For the first time in history, the U.S. Centers for Medicare & Medicaid Services last week released quality ratings for the 15,800 nursing homes that participate in Medicare or Medicaid, based on health inspection surveys, staffing information and quality-of-care measures.
The ratings, posted on the Nursing Home Compare Web site at www.medicare.gov, use a five-star system to rate a home from “much above average” (five stars) to “much below average” (one star). Rankings are dynamic and will be updated monthly.
The goal, said CMS Acting Administrator Kerry Weems, is to “provide families a straightforward assessment of nursing home quality, with meaningful distinctions between high and low performing homes.” But not everyone sees it that way.
Virginia Burke, president and CEO of the Rhode Island Health Care Association, the state’s largest trade association of nursing homes and rehab facilities, explained her group’s concerns.
PBN: How does the new system work?
BURKE: The formula for assigning stars is based on how nursing homes perform on the annual inspections or “surveys,” conducted by regulators to assure compliance with Medicare and/or Medicaid rules. Each nursing home is assigned from one to five stars, based on the number of non-compliance incidences or “deficiencies” uncovered on recent surveys. That number can then be bumped up or down on the basis of staffing, as well as on the home’s performance on 10 “quality measures.” These are data items that nursing homes must report to CMS on a quarterly basis, and include such items as the prevalence of pressure ulcers among its residents, or the number of residents who receive flu shots.
PBN: What is your concern about the system?
BURKE: That it does not reflect the outstanding performance of Rhode Island nursing homes on national quality measures. According to CMS data, we have the lowest average number of deficiencies per survey, as well as the highest percentage of nursing homes with deficiency-free surveys. Rhode Island nursing homes also had the highest scores in the country on 2007 satisfaction surveys conducted by My InnerView, a leading national supplier of satisfaction measurement applications for the senior care profession. … All of this is invisible in the five-star system, since nursing homes are primarily benchmarked against other homes in the same state. A Rhode Island nursing home with two stars may provide better care than a three-star nursing home in an adjacent state, and consumers have no way of knowing this.
PBN: You have other concerns as well?
BURKE: The system does not measure quality in a realistic or effective way. The survey system measures regulatory compliance – which is not the same thing as quality. Surveys only measure deficiencies and do not recognize high performance.
And there are obviously some glitches in the system. Alaska, for example, scores among the worst in the country for nursing home performance on surveys, while Rhode Island scores the best. Alaska does worse than Rhode Island on quality measures. Yet Alaska has the second-highest percentage of five-star nursing homes and is the only state with no one-star homes. In Rhode Island, the two-star homes include some of the best nursing homes in the state.
The five-star system does not measure special capabilities such as dementia care, and the staffing component of the score is skewed unfairly for facilities offering subacute rehabilitation. Another pressing concern is the absence of satisfaction survey data.
PBN: Why are satisfaction surveys important?
BURKE: While families may be interested in whether a nursing home’s dinner plates meet regulatory requirements for size and appearance, they are certainly more interested in whether the residents are treated with kindness and respect. Regulatory surveys measure the one, satisfaction surveys measure the other. Who better to judge the quality of a nursing home than the people who use its services? Certainly customer satisfaction is an essential element when judging the quality of a nursing home, or any health care facility.
PBN: How do you get past that? Is there a better way for elders and their families to choose a nursing home?
BURKE: A person looking for a nursing home should get referrals from physicians, friends and advocates. Then, most importantly, make a personal visit. Nothing takes the place of seeing and experiencing a home for yourself. It’s also a good idea to ask for the results of recent satisfaction surveys. If a given facility’s five-star rating raises concerns, speak with the nursing home’s administrator to fully understand the data.
