Democratic House leadership announced this past Thursday that the proposed $850 billion economic stimulus plan includes a $90 billion shot in the arm to states by way of a temporary increase to the Federal Medical Assistance Percentage, as well as a few bundled programs, the most notable of which is $20 billion to hospitals and physicians to jump start EMR programs.  

Generally, the proposed stimulus package has come under not inconsiderable scrutiny because of a perceived lack of oversight in how the dollars will be spent.  However, many critics see this as a backlash from the complete lack of oversight when the first half of the so-called “financial system bail out” was delivered.  At any rate, the Medicaid component of the new stimulus plan is not immune to critics who wonder aloud whether the taxpayers will be getting the most bang for these billions of bucks.  

For example, McKnight’s reports that civil rights groups are particularly concerned about tying EMR adoption to these funds, without setting up a privacy assurance protocol/oversight committee.  What has not been mentioned is the connection between this money and the Deficit Reduction Act (discussed, obliquely, here) and whether the DRA programs may be a “shovel ready” protocol that could watch-dog the delivery of this money.

Illinois Attorney General Lisa Madigan and the Office of Management and Budget re-worked language in a loan plan worth $1.4 billion so the State can pay some of its lat Medicaid payments and other obligations.  The Attorney General was concerned about language in the loan plan which asked her office to certify the forthcoming loan was free of civil and criminal liabilities.  Clearly, with the ongoing investigation of Illinois Governor Rod Blagojevich and his chief of staff John Harris,  AG Madigan was unable to make such an assertion.  However, once the liability requirement was modified, the loan went through rather quickly.  The Governor’s office issued a press release last Thursday indicating that the state should receive the funds from the short-term borrowing before the start of the New Year.  Under that scenario Medicaid payments to providers should be occurring in January.  

The amount of these payments is still undetermined, but lobbyists in the affiliate Life Services Network indicate it could be anywhere between one and three months arrears.

It turns out the main stream media has somehow received the Five Star data ahead of many nursing homes. The listserves are abuzz with Administrators complaining of having to talk to newspapers, televisions stations and the like about their five-star rating, without actually knowing the rating themselves.

Furthermore, there seems to be a lot of grumbling about the accuracy and precision of the Five Star Ratings. The five step “How the Ratings are Calculated” guide CMS sent to MDS mailboxes is pretty basic. In case you haven’t seen it, here it is:

How the Ratings are Calculated:

A nursing home’s Overall Quality rating on Nursing Home Compare ( is based on its ratings for Health Inspections, Quality Measures (QMs), and Staffing. Ratings for each domain and the overall rating range from 1 star to 5 stars, with more stars indicating higher quality. Based on these three ratings, the overall 5-star rating is assigned in 5 steps:

Step 1: Start with the Health Inspection Rating.

Step 2: Add one star if the Staffing rating is 4 or 5 stars and also greater than the Health Inspection rating. Subtract one star if the Staffing rating is 1 star. The rating cannot go above 5 stars or lower than 1 star.

Step 3: Add one star if the Quality Measure rating is 5 stars; subtract one star if the Quality Measure rating is 1 star. The rating cannot go above 5 stars or lower than 1 star.

Step 4: If the Health Inspection rating is 1 star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings.

Step 5: If a nursing home is a Special Focus Facility that has not graduated, the maximum Overall Quality rating is 3 stars.

Nursing Home Compare provides a five-star rating for each of the following three components:

1) Health Inspection ratings:

• Ratings are calculated from points that are assigned to the results of nursing home surveys over the past three years, as well as complaint surveys from the past three years and survey revisits. More recent surveys are weighted more heavily.

• Points are assigned based on the number, scope and severity of a nursing home’s health deficiencies. If multiple revisits are required to ensure that major deficiencies are corrected, additional points are added to the health inspection score.

• Lower health inspection scores result in a better 5-Star rating on Nursing Home Compare.

• Nursing homes are ranked within their state based on their score, and the number of stars is based on where the nursing home falls within the state ranking.

• The top 10% of facilities get 5 stars, the bottom 20% get 1 star, and the middle 70% of nursing homes receive 2, 3 or 4 stars, with equal proportions (23.33%) in each category.

• Health Inspection ratings are re-calculated every month to account for new survey results entering into the system.

2) Quality Measure ratings:

• Ratings are calculated from a nursing home’s performance on 10 Quality Measures (QMs), which are a subset of those reported on Nursing Home Compare.

• The QMs include 7 long-stay (chronic care) QMs and 3 short-stay (post-acute care) QMs.

Long-Stay QMs Short-Stay QMs

• ADL Decline

• Mobility Decline

• Catheter

• High-Risk Pressure Ulcers • Physical Restraints

• Urinary Tract Infections

• Moderate to Severe Pain • Pressure Ulcers

• Moderate to Severe Pain

• Pressure Ulcers

• Ratings are calculated using the three most recent quarters of data.

• ADL Decline and Mobility Decline contribute more heavily (each weighted at 1.667 times) than the other QMs.

