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Choosing a Medical Director: One Size Does Not Fit All

April 1, 2003
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An interview with Keith Krein, MD, CMD
AN INTERVIEW WITH KEITH KREIN, MD, CMD The medical director of a skilled nursing facility must wear many hats and please many people, and this professional's dual roles as both physician and administrator might seem, at times, contradictory. This person is expected to juggle regulatory pressures and clinical best practices with all the aplomb of a seasoned circus performer.

How does a skilled nursing facility go about finding a physician who can attend to clinical matters while staying on top of the many administrative duties the job of medical director entails? Editor Linda Zinn asked long-time medical director Keith Krein, MD, CMD, the corporate medical director for Cleveland, Tennessee-based Life Care Centers of America, and former president of the American Medical Directors Association (AMDA), to share his insights on finding a well-qualified medical director and, once hired, what to expect from him or her. Zinn: What qualities should nursing home administrators look for in a prospective medical director?

Dr. Krein: In addition to the appropriate medical credentials, he or she should have a genuine interest in caring for the frail elderly. Enthusiasm for individual patient care is, of course, important, as well as enthusiasm for medical management of the population as a whole. For example, the medical director will need to assist in the oversight of infection-control surveillance, vaccination programs, efforts to reduce the risk of falls and use of restraints, adequacy of nutrition, hydration and skin-integrity programs, and quality-improvement analysis and processes. Additionally, the medical director can be very influential in establishing a professional and caring culture in the organization.

Well-qualified medical directors also should complete the appropriate continuing education in administrative medicine and medical-management curricula. He or she should be a team player with good interpersonal and conflict-resolution skills, to enable him or her to work effectively with the interdisciplinary team. He or she should have a flexible nature and be a good listener, with tolerance for addressing regulatory-compliance issues.

It will be helpful if the prospective medical director has an interest in administrative medicine and/or previous administrative experience, having served in such capacities as committee chair, department chair, or chief of staff of a hospital or in some other civic or community leadership/administrative role. Simply finding a physician with the largest or busiest medical practice in town is not the answer. Such a physician might hate dealing with administrative and regulatory issues and participating in committee meetings. If you hire someone like this, you will both be disappointed.

Zinn: Do you think it's a good idea for a facility's medical director to have a percentage of his/her own patients residing in the facility?

Dr. Krein: This is a much more complicated question than it might seem. As a result of both Medicare reimbursement rules and the Stark Regulations (which deal with patient referrals and "fair market value" payment for services, etc.), facility administrators must realize that the compensation a physician receives for his/her administrative responsibilities as medical director is separate from his/her patient practice as an attending physician. In light of the Stark Regulations, one could even argue that having a medical director with no patients in the facility would be the least complicated and cleanest scenario. However, I want to be quick to point out that these regulations certainly do not require such a scenario, but rather create "safe harbors" for patient referrals, compensation, etc.

On the other hand, one could argue that if the medical director were also the attending physician for several of the facility's residents (say 10 to 30%), he/she would experience firsthand the adequacy or inadequacy of clinical policies, communication between nursing staff and community physicians, medical rec-ord documentation, resident care outcomes, etc.

In most facilities across the country, it is the norm for a facility medical director also to care for some percentage of the resident population; how much varies greatly, from a handful to 90% or more, with perhaps 10 to 40% being the most common range. I am not, however, implying that there is one clear answer to the question of what percentage is advisable. I have witnessed situations that could only be described as extremely successful and productive, in which a medical director provided no direct patient care but was otherwise highly skilled and qualified. On the other hand, I've seen situations in which the medical director cared for more than half the facility's residents, yet was not even conversant with the adequacy of facility policies, documentation, communication, care outcomes, etc.

Of course, this discussion brings us back to the qualities of a good medical director. If those qualities are present, success is likely regardless of the number of patients to whom he or she provides attending physician services.

Zinn: Do you think it's a good idea for facilities to hire medical directors who are retired from private practice? Why/why not?