Taking Healthcare by Storm: Industry Insights with Dr. Brian E. McGarry

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Brian E. McGarry, Ph.D., a physical therapist and health services researcher with an interest in the economics of aging. 

Dr. Brian McGarry discusses his path to becoming a researcher, the impact of public policies on Medicare navigation, and the vital role of consistent healthcare staff and certified medical directors in improving care quality in nursing homes. He highlights the importance of addressing staffing shortages, patient preferences for home-based care, and the lessons learned from the COVID-19 pandemic.

Read the research articles:

• Trends in hospital discharge outcomes among high-risk Medicare beneficiaries before and during the COVID-19 pandemic
• Preferences for Postacute Care at Home vs Facilities
• Health Care Staff Turnover and Quality of Care at Nursing Homes

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

Publication number QI-072525-GK

Transcript

 Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hello everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical Director of Quality Insights, and today I am excited to be joined by Dr. Brian McGarry. He's a physical therapist and health science services researcher with an interest in the economics. Of aging.

Something that is so very important right now is we have a further increasing aging population. His research focuses on older adults, navigation of the Medicare program and the long-term care system. Something that I know firsthand can be very confusing. For many individuals as well as the impact of public policies on the cost and quality of care delivered to older adults, something again, very relevant, very important.

Right now. He completed his PhD in Health Services Research at the University of Rochester School of Medicine and Dentistry, and a postdoctoral fellowship. In health, economics and policy at Harvard Medical School, and today we're gonna be talking about three of Brian's published papers and what the implication of those papers are in long-term care in just healthcare in general for older adults because.

I think sometimes we see papers that are published  and many of us are say, okay, so what does that have to do with anything? Or how can this be useful? Or What insights can we glean to kind of guide us forward in initiatives or interventions? Whether we're providers, whether we're staff in long-term care facilities, whether we are providers serving the outpatient setting.

I think that these papers can be very useful and I am very excited to jump in and talk about them. Brian, Dr. Brian McGarry, thank you very much for being with us today. My pleasure. Happy to do it. Great. So tell us how you came to do what you do and what are your interests in healthcare? Yeah, that's a great question.

 I think maybe took a little bit of a circuitous path to get here. Really envision myself as being a practicing physical therapist, and probably at the start of my career, really thought I would be like a sports physical therapist working with younger people at their peak physical condition, helping them rehab from injuries.

And over the course of my sort of early days in physical therapy. I kept finding myself sort of pulling to this older adult population. And so that started to sort of plant the seeds of, being interested in the intersection of, our healthcare system and, how we take care of older adults.

And then I became really interested in kind of the ways that our public policy shape. How we're able to deliver healthcare and long-term care and how we separate health and long-term care systems from each other and all the ways that this makes it, you know, really  truthfully complicated for older adults to navigate this as well as their families.

So that really kind of sparked my interest in understanding. How the system that we create from a state and federal government standpoint sort of creates the actual health and long-term care systems that we end up using in our day-to-day lives. So I decided to kind of pivot my career a little bit and went back to school and as you mentioned got a PhD to.

Learn more about public policy and also how to do research in that space. And it was really in grad school where I, I really fell in love with the research aspect of it. And to your earlier point we love  I love sort of answering tough, tricky questions and helping to sort of translate the answers to those questions from a scientific standpoint into.

Actionable insights that hopefully can serve policy makers at all different levels to try and do better  to make a better functioning health and long-term care system to make sure that we can do right by our older adults and make sure that they have the chance to. be as healthy as possible and to age with dignity and receive care that's consistent with their preferences, and that is good care that, you know, you would want for a family member.

 Yeah  that's really kind of my path, I guess. So I, I don't actually  treat patients as a physical therapist. Now  that's more sort of something that's  in my background and kind of gives me that. Clinical context that I think informs a lot of the research that I do. But for the most part I, spend my days in the academic setting doing research, doing some teaching, and hopefully moving the needle somewhat in terms of informing public policies in the us.

And I definitely think you're doing that. I had a hard time picking out what papers I wanted to discuss today because I think they're all really important. So starting with COVID pandemic, and I think a lot of people want to leave it behind.  You know, I know it was difficult for me. I was in several long-term care facilities as a medical director, as the only physician in the facilities during the pandemic, but I think.

It's important. This paper is important and I'm gonna mention the title in a minute.  I think it's important because we've really forgotten lessons that maybe we could have learned and maybe we should learn now that could be useful for us now. And I think if you just kind of say, oh, whatever, it's over, or, we did a poor job, or we did a good job, or whatever you think, you know  you really lose the benefit.

