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Evaluating Nursing Home Quality:
Why I Can’t Rely on Medicare’s Five-Star Rating System

                  Would You Hail A Cab With A Flat Tire?   Part 4
The writer formerly was responsible for the quality of all the long-term care beds in New York County under the aegis of the federal government. In addition, he has lectured on quality assurance, assisted in the delivery of the first geriatric medical residency, designed the first clinical rotation for physician assistants in geriatric medicine among other accomplishments in the field of gerontology. Most importantly, he has been an advocate for caregivers and their families- including assisting in nursing home placement - for over 40 years.
The CMS Nursing Home Compare Website

The Centers for Medicare & Medicaid Services (CMS) established the Nursing Home Compare website and rating system in 2008. Today it remains as a primary resource for caregivers and case managers to evaluate and assist in the selection of appropriate nursing home placement of their families and patients under their care. Applying multiple criteria such as state inspection findings and quality measures, it collects and compares information from nursing homes across the country and presents it via a Five-Star Quality Rating System.

Facilities value the ratings and utilize them in marketing and promoting their institutions.

Nursing home associations offer guidance to their membership on how to interpret and improve the rating score is.

History of Five-Star Rating: Its Uses and Applications

The Five Star Rating System was introduced in the mid-1800s in travel guides to identify worthy points of interest, then added hotel ratings, from poor to luxurious. It has expanded further to restaurant guides, theater productions, and even household items for today’s website shopping.
Five-star ratings have become embedded in our culture and lexicon.

Amazon’s 5 star rating          
5 = I loved it

National Highway Traffic Safety Administration 5 star rating
5 Stars = Excellent features on this child restraint for this category

What’s My Problem?

When I see a five-star rating, and I believe this to be true of all consumers, it immediately connotes excellence, an outstanding service or product as in five-star hotel, five-star general, five stars on Amazon. This is the standard application.

Nursing homes with the five-star rating, however, are not necessarily excellent. Facilities touting five stars may have issues. Examples of family experiences include extensive delays in obtaining nursing assistants, incorrect medications instructions upon transfer to the hospital, obstacles in receiving timely medical care.
How or Why Does This Come About?

Why are such experiences not reflected in the nursing home compare tabulation? Simply put, they are not reported by families.

Other limitations in the rating system have been identified. Some have been corrected. CMS reviews and updates its criteria regularly.

In a recent study entitled, Winning at All Costs: Analysis of Inflation in Nursing Homes’ Rating System researchers analyzed data from over 1200 nursing homes in California. “We argue that the rating system is prone to inflation in self‐reported measures, which leads to biased and misleading ratings.”
Medicare has a disclaimer on its website. Such disclaimers are not included in the nursing home advertisements.
Consumers are presented with the verbiage and imagery about a facility:
Rated Five Stars
by the Centers for Medicare & Medicaid Services!
To me, it implies a program delivering outstanding care supplemented with amenities as one would expect in a 5 Star hotel, especially when it bears the certification of CMS.

That is my problem.
To be continued
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