Nursing Home “Quality Measures” Do Not Reflect Quality of Nursing Home Care

The federal website for information about nursing homes, Nursing Home Compare,[1] reports information for each Medicare-certified and Medicaid-certified nursing facility in three categories – health inspections, staffing, and quality measures – as well as an overall score that combines the three domains. The health inspections domain reflects the findings of standard (annual) and complaint surveys that are conducted, unannounced, by state survey agencies. The staffing domain reflects staffing “based on payroll and other verifiable and auditable data.”[2] The quality measures (QMs) domain reports primarily resident assessment information, self-reported by nursing facilities.[3]
Unfortunately, the nursing home industry often uses the quality measure domain to mask poor care. When the media describe deficiencies cited at facilities and enforcement actions that the Centers for Medicare & Medicaid Services (CMS) or states are taking against them, facilities often point to their “quality” to counteract the bad press.[4] CMS should not allow nursing homes to mislead consumers about nursing home quality in this way.
In December 2011, the Center showed that Special Focus Facilities – the nursing facilities nationwide that are identified by CMS as among the most poorly performing facilities in the country – nevertheless reported assessment information that gave them four and five stars in the QM domain.[5]  Several years later, The New York Times reported that incomplete and, at that time, largely self-reported information for staffing as well as quality measures enabled facilities to “game” the system and achieve high ratings on Nursing Home Compare.[6]
CMS has apparently gotten the message. Effective April 24, 2019, Nursing Home Compare no longer gives star ratings to Special Focus Facilities in any of the three domains and no longer reports any information about quality measures for Special Focus Facilities.[7] CMS’s implicit recognition of the misinformation contained in quality measures for Special Focus Facilities is a good first step, but CMS could do more to protect all nursing home residents and families:

1. CMS could improve transparency by relabeling quality measures “resident assessment data” so that facilities cannot cite the domain to falsely assert that they provide high quality care;
2. CMS could not assign a star rating to the quality measures domain and only factor health inspections and staffing in the overall star rating; and/or
3. CMS could remove quality measures from Nursing Home Compare

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[1] https://www.medicare.gov/nursinghomecompare/search.html?.
[2] Section 6106 of the Affordable Care Act, 42 U.S.C. §1320a-7j(g).
[3] Twelve of the 17 measures that are used to determine the quality measures ratings are based on resident assessment data; give are based on Medicare claims.  CMS, Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users Guide, p. 11(Apr. 2019), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/usersguide.pdf.
[4] Wentworth Rehab, a Chicago nursing facility, was the only Special Focus Facility in Chicago, but reported on its webpage that it had a four-star quality rating from the Centers for Medicare & Medicaid Services.  The Chicago Tribune pointed out that the four-star rating was for quality measures.  Sam Roe, “Inside Chicago’s worst nursing home: bug bites, bruises and death,” Chicago Tribune (Jun. 14, 2018), http://www.chicagotribune.com/investigations/ct-wentworth-nursing-home-violations-20180403-story.html.
[5] Center for Medicare Advocacy, “Special Focus Facility Study: Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys” (CMA Alert, Dec. 22, 2011), https://www.medicareadvocacy.org/special-focus-facility-study-nursing-facilities-self-regulation-cannot-replace-independent-surveys/.
[6] Katie Thomas, “Medicare Star Ratings Allow Nursing Homes to Game the System,” The New York Times (Aug. 24, 2014), https://www.nytimes.com/2014/08/25/business/medicare-star-ratings-allow-nursing-homes-to-game-the-system.html?searchResultPosition=2.
[7] CMS, “April 2019 Improvements to Nursing Home Compare and the Five Star Rating System,” QSO-19-08-NH (Mar. 5, 2019), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-08-NH.pdf