Of lessons learned that could help us now, so the title of this paper is Trends in Hospital Discharge Outcomes Among High Risk Medicare Beneficiaries Before and During the COVID-19 Pandemic. So this study highlights how hospital outcomes for high risk Medicare patients evolved during the pandemic.

And I certainly saw this  it was a very interesting, I think the evolution of what was happening was. As I look back, it was very interesting, so particularly around length of stay and discharge patterns. What surprised you most about how quickly or slowly health systems adapted o over the course of the pandemic?

it's a great question. And I, before I answer the question, I'll just, I'll quickly acknowledge  Tony Roberts who's a graduate student at  brown University. He led this paper and did a lot of great work on it. But I think in terms of what surprised us maybe is in the broader context, both of this paper, and I think just what we observed during the pandemic was.

Maybe some of the, disconnect in terms of how responsive different places were, and I'm thinking specifically of, you know, differences between how the hospitals responded and how say a nursing home responded. The pace seemed to me very rapid at hospitals. I think early on in the pandemic there was so much attention given to.

Maintaining hospital volume, right.  we were very worried about having enough beds to accommodate surges and COVID infected patients. A lot of focus on whether or not places had enough ventilators, enough PPE in the hospitals. So that really became   a primary policy focus at the time. We did a lot to sort of bolster hospital capacity, right?

We built in some of the major cities like New York City, we had the temporary like field hospitals and the hospitals on naval ships that were at the ready if they were needed. And we also put a lot of emphasis on. Clearing hospital beds once patients were stabilized. And that created this kind of conundrum of  what do you do with these patients once they're stabilized and maybe don't need an ICU bed or don't need an inpatient hospital bed?

Where do you send 'em after that? And in the past, you know, nursing homes or skilled nursing facilities have been the primary place that's filled that role. And so I think initially. Particularly in certain states, we just kinda stuck with the status quo. And so this is an example of like maybe not shifting rapidly enough in the nursing home setting to say like, okay, well, this patient's ready to be discharged.

Normally we send a skilled nursing facilities, so we're gonna ship these patients to skilled nursing facilities to continue their rehab and recovery. Of course that almost seems absurd. I think talking about it now in hindsight, where we know like these nursing homes also were housing, you know, probably the most vulnerable population.

So the idea of sending  COVID positive, but recovering patients there seems kind of crazy now.  At the time I, don't think we knew that and when, I think we were really focused on maintaining hospital capacity and throughput and that became the priority. But as we went through the pandemic and I think, you know, saw  that probably was not best practice.

And, I have a paper that shows. Basically that facilities that did take COVID positive patients early on in the pandemic  at the nursing home level they did experience higher levels of COVID cases and deaths in the aftermath, which is really consistent with.

Recovering COVID positive patients, seeding outbreaks. So, I shared that story mostly as the contrast between how we very rapidly sort of adopted hospital practices and I think adaptation at the nursing home level sort of lagged behind. So I think there's a real lesson to be learned there in terms of thinking about the health.

And by extension, the long-term care systems, which we often separate those two.  But nursing homes are at this weird intersection where they are very much part of the health system and facilitating rehabilitation for recently hospitalized patients. And they're also the backbone of our long-term care system providing care for disabled older adults who can't live on their own in the community.

So thinking about the health system holistically across the whole continuum, including the long-term care system and sort of optimizing resources and the big picture as opposed to kind of doing this in a very siloed fashion.  at starting with just hospitals and then sort of dealing with the unintended consequences of prioritizing hospitals.

As the next phase of it.  I think we could be much more thoughtful and kind of big picture focused. Hopefully we don't, but if we had the opportunity to kind of do this again, I think that's probably one area we could improve on.  I agree. And I think we learned, you know, I think maybe people assumed, oh, you're isolating them or whatever.

We learned  that's not the best course of action for quality of life. For long-term care residents, like they were in isolation. People were locked down for  long time. And yeah, it's a, I personally feel like we've learned that we need a different solution. I'm just waiting for measles to show up in facilities and I'm sure that's already happened.

 So it's a big challenge. So shifting to the next paper, which I think is very interesting, its preferences for post-acute care at home versus facilities. And this was published in JAMA Health Forum. We're gonna link all these articles in the podcast. And I think this is a really, interesting question to ponder.

