Ask the payment expert: explaining the case mix component of the Five-Star rating system
Ask the payment expert
A lot of people are confused about the Case Mix component of Five-Star. The case-mix staffing calculation utilizes the time studies that were completed in 1995 and 1997 by the Centers for Medicare & Medicaid Services to determine the original RUGs 44 Grouper and later applied to the RUGs 53 Grouper. These numbers will be updated once the STRIVE studies are published.
The actual RUGs 53 minutes are applied to each resident in your long-term care facility on the last business day of the quarter that includes your survey to determine your adjusted staffing, based on what you submit to the state on your CMS 671 form.
By applying the minutes to each resident, it tells you how many RNs, LPNs and CNAs you should be staffing in your facility according to the acuity level of your residents.
That is then used along with your actual staffing and the national average to compute your adjusted staffing. That adjusted staffing is then used to determine your star rating for RN and total staffing, and your overall staffing star rating. The staffing star rating is used to raise or lower your overall star rating, depending on your outcomes.
If that seems confusing, you are right. It is.
You should run your case mix on a quarterly basis so that you will always be prepared with the data CMS may be using. Most providers are struggling to understand the concepts of the Five-Star rating.
It's important to get education on the Five-Star process so that you can explain it to your consumers. Each component of Health Surveys, Staffing and Quality Measures is an important calculation to determine your facility's overall star rating.