James M. Berklan

One day I asked a friend who runs a great restaurant in town why he looked so down.

“The local food critic just lowered us a few notches,” he said sadly.

The appetizers not so tasty any more? No. Main courses using cheaper cuts of meat? Not that. Maybe the desserts aren’t so fresh any more? Not at all, he said.

I have it! I shouted. Customers must have found mouse droppings, peeling wallpaper or at least a greasy spoon or two, right? No, no and no.

“The reviewer said we have too many top-rated restaurants nearby so somebody had to be clicked down,” my friend explained, the blood draining from his despondent face. “He said people couldn’t make up their minds where to go because of so many high ratings.”

That is sad, I agreed. Since when did having numerous well-qualified options become a not-so-desirable thing? So there was no consoling my friend, who months earlier had been the toast of the town and now had to worry about attracting enough customers to keep his nursing home, er, restaurant afloat.

Pardon the slip. Nursing home operators must be having the same feelings as my restaurant friend. Some of them are being told that, despite good customer service and business practices that might have once been the talk of the town, they’re being downgraded.

In skilled nursing’s case, D-Day (D standing for demotion) is April 24. That’s when the Centers for Medicare & Medicaid Services is expected to officially move the cheese again. Amid a handful of well-conceived changes, the agency admits it is also making it harder for providers to achieve four or five stars, or any other high ranking, in the Five-Star Ratings System.

Why? Because consumers said they were getting confused due to insufficient differentiation among five-star earners, an agency official explained. In other words, the noble citizenry appears to be having a hard time deciding whether to dine on prime steak, delicate seafood or dazzling pasta because highly regarded restaurant options existed for all. And somehow, restaurant owners are being punished for customers’ indecision.

This is indeed very serious stuff for nursing home operators because everybody from insurers to investors, and of course consumers, have come to rely heavily on Five-Star ratings, perhaps more than CMS ever intended.

An industry analysis by the American Health Care Association shows that about half of the nation’s 15,000 nursing homes will not see a change to their ratings come April 24, while about one-sixth can expect an increase. An estimated one-third, however — roughly 5,000 facilities — will suffer a ratings drop overnight. Why? For many, for doing nothing other than whatever they did before going to bed April 23.

Although the recalibration had been announced much earlier and was generally well known, that didn’t stop hundreds of attendees at the joint AANAC / AADNS conference from reacting with indignation Friday when CMS officials discussed the reasons for the ratings changes.

The deeper story

In brief, there is no debate. Changes are coming. But to gain a higher level of understanding, the agency’s explanation bears further airing.

On one level, it might come down to semantics, or regulators simply needing to hammer their message a little differently.

As explained to me by a respected CMS official, the star-ratings should be viewed through a different qualitative lens than the one posed above. One star equals “Much Below Average,” 2 stars is “Below Average,” 3 stars is “Average,” 4 stars is “Above Average” and 5 stars is “Much Above Average.”

Therefore, by definition, one should never have 50% of providers “Much Above Average” in any category, as is currently the case within the Quality component.

“As compared to all nursing homes, some of the top 50 percent in the country should naturally fall into the average (3-star) and above average (4-star) categories,” the official explained, adding that there is “a lot of variation” among the 50% of facilities now receiving five stars in the Quality Measurement domain.

Sounds like a bit of agency