What's next?

TY - JOUR

T1 - What's next?

AU - Tangalos, Eric G.

N1 - Funding Information: Eric G. Tangalos MD, CMD Professor of Medicine, Director, Chair a b * a Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota b Program on Aging, Mayo Clinic, Rochester, Minnesota * Address correspondence to Eric G. Tangalos, MD, Baldwin 5B, Mayo Clinic, 200 First Street, SW, Rochester, Minnesota 55905. Looking back on the last 25 years of nursing home care and the advent of the medical director, it is hard to imagine what the field might look like when today's newly minted doctors are asked to make some mid-career observations. Certainly this has been a time of change and opportunity for physicians in long-term care settings. Since the Institute of Medicine (IOM) 1986 report, “Improving the Quality of Care in Nursing Homes,” a lot has happened. The report was immediately followed by the Omnibus Budget Reconciliation Act of 1987 (OBRA-87), which was designed to improve care provided in institutions through changes in the medical assessment and treatment of nursing home residents. 1 Some recommendations brought about dramatic change (restraints) while other suggestions have been slow and uneven in implementation (enforcement). The impact was profound and not to be felt again so strongly until the advent of the prospective payment system. But more on that later. There has also been significant growth in the field of geriatrics, in our knowledge base for care of the frail and the vulnerable, and in the body of knowledge that comes with the responsibilities of medical directors. Long-term care, and how to deliver it, has been better defined, and the tools available to us for our patients include the Minimum Data Set (MDS), practice guidelines, and quality indicators. Medical schools include geriatrics curricula; the hospital experience for residents in training must include a geriatric focus. Fellowship opportunities even exist for special training as a medical director. High water marks for our career choices include the development of a medical director curriculum based on a fund of knowledge and a certification process. Significant changes in reimbursement for nursing home visits in the early 1990s 2,3 also brought good physicians back into nursing homes. This allowed for physician services in subacute care later in the decade. Even the growth of the American Medical Directors Association, with its organizational structure to support like-minded individuals, was beyond anyone's expectations. In December 2000, the IOM issued its second report on “Improving the Quality of Long-Term Care.” 4 This work was commissioned by the Robert Wood Johnson Foundation with additional support by the Archstone Fund, Irvine Health Foundation, Department of Veterans Affairs, and the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA). The work was undertaken because there remain persistent concerns about the quality of long-term care, particularly in the nursing home. It is a report card, perhaps, on the last 15 years since the first IOM study. This would also be an opportunity to look at the alternatives to nursing homes, including noninstitutional settings that might include home health care, personal care, residential care, care management, and other services. The IOM was asked to examine the following: • the demographics, health, and other characteristics of individuals requiring long-term care; • the roles of different long-term care settings in community health care systems and the movement of people among long-term care and other settings (their relationship to other components of community care systems); • the current quality of long-term care settings and the extent to which this has improved or deteriorated in the past 10 to 15 years; • the impact of regulations, especially the nursing home reforms in OBRA-87, on such matters as the use of physical and chemical restraints, advance care planning, provision of adequate nutrition, identification of substandard facilities or programs, and public access to information on quality of care; and • the strengths and limitations of existing approaches to measure, oversee, and improve the quality of care and outcomes in nursing homes and other long-term care settings and ways of improving them to promote better quality of care and other outcomes, regardless of setting. In nursing homes, the committee found that, since OBRA-87, the quality of care has generally improved over the past decade, even though nursing homes are serving a more seriously ill population. However, the committee was also well aware that pain, pressure sores, malnutrition, and urinary incontinence remain serious quality-of-care issues in some facilities. The quality of life for nursing home residents has also shown some improvements, but to a lesser extent. Outside of nursing homes, little is known about the quality of care or outcomes of services provided by medically oriented home health agencies, and even less is known about the quality of social service oriented home and community based services. There are also indications that consumers may receive too little information to make informed choices about residential care or assisted living. A number of recommendations in this report deal with quality assurance through external oversight. The following recommendation has the most impact on the management of the clinical conditions for which the medical director is ultimately responsible. Recommendation 5.1 The committee recommends that: • federal and state survey efforts focus more on providers that are chronically poor performers by surveying them more frequently than is required for other facilities, increasing penalties for repeated violations of standards, and decertifying persistently substandard providers; • HCFA's monitoring in all areas of stated survey and sanction activities be improved by ensuring greater uniformity in state surveyor interpretation and application of survey regulations, and that they be reinforced by assistance and sanctions as necessary to improve performance; and • an analysis commissioned to examine if increased funding is needed to allow HCFA to improve the state survey and certification processes for nursing homes. Much has been said of nursing home staffing. These issues have also had a major impact on how care is delivered, how quality is perceived, and how outcomes are ultimately measured. This IOM committee concurred with another 1996 IOM report on nurse staffing 5 and made the following recommendations: Recommendation 6.1 The committee recommends that HCFA implement the 1996 IOM recommendation to require presence of a registered nurse 24 hours per day. It further recommends that HCFA develop minimum staffing levels (both in number and skill mix) for direct care based on case-mix-adjusted standards.  