SNFs Appear to Have Gamed the System When Staffing Was Self-Reported

The federal government has spent the last few years focusing on staffing as a key area of improvement for nursing homes, requiring operators to provide payroll-based evidence of their labor hours and tightening the requirements for achieving the top scores — all based on the assumption that there’s a direct line between staffing and quality.

But a recent study argues that when SNFs had to self-disclose that information, care did not improve even when the facilities reported increased staffing.

When the Centers for Medicare & Medicaid Services (CMS) increased the level of staffing required to maintain star ratings in 2012, facilities that reported an increase in staffing did not see a corresponding decline in bedsore rates.


Specifically, SNFs in competitive markets were more likely to report such staffing boosts without an improvement in care quality, according to an article published in Strategic Management Journal by Amandine Ody-Brasier of Yale University and Amanda Sharkey at the University of Chicago.

“One would expect that raising the bar in terms of nursing hours required by regulation would lead to better outcomes for residents in nursing homes,” Ody-Brasier said in an article published in Yale Insights last week. “But we see an increase in staffing levels does not seem to move the needle based on one very basic health outcome: bedsores.”

Ody-Brasier and Sharkey ran analyses to determine whether SNFs hired less experienced labor at lower wages, or whether more time was needed to show improvements in bedsore rates and determined that neither scenario was the case, according to Yale Insights.


In addition, the researchers found facilities that reported boosts in staffing didn’t indicate a corresponding rise in salary costs and hours, a conclusion that they note doesn’t make much sense.

“As in other settings where researchers have used indirect approaches to shine a spotlight on possible gaming, we acknowledge that we cannot definitively establish that nursing homes reported false data,” Ody-Brasier and Sharkey concluded. “However, having sought out and thoroughly investigated other possible explanations for our findings, we are left to conclude that false or misleading reporting is a strong possibility.”

The change in 2012 meant that if SNFs were on the brink of the number of nursing hours per resident per day needed for “acceptability,” according to Yale Insights, they would have to increase their staffing hours to keep up their star rating.

A different study, from researchers at the University of Connecticut and Florida Atlantic University, in 2017 found evidence that SNFs in California had inflated their self-reported quality and staffing measures.

CMS has since required that nursing home providers submit payroll-based journal (PBJ) data to back up their staffing claims, a shift that also raised claims of gaming under the past system: The New York Times in 2018 released a bombshell story claiming that most skilled nursing operators had artificially inflated their staffing levels, which in turn prompted CMS to slap 1,400 properties with one-star ratings in the staffing domain.

Staffing also played a key role in CMS’s recent overhaul of the five-star rating system. Starting this April, the federal government raised the bar that operators must clear in order to earn solid staffing stars, among other changes designed to make the top ratings harder for operators to earn and maintain.

“Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes,” the agency said when releasing the new standards this past spring. “CMS found that as staffing levels increase, quality increases.”