OBRA Regulations

Abstract

To the Editor:—At the annual meeting of the American Medical Directors Association held in San Antonio, Texas, on March 1–3, 1991. I listened to several speakers representing patient advocates and the federal government expounding upon new requirements regarding nursing home patient care (the Omnibus Budget Reconciliation Act of 1987 and subsequent amendments). These regulations became effective in October of 1990 and command new responsibilities for physicians attending nursing home residents to ensure patient rights and quality of care, especially as they relate to restraints, psychotropic drugs, and several common clinical problems, eg incontinence. I have no major disagreements with the content of these regulations and feel that if they are followed, the quality of life and medical care in this country's nursing facilities will be greatly enhanced. As questions and comments followed the several presentations I listened to a number of my colleagues react strongly and negatively to these regulations, and some personal thoughts crystalized which I am writing to share. OBRA rules and existing laws in many states prohibit aversive therapy or punishment to modify problem behaviors in patients. Aversive therapy and punishment are generally thought to be unethical and less effective than positive reinforcement. OBRA seeks to modify problem behaviors of physicians. The perception of physicians (if not the US Congress’ intent) regarding OBRA rules appears to be one of increased “hassles” and implied threats of punishment. This is coupled with a lack of positive reinforcement (adequate and reliable physician reimbursement for nursing home care from state and federal payors, strategies to help physicians efficiently deliver services, etc.). The “therapeutic plan” to improve physician performance in providing nursing home services seems unsound. While altruism and personal commitment to the provision of “state of the art” care are proud traits of our profession, it may be unwise for patient advocacy or government to rely on these intrinsic positive reinforcers alone to motivate necessary changes in practice behavior. Stronger federal support of undergraduate, graduate, and continuing medical education concerning practice issues and medical direction in long-term care and the urgent implementation of plans to upgrade and ensure remuneration for legitimate long-term care services are required to prevent an exodus of physicians from involvement in nursing home care.