5-Star rating system limited

Value, quality and efficiency are buzzwords in the field of contemporary health care services.

Health care payers, such as health systems, health insurers, accountable-care organizations, bundled-payment conveners, hospital networks, and similar entities, are seeking these objectives as they develop networks of providers for skilled nursing services and other long-term-care needs. While we all agree with these objectives, we also need to ensure there is a balance that reflects consumer preference, especially given the more personalized nature of long-term care.

Current efforts are focused on “narrow networks” or closed networks that raise concerns among providers and other stakeholders, because in some cases they are being developed without sufficient regard to the specialized needs of our older population.

Given the rapid pace of change in the health and long-term-care arena, shortcuts are taking place.

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Oftentimes, the CMS 5-Star nursing home rating system is being used as a blunt tool to determine nursing home provider eligibility for networks. The 5-Star system has several limitations that could inadvertently (or inappropriately) exclude a nursing home from a network due to their rating. In theory this sounds like it benefits the consumer or payer, however, in actuality the 5-Star system relies too heavily on nursing home surveys, has other significant flaws, and does not consistently reflect overall quality of care. One bad annual survey, based on a singular incident, can generate a handful of deficiencies that can dramatically affect a home’s star rating. In one actual scenario, a nursing home’s rating was adversely affected when they were cited for “two large cookie sheets not inverted on the top of the steamer and eight bundt pans on the top shelf of the storage rack that were not inverted” – deficiencies that clearly are not relevant to the quality of care provided. The 5-Star system was created to help consumers begin the process of selecting a nursing home, and was never intended to be used as the only standard of measure.

As we overhaul and integrate our health and long-term-care systems, consumer preference must remain a fundamental component of reform. Post-acute and long-term care is a highly personal decision that is often made when an individual is in a very frail and delicate situation. Indeed, a more deliberate process that factors in the quality and cost-effectiveness of care, the appropriate location of care, and other important factors should become the new standard for network development.

While some health care entities have begun using tiered or report-card type of approaches for evaluating nursing homes based on specific and diverse criteria from various data sources, these nascent efforts do not yet incorporate clear and consistent criteria that promote quality of care and allow for consumer choice. Specifically, our association of nonprofit providers would encourage networks to:

n Develop a slate of specific, relevant quality measures for the target population, which for nursing homes could include pain or pressure-uIcer prevalence, along with data from other sources on measures like hospital readmissions and length of stay. Consideration also needs to be given to small homes, where a handful of residents can affect their score.

n Incorporate the 5-Star staffing measure, especially since it will soon be collected electronically based on payroll records, which should improve its accuracy. This will help reflect the correlation between higher staffing levels and quality of care, as evidenced by dozens of research articles.

n Provide the flexibility and autonomy for nursing homes and other providers to manage the post-acute care of the individual, given that they have vast skill and experience with the older population. Predetermined care requirements or other mandates do not honor the unique, individualized care given by nursing homes and other post-acute-care providers.

n Establish a plan to incorporate additional factors in any evaluation process, including use of electronic health records, clinician and nurse practitioner availability, clinical protocols/care pathways for specific diagnoses, and resident/family satisfaction survey scores.

Health care management is more than a system of costs and bottom-line assessments. This industry is all about people and their quality of life, necessitating more subjective measures. There is research that indicates that long-term care consumers value kindness, choice on aspects of their daily lives, and other consumer-friendly factors when choosing a provider.

So while specific measures can be used to begin the process of developing a network of care, human interaction with these organizations must be taken into consideration and factored into ultimate decisions. Without solicitude, health care management simply becomes fiscal management, and could potentially overlook the needs of the same frail people for whom the system was created to serve. •

James P. Nyberg is director of LeadingAge Rhode Island, which represents nonprofit nursing homes, assisted-living residences, senior housing and adult day centers.

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