Like many of you, I have been pouring over the CMS Nursing Home Compare Five Star Ratings today.  The results have been . . . unexpected.  I operate a facility in Illinois, a state somewhat notorious in the Long Term Care industry, and when I looked at the ratings of facilities in my geographic region, I was truly surprised.  The variance is what got me.  Homes I know are pleasant, and seem to be well-run, scored much worse than those with bad reputations.  Many had perfect marks in the Quality Measures domain, but only one star in the Health Inspections domain.    

To try to get a handle on this new metric, I have also been pouring over the Technical Manual for the Five Star Rating System.  Entitled, “Design for Nursing Home Compare Five-Star Quality Rating System: Technical User’s Guide”, the 23 page report does  a fair to good job of laying out hte technical details of how the different domain scores are calculated.  My objection to this manual is that it does not give a very good rationale for why the score algorithms were selected over others.  I found myself wondering, ‘how did the Techincal Expert Panel (TEP) decide to score a domain this way instead of another.’  There are vague justifications: “distribution is based on CMS experience and input from the Project’s TEP” (page 5), but no real explanation or rationale.  

This Technical Manual may be (somewhat) easy to use then, but difficult to critique.  However, I would like to discuss one issue that bothered me.  First, I found it difficult to locate the study cited to on page five, “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care.”  (executive summary located here).  But, in the process of searching for this 2001 CMS staffing survey and study, I discovered the following, interesting article, first published in the scholarly journal, The Gerontologist: “Comparing Staffing Levels in the Online Survey Certification and Reporting (OSCAR) System With the Medicaid Cost Report Data: Are Differences Systematic?,” Bita A. Kash, PhD, Catherine Hawed, PhD, and Charles D. Phillips, PhD.  (abstract located here).  This article discusses some interesting results from a study of the OSCAR system.

The Techincal Manual cites the Online Survey Certification and Reporting (OSCAR) System as the source data for the staffing measures/Staffing Domain.  This is the same data used now for Nursing Home Compare, although the staffing data was not compressed into a quintile metric before the Five-Star Rating.  The OSCAR database includes essentially every piece of information a surveyor gathers during certification/licensure surveys and complaint surveys.  However, information on nursing home operational characteristics (like staffing ratios and Case-mix) are reported by the nursing homes themselves.  Inspectors review the information, but the data are not formally audited to ensure accuracy.  The study Kash, Hawes and Phillips study cited above arrives at a critical result to this operation.  The study sought to assess the validity of the OSCAR staffing data by comparing them to staffing measures from audited Medicaid Cost Reports.  The results of this study were that “[A]verage staffing levels were higher in the OSCAR than in the Medicaid Cost Report data.”  Meaning that “[C]ertain types of facilities consistently over-report staffing levels.”  This 2007 study went on to say that the implications of these findings are that “reporting errors will affect the validity of consumer information systems, regulatory activities, and health services research.”  

In other words, OSCAR data is inaccurate in reporting staffing levels and some facilities will have a lower staff-to-patient ratio than the data reflects.

What does this mean with respect to the Five-Star System?  Because the staffing ratios/RUG-III modifiers are relatively scored (i.e. a score based on how your facility matches up to other facilities in the same category), if a facility is over-reporting its staff ratios (as the above study suggests OSCAR does), then every facilities score in the Staffing Domain will be inaccurate.  If your facility happens to have a lower-ratio and higher complexity modifier than one of the innaccurate reporting facilities, your relative position will be even lower than it otherwise would have been if all facilities staffing ratios were accurately reported.  

The Staffing Domain can skew the entire star system.

Of course, it would be wrong to discard CMS’s new system based on the strength of one adverse study, but Administrators and academics need to give the whole Five-Star System a hard look.  The Staffing Domain is an important indicator of quality of care.  It should be in any comparison metric, provided the data source is accurate.  There have been a lot of criticisms leveled at the Five-Star System, but drilling down into the technical manual, I think, can provides the most salient.  

I encourage everyone reading this to do just that.  Keep this conversation going.

Advertisements

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 (www.medicare.gov) 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 (http://www.cms.hhs.gov/CertificationandComplianc/).

 

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.

Centers for Medicare/Medicaid Services reached out to nursing home administrators today in an attempt to quiet anxieties over next week’s roll out of the new Five Star Rating on CMS’ Nursing Home Compare website.  CMS Regional offices set up teleconferences with LTC affiliates, so member nursing homes could hear directly from CMS staff how the roll out was going to work and what last-minute changes were being made.  The key facts that made me take notice were:

1) State license and complaint surveys are going to be weighted so the five-star comparison is intra, not inter-state.

2) The Staffing tab data will be weighted across with RUG scores before being tabulated into the five-star algorithm

3) Nursing Home Compare will be kept up to date (within a quarter) and the Five Star will be updated monthly.  

I will be interested to see how this plays out next week when the Five Star rating is debuted.  As I said in my earlier post, though, I remain positive on the Five Star rating, though, it should be mentioned, this objective metric will never be able to capture the full scope of care being provided.

Choosing a Nursing Home

December 10, 2008

The Centers for Medicaid/Medicare Services (CMS) have published a new edition of Guide to Choosing a Nursing Home.  It breaks a little long, 68 pages, but is strikingly comprehensive.  It includes chapters on payment structures, regulatory issues and offeres checklists for residents and their families to use when discussing LTC with an admissions coordinator.  

Unfortunately, it is difficult to streamline the nursing home admissions process.  New residents are bombarded with confusing information, even when they spend time researching Long Term Care before they are sick.  To say it can be a stressful situation is a gross understatement.  I am gladdened by guides such as this one because they provide clear, easy to digest information that is free from any commercial content.  

Operating a nursing home is many ways an exercise in advocacy.  The more resident-readiness literature is out there, the better.

Thanks to the Nursing Home Law Blog for alerting me to this new guide.

Around this time of year, many Congressional advisory committees start circulating their ideas of major recommendation reports.  The Medicare Payment Advisory Commission (or MedPac) is no different.  It was reported recently that MedPac sent a balloon up, testing the atmosphere for a recommendation that Medicare payments stay where they are for skilled nursing facilities throughout 2009.  This means no new payment updates until FY 2010. 

Take a breath.

Now, take another one. 

I’ve been giving these two pieces of advice to people all day.  I mention MedPac’s possible recommendation to Congress, and my administrative staff starts teeth-clenching. 

The merits of MedPac’s recommendation are up to not inconsiderable debate.  And, this would not be the first time such a recommendation has been discussed in the pre-report phase.  (FYI, MedPac’s two major reports are released in March and July each year).  What surprised me as I discussed this news with colleagues was how little understood healthcare legislation seems to be.  MedPac reports are a major component of the Medicare legislation package, but those I spoke with had only a faint notion of what MedPac is — usually just a vague memory of once hearing the name.   

I’m not sure if my facility is typical in this regard, but my guess is that it must be.  Even though two of my administrative nurses are Nursing Practice Act fiends (i.e. they review/discuss every proposed change) my staff in general is not keyed in to the political nature of their profession.  This is completely understandable; health care training is focused on the care, not the business side of things.  This is only right, but public health financing is a topic my residents and their families obviously care about.  As a profession, we should strive to educate ourselves to at least be conversant in the operation of health care legislation — if for no other reason than to be able to discuss it with patients.