Recommendation 6.2 The committee recommends that Congress and state Medicaid agencies adjust their Medicaid reimbursement formulas for nursing homes to take into account any increases in the requirements of nursing time to meet the case-mix-adjusted needs of residents.  Recommendation 6.4 For all long-term care service workers and settings, the committee recommends that federal and state governments, as appropriate, undertake measures to improve work environments, including competitive wages, career development opportunities, work rules, job design, and supervision that will attract and retain a capable, committed work force. The December 2000 IOM report 4 also notes that research remains notably lacking in areas that pertain to physician involvement and physician intervention in long-term care. In reviewing the information and data available, the IOM committee concludes: It is easier to propose a comprehensive examination of long-term care than to identify, collect, and analyze relevant data to support comparable descriptions and assessments across the diverse settings, services, and populations. Defining or evaluating quality of long-term care is fraught with problems, made more difficult by the unevenness of the available empirical evidence. Information to evaluate quality of care in nursing homes is extensive and systematic, but for most other settings it is nonexistent or very limited and lacking in uniformity. With just as much career ahead as behind me, the IOM report can serve as a midpoint marker. However, as one gets older, it is hard to escape the pessimism that comes with more knowledge. Policy decisions based on physician involvement in long-term care are hard to make, though some data do exist. 6,7 In the evidence that has been presented, teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. However, it has been difficult to balance capitated rates with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide care. For assisted living, there is even less to say about physician involvement. It was a real struggle in putting together the IOM report to find evidenced-based publications on physician practice and intervention in peer reviewed journals (one of the committee's responsibilities is the discovery of factual data to back up any policy recommendations). We have again entered more difficult times to be caring for patients in most long-term care settings. There are now 97 geriatric fellowship programs across the country with 297 filled positions through June 2002. This is woefully inadequate as our aging population continues to grow and outpace provider capacity. The failure of the Bipartisan Commission on Medicare (created in 1997) to reach any conclusions or develop any policies signaled difficulties ahead for our patients and our facilities. In fact, the commission failed even to receive the 11 votes needed to report to Congress in March 1999! A drug therapy benefit may also adversely affect overall benefits to long-term care residents. However, it is the prospective payment system (PPS) that continues to exact its toll on long-term care facilities and forms the basis for the “rest of this story.” The Balanced Budget Act of 1997 (BBA ′97) mandated the establishment of case-mix-adjusted PPSs for various Medicare postacute care services, 8 including skilled nursing facility services (effective July 1998) and home health services (effective October 1999). Between 1998 and 2002, the PPS, along with other changes, were initially estimated by the Congressional Budget Office to produce savings of $9.5 billion in skilled nursing facility expenditures and $16.2 billion in savings for home health expenditures. 9 Currently limited to Medicare (about 10% of nursing home patients qualify at any one time), the skilled nursing facility prospective system is a bundled, case-mix per diem payment that is playing off of the success of hospital-based diagnostic related groups a decade earlier. However, for skilled nursing facilities, the case-mix basis is related to function rather than clinical condition. Under PPS, the MDS and the Minimum Data Set-Post Acute Care 10 will continue to determine eligibility for Medicare services and establish the level of reimbursement. Perhaps its greatest limitation remains the focus on rehabilitation rather than on medical complexity and the antecedent costs to provide care. 11 Recent changes to the payment systems to nursing homes have had a significant impact on how care is delivered. Moreover, both the General Accounting Office (GAO) and the Office of the Inspector General (OIG) have published numerous findings in the last few years implicating poor care in our nation's nursing homes and have cited issues of malnutrition, dehydration, and pressures sores as markers of poor quality. CMS has developed a web site called “Nursing Home Compare” ( http://www.medicare.gov/NHCompare/home.asp ) that gives consumers the opportunity to look at recent survey deficiencies and judge for themselves the quality of long-term care available by state, county, or city. The most recent IOM report on “Improving the Quality of Long-Term Care” 4 focused on staffing issues as a potential area to improve quality. The report was for nursing and nurse aides, as there was no strong evidence to include physician services or the role of the medical director directly in the debate. The OIG has now completed, but not yet published, its 2-year study on the role of the nursing home medical director. The survey instrument for medical directors was sent to 235 medical directors in the seven target states (California, Ohio, Maine, New