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

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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."

The second change involves the way staffing ratios are weighted under the star rating system. Staffing levels are currently based on an absolute resident-to-staff ratio that facilities must meet. AHCA would like to see staffing turnover figures included as well, because they are “equally if not more important as an association with quality” than ratios, Gifford says, adding that this change could be made with “little difficulty.”

The third change AHCA seeks, which would be far more complex to implement, involves consumer satisfaction scores for facilities. Essentially, consumer satisfaction would be added as a quality measure, Gifford says.

It should be noted that while the interview with Gifford preceded AHCA’s recent announcement of the new quality objectives it is asking members to meet, the desired changes to the Five-Star Quality Rating System discussed above are in line with the association’s new quality initiative—that of reducing resident re-hospitalizations, lowering staff turnover and improving consumer satisfaction scores.

Overall, Gifford says AHCA supports the use of an aggregate star rating, so long as it is “easy to understand and up to date” by implementing these changes.

“We think that having some sort of five-star rating is a good thing, but it needs to include information that is important to consumers,” he says.


Representing non-profit providers, LeadingAge does not agree with an aggregate overall rating and would instead prefer separate ratings under each of the domains, says Evvie Munley, senior health policy analyst with the association.

And there are other areas of disagreement, the largest being that LeadingAge does not support the use of quality measures under the Five-Star Quality Rating System, Munley says.

“I can’t speak to what [the quality measures] are going to look like under MDS 3.0,” she says, “but the original intent of those was to act as triggers for further investigation. They were never intended as a ranking system, or to be used in conjunction with or as a purpose for ranking, so we’ve had concern from the outset with the use of the quality measures as part of five-star.”

Other changes LeadingAge would like to see implemented involve the way complaints are reported as deficiencies. In-house complaints and self reports under Nursing Home Compare are incorrectly lumped together as generic complaints, Munley says. “To us that was always a distinction because there is a difference between an external complaint—somebody calling with a problem—and a facility doing quality assurance, recognizing that there’s something that needs to be worked on, identifying it, correcting it.”

Although there is a caveat on the website describing the different types of complaints included, “you can’t tell one from another—they’re just listed as deficiency cited,” Munley says.

There is an additional change that is forthcoming under Section 6106 of the Affordable Care Act that LeadingAge supports, and it involves the electronic collection of staffing information in nursing homes. One of the most frequent complaints LeadingAge hears from its members is that information is either inaccurate or not current on Nursing Home Compare, and any changes have to go through the state. “That’s one of the reasons we really support the electronic collection of staffing data. They’re going to do it off of payroll, and that’ll be far more accurate,” Munley says.

CMS is working on this change, but is not expected to meet the healthcare reform law’s target date of March 23, 2012.


Notwithstanding the differences in opinion shared by both AHCA and LeadingAge, both associations do agree on something: Surveys are given far too much weight under the Five-Star Quality Rating System.

“The way it is right now, the vast majority of the five-star rating is based on the survey results and not the others,” Gifford says. “It’s essentially driven by the survey results, which only happen about every 12-14 months.”

And that’s a problem, because the survey system is far from perfect, Munley says.

“I’ve gone through a lot of analysis with people questioning their rankings, and I’ve never had a problem with the math. The math is always correct. When you dig deeper and go into the inconsistencies of the survey system, you’re opening a whole other discussion,” she says, laughing.

“So I mean whether the five-star system is a good measure, that goes way deeper than I think what some of the scores are.”

Topics: Advocacy , Articles , Medicare/Medicaid