We are in a brave new world when it comes to paying for skilled nursing care. There are Senior HMO’s, post-acute provider networks and a wide variety of ACO’s.
I have written before about the faulty nature of the Medicare Nursing Home 5 Star Rating System. This New York Times Article is further evidence that it is a failed system when it comes to identifying good and bad skilled nursing facilities. There are at least 3 major flaws:
- A facility can unfairly have less than a 5 star rating because they are taking more medically and behaviorally complex residents. This provides a disincentive for great skilled nursing facilities to take these difficult patients.
- A facility can lose or miss a 5 star rating over something stupid and inconsequential. It can then take several years to get their 5 star rating back.
- Worst of all, there are some skilled nursing facilities that have a 5 star rating and yet . . . they have serious, real problems.
Scamming the System
I want to start by saying that, even though the skilled nursing facility targeted in the New York Times article is near where I live, I have no personal knowledge about the quality of care. It could be that they have real problems or this could be a Pro Publica style hatchet job. Regardless, the fundamental point about the 5 star system being gameable is a serious issue.
According to the article, scamming the system to get a 5 star rating looks like this:
- Two of the three components that make up the the 5 Star rating are staffing levels and quality indicators, both of which are self-reported. This means that fudging or even outright lying is a huge temptation. Too often skilled nursing facilities just plain “forget” or fail to report information that would reflect badly on the facility.
- Because the inspections are all conducted by state surveyors, there is tremendous variability from state to state as to how the rules are applied. So the first way to game the system is to be in the right state.
The Other Big Hole
The 5 star system does not factor in fines and other enforcement actions against facilities. It also doesn’t look at the number of complaints a facility has received. While to a large degree it is fair that unsubstantiated and uninvestigated complaints should be viewed with great skepticism, a large number of complaints could suggest problems. Perhaps substatiated complaints should be a factor.
Why It Matters
We are in a brave new world when it comes to paying for skilled nursing care. There are Senior HMO’s, post-acute provider networks and a wide variety of ACO’s. Before it all shakes out we will see even more new payment schemes in an effort to improve care and reduce costs. Today the 5 Star rating is one of the biggest things these payor organizations look at. It may not be fair, but it makes sense that they look at the 5 star rating. First, what else do they have as a benchmark? Second, if a patient gets sent to a four star or three star facility and something goes wrong, the liability both from a financial standpoint and a publicity standpoint is huge. The easy way out is to only use 5 star facilities.
There seem to be three solutions to the problem:
- For the industry (primarily trade associations) to put pressure on the government and elected officials to make the system better. This seems obvious, but in fact it is problematic because in order for the industry to do this they need to start by acknowledging that some of their members are part of the problem.
- For those buildings that are doing a great job but don’t have a 5 star rating it becomes critical that they develop personal relationships with the organizations that control the flow of patients and dollars. With those relationships in hand, it then become possible, perhaps even relatively easy, to tell the complete story.
- This challenge creates a very real opportunity for accreditation organizations to step into the gap.
What Do You Think? Steve Moran
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I am the Administrator and CEO of a small not-for-profit nursing facility. I agree with everything that has been said about the 5-Star rating system. It really is a joke, and a disservice to consumers. Our trade association has repeatedly advocated with CMS for a complete re-work of the system to no avail. I have no idea how a consumer can make any sense of it when a facility can receive a 5 star for “quality indicators” but a 2 star for “staffing.” I would conclude then that less staffing leads to better quality. How can a facility receive a 5 star for “inspection results” when it has had multiple complaints within the last year? These are inconsistencies that I see all the time. Don’t even get me started on the survey process and the incredible inconsistencies with the process and scope and severity determinations. How is it that a facility can be rated over-all 5 stars one month, and then three months later.. with no change in operations.. drop down to a 3? How are consumers supposed to make any sense of this? And why won’t CMS seriously look at these problems?
Julie you make some great points. I think on of the big challenges is that somehow when it comes to healthcare we as a country don’t do a good job of empowering the public to be proactive consumers. Families need to visit these communities in the evenings and nights as well as the day time. I think much of the solution will be in the form of more consumer reviews where people can share their good and bad experiences.
In a sense, this isn’t any different than A Place for Mom, etc. Consumers are given the names of communities THAT HAVE PAID to have that “honor” of being on the list to choose from. For those that don’t, or can’t, pay, they aren’t listed or given to consumers. Hence, consumers think that they are the only places that are in their area that are the “good ones.” Many people I have spoken with, don’t realize the high fees they charge to the communities.
I’m so fortunate my family owns and operates these 3 facilities and Always remembers it’s all about the residents. Massive corporations are worried about bottom line period. I’m called 24/7 about everything and have authority to get residents what they want immediately without the red tape. If the big guys realized this their census would be 98% as well for 10 plus years. They are too near sighted and quite frankly don’t truly care. Not the employees the corporate ownership.
Hi Andy: I think there are lots of great family owned communities. I also think there are some great communities that are owned by both large and small corporations. Conversely, I can point you to dozens of small family owned communities that are pretty terrible. It really has to do with the philosophy of management regardless of large or small or profit or not for profit.
I am always encouraged to hear from and about companies like yours that take great care to heart.
I think there are many reliability issues with the 5 star rating and some faculties look better than they are while other much worse than they are. But some of this article might be misleading.
Substantiated complaints are part of the 5 star rating because when a complaint is substantiated it results in a citation. All citations are listed not just your annual survey.
Second the quality rating comes from our MDS data although we (our nurses) do fill in our MDS there are many reasons a facility would not want to lie on a MDS. The MDS drives both clinical care and payment so that intently lying on an MDS could involve sanctions, fines, and possible jail time. I doubt anyone especially the RN filling it out and signing it would risk all of that just to improve a 5 star rating.
One of the really weak areas in the 5 star rating is staffing. It is totally self reported during the annual survey. I believe this number is sometimes not accurate. Also staffing is calculated from the last two pay periods starting from the day the surveyors enter the facility and then compared to the census on the day the survey team arrives. So let’s say you had low censes for the last couple of weeks so you adjusted your staffing down and then censes bounced back a day or two prior to your annual survey- your average staffing for the last few weeks would appear very low compared to the one day that censes had rebounded and your surveyors walked in your door.
I also agree that states widely differ in how they give out citations. The new QIS process has helped but enforcement of complaint investigations can vary greatly from state to state this would also lead to inaccurate results. All in all the 5 star rating is just a kick off point in looking for a quality facility.
Kate you make some great additional points.
Another problem with the system is that no facility moves up any stars, until another facility moves down. So your facility may be a 3 star facility, but has all the factors and scores to be a 5 star facility. Your facility will not move up until a current 5 star facility score goes down.
There is to be only so many 5 star facilities, 4 star and 3 star facilities and the rest. So you may stay at a 3 star for months or a year before moving to the 5 star rating.
Chris that is a great point.
There was a statement in the NY Times article that facilities can increase their staff because they know when surveyors will be at their door. This is not accurate. Facilities may know their “window” (within weeks or months) when the state may show up, but in no way do they know what day, so staffing up would be a waste of money for facilities.
It’s not like the hospitals who know the exact time frame that the Joint Commission will be doing their survey.
I am not sure what Chris is talking about. You can move between Star ratings independent of the number of homes that have 5, 4, 3, etc. Star ratings.