York, Tennessee, Texas, and South Dakota) in 2000. The OIG's study design indicated that it will use the data in an attempt to determine whether facility or medical director characteristics influence or are associated with differences in roles and functions. Physicians serving as medical directors remain caught in the mismatch between medical directors’ responsibilities and regulatory authority. Without sound scientific study, the outcomes of our increased participation in long-term care facilities these past 20 years is now subject to further review. As CMS steps up its focus on enforcement, a variety of issues will rise to the surface. The role of nutritional support will come under even closer scrutiny. Medication management, medication errors, and the safety and well being of our patients will receive close attention. CMS surveyors will certainly come to find the medical director increasingly responsible for failing to ensure that nursing home residents received appropriate care. CMS will hold accountable physicians for survey violations in the nursing home, and one focus will continue to be the facility's capacity to feed patients, provide good nutrition, and recognize the warning signs of malnutrition and dehydration. The IOM study calling on tougher penalties for repeat violations should come as no surprise. Interventions will need to be cost effective, deliver quality care, and reduce risk to both patients and providers. The BBA ′97 also called for a medical review to reduce fraud and ensure compliance. This has brought physician peer review organizations (PRO) into long-term care where they have not been before. CMS recently completed a five-state demonstration project that brought together state funding agencies (Medicaid for Massachusetts, Maryland, and Arizona), Medicare fiscal intermediaries, state survey agencies, and the local PRO. Colorado and North Carolina were the other two pilot states, while the contract for statistical analysis went to ProWest of Washington. Data sources included the HCFA Customer Information Services, the MDS, the Online Survey Certification and Reporting System, and Medicare inpatient claims. More will come with perhaps greater physician opportunity to design programs that improve outcome. For now, the reader can access the “SNF PPS Quality Medical Review Pilot Project” at http://www.hcfa.gov/medicare/qmrpps.htm . In July 1998, the GAO released “California Nursing Homes: Care Problems Persist Despite Federal and State Oversight,” the follow-up report to the 1997 US Senate Special Committee on Aging hearings. This report documented extreme and, in many cases, untreated health problems, such as malnutrition, among nursing facility residents. On September 14, 1998 the OIG also released its report, “Improving Safeguards in Long-Term Care,” to the US Senate Special Committee on Aging, which is posted to web site address oig.hhs.gov/oas/reports/aoa/testimony.pdf. These reports confirmed that nutrition care is necessary to address serious health problems, maintain health, functional status, and quality of life for nursing facility residents. The question of physician liability continues to be an important reality given the full implementation of the enforcement regulations. Attending physicians are under greater scrutiny to provide high quality care to their nursing home patients or face medical malpractice and criminal prosecution. 12 A significant risk to our patients under the PPS is that when physicians and the facility providers find themselves unable to control costs and maintain quality, then access to care will be diminished as investments in capital, career development, and research go elsewhere. Prospective payment demonstrates the disconnect physicians have in the practice of long-term care. Physician services under Part B Medicare are exempt from the defined contributions and global payments that come with case-mix reimbursement. Attending physician actions, especially as regards drug selection and ordering rehabilitative services, have direct impact on facilities and their abilities to make ends meet. Yet these actions carry no economic consequences to either patient, family, or attending physician. The partnership for care needs further development, including a better alignment of physician incentives with facility incentives. Common ground should be quality of care. Although a tension should exist between medicine, nursing, and administration, the balance in the nursing home is not the same as in a hospital or medical practice setting. All too often the medical director can be marginalized or, even worse, placed at risk by policy decisions based on financial needs. A new paradigm to improve the interaction and roles for the attending physician and medical director has also been suggested. 13 What lies ahead is uncertain. The diverse goals of nursing home care, the heterogeneity of nursing home residents, and the varied circumstances under which physicians care for them continues to evolve. 14 Change will continue, care will be provided, new breakthroughs will occur, and there will be more sick old people. There will still be nursing homes, patients, and medical directors. There will be more enforcement and regulation, not less, and it will move swiftly into assisted living on a state-by-state basis. Interdisciplinary care and greater physician involvement remain critical as we begin our second decade of experience with the MDS and Resident Assessment Protocols. It is best to take heed of the IOM report, produce some good research as regards medical care in long-term care settings, and get on with the tasks at hand. Physicians need to provide medical care and directions to those most frail, most vulnerable, and most in need of our services.

PY - 2002

Y1 - 2002

UR - http://www.scopus.com/inward/record.url?scp=23644435943&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=23644435943&partnerID=8YFLogxK

U2 - 10.1016/S1525-8610(04)70466-1

DO - 10.1016/S1525-8610(04)70466-1

M3 - Article

C2 - 12807667

AN - SCOPUS:23644435943

SN - 1525-8610

VL - 3

SP - 199

EP - 202

JO - Journal of the American Medical Directors Association

JF - Journal of the American Medical Directors Association

IS - 3

ER -