Medicare's Nursing Home Rating System

Consumer Alert: Exposing the Flaws in Medicare's 5 Star Rating System of Nursing Homes

The Centers for Medicare and Medicaid Services (CMS) recently began a new rating system to help consumers compare nursing homes. It adds an additional feature to the Nursing Home Compare component on the Medicare Web site, rating nursing homes that receive Medicare or Medicaid funds according to five criteria, giving each one "stars" to indicate high or low ratings. A one-star facility would be much below average, while five stars designate far above average. It is not surprising that with a governmental rating project in a bureaucracy this large, various shortcomings exist.

Problems with the 5-Star Rating System

Even the Medicare Web site points out that the data for the 5-star rating system is limited. In giving a nursing home a rating, the rating system considers Medicare's health inspection reports, the facility's staffing, and ten nationally standardized quality measures in providing its ratings to the public. CMS acknowledges that there are differences in state licensing requirements from state to state that affect quality. The five-star rating system is only appropriate to compare nursing homes within the same state. Health inspection reports, therefore, do not provide a reliable way to see if one nursing home is better than another, if a state line happens to be between them.

Staffing is another basis for CMS's rating system, and staffing is self-reported by the facility. What's to keep a facility from providing incorrect information to CMS to make itself look better? Nothing we can determine. Staffing data are reported just once a year and reflect staffing over a two-week period only. That report, which becomes public information, could be wildly inaccurate in describing average staffing levels over a year's time. We consider this to be the worst defect in the rating system, and potentially the most dangerous if a consumer relies on it.

Another weakness of the five-star rating system is that the quality measures are also self-reported by the nursing homes. In addition, the rating system does not measure all of the critical aspects of safety that the family of an elder entering a nursing home should know. It focus instead on a few aspects of care at a most basic level, like eating and dressing, and does not provide any information about how often things go wrong with these measures.

Why These Flaws Are Fatal

From a legal point of view, one of the glaring weaknesses of every government rating system is that consumers have no way of knowing how often or whether the nursing home has been sued for neglect or abuse of its residents. We have no national database to record how many civil lawsuits have been filed against nursing homes, and to describe which homes have lost lawsuits that went to trial. There is, of course, some relationship between below-average nursing homes and citations those facilities receive from CMS for failure to properly deliver care, or meet other requirements, but this is not at all a clear indicator of how bad things could be. Facilities often fight citations through the hearing process CMS makes available, and the degree of the violation for which a facility was cited by CMS can end up being reduced before the public even learns of it. It can be deceiving, making a citation for poor care appear to the public as if it is not as bad as CMS originally found it to be. The public record of a citation against a nursing home is neither the whole story of what happened nor of how extensive the violation was.

How to Get More Accurate Information on Nursing Homes

What's the takeaway message here? Consumers who are searching for a nursing home should plan to spend as much time as they can investigating all sources of information about the nursing homes they are considering. The Medicare Web site alone is not reliable enough for access to complete information. Newer nursing homes and poor quality homes which have had a change of name or ownership within the fifteen months prior to the implementation of the 5-star rating system do not even show up in Medicare's ratings. No rating information will be stored on the Medicare site for those nursing homes which have changed names and had to apply for recertification by Medicare because of the name change. Go to your state's Medicaid Web site to investigate as much as you can find before making your choice.