When Best Nursing Homes 2014 launches online on Feb. 26, the public will have free access to detailed assessments of more than 15,500 nursing facilities. Each facility's profile will display an overall rating of one to five stars, based on federally supplied data in three categories: the facility's record in health inspections, the quality of its clinical care and the amount of time its nurses spend with residents. Each facility also will receive a rating of one to five stars in the three individual categories. All of the star ratings are assigned by the Centers for Medicare & Medicaid Services, which administers payments to nursing homes for residents covered by Medicare and Medicaid and posts the star ratings on Nursing Home Compare.
The fundamental approach to awarding star ratings has not changed since U.S. News began publishing Best Nursing Homes in 2009. Nor has the number of rated facilities moved significantly. The new results, however, reveal a tectonic shift in just five years.
[Read: How We Rated Nursing Homes.]
In 2009, 11.8 percent of all nursing homes earned the highest possible overall rating of five stars. In 2014, the percentage has more than doubled, to 24.9 percent. Most of the difference can be found in the shrinking number of bottom-rated one-star homes, which accounted for 22.7 percent of the total in 2009 but only 10.1 percent in the 2014 tally. The percentages of facilities receiving four, three and two stars, by comparison, have changed by a handful of percentage points or barely at all. The bulge in the performance curve has steadily shifted to the right, and the trend seems to be speeding up.
Are nursing homes that much better in 2014 than they were in 2009? "It's a very reasonable question," says David Gifford, senior vice-president for quality and regulatory affairs of the American Health Care Association, which represents about 10,000 nursing homes. His answer is affirmative, largely because of increased management sensitivity at every level, from individual facility administrators to corporations that run hundreds of homes, to the importance of a high rating in a competitive market.
"What has changed – what I hear from our members – is that people are using the five-star rating as an incentive for measuring performance," says Gifford. "It’s being written into employment contracts and bonus incentives."
For example, says Gifford, large numbers of nursing homes have bolstered their staffing, allowing nurses to spend more time with residents and potentially improving their staffing star rating. He also says nursing homes are providing better clinical care to residents, which can push up the star rating in that category. Facilities are paying more attention to cutting down on the use of antipsychotic drugs that make residents easier to handle, says Gifford, and are becoming more diligent about taking precautions to prevent bedsores.
[Search: U.S. News-rated nursing homes.]
A statement from CMS responds that the agency plans to examine the changes in these clinical quality scores more closely. "While there is good evidence to believe that much of the increase reflects true improvement in resident care," says a spokesperson, "we wish to confirm that the increases are not due to changes in nursing home reporting."
The uncertainty is due at least in part to the fact that CMS counts on nursing homes to collect and report the staffing and clinical data used in the ratings, with no independent verification. CMS warns on an out-of-the-way page on Nursing Home Compare: "All of these data are reported by the nursing homes themselves. Nursing home inspectors review it, but don’t formally check it to ensure accuracy. This information changes frequently as residents are discharged and admitted, or residents' conditions change. The information should be interpreted cautiously and used along with information from the Long Term Care Ombudsman's office, the State Survey Agency, or other sources."
"I find it very difficult to believe that a quarter of all nursing homes are five-star," says Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care, a Washington, D.C.-based advocacy group that represents consumers and the ombudsmen in every state who try to resolve nursing-home complaints from residents and the public. "I worry that serious problems are not being identified, and our sense is that this failure is increasing. From what we hear from consumers and from ombudsmen, it just doesn’t correlate with one in four homes rated at five stars."
"How would you game the system?" Gifford wants to know. "What we have done for our members is to provide them with a calculator that tells them how much better they need to do in each category to move up. But that’s a good thing. If I put my pressure ulcer rate down to 30 percent, I can move up a star rating. That’s not gaming. That’s a good thing."
All interested parties agree that another good thing would be to substitute nursing staff turnover for time spent with residents, which Grant calls a "very inaccurate" measure. "It overreports time with residents," she says, citing a Texas study. "How to fill that form out is subject to interpretation."
For years CMS analysts have talked wistfully about plugging in nursing turnover, cleanly and directly calculated via payroll data. Doing so, however, would require additional staff and funding, which until now have been unavailable. Even if that changes, turnover information has to be added to the system until a reliable critical mass is reached. That would take two or three years.
Consumer advocates, U.S. News, CMS and most nursing home organizations have long stressed that stars and data are no substitute for unannounced visits to a facility and explicit discussions with key staff, such as the director of nursing. That advice is still sound even if star ratings are blindingly bright.
[Read: Questions to Ask on Home Visit.]