CMS's confusing kick in the teeth

James M. Berklan
James M. Berklan

One gets the feeling that federal regulators, no matter how proper the official talk went, took a bit of pleasure in sticking it to nursing home operators over rebasing their star ratings the past week and a half.

First, they hold a conference call where they inform providers of the “courtesy” they are extending in letting them know a week ahead that their value in the public's eye will be undercut.

A possible mess to explain to residents, family members, board members, the general public and anybody they might be trying to make a positive caregiving alliance with? Oh well.

Then, Friday they publicly announce “an expanded and strengthened” nursing quality rating system that brings “improvements.” Not so prominent is the fact that nursing homes' star ratings were cut overnight simply due to administrative decisions.

(No drop in quality performance despite the markdowns. But, hey, did we mention how courteous they were about letting you know a week ahead of time?)

According to industry and media calculations, more than 30% of nursing homes are expected to have lost a star in their overall Five Star rating. A majority also dropped in their quality numbers. And why? Just for waking up the next day.

The Centers for Medicare & Medicaid Services clearly has many insightful people in its employ. Could one of them have produced some prominent form of communication that says, “Hey, we're basically starting everybody over on this star-rating thing, and we're also adding a few more measures that we think will make all of this more accurate anyway”? Might be helpful in what could be an initial rough ride for some providers.

To be fair, the 21st line of the fact sheet CMS put out concedes: “However, the changes in the quality measures star ratings released in February do not necessarily indicate a change in the quality of care provided.” Not hard to divine what the original supposition was on that one.

For providers, that's burying the lead, as they say in journalism. A brief scan of some major mainstream news outlets shows what they led with, and it didn't make providers sound particularly good. USA Today's “Nursing home quality scores drop in new federal ratings” is a good example. Others noted an “altered” system or “toughened standards,” which could be more helpful in the perception game, but only if you're up to speed with what's been happening.

By taking the, “We're toughening up things” stance, CMS set the tone. Eventually, it gave a few complimentary pats on the head to providers, but the overall implication was: Something's amiss, but we're getting these scoundrels cleaned up.

Here's another way to look at it: How would you like to wake up tomorrow and find your home's value dropped by 20% or more, despite keeping it spruced up and maybe even improving it lately?

Or how about if upon arrival at work today you were told that, while we recognize you've been trying hard and actually made some progress, we're sorry but you're now going to receive 20% to 30% less salary? (The relative value of losing one star in a five-star system) Would a week's courtesy notice make it better?

Or best of all, you send you children to school and tell them to work hard to earn good grades. After all, college is not far away. And what do you know, they pull their GPAs into Honor Roll territory, a 4.0 on a 5.0 scale.

The next day, however, the principal announces that 4.0 GPA is a 3.0 because, well, too many students have done well and it doesn't look good to have them bunched together like that at the top. If you resist the urge to punch that principal in the nose, you might get your kids to buckle down even harder and eventually make the Honor Roll again.

But then think how demoralizing it would be to have to look them in the eye two years later and tell them that the bar has moved again. Nice job, but, hey, your grade just isn't worth what they told you it would be because, you know, they said they might want to rebase the scale again.

The last example is perhaps the best illustration of what providers feel they're up against.

“Measuring in Five Star is here to stay, but when you change the rating system in a way that doesn't reflect the level of improvement, that's not right,” observes David Gifford, a physician and the director of quality efforts at the largest nursing home association in the country.

“If they announced to the world that you'll now need a 95 and next a 96, that's fine,” he says, drawing on the classroom analogy. “But they didn't announce that. This year they said you need an 85 and next week, we'll move that to a 95. It wasn't a short or gradual change. It was dramatic. And now one-third of the class no longer gets an ‘A.' “

Worse, Gifford says, CMS appears to be making the same mistake as it did in the past. He's in favor of adding more quality measures as CMS sees fit — appropriately vetted and calculated, of course. But then average them into the current star basing. Don't take away.

It's hard to argue with the logic, yet it's apparently something CMS has considered and rejected. If others do well, that doesn't mean you should get clicked down merely because the Honor Roll gets more crowded. Former Health and Human Services Secretary Kathleen Sebelius seemed to reject such a mandatory redistribution system herself several years ago on this subject.

There is bound to be friction between government regulators and those they regulate. But let's get this tweaking process right. Prod continual improvement but stop moving the goalposts. Add criteria, but keep the framing the same, so everybody in the game or watching from the sidelines can keep perspective and keep up with what's going on.

To do otherwise borders on sadistic.

James M. Berklan is McKnight's Editor. Follow him @JimBerklan.

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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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