Why the Five-Star Rating System Needs an Overhaul — And How to Fix It

The five-star quality rating system has been a thorny issue for a lot of operators in the skilled nursing space, with many calling for a significant overhaul to quality metrics as facilities drown in seemingly endless federal benchmark adjustments.

Even academics and consultants monitoring the sector believe the ratings system needs to be updated – the Convergence Center for Policy Resolution, for one, called on the Centers for Medicare & Medicaid Services (CMS) to base ratings more on resident and family lived experiences.

“Most of the measurements are focused on safety, not really on quality. It doesn’t tell you anything about the quality of the lived experience of a resident,” said Howard Gleckman, co-author of the Convergence report and senior fellow at the Urban-Brookings Tax Policy Center at the Urban Institute.

Coupled with a lack of consumer input is the reality that the data is stale, Rachel Little told Skilled Nursing News.

Little, who serves as director of clinical compliance for St. Louis, Mo.-based Lutheran Senior Services, said many facilities are still waiting on their annual licensure survey – some haven’t had a survey in three years, meaning star ratings are anywhere from three to six years old.

“A lot of things can change in that timeframe. It’s not a true reflection of what is happening today,” Little said.

Other sector leaders, including Zimmet Healthcare Services Group Chief Innovation Officer Steven Littlehale, believe five-star has a disproportionate effect on nursing homes that specialize in certain services like behavioral health, or those that have a high rate of either Medicaid beneficiaries or high intensity, short-term rehabilitation patients.

The most recent added data points incorporate weekend staffing and annual turnover as part of the staffing measure – total nurse staffing hours per resident per day on weekends, overall nurse turnover within a given year, annual registered nurse (RN) turnover and annual number of administrators who left the sector.

The five-star “stool” is made up of three legs, including staffing, quality and regulatory measures. Historically, regulatory measures have been the most weighted, followed by staffing and then quality.

Five-star’s broad brush, with old data

Littlehale was once brought in as an expert in a nursing home legal case – the facility specialized in behavioral health patients and lawyers were using the five-star system to prove the lack of quality and safety in the facility, he said.

“I was able to show them that all facilities in the United States that have the same proportion of people with behavioral health and mental health illness are always a one- or two-star facility,” he said. “They’re always struggling on surveys and it shows the rigidity of the survey system.”

Facilities are all so different in terms of who they are treating and what the area community actually needs. That diversity shows up on surveys, which is what’s really driving the five-star rating system, according to Littlehale.

Data incorporated into five-star doesn’t reflect what is occurring in the nursing home in real time, Little added, with CMS so behind on annual surveys. They don’t really capture resident outcomes over a long period of time either.

“There needs to be a revamp of the look-back period. Much of this data that is being publicly reported is anywhere from 12 months or greater … and so more real time if possible would be a good thing to capture,” Little said.

Reworking the system starts with the consumer

Industry leaders agree that a crucial change to five-star must start with residents and their families – CMS must ask them what they value in a nursing home and then incorporate those values.

Safety, not quality, is measured in five-star, but safety should already be guaranteed, Gleckman said.

“Sometimes I make the analogy to a hotel. You want to make sure that there are no vermin in the rooms, and the shower has a nonstick bottom so you’re not going to slip and fall in the shower … you want the basic safety stuff, but every place should give you that,” he added.

A resident, or in this analogy a hotel guest, would really want to know what the amenities are like, what the food is like and if the staff is friendly. As designed, five-star really doesn’t give the resident that kind of information.

Five-star should also give residents and their families the ability to compare facilities across state lines. Gleckman used Washington, D.C. as an example, with residents potentially going to facilities in Washington, Maryland or Northern Virginia.

“It has to be the voice of the consumer,” Littlehale said of a five-star overhaul. “We’re struggling and striving for patient-centric care, but sometimes it feels like it’s external stakeholder-centered care, or CMS-centered care. It’s not about the consumer.”

The industry is “pretty close” to getting mandated family and resident satisfaction in five-star, he said.

Ripple effect of benchmark adjustments

When facilities see their star rating decline as a result of data changes and of CMS recalibrating the staffing benchmarks, external stakeholders don’t see the why — only the result, Littlehale said.

“External stakeholders are evaluating them by using five-star; they are not understanding the weaknesses of the system. They’re attributing change and differences to the provider,” Littlehale said.

A facility owner could go to sleep on a Sunday thinking they have a three-star building, only to wake up on Monday with a two-star building, he said. In many cases there’s no survey, there’s no additional staffing data added – nothing has changed except for the federal methodology or benchmarks.

Three of Lutheran Senior Services’ 10 communities lost a star when the staffing updates were made to the system in July, Little said.

“That’s really hard when there’s an external stakeholder which might be a lender, it might be consumers. It might be an insurer, it might be the state agency,” he said. “They wake up and they say, ‘Oh, this facility has downgraded, they now defaulted on their loan covenants,’ or ‘they are going to have an adjustment of their PL/GL rate,’ or ‘we’re going to require an external monitor.’”

Generally, five-star’s current measures are proxies, added Gleckman. They’re process measures – they’re not measures of outcomes. The five-star system is working with what an analyst would call correlation and not causation, he said.

Staffing turnover, for example, is a proxy of quality care, but it would be much better if five-star consisted of quality metrics.

“In an ideal world, we would have a series of really robust quality measures and essentially say to the facilities, ‘We don’t care how you get there as long as you get there, as long as you can provide excellent care to your residents. Let’s all agree on how to define excellent care. If you can do it with half the staff, that’s great,’” said Gleckman.

Five-star shouldn’t be the end-all and be-all

Overall, five-star helps residents, their families and other parts of the care continuum discern excellence from poor quality, Littlehale said, but in a very broad, simplistic way.

To be fair, CMS never meant the five-star system to be an end-all and be-all answer to measuring quality in nursing homes, industry leaders agreed. The system is supposed to work more as a tool for consumers and nursing home partners when choosing a facility to go to or work with.

“A four star building is different than a two star building, but even then those statements start to lessen,” said Littlehale. “If you knew how to read between the lines or read the details of what goes into those metrics, you would see that maybe even a four and two were more similar than different and then it’s completely meaningless when you’re one point away.”

The creators of five-star took quality measures from hospitals like falls and facility-acquired infections and made that the rating system, according to Gleckman. Ultimately, nursing homes are a very different environment and deserve their own quality measures.

“You can count UTIs, you can count falls, but you can’t count quality of life. [CMS] said, ‘let’s require them to meet standards that we can measure,’ and that’s what they did,” said Gleckman.

CMS is well aware of this issue, he said, but creating quality outcome measures rather than proxies in place right now will take some work.

“They still are very much in the mode of thinking about process rather than outcomes, but they’re aware of the fact that outcomes will be better,” said Gleckman. “Getting consensus among the consumer groups and the providers on how to actually measure quality rather than measuring safety is going to be a really hard, long difficult process, but I really hope they get going on it.”