And so you the paper demonstrated as that individuals have a strong preference for home-based care, which makes sense. It makes sense. People wanna stay at home even if there's a willingness to pay more to stay at home. So what do you think this suggests that how we should rethink the way post-acute care is delivered and financed in the United States?

Yeah. Quickly I'll just I'll give a, shout out to Fang Gang who  led this paper. This was part of her dissertation work. She's now a faculty member at Brown University. She led this really great paper, I'm just sort of writing her coattails here.  But really used a very creative, clever method to kind of get at people's underlying preferences.

And  as opposed to just sort of going and asking people, right? Where sometimes these concepts are sort of abstract and it's hard to kind of tease out people's real preferences. She gave people kind of in an experimental setting, all these different scenarios and ask them to sort of make like tough trade-offs between if you were injured and recovering, would you rather recover at home if you knew that a loved one was gonna have to spend, eight hours a day helping you or would, in that scenario, would you rather be in a nursing home? So really valuable information about kind of how people weigh off these different trade offs between different settings. So with that information in hand to, to kind of think about your question of what should we take away from this?

 I think we've known this for a while and the post-acute care system has been moving in this direction of. Understanding that for most people, we'd much rather prefer to be at our home where we're most comfortable as opposed to an institution. I think we've been trending in that direction.

   Skilled nursing facility use has been going down over, over the years. This is  pre pandemic data or, and trends, but. Gradual decline in the use of skilled nursing facilities following a hospitalization with a corresponding increase in the use of home care at home, aligning with those patient preferences.

And I think it starts to raise important questions from a policy perspective about capacity.  You know, do we have enough home care capacity? I think the answer there is, probably not,   we're struggling with. Worker shortages in that area.  Concerns about there being lags and sort of how long it takes for patients to get discharged before they start their actual episodes of home care following the discharge.

And then correspondingly  this was kind of an interesting pre pandemic question of like, how much nursing home capacity do we need? Knowing that we had kind of seen these gradual declines in the number of nursing home beds and also the number of people in those beds. So I think there was kind of this sense that we were gradually shifting towards more home-based care and starting to downsize or sort of right size our nursing home capacity.

So then comes the pandemic and that really accelerated, those trends and the first paper we discussed, I kinda skipped over this but it really shows that clearly that nursing home use, following a hospitalization really dropped off during the pandemic.  And still  with some current data we're looking at, I can say still hasn't recovered to those pre pandemic levels.

And the reasons for that are complicated. I would say. I think it's a mix of. Demand for these beds. So like patient preferences, obviously during the pandemic. All that you heard about regarding nursing homes was bad, right? It did not do anything, I think to bolster people's interest in going to a nursing home or using  nursing home-based rehab services.

 So we do think the pandemic probably accelerated those patient preferences to do their rehab at home if possible. As fan Lee demonstrated in her  paper that she led, but at the same time, the pandemic has also been really challenging for nursing homes. From a financial perspective, increased costs  has led to historic staffing shortages that still haven't recovered  to pre pandemic levels.

And because of the inability to hire and retain staff  anecdotally at least we think that nursing homes have had to take beds off of line or close entire units or wings of their nursing homes. So our sense is  and we're actively doing work in this space but our read of the data is that the nursing home industry outpaced or it lost capacity at a rate greater than we were seeing.

The demand for nursing home beds decline. Our feeling is we probably have too few nursing home beds in operation. And so that raises concerns about patient's ability to access care. Because I think, you know, as much as we talk about patient preferences to rehab and this extends into the long-term care space too, of like. patients prefer to age in place older adults prefer to age in place and receive, long-term care services in their home as opposed to an institution. But there is this sort of core population who is always gonna need institutional based rehab or institutional based nursing home care.

So. The people we're talking about of sort of shifting from the nursing home to home, we would describe those patients as being like, they're on the margin, right? They could clinically go to either space and probably have a good outcome. But for some types of patients, and these could either be because of the complexities of their conditions or the needs for the types of services that.

Only a nursing home can provide because it's an inpatient setting or the need for sort of 24 hour supervision or the lack of a suitable home environment to have home-based rehab, or a spouse or a loved one who can provide. The kind of unpaid additional support that home care implicitly relies on.

All of those factors may lead a big chunk of the population to really not have the option of doing rehab at home. So we think there's always gonna be a need for some sort of institutional based, post-acute care, even if that's not all else being equal, where patients would most prefer to do their rehab.

