The Five-Star Quality Rating System is a convenient and widely used tool created by the Center for Medicare and Medicaid Services (CMS) to help people find good nursing homes, but it can be a subject of controversy when it comes to specific metrics that it uses.
In 1998, the Center for Medicare and Medicaid Services (CMS) initially launched Nursing Home Compare as a federal website for information about nursing homes. The Five-Star Quality Rating system was an update made in 2008 to help the public better identify and compare nursing homes based on an automated score generated by specific metrics of the nursing homes. The Nursing Home Compare website works by requesting the zip code of the user and listing all available nursing homes within a 25 mile radius. The user can then select up to three to compare the ratings based on reports certified by the CMS (see screenshot below). Providers are given a score from one to five stars on criteria such as health inspections, staffing and quality measures, where one star represents below average and five star represents above average.
While the star rating method is an easy way for consumers to visualize differences in quality between nursing homes, there might be issues which could threaten the validity of the assessment.
In an academic study published in 2018, researchers found that higher ratings on Nursing Home Compare did not directly translate to a lower rate of hospitalization, deeming the Five-Star Quality Rating System to be “less meaningful as an indicator of nursing home quality for post-acute care patients.” This study raises the concern that the rating system might not be incentivizing nursing homes to focus on patient care, but rather on simply meeting the standards that are checked during inspections in order to receive a higher rating.
Another criticism regarding Nursing Home Compare is the lack of understanding towards assessing overall quality of nursing homes. In the most recent change to the system, a facility will automatically be assigned a one-star rating for the “registered nurse staffing” category if it reports four or more days per quarter with no registered nurse on site. The CMS said this change was to reflect that “nurse staffing has the greatest impact on the quality of care nursing homes deliver.” This change, while positive, was met with criticism from the American Health Care Association (AHCA). In a statement, the AHCA says that “the staff rating still does not include therapists” who also play a critical role in ensuring patient-centered care. While the CMS is continuously making strides to improve the system, they may well be overlooking other vital components of quality care.
The most recent study by the CDC in 2016 found that there were about 15,600 nursing homes in the U.S., however, that number is dropping. In an interview with the New York Times, University of Pittsburgh health policy researcher Dr. Nicholas Castle said that 200 to 300 nursing homes close each year due to declining number of residents who might choose alternatives such as assisted living or other ways to stay at home. Meanwhile, the Population Reference Bureau projects that by 2060, nearly 100 million Americans will be 65 or older, which is more than double the number from 2016. Putting these pieces of information together, there will be an inevitable rise in demand for better nursing home facilities, and for an accurate rating system to help people find those homes.