Guest Columns

Where were YOU when CMS changed the Five-Star rating system?

Steven Littlehale
Steven Littlehale

Certain events in our personal or professional lives have such an impact that we can remember exactly where we were, and what we were doing when they occurred. Where were you on February 12 when CMS publicly announced immediate changes to the Five Star Quality Rating System for Nursing Homes?

This came four months following the October 6, 2014, executive order to revise the program. Why was this such a significant event? Because one-third of our nation's skilled nursing facilities saw their Five-Star rating affected. Nationwide, 28% of SNFs lost one star overall and 3% lost two stars overall. In the other direction, 2% of SNFs gained two stars overall and 67% of facilities saw no change whatsoever.

These percentages warrant a deeper dive into understanding more about the CMS Five-Star ratings and what it means going forward; more specifically, if yours was one of the facilities that lost stars, what can you do to get them back?

What changes did CMS make?

Before you can understand how to reclaim your stars, you have to first understand exactly what changes CMS has made to the rating system. CMS raised standards in the Staffing domain. Previously, facilities receiving an RN Staffing rating of 3 and a Total Staffing rating of 3 were assigned an Overall Staffing rating of 4 stars. Essentially, facilities that proved to be “average” in both RN and Total Staffing were being awarded an “above average” Overall Staffing rating. This is no longer the case. Now, in order to receive 4 stars for the Overall Staffing rating, you must have an “above average” rating for either the RN or Total Staffing rating.

Next, CMS added two Quality Measures in the calculation for the Quality rating: short-stay and long-stay use of antipsychotics. The agency also changed the number of points it takes to reach the different star levels. Over time, SNF providers have improved in many outcomes of quality, making it necessary to revise the star distributions and set new cut points for performance aligned with quality points.

In essence, by rebasing and recognizing that providers have improved over the years, it's now harder to achieve the highest QM star ratings. Several corporations went from portfolios with less than 5% of facilities at 1 or 2 stars in Quality to now having portfolios with 20% to 40% of facilities at one or two Quality stars. The states most affected include Louisiana, Kentucky, Mississippi and Texas, dropping from 28% to 34% in their QM star ratings, while Hawaii, Arkansas, California and Washington, DC only saw declines of 4% to 11%.

One of the most important questions you may be asking yourself is, will the change hurt your organization long-term? Well, it might. Although CMS's “effective immediately” change in the methodology may have decreased your rating seemingly overnight, it does not mean your quality of care or staffing levels actually changed.

However, providers now have to explain this change to other stakeholders who use Five Star in ways never intended. Accountable care organizations (ACOs), Real Estate Investment Trusts (REITs), hospitals, lenders and owners alike have already misinterpreted the sudden downward shift in Five Star, placing new demands on SNFs. Some providers report that their interest rates are increasing; they're being dropped from referral networks, along with other negative consequences. What that means is that a rapid response is required and the race is on for providers to redeem their star ratings!

But remember, Quality stars are based on nine months of data, so those that can respond the quickest are those who can analyze their data, identify root causes and institute evidence-based interventions in the appropriate care areas. Based on how the QM star rating is calculated, it remains to be seen who the leaders will be as they break from the pack about six months from now!

To be certain, the rebasing needed to happen — in fact, it should have happened some time ago. Adding additional QMs is the right thing to do. How can I be so confident? After 25 years devoted to this industry, I've learned to never underestimate the commitment and creativity to improve performance.

That being said, I hope the next significant event when you remember exactly where you were or what you were doing occurs on the very date you see your Five-Star rating improve. You can do it with a little help from your friends — i.e., your work team, your quality processes, and with predictive analytics as your guide.

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

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