So it raises concerns about.  We've placed a lot of emphasis on shifting care to home care. I think we've thought more about bolstering that area in terms of growing capacity and our ability to provide that care as a, US health system. And some of the insurers, I think, prefer to provide post-acute care in the home setting because it's, you know, inherently cheaper.

 Cause you don't have to pay for room and board. It's not 24 hours a day. But now we're in this position where the pandemic kind of may have taken it too far in the one direction, and now we're worried about  do we have enough capacity and enough nursing home beds to meet the needs of those patients who really need to be in that setting.

Yeah. And you touched on staffing, which is like the huge challenge right now in the post. Absolutely. So, Leading into the next paper that we're gonna talk about, healthcare staff turnover and quality of care at nursing homes which was published in Jam Internal Medicine is just really interesting.

So given the clear link that was found between turnover and lower care quality. Especially around patient functioning. What kinds of strategies or policies do you think are most urgently needed to stabilize the workforce in nursing homes? I know the staffing mandate was recently struck down, so  I'd love to hear your thoughts around this issue.

Yeah, it's such a great question. And you know, I think with the research right now, the paper you mentioned plays into this, we're finding staffing is so important not only for determining the quality of care delivered in nursing homes you know, as I mentioned earlier. The staffing availability is really setting capacity right now.

 We have plenty of physical beds, but we don't have enough staff to staff them all. And so because of that the inability to hire and retain staff really becomes  the binding constraint in terms of how many beds we have in operation in our, healthcare system at any point in time.  it's a huge issue.

And to your point, the Biden administration's federal Minimum Staffing rules. I think we're still kind of seeing what the end result is going to be for that. Interestingly from what I've have seen, I, I have not seen the Trump administration take a stance on it. I think many observers are expecting, they probably will not support or continue to fight in court to have those be enacted.

But thinking back to a, year ago when we thought that these were gonna be the law of the land. A huge, significant step. I mean, it certainly has the policy itself has lots of critics, but, you know, really one of the, the largest reforms  at a federal level around nursing home staffing and quality in multiple decades.

 So it was a big deal.  I think important that it really acknowledged the importance of staff and placing the onus on facilities too. have enough staff to provide high quality of care to residents. I think we know staffing levels are important. Our paper shows, it's not just about the levels, but it also matters that you have a consistent high quality group of people working in the facility.

It's not just about, you know, having bodies there, like these are tough jobs. I always describe. Working in nursing homes, particularly for the CNAs who are really on the front lines of this, but applies equally to the LPNs and the RNs working in nursing homes as well.

These are tough jobs. They're physically demanding. They're very hands-on, they're emotionally demanding. You mentioned this earlier with the pandemic, but we really relied on isolation as a strategy to try and protect patients from COVID and. Because of that staff, filled in for family oftentimes, and they were the people who were.

Holding residents hands in their final hours or providing emotional support as well as like the day-to-day physical care needs. So these are tough jobs  that ask a lot of the people who work in them, and they don't necessarily pay them that much differently than other sort of competing jobs in like the service sector or  working for Amazon or working in food services or something like that.

  I think that's. That's a real issue that we need to tackle  and to think about whether we as a country are investing enough in these jobs  and paying them at rates that are commensurate with the value of the services they're providing so that it's easy to say that, right? Like we need to pay them more.

That leads to some tough questions of where's that money gonna come from? This is touching on a, heated debate. There, there's the one side of the debate that would say there's plenty of money in  system. It's just that we need more accountability. We need to make sure nursing homes.

Are spending that money, investing it on things that directly impact resident care as opposed to profits.  My colleague Ashvin Gandhi  at UCLA has a really great paper that shows using some really detailed cost report data from the state of Illinois that this concept of sort of profit tunneling  or hiding profits by nursing homes.

Basically paying themselves at elevated rates to provide like maintenance services for the facility or something like that through related party transactions. That this isn't just a myth it gets talked about a lot. It is something that is done in practice. They show this in their data that. Once facilities are acquired by these conglomerate groups  they start paying higher prices for these types of services.

So I think that's a real concern, and I think the way to address that is through greater financial transparency and holding facilities accountable for the dollars that they receive from the various payers. Medicare, Medicaid and private pay. And to make sure that they're investing those into resident care.

But I think the critics on the other side also, you know, have a really valid point that we've decided to finance nursing homes through this kind of  two tier system where Medicare is paying for the short stay rehab patients. The long stay patients are being paid a much lower rate typically on a daily basis from the state Medicaid programs.

