Medical director involvement in nursing homes, 1992-1996

Objectives: To present national data from federally certified nursing facilities regarding reported involvement for two domains of nursing home physician serviceS: (1) medical directors, excluding activity as personal physician to residents; and (2) salaried physicians who supervise care of residents when the attending physician is unavailable and/or are available to provide emergency services on a 24-hour basis. A second objective was to evaluate facility characteristics as predictors of reported participation within these domains. Design: Repeated cross-sectional surveys. Multivariate Tobit analyses were used to assess facility-level correlates of staffing reports. Setting: All federally certified nursing facilities. Participants: 14,037 nursing facilities in 1992; 14,810 in 1993; 15,181 in 1994; 15,507 in 1995; and 15,694 facilities in 1996. Measurements: The Online Survey Certification And Reporting (OSCAR) data files for 1992 through 1996. Rural facilities were identified using information from the Bureau of Health Professions Area Resource File. Within the above domains, involvement was assessed in terms of reported full-time equivalents (FTEs) per resident. The following facility characteristics were considered: proprietary status, government ownership, hospital affiliation, chain affiliation, resident payer mix, functional dependence of the resident population, and rural location. Results: In the most recent year analyzed, 1996, facilities reported an average of 0.15 FTEs per 100 residents for medical directors and 0.05 for salaried physicians providing backup supervision and/or emergency coverage. Zero FTEs were reported at 20.4% of facilities for medical directors and at 71.3% of facilities for salaried physicians providing backup supervision and/or emergency coverage; 18.8% reported zero FTEs for both categories. Reported medical director involvement was consistently positively associated with a facility's being hospital based and with having a high proportion of Medicare residents. It was negatively associated with chain affiliation and rural location. Reported FTEs for salaried physicians providing backup supervision and/or emergency coverage were negatively associated with a facility's being hospital based and positively associated with government ownership and having a high proportion of Medicaid recipients. For both categories, rural location was negatively associated with reported involvement. These results were replicated in the prior four years. Conclusions: Wide variability was found in reported involvement patterns among and between medical directors and salaried physicians providing backup supervision and/or emergency coverage. Despite the 1990 implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) requirement that all facilities have a medical director, 4.8% of facilities in 1992 reported zero medical director FTEs, and, by 1996, this percentage had risen to 20.4%. It remains unclear whether these reports indicate an actual decline in medical director participation or an increase in volunteer or alternative arrangements where the facility did not directly reimburse the medical director and thus did not report FTEs.

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