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Revising the five-star quality rating system: What stays, what goes?

February 23, 2012
by Kevin Kolus, Editor
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Editor's Note: To see the most recent news related to the Nursing Home Compare website, click here.

It’s an annual narrative that local journalists would be remiss to ignore. The U.S. News & World Report rankings of the nation’s nursing homes are a convenience to hometown news outlets, providing grist for reports on the poorest performing facilities, particularly those that have not seen a change in their rating from year to year.

Those rankings, of course, come straight from the Centers for Medicare & Medicaid Services’ Nursing Home Compare website and are based on the controversial, provider-maligned Five-Star Quality Rating System. As the fruits of this system are borne each winter to national attention, so too are its faults—to the providers who are affected, and those who remember the recent past.

First unveiled in December 2008, debate around the star rating system has cooled off from the days when advocates and observers heavily questioned its validity and subsequent influence on consumer decision making. Arguments have included whether or not a facility’s star rating actually aligns with resident satisfaction, and that it could therefore be an inaccurate representation of provider quality. It has also been said that the ratings do not clearly convey differences between a two-star to a three-star facility, a three-star to a four-star facility, and so on.

The most forceful criticism came in August 2009, when 31 state attorneys general wrote a collective letter to Health and Human Services Secretary Kathleen Sebelius requesting the Five-Star Quality Rating System be suspended and revised. Their objection: despite agreeing with the five-star criteria for evaluating nursing homes—aggregating data on quality measures, staffing ratios and survey inspection records—the individual ratings are based on fixed quotas to determine provider performance by state, “making it impossible to evaluate nursing homes across state lines.” This bell curve requires each state to have 20 percent of its facilities ranked as the poorest (one star) while 10 percent are ranked best (five stars), and the in-between 70 percent share the remaining ratings, meaning a low-ranked facility in one state could be providing superior quality to a similarly ranked home in a different state.

That following March, Sebelius, while addressing these concerns with the star rating system, was quoted as saying, “I think that’s serious criticism that needs to be looked at; the last thing we want to do is have an arbitrary bell curve just for the sake of having a system.”

Nearly two years have passed since that quote from Sebelius. Today, nursing home providers grapple with more immediate concerns, and the Five-Star Quality Rating System appears to be largely unchanged—at least for the time being. David Gifford, MD, senior vice president for Quality and Regulatory Affairs at the American Health Care Association, says an amended version of the star rating system may be implemented later this year.

“My understanding is that they’re working on revising [the star rating system] for a new version that isn’t just including the new MDS 3.0 clinical measures, but also looking at things slightly differently. So they are working on tweaking it,” Gifford says. Tweaking it how, and looking at what things differently, Gifford was not able to comment on. He did, however, provide AHCA’s stance on what changes should be included in a redraft of the system.


AHCA would like to see three major changes to the Five-Star Quality Rating System, Gifford says. The first change involves clinical outcome measures, which are temporarily frozen because of the switch to MDS 3.0. The MDS 3.0 quality measures are scheduled to be released April 19, 2012, on Nursing Home Compare, “but the question is then that the five-star rating really is only based on surveys and staffing ratios” at this time, Gifford says. “They should at least acknowledge that on the website in a very explicit way.”  

Gifford says that there are currently no measures looking at post-acute resident care, and that CMS needs to add measures on re-hospitalization rates and percent of post-acute residents discharged home. “There’s an additional 1.7 million Medicare beneficiaries who are going to be coming through these facilities for post-acute rehab,” Gifford notes, stressing the need for measures on care for this population, “which is so important to Medicare and important to a lot of consumers to understand."