So that creates some real disparities. And I think there's certainly some evidence to support the notion that, nursing homes are not making much or any profit in some cases are losing money on their long stay Medicaid patients and sort of trying to recover those losses with their short stay rehab patients who hopefully they can discharge back home at the end of their stays, and so that creates some weird incentives for the nursing homes.

Going back to my earlier point about there not being enough capacity in the system. It probably won't come to a surprise to your listeners that if the nursing homes are short on beds  to give out to new patients, they're gonna prefer to give those beds to the most profitable patients. So further, kind of raising concerns about access and in tough financial times, the facilities  are probably not gonna be able to, do the necessary investments in staff to sort of reduce turnover, bring in new staff, and really recruit and pull workers away from other healthcare settings and other sort of service sector jobs that maybe are asking less of them.   I've said a lot of words on  I think some of the financial pieces of, what  the system might be able to do.

But I would be remiss if I didn't sort of mention as well that a lot of this goes beyond finance  and how much we're paying these workers and what their, you know, health and other benefits are. And it has to do with I think job quality is really important. Nursing homes. Are at a disadvantage in that they're open 24 hours a day, so they need to staff 24 hours a day.

Lots of reports of facilities using sort of staffing practices where, staff are, on call, they're, they have mandatory reporting.  If the facility's short staffed, they have mandatory overtime, that can really make it difficult for workers to juggle work  and home life and responsibilities to family and children.

Long shifts are, an issue here. When you're short staffed, that inherently places more demand on the staff who are there. So that can certainly contribute to burnout. And then there's this kind of other issue of  is there opportunities for career growth in the nursing home?

And I think that's something we could definitely do more to invest in, is to take people who are, motivated, feel passionate about. Providing high quality of care to older adults and are maybe entering into the system as  certified nursing assistants, which, you know, admittedly the facilities do a pretty good job, I think of.

Recruiting those patients and doing their training either in-house or paying for them to get their certified nursing assistant certification. But I think it's that next step of is there opportunities for them to grow, to take on sort of like leadership positions within their care teams.

And then I think one piece that we haven't invested enough in is. Helping people make the transition from, you know, maybe being a CNA to moving up into the, licensed practical nurse space where they're getting additional training  they're getting additional  license in fact to be a nurse.

 And I think really have opportunities to grow their career. I will say, just speaking about the minimum staffing requirements from the Biden administration. Sort of talking about these hypothetically at this point now, but they provided specific staffing targets for RNs and CNAs, which in my opinion, that was probably a mistake.

I think being silent on LPNs in terms of needing a minimum number from either any type of nurse or having something specific about LPNs as opposed to registered nurses Had the potential to have this unintended consequence of sort of crowding LPNs out of the types of staff that nursing homes were incentivized to hire.

And I think LPNs really fill a critical kind of middle ground between CNAs and RNs. And I think really are that key. Rung in kind of a career ladder to help retain your best CNAs and give them a path to move up into positions with more responsibility and hopefully better pay and better benefits and more consistent hours.

So that is a place I would like to see us do better on, is to really think about how do we invest in  recruiting people into this space and then giving them opportunities to. Advance their standing and advance their qualifications. And I think  that pathway from CNA to LPNs is a really great pathway that we should be probably investing and promoting more.

Yeah  I will agree. And I'll just say I have one, one of my. Favorite individuals in the long-term care space was a CNA and is now in a nursing home administrator. And just, it's a  it is just a really wonderful way. I've met so many individuals who have started as CNAs and facilities  and then worked their way up to whatever position, and it is, it's a really it's really wonderful to see.

 So kind of on that vein, I am very interested in the medical director of facilities.  Obviously leadership influences care quality in long-term care facilities. So we know that in California uh, it is required of all facilities, I think by 2026, that all medical directors must be certified  by Pulp Med Post-Acute and Long-Term Care Medical Society.

And  I am A-C-M-D-I. Part of the faculty that teaches that course of volunteer faculty. And I love it. I think it is just a wonderful curriculum.   I believe in it, it makes sense to me. I've seen how applying the principals directly does improve care in a facility. So from your perspective, how does having a certified medical director in a nursing home impact key quality measures?

Yeah, that's a great question. I think from a research standpoint, this is like a very new kind of area where I think we're starting to shift away a little bit from just thinking about the frontline staff to starting to think about the role of, as you said, the role of leadership  the role of  clinical presence at nursing homes and how that affects the quality of care.

And I think the COVID Pandemic really shone a light on this where I think that was often found. Lacking at a lot of facilities and our tendency to kind of carve nursing homes out from a typical healthcare system and having sort of a lighter clinical presence at nursing homes  really came to the forefront and I think highlighted why some facilities early on struggled with implementing best practices around infection control.

