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"Medicare Star Ratings Allow Nursing Homes to Game the System"

By Sudip Bhandari | 25 Aug, 2014

I want to share this worrisome article that brings to light some flaws in a federal quality assessment tool which uses star ratings to rank nursing homes in the United States. The article includes a fascinating video of a family that believes their loved one’s death can be attributed in part to the substandard care received at the nursing home they chose - a nursing home with the highest rating of 5 stars. In light of this article, it would be very interesting to hear opinions and experiences from members here. Can anyone speak to their experiences working in settings where quality assessment has been a major priority? How can we ensure that the quality measurements in place are actually helping patients choose the right care?

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Lindsay Jubelt Moderator Emeritus Replied at 11:20 PM, 27 Aug 2014


Great post. I think we are going to see much more attention focused on the post-acute care setting in upcoming years given the rising costs attributable to nursing homes and postacute care facilities, the aging of the U.S. population, and the general dearth of information on these facilities.

One signal that is appears repeatedly in the health services literature is the importance of ownership status (non-profit vs. for-profit) on the quality and outcomes from nursing homes. Have others had experiences or heard stories that support this finding?

As a clinician, I believe it would be helpful for consumers to have access to patient experience data on post acute care facilities to inform their choices. There are three CAHPS surveys for nursing homes: long-stay resident survey, discharged resident survey, and nursing home family member survey. I look forward to seeing the adoption of these surveys in nursing homes as we've seen in the acute hospital setting.

Angie McCrone Replied at 3:02 PM, 29 Aug 2014

Hi Lindsay and Sudip,

I haven’t had much experience working in a Nursing Home, but I have experienced working in a day program for individuals with developmental disabilities and my mother is a hospice nurse. From those experiences, I think there are big differences between non-profit and for profit facilities.

There was a recent article in the Washington Post (linked below) explaining that some states have an average discharge rate from their hospices of more than 30%. That is a large number of individuals that are supposed to be receiving end of life care, and should therefore, never be discharged.

This means two things may be happening. Patients are being discharged because they can’t pay (most patients end up back in the hospital days later) or they are enrolling patients that aren’t actually dying into their care to make more money.

In the case of day programs for individuals with developmental disabilities, I saw several programs that were rated by Medicare, but the staff knew when assessors were coming in to do the evaluation and made sure they followed all the guidelines during that time. They had other modes of assessment and strong management to ensure they followed the guidelines permanently, but I could easily see the Medicare rating would not be trustworthy without management keeping them accountable.


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William Martinez Moderator Replied at 11:02 PM, 1 Sep 2014

Curious if anyone knows how often patients and familiies use these Medicare ratings in their decision making and how much wieght they assign to the rating? Is there any data on this?

I have not looked at the ratings myself. Seems like one step would be to require that these ratings always be accompanied with "based on self-reported data by the nursing homes that is unverified." As we know, transparency is critically important in so much of what we do. It is of course not enough, as this also might be a case of junk [data] in, junk [data] out. But let's at least make the limitations of the data clear to patients and families that may choose to access it, so they can weigh it accordingly while efforts are made to improve the ratings and validate them. Of course, if the ratings really unreliable perhaps they should go entirely until the process can be sufficiently improved?

Mighty Casey Replied at 12:00 PM, 2 Sep 2014

I know that the primary deciding factor when I was trying to figure out what nursing home to put my parents in was a relationship with someone inside the organization.

A family friend worked for the foundation run by the non-for-profit health system whose nursing home we selected (which is, according to the Medicare star ratings, only an overall 2.5 star facility), and I did a site visit there, and at a couple of other nursing homes, before making the decision.

Picking something like this off a list of star ratings guarantees problems, IMO. Without eyes/boots on the ground, you can't make an informed decision.

William Martinez Moderator Replied at 2:35 PM, 2 Sep 2014

Yes, I would think that most folks don't give the rating a ton of weight. Anyone else have experience using these rating?

Would be nice if the rating were reliable but even still there are other important factors to consider like you pointed out. Since public reporting of quality data is becoming more and more common, it will be interesting and important, I think, to understand how folks use and interpret the data. Would hope that we would make sure the data is accurate, help make it most useful to patients and families, and make it easily understood and accurately interpreted. Involves attention to what and how we measure, how we present it, and how we support folks in understanding and using it, and working to make it literacy and numeracy level appropriate. All tall tasks that seem to be in need of attention.

Mighty Casey Replied at 3:14 PM, 2 Sep 2014

CMS ratings are suspect anyway, since they seem so un-dedicated to making them meaningful. Leah Binder of Leapfrog Group has a post on THCB datelined this past Sunday talking about hospital quality. I've linked it below, and will emphasize what I think is the money shot here:
"The ultimate example of our tendency toward non-disclosure came last week, when USA Today reported that CMS quietly removed from public disclosure the incidence of certain 'never' events, like objects left in after surgery. Experts disagree on the merits of how CMS counts these 'never' events, and CMS—no doubt influenced by lobbyists—believes that they aren’t fair to hospitals. Yet, in a culture of transparency, CMS would do the opposite: first err on the side of reporting the 'never' events, then let the experts refine the measure over time."

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This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.