• A nursing home’s performance on the ADL Decline and Mobility Decline QMs is ranked against all other nursing homes in the state.

• A nursing home’s performance on the other 8 measures is ranked against all other nursing homes in the nation.

• Points are assigned for each QM based on what quintile the facility falls in comparison to other nursing homes. Points for each QM are added together for a total point score.

• Based on this total score, the top 10% of facilities nationwide get 5 stars, the bottom 20% get 1 star, and the middle 70% of nursing homes receive 2, 3 or 4 stars, with an equal proportion (23.33%) in each category.

3) Staffing ratings:

• Ratings are calculated from two measures: RN hours per resident day and total staffing hours (RN, LPN, nurse aide) per resident day. These two measures contribute equally to the Staffing Rating.

• Staffing measures are derived from OSCAR data that is then case mix adjusted based on the facility’s distribution of MDS assessments by RUG-III group, based on the number of RN, LPN, and nurse aide minutes associated with each RUG-III group

• Other staff, such as clerical, administrative, and housekeeping staff, are not included in the calculation of the Staffing ratings.

• For each staffing measure, a 5-Star rating is assigned based on where the facility ranks compared to the adjusted staffing hours for all freestanding facilities AND where the facility ranks compared to optimal staffing levels identified in the 2001 CMS Staffing Study.

• To earn 5 stars on the Staffing rating, the nursing home must meet or exceed the CMS staffing study thresholds for both RN and total nursing hours per resident day.

• The Nursing Home Compare website will include a “drill down” that shows the nursing home’s rating for RN Staffing.

The RN Staffing Rating for Nursing Home Name is .

Ratings are provided only for nursing homes that have had at least two standard health inspection surveys. Nursing homes that have not yet had two standard health inspection surveys are listed as ‘too new to rate,’ and no rating information is provided for the nursing home If the rating indicates ‘data not available’ then the data needed to rate the nursing home were not available.

If Your Rating Isn’t What You Think it Should Be

If your nursing home’s rating seems to be markedly different from your expectation, it may be that a recent survey has not yet been entered into the database. It may also arise from a dispute resolution or appeal decision that has not yet entered into the database. You can check the health inspection detail on Nursing Home Compare for more information about the particular deficiencies that entered into the calculation.

If your quality measure rating states “data not available,”, it means that there were too few eligible residents for us to calculate a reliable quality measure. If your staffing score says “data not available,” it means that the number of hours of staffing were found to be a value that were so extremely high or low that they were not plausible. In this case, please check with your state survey agency to confirm the staffing values you reported.

A technical manual containing additional information can be found on the CMS website (


If you have questions, please contact the 5-Star Helpline at 1-800-839-9290.

To make matters worse, as of this writing, the technical manual has not yet been published on CMS’ website (the link above). So, some Administrators are getting some pretty bad news, with no technical context in which to frame it.

Whether the Five Star Nursing Home Compare site will be a highly used tool by the public remains to be seen, but the five star system needs to accurately reflect the quality of care if it is to be a usable metric.  My fear (and I’m sure I’m not alone in this) is that the Five Star system will make a confusing, relatively difficult to use, flawed data set (the Nursing Home Compare website) less difficult to use, but still just as flawed.  I know my own facility’s overall star rating was less than I anticipated.  I intend to pour over the technical manual, looking for a way to match the Nursing Home Compare Five Star Rating with the quality of care I know my staff provides every day.

*Update: the technical manual is now online.  I’ve made the link above live.

As was reported by Life Services Network, Governor of Illinois Rod Blagojevich and his Chief of Staff, John Harris were arrested this morning by FBI agents on federal corruption charges alleging that they and others are engaging in ongoing criminal activity; conspiring to obtain personal financial benefits for Blagojevich by leveraging his sole authority  to appoint the United States Senate seat vacated by President Elect Obama; threatening to withhold substantial state assistance to the Tribune Company in connection with the sale of Wrigley Field to induce the firing of Chicago Tribune editorial board members sharply critical of Blagojevich; and to obtain campaign contributions in exchange for official actions both historically and now in a push before a new state ethics law takes effect January 1, 2009.  (See US Attorney’s Press Release and Criminal Complaint).

This is shocking news to everyone who lives and works in Illinois, but it is making LTC Administrators terribly nervous.  Illinois is last among the fifty states in two important Medicaid payer source metrics: 1) amount paid per resident day; and 2) (in)frequency of state payments.  A few days ago, state officials agreed to borrow 1.4 billion dollars and begin paying off the nearly 4 billion in accumulated debts.  (See story here).  One of the chief among these debts, of course, is the State’s Nursing Home Medicaid payments.  

 It is unclear whether and how the arrests of the Governor and his Chief of Staff will affect the loan/payoff plan.  The issue is really a Comptroller’s Office one, but with Medicaid payments over half-a-year behind (and no payment for over a quarter), any shake-up at the upper levels of government has the potential to make things much worse rather than better. 

We will be following this story very closely.