Five-Star insights: Will those stars ever illuminate your path?

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Steven Littlehale
Steven Littlehale
I recently asked a hospital discharge planner how she chooses which nursing home to discharge to. “Five-Star” was the reply. Was I surprised? Not at all. Once again, it demonstrates just how far this Centers for Medicare & Medicaid Services consumer initiative reaches.

The Five-Star Quality Rating System provides a ranking from one star (the worst) to five stars (the best) for the nation's nursing homes in the areas of health inspections, staffing and quality measures. It also gives an overall facility ranking. Since October 2010, Five-Star has been in a “modified mode,” waiting for CMS to update the Quality Measures and Staffing domains. Yet consumers and other stakeholders continue to use it. 

Concerns were raised over the fairness and usefulness of the system and the fact that it was not “taken down” during the transition from MDS 2.0 to MDS 3.0. During this time, ratings have continued to be used by many entities, such as hospitals when planning post-acute placement, Medicare Advantage Plans to determine quality of service delivery, litigators when investigating claims, and the media.

The change from MDS 2.0 to MDS 3.0 affected the quality measures and staffing areas, leading to a modified system until CMS completes its updates. The Quality Measures domain had been based on outcomes from 10 MDS 2.0 Quality Measures (QMs), and has essentially been frozen, retaining and using clinical outcome measures from the third quarter of 2010.

New MDS 3.0 QMs have been developed and CMS selected 16 outcome areas for use in public reporting on Nursing Home Compare (NHC). These new QMs were to be posted in early 2012 but are not yet available. The NHC website also states that these measures (when available) will not be used in the Five-Star Quality Measure domain or the Overall rating calculation until late 2012. More to come …

The second area affected by the change from MDS 2.0 to MDS 3.0 has been the staffing domain, which adjusts staff hours based upon resident acuity. Over the past 1.5 years, staffing hours obtained during the standard survey were adjusted using resident acuity obtained from MDS 2.0 data (from the third quarter of 2010). 

In April 2012, it appeared CMS began adjusting acuity using MDS 3.0, not dated MDS 2.0 resident data.  In other words, the staffing domain is now reflective of staffing hours and resident case mix from the same period:  the annual survey.

But what impact has this had on Five-Star staffing? PointRight investigated.

We looked at public data for March 2012 (outdated MDS data for acuity adjustment) and compared to April 2012 (updated data). For the 13,413 facilities that did not have a new survey entered (meaning unchanged staffing hours) it was found that 22.8% had a change in their staffing star rating. What's more, 9.8% had a change in their overall stars ratings.

And for that Hospital discharge planner? We studied the correlation between 30-day rehospitalization rates to overall Five-Star ranking. After appropriate case-mix adjustment to “level the playing field,” SNFs within each star are almost the same in terms of hospitalization rate. Choosing a one- or five-star facility for placement has no impact on likely rehospitalization and is not a solid strategy.



As healthcare reform initiatives such as accountable care organizations, bundling, and pay-for-performance are implemented, it's expected that this public reporting system will be integral in appraising the quality of nursing home service delivery.

Watch for the comptroller general's report to Congress (ACA §6107) studying CMS's Five-Star Rating System. This analysis covering implementation of the system, associated implementation problems and how the system could be improved will be of significance to providers. Knowing firsthand the far-reaching effects of the program, stakeholders should continue to closely monitor and provide feedback to CMS's proposed revisions.

Steven Littlehale is a gerontological clinical nurse specialist, and EVP and chief clinical officer at PointRight Inc.


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