A Five-Star Invitation: CMS Solicits Input Regarding Nursing Home Rating System

July 16, 2008

Participate in improving your government before it participates in “improving” your governance

“More than three million Americans rely on services provided by a nursing home at some point during the year. The new “five-star” rating system will provide a composite view of the quality and safety information currently on Nursing Home Compare (“NHC”) to help beneficiaries, their families, and caregivers compare nursing homes more easily,” or so says Kerry Weems, CMS acting administrator. CMS is also requesting your assistance to improve the NHC website. You should take the opportunity.

The proposed plan will provide a nursing home quality of care rating of 1 to 5 stars derived from three data sources. The ratings will include health survey inspections, quality measures and nurse staffing information to consumers in a “simple, easy to understand,” five-star rating similar to the National Highway Traffic Safety Administration ("NITSA") ratings. Unfortunately, to create the “easy to understand” rating system, a lot of real data must be “converted” into quality measurements. The stated goal is to distinguish between high performing and low performing homes. If the federal government’s history of five-star ranking systems is any guide, the five stars will become the functional equivalent of the standard of care in the industry.

For example, let’s look at the staffing component. CMS cites various studies that support the undisputed maxim that higher levels of staffing equate to lower hospitalizations, fewer infections, fewer pressure ulcers, less weight loss and, in general, better care. It is also true that lower staff turnover, long tenure employees and well organized teams can provide better care (even when one or more team members call in sick) than a fully staffed shift of agency substitutes that do not understand the patients’ histories and needs. The eventual reality of a five-star rating based on census, however, will be higher agency costs. Replacements will be necessary to prevent star loss, regardless of whether it improves care for the patients.

If NHTSA’s five-star program is any guide, the proposed CMS five-star program for nursing homes will become quality benchmarks, particularly when they are not attained. CMS intends the quality measures to be irrelevant to any individual patient, but rather indicative on the care provided to a population of residents at that facility. That distinction becomes irrelevant itself when litigation arises from the care provided to a resident from that specific population. From our previous example, litigation regarding injury to a patient where there is evidence of “sub-star” level staffing will quickly become “relevant” in a trial about the quality of care—regardless of whether the true efficacy and efficiency of the understaffed team was better without a “five-star” census. Five-star ratings, whether they correctly assess the ability of a team to provide care, become the accepted standard of the people. Like it or not, the five-star rating becomes the standard of care handed down from our government.

CMS launched its current NHC website in 1998. It is a useful tool for American consumers of senior care with valuable information for their decision making process. Perhaps it needs an updated website; perhaps that website could include additional helpful information (e.g., what languages are spoken at a facility, what accreditation has been provided), but a system whereby the federal government ranks each facility in a one-size-fits-all, five-star system is not the answer to providing better care. As usual, a government solution to a varied and complicated issue produces mediocre improvements and vast inefficiencies.

CMS has requested your input on the proposed five-star system. Take the opportunity to participate in your government at BetterCare@cms.hhs.gov. A five-star rating system is not necessary to the development of an information system that provides consumers with the necessary information to make their own rankings and decisions.

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