SNF operators should review their PBJ reporting practices for medical director hours, as the study identifies widespread gaps, whether from non-compliance or underreporting, that may draw increased regulatory scrutiny; the OIG has added a review of medical director engagement and PBJ data accuracy to its work plan, with completion targeted for 2026.
Medical director presence and time in U.S. nursing homes, 2017–2023
More than a third of U.S. nursing homes (36.1%) reported zero medical director presence in Quarter 1, 2023. Medical director presence fluctuated between 2017 and 2023 with a decline over the past 4 years. Among nursing homes reporting a medical director, the medical director was on payroll for an average 36 min per day or 4.2 h per week per facility, and less than 1 min per resident day. 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. Facilities seldom (0.2%) receive regulatory deficiencies for medical director requirements.
Goldwein, Eric L., et al. “Medical Director Presence and Time in U.S. Nursing Homes, 2017–2023.” Journal of the American Geriatrics Society, vol. 73, no. 1, Jan. 2025, pp. 29–38, https://doi.org/10.1111/jgs.19161.
SNF medical directors cautiously optimistic about fed plans to examine their work
The Office of Inspector General has announced it will take a magnifying glass to how nursing homes employ and pay medical directors, as well as keep track of the work performed.
The announced Health and Human Services OIG effort is an outgrowth of previous studies that revealed as many as 36% of US nursing homes didn’t report having any medical director hours. Nursing homes are required to report hours worked by medical directors to the CMS Payroll-Based Journal system.
— McKnight’s Long-Term Care News, June 17, 2025
The crucial role of medical directors in nursing homes
If this data is accurate, more than one-third of the nation’s roughly 15,000 Medicare certified nursing homes are not complying with the OBRA ’87 law that mandates that each nursing home have a medical director.
Whether the number is accurate isn’t the point. What truly matters is if anyone, from the public to the nursing home industry, to policymakers, is invested in the person serving as the medical director. We believe that the inaccurate medical director data entered by many nursing homes reflects the importance they attach to these positions.
— McKnight’s Long-Term Care News, October 9, 2024
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.
Kumar said the problem likely stems from the data supplied by nursing homes and how medical directors account for their time. 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.
— McKnight’s Long-Term Care News, September 3, 2024
Report: More than one-third of nursing homes don’t have required medical director
The presence of medical directors varied by the state the nursing home was in and who owned it. For example, 61.4% of for-profit nursing homes reported a medical director presence compared to 71.3% of nonprofit nursing homes and 66.5% of government facilities. In just 0.2% of cases, the nursing homes were cited for regulatory deficiencies for not meeting medical director requirements.
“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. 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,” the authors wrote.
— McKnight’s Long-Term Care News, September 3, 2024
Study highlights lack of nursing home medical director presence
Medical directors ensure that residents receive high quality care based on their specific health needs, preferences and abilities. Inadequate care and oversight can lead to poorer outcomes, including loss of function, increased fall risk, increased hospitalizations, and even premature death.
“Our findings highlight a significant gap in the presence and involvement of medical directors, particularly in for-profit facilities, which raises serious concerns about the adequacy of care provided to residents,” Richard Mollot, executive director of Long Term Care Community Coalition (LTCCC) and co-author of the study said in a statement.
— Association of Health Care Journalists, September 2024
