kumar, MD, president of PALTmed, based on his reading of the study’s abstract.
Researchers used journal data from the first quarter of 2017 through the end of the first quarter in 2023 to determine that 36.1% of nursing homes “reported zero medical director presence” from Jan. 1 to April 30, 2023. They also found a decline in how frequently medical directors were onsite over the past four years.
Published Monday, the study was conducted by researchers from the Long Term Care Community Care Coalition; Michael R. Wasserman, MD, California Association Long Term Care Medicine; Charlene A. Harrington, PhD, University of California, San Francisco; and Mary Ellen Dellefield, PhD, also of UCSF.
Among nursing homes reporting a medical director, the medical director was on payroll for an average 36 minutes per day or 4.2 hours per week per facility, and less than 1 minute per resident day, the investigators found.
“For-profit nursing homes reported a lower rate of medical director presence (61.4%) compared to non-profit (71.3%) and government (66.5%) nursing homes and reported that medical directors spent less time in the facilities,” researchers wrote. “Facilities seldom (0.2%) receive regulatory deficiencies for medical director requirements.”
But Kumar told McKnight’s Long-Term Care News Tuesday that he suspects the data showing some facilities had no medical director onsite for four months is askew.
“I would be appalled if that were the case,” he said. “It would be really, really alarming if that were to be true.”
Data flaws?
Kumar said the problem likely stems from the data supplied by nursing homes and how medical directors account for their time.
Other than at very large nursing facilities with several hundred residents, medical directors for long-term care facilities are contract workers, he noted. The physicians perform two different types of work for nursing homes: clinical work of treating residents and acting in the administrative role of medical director. That administrative work, the hours spent performing it, and the payment reimbursements may not be fully accounted for in the payroll journal data, Kumar explained.
The time spent performing clinical work as a treating physician is not to be included in the payment for and hours counted as the administrative work since doctors are separately reimbursed by the payer — either private insurance or a government program, Kumar said.
“PBJ is a flawed system,” he added, noting that the facility employees entering payroll data may not have had access to hours from physicians for the medical director work, depending on how and when a physician submitted that information and how it was reported by other employees in a facility’s system.
The Centers for Medicare & Medicaid Services requires medical directors to implement resident care policies and coordinate medical care. That vague language leaves a lot of room for interpretation, Kumar said, noting that medical directors attend quality assurance meetings and resident care planning meetings, collaborate with pharmacists either to strategize better medicines for the facilities or for individual residents, and work with the director of nursing, among other administrative duties.
The amount of time a medical director spends onsite is also left up for interpretation. Before shifting more into a consulting role, Kumar said he was contracted as a medical director at two nursing homes — one with approximately 150 residents and another with approximately 100. He would spend 16 to 20 hours per month combined on administrative duties for the two facilities.
An elusive measurement
The CMS definition of the role of a medical director dates back to 2005. In 2011, the Society for Post-Acute and Long-Term Care Medicine released a white paper to provide clarity on the role.
“There is an ever-expanding role for medical directors in facilities,” Kumar said. “The citations that come from surveyors for lack of medical-director engagement comes from interpreting [the CMS] guidance. It’s very hard to either approve or disprove a medical director’s engagement.”
In an email to McKnight’s Tuesday seeking comment on the concerns raised about the data, Richard Mollot, executive director of the Long Term Care Community Coalition, said he thought it was clear that people asking questions had not read the full study, which sits behind a paywall.
“It is disturbing to hear that they are drawing such conclusions,” he said. “This is not an opinion piece.”
It appears the researchers and Kumar were in agreement on at least a few points.
“It is unknown whether some [nursing homes] do not have [medical directors], in violation of the regulations, or whether [nursing homes] are simply not reporting [medical director] time,” the report authors wrote.
“Potential reasons for failure to report time include that [nursing homes] have not established mechanisms for obtaining and reporting the data from [medical directors] as required or that [medical directors] are not cooperating with the reporting requirements,” they added. “It is also possible that hours could be overreported.”
