乌鸦传媒

It's just a two-page, barely 200-word bill. But if passed as the authors intend, it would require all 15,000 Medicare-approved nursing homes in the nation to publicly report the name of their medical director.

Physicians involved in skilled nursing home care say that's a critically important step toward dramatically improving transparency and accountability for seniors and their families and the health systems that serve them.

That essential information has often been secret and elusive, especially during the pandemic, Suzanne Gillespie, MD, president of the AMDA, the Society for Post-Acute and Long Term Care Medicine, told 乌鸦传媒.

For example, she recalled the experience of a family member who tried repeatedly to express concerns about the quality of care her loved one was receiving, but couldn't find the staff who would be responsible.

"She was trying to reach the medical director, and there were unnecessary delays. She wasn't able to connect until the loved one had gotten even more ill," she said. The patient died.

If the bill introduced August 23 by Rep. Mike Levin (D-Calif.) and Rep. Brian Fitzpatrick (R-Pa.) passes, Gillespie believes -- based on documents from the authors -- that CMS would publish at least the name of each nursing home's medical director on , viewable with just a few clicks.

For now, the bill vaguely calls for disclosure of "information" about the medical director. The exact scope of what information will be published will be determined by the regulatory process, Gillespie said. It could be more than just the doctor's name and nursing home; board certification could be published, for instance.

The AMDA is urging the public's .

Managing Too Many Facilities?

There are many reasons why the public needs to know the name of the medical point person in these facilities since this person's job, as required by CMS, is essential to assuring that staff members have credentials, know proper transfer protocols, prepare for disasters, and understand the specific needs of highly vulnerable geriatric patients.

The public needs to know the physician in charge competently performs peer review, like making sure that the patients' own physicians are providing appropriate care, and that employees have appropriate competencies, like knowing what to do if there's a Valium shortage.

Patients and their families also would then be able to learn how thinly spread the director's tasks might be. Gillespie said she has heard of a medical director who oversaw 16 separate nursing home buildings in different locations, all at the same time.

"It depends a little bit upon the facility, its complexity, the type of care that it's providing," said Gillespie, who is medical director for two nursing homes in the VA Finger Lakes Healthcare System in Rochester, New York. It's not unusual to have a doctor be in charge of a few buildings, she said, but maybe not 10.

"There is a tipping threshold to where it becomes difficult, dare I say impossible, to be engaged in the ways that you'd want a medical director engaged," she said.

Which Doctors Qualify?

Other reasons for publishing names of medical directors include being able to see provider qualifications, said AMDA's immediate past president Karl Steinberg, MD, a San Diego-based medical director of two nursing homes and chief medical officer of two nursing home service corporations whose facilities each have their own medical directors.

He has heard of nursing homes hiring an interventional radiologist, a retired surgeon, and a pediatrician as their medical directors, despite those individuals having no training in geriatrics, long-term care medicine, end-of-life care, or the complex regulatory framework under which nursing homes must operate.

"What do you do for patients with diabetes, COPD? What do you do with a change of condition? What do you do for prevention of bedsores, prevention of falls?" Steinberg said. "The medical director is supposed to review all of the policies and procedures and make sure that they are up to date."

These likely are not skills they learned in medical school, he added.

Many SNF medical directors are independent contractors budgeted at between 5 and 20 hours monthly, he said. While many if not most do serve as attendings for some patients, and provide direct patient care, they are not otherwise specifically responsible for delivering direct patient care.

They do, however, need to make sure that those patients' own doctors attend to their needs, visit their patients at least once a month, and make necessary visits when a patient's condition changes.

He gave several examples where appropriate nursing home care procedures deviate from what non-geriatric specialists were taught in medical school.

For example, when a geriatric patient with diabetes is hospitalized, doctors do fingerstick checks four times a day, with sliding scale insulin, he said. When they're discharged to a SNF, an unenlightened medical director may allow that to continue for months, "even though it's unnecessary and detracts from the patient's quality of life."

For a geriatric patient nearing end of life, "you really don't care about tight diabetes control," Steinberg said. "You let them eat what they want because you don't want them losing weight and failing to thrive. The time horizon for damage from elevated blood sugars is longer than they're going to live anyway."

Steinberg does chart reviews and frequently sees patients still getting fingersticks four times a day after three months, "and they're all between 120 and 160 mg/dl. They're still getting two units of insulin if it's over 150," he said. "It's strictly ignorance and inertia."

California Leads the Way

AMDA would like to see federal policy evolve along the lines of policy shaped by California.

Steinberg was a member of the California Association of Long Term Care Medicine leadership team that got a passed last October that goes much farther than the House bill.

It mandates that all nursing home medical directors in the state must take a 40-hour online course in nursing home care -- one that costs roughly $4,000 -- and receive a "CMD," medical director within five years, or by Jan. 1, 2027.

They also have to submit a resumé, and show proof that they are board certified "in a medical specialty consistent with the type of care provided" in long-term care facilities. They also must demonstrate they've had experience as a nursing home medical director for at least two years.

It is the only such legislation in the country, Steinberg said, although Maryland may have a similar statute that's not enforced. California lawmakers easily passed it without opposition in any committee or legislative chamber after they were "shocked that a nursing home could hire an interventional radiologist to be their medical director or a retired surgeon, or a pediatrician," Steinberg said.

It also was becoming clearer during the pandemic that "some nursing homes and chains will hire medical directors to just do what I call the three S's: Sit down. Shut up and sign. Don't make waves," Steinberg said. "We know there are definitely those among us, and that's what we wanted to address with this bill."

Having a registry of nursing home medical directors would have been so helpful during the pandemic, Steinberg continued, saying "it's tragic that we didn't."

"There were just so many different sources of information, and they were not always reliable with conflicting guidance from local, versus state, versus federal agencies. It would have been nice to send all that to the medical director" to clarify the correct policy, he said.

COVID's Silver Lining

Gillespie and Steinberg noted that medical director organizations and patient advocates have been arguing for medical director legislation for more than a decade but resistance always won. COVID, however, revealed the gravity of the problem and got peoples' attention.

For example, the National Academy of Science and Engineering Medicine's April , "The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff," made many recommendations now codified in the California law.

Nursing homes should report to CMS baseline demographic on medical directors, and that medical directors should an "education and certification program specific to the care of older adults, and certification in infection control and prevention," the report recommended.

"These are super vulnerable old people who are sick. And if you don't have somebody watching the chicken coop, things will slip through the cracks," Steinberg said.

Levin and Fitzpatrick made many of these points in a to then CMS Administrator Seema Verma in May of 2020, just as the public was realizing the horrifying impact the pandemic was having on nursing home residents.

Added Gillespie, COVID "has been the silver lining in the cloud, shining a light on long-standing concerns about nursing home care, and brought interest from many others."

Pushback Begins

Already, however, the proposed bill is getting pushback. Asked for reaction, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) said it is reviewing the bill to see if it would accomplish greater transparency, but suggested to 乌鸦传媒 in a statement that it is cautious.

"While we support transparency efforts that help consumers make decisions about where they or a loved one should receive care, we cannot support additional reporting requirements that take time away from resident care."

The statement noted that the nursing home industry is in "the worst labor shortage" it has ever faced, and that the organization needs to ensure "that it does not discourage qualified and interested physicians from serving as medical directors in our communities."

LeadingAge, an association of non-profit providers including nursing homes, had a different take: "Transparency of information is an important element of building trust between providers, residents and their families, and we support nursing homes' disclosing this information about medical directors," a spokeswoman said in an e-mail.

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