So I think this is a great area to be thinking about and discussing. It also happens to be an area I have some sort of ongoing work that, that we've been  focusing on myself and my colleague David Grabowski at Harvard. And so here we're studying what happens when nursing homes hire a new medical director.

Who either has their CMD or will go on to get it.  And to your point, we do find quality improvements after the nursing homes hire These new medical directors and the quality improvements seem to be concentrated around hospitalizations. We see reductions in hospitalizations which I think really speaks to the role of clinical decision making and deciding sort of what can be treated on site versus what needs to be sent.

To the hospital. I think we all know hospital visits for older adults in nursing homes can be very disruptive and detrimental. So we try to avoid those at all costs if they're not absolutely necessary. But I think the real big  uncertain question right now and the state of California provides a really exciting opportunity to try to answer this question is.

The quality effects that we've been seeing in our ongoing work, whether those are a product of essentially just hiring like good medical directors who are, highly motivated and are passionate enough to self-select into going on to get the additional CMD training or if there's something really special about the training where.

If you take the typical person who works as a medical director and then give them this additional training, does that influence their practice and change their ability to shape quality at the nursing home? So pulling back the lens a little bit, I think the question is leadership matters.

 I think there's sort of growing consensus around that, that leadership is important. The question I think is more, is it about sort of hiring the right person to be the leader, or can you create a good leader with additional training and, is the CMD certification, that additional training to, create a good leader, an effective leader within a nursing home?

Yeah. And I will say I am really excited to see how things turn out. I'm really looking at California, and I think it's, On the legislative docket for many states  West Virginia being one of them. 'cause I think Dr. Mercer, the  pulp Med Medical director of the year kind of got together with Joe Manchin to suggest that, and I think it's gonna be really fun to watch.

Yeah. So  I presented some early work on this at the, pulp Med 2025 conference. And. Really was struck by the, I'll say passionate conversation that happened during the session around some in favor of moving towards this legislative approach of mandating  the CMD requirement for all medical directors, but also some vocal critics really pushing back to say, you know, I think their points were like.

We shouldn't be focusing on kind of requiring this additional training. The emphasis should maybe be more around transparency and like being able to publicly view who's the medical director at each facility.  I know that there's a lot of concern over the sort of offsite medical director model where.

A physician who maybe has a, full practice somewhere else is also the medical director at 10 facilities. And, you know, their main function is just sort of checking that box of meeting CMSs requirement to have a medical director on paper, but not really being involved in, in the day-to-day. And so I, I,  I do think that there's like a, healthy debate going on.

Among the, people in these roles and also policy makers thinking about it. But certainly California, as you said they are doing the work and providing what we call in our research business, a natural experiment where they have this law, they're gonna require it. They're, they have a five-year phase in period and they're coming up, I think maybe  at the start of, so like 2026 I think is the last year, people have to sort of get it, and then starting January 1st, 2027 the, law becomes sort of like binding, I think. from what I've heard  they're seeing movement, they're seeing some people um, get the certification, the, their numbers are going up.

 As people prepare for that, and I think our job as researchers is to track this and to see what happens to quality outcomes in the facilities of those medical directors who were sort of moved by the policy  who didn't have the CMT training, but went out and got it because of the legislation and to try and get some hard data to answer this question of, is it just about hiring the right person to be your medical director and insisting that they be an active, engaged medical director as opposed to a remote, offsite, disengaged medical director, or can we train people to become sort of exceptional medical directors by providing them with additional skills and knowledge base?

Yeah, it's a really interesting question and I'm excited to learn more. I'm  maybe we can have you back on when we have some more information. Yeah, I would love it.  I've made this joke among colleagues before, but I. As researchers, we like when  policies get enact like overnight, they go from off to on.

It makes for good research, it speeds up the process.  It makes our lives easier. That doesn't always work from an actual implementation standpoint. So we're all kind of on the edge of our seat As California took this sort of gradient approach where they, sort of ramp up a little bit over time and they give  physicians, you know, this five year grace period to, to get the training done and to get into compliance.

So it's left us all sort of you know, sitting on the edge of our seats waiting for the policy to take full effect. Yeah. Exciting. Thank you very much for being with us today. We will link all of these articles if you're interested in, looking at the paper in the podcast. But Brian, thank you very much for being with us today.

My pleasure. This was fun. 

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

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