Doctors’ Work in Nursing Homes Scored

Each year state investigators document case after case of mistreatment and neglect of elderly patients in California nursing homes. Now state regulators and legislators are being asked if doctors should share in the blame.

Citing poorly monitored and often substandard medical care offered to patients in the state’s nursing homes, California’s Little Hoover Commission in a report last week laid the blame on physicians and urged legislation and state agency action to correct the problem.

For years the state’s nursing homes have been under intense public scrutiny for the overall care they provide California’s older residents, but the Hoover Commission report focuses attention specifically on doctors rather than on nursing homes in general.

“It’s an incredible problem and this is the first time I’ve seen it really being addressed. I think it permeates the nursing home industry,” said Patricia McGinnis, executive director of the Bay Area Advocates for Nursing Home Reform.

Legislation spawned by the Little Hoover Commission report is already being drafted and it, as well as the commission’s findings, is getting mixed reviews from organized medicine, nursing home associations, public advocates and state regulators involved in the nursing home scene.

“This is the hottest thing going in our area,” said Dr. Donald N. ReVille, past president of the American Medical Directors Assn., medical director for 12 California nursing homes and the physician for numerous nursing home patients.

The Little Hoover Commission, a state watchdog agency formally known as the Commission on California State Government Organization and Economy, ventured into the seldom-explored subject of medical care in nursing homes because, it said, its years of investigating nursing homes had turned up numerous complaints about neglect by physicians. The commission only has the power to make recommendations and findings.

“What we found was appalling,” said Chairman Nathan Shapell in a cover letter to the report. “Some doctors may ‘visit’ 30 to 50 patients in an hour by glancing through charts and signing medical orders. Patients may be overmedicated or suffer for weeks from adverse reactions to combinations of drugs before a doctor responds to their changed condition.”

Admittedly short on statistics and quantitative data to back up its conclusions because no government agency tracks physician care in nursing homes, the report said nursing home doctors operate in a system that virtually makes them immune from accountability for inadequate care.

The Little Hoover Commission criticized the state Board of Medical Quality Assurance for being “singularly inactive” in disciplining doctors. The commission also complained that a lack of coordination between the board and the Department of Health Services Licensing and Certification Division, which inspects nursing homes, has made it nearly impossible to spot problem doctors.

In a series of wide-ranging recommendations, the commission suggested:

- Establishing a peer review system in nursing homes to monitor physician care.

- Enacting new laws to set penalties and definitions for patient neglect and mistreatment.

- Setting up Board of Medical Quality Assurance procedures for fining doctors who provide substandard nursing home patient care and giving board investigators new powers to obtain nursing home medical records.

- Providing more instruction in geriatrics for medical students and doctors who treat the elderly.

Jeannine English, the commission’s executive director, said members of the Assembly Democratic Caucus have tentatively agreed to carry legislation that would put many of the recommendations into effect.

Response to the report has been varied. Doctor groups and nursing homes object to the proposals for sanctions against physicians. State regulators chafe at the suggestion that they have been lax but applaud recommendations for closer coordination between agencies and increased powers for medical board investigators. Although there was wide disagreement on the extent of the problem, there was none on the need for better physician care in nursing homes.

“Yes, there is a problem in our view and I think it is a problem that needs to be addressed,” said Charles McFadden, California Medical Assn. executive director. “(But) their approach seems to be that they want to beat up on physicians until they do what the Little Hoover Commission wants.”

Shortage of Doctors

He said the root of the problem was an acute shortage of physicians who specialize in geriatrics, an area of medicine many find unglamorous, unrewarding and low-paying.

“It goes to what makes people go into medicine,” he said. “They want to go in there and bang-bang, make people well. With a person 88 years old who has multiple problems, the physician doesn’t always get the outcome he or she wants.”

The medical community appears divided on a commission recommendation to require nursing homes to establish a peer review system for monitoring physician care similar to that used by hospitals.

While McFadden saw it as a punitive measure that would be unworkable in a nursing home setting, ReVille, a member of a commission advisory committee, said peer review would encourage better medical care.

“I applaud it,” said ReVille, who estimated that 6% to 10% of the doctors dealing with geriatric cases provide substandard care. “I don’t mind anybody looking at my charts, but I certainly know physicians who would mind people looking at their charts.”

Even before the release of the report, Paul Keller, chief of field operations for the Department of Health Services Division of Licensing and Certification, said his agency and the medical board had established better coordination in anticipation of the recommendations. Months ago, he said, nursing home inspectors were directed to be on the alert for “physician problems” and report them to the medical board.

Kenneth Wagstaff, executive director of the Board of Medical Quality Assurance, generally gave the report “good marks,” although he considered the criticism of his agency overly harsh, saying a shortage of investigators had created a huge backlog of cases.