Starting in 2015 Medicare Revises Nursing Home Rating System

The federal government on Monday announced substantial changes to the government’s five-star rating program for nursing homes, a widely used consumer tool that has been criticized for its reliance on self-reported, unverified data.

article By KATIE THOMAS, The New York Times |  OCT. 6, 2014

The five-star rating system has become the gold standard for evaluating the nation’s more than 15,000 nursing homes since it was put in place five years ago, even though two of the major criteria used to rate the facilities — staffing levels and quality statistics — are reported by the nursing homes themselves and generally are not audited by the federal government.

On Monday, officials said they would make several changes, starting in January, aimed at addressing some of these concerns.

Nursing homes will have to begin reporting their staffing levels quarterly using an electronic system that can be verified with payroll data. And officials will initiate a nationwide auditing program aimed at checking whether the so-called quality measures rating — which is based on information collected about every patient — is accurate.

Beginning in January, nursing homes’ ratings will also be based partly on the percentage of its residents being given antipsychotic drugs.

In August, The New York Times reported that the rating system relied so heavily on unverified and incomplete information that even homes with a documented history of quality problems were earning top ratings. The number of homes with above-average ratings has increased significantly since the program began: In 2009, 37 percent of homes received four- or five-star ratings. By 2013, nearly half did.

Marilyn Tavenner, the administrator of the Centers for Medicare and Medicaid Services, which oversees the rating system, said she hoped that higher-quality reporting would lead to better health outcomes for patients. “We are focused on using as many tools as are available to promote quality improvement and better outcomes for Medicare beneficiaries,” she said.

Greg Crist, a spokesman for the American Health Care Association, the lobbying group that represents for-profit nursing homes, said many of the changes would capture data reflecting quality improvements that the industry had already been working on. “We’ve seen the improvements in quality across the board,” he said. “Some questioned that a few weeks ago. Yet this push for greater accuracy should help reassure patients and families those improvements are both real and making a difference in improving lives.”

Although the federal health care law, passed in 2010, required that nursing homes’ staffing data be collected electronically, the provision was never adopted. Instead, nursing homes reported their staffing levels on a form during their annual inspection, which was rarely audited.

On Monday, President Obama signed into law a bipartisan bill passed in September that provides $11 million in funding to set up an electronic collection system. The bill, the Improving Medicare Post-Acute Care Transformation Act, or the Impact act for short, also requires more frequent inspections of hospice facilities. Hospices must now be inspected at least once every three years. Previously, there was no such requirement, meaning many facilities went years without any inspections.

The law also allows Medicare to review hospice programs in which a large proportion of patients receive care for six months or more, which is considered a long hospice stay.

The changes come as the number of hospices has grown rapidly in recent years, from 2,500 organizations caring for about 870,000 patients in 2005 to 3,600 caring for about 1.2 million in 2011. For-profit hospices now dominate the field, and many are affiliated with national chains.

Federal officials said the new system for collecting nursing home staffing data would do more than just verify the accuracy of staffing levels. It will also eventually allow consumers to view other statistics like staff turnover, another key measure of quality, they said. The homes will begin reporting the data electronically in 2015, but the information will not be reflected in the ratings until 2016, officials said Monday.

Advocates for residents of nursing homes said improving the reporting was crucial. “Nursing home quality hinges upon high staffing levels,” said Brian Lee, executive director of Families for Better Care, a nursing home watchdog group. “If we are able to get better information on staffing levels, the higher the quality is going to be in the long run.”

The government will also begin taking a closer look at the quality measures rating. This score is based on electronic data on every patient, such as whether bedridden or wheelchair patients are developing bedsores and how many residents experience serious falls.

Homes’ ratings in this area have improved significantly since the program started, including those with a history of problems: In 2009, 36 percent of homes held a four- or five-star rating for quality measures, but by 2013, 65 percent did.

Officials said they would be expanding an auditing program that they had been testing at the state level, and would be subjecting some homes — both those chosen at random, as well as those targeted for a specific reason — for closer scrutiny. They said they would also be adding some additional measures to the rating system, including the percentage of residents being given antipsychotic drugs. Such medications are often inappropriately given to help sedate residents with dementia, even though doing so can be dangerous.

Nursing homes must already report this statistic — 20.3 percent of long-term nursing home residents currently receive such medications — but until now it has not figured into a facility’s rating.

Plans to add other measures are also underway, the officials said, including the percentage of residents who are readmitted to the hospital, and the percentage discharged to the community.

Mr. Lee, of Families for Better Care, said the next step the federal government should take is to improve the requirements for what nursing homes report about their ownership. Although basic information is available on the federal website where the ratings are available, the names of the chains that own or manage the homes are rarely listed because of the companies’ complex business structures.

“It could be some company that is 10 states away,” he said. “You have no idea."

Paula Span contributed reporting

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Medicare’s Skewed Star System for Nursing Homes

A five-star rating system of nursing homes begun in 2009 is intended to provide consumers with a way to measure quality. A home’s rating is based on three criteria: its performance on annual health inspections, its staffing levels and its performance on quality indicators that are collected for every patient. But only the health inspections are performed by the government; the other two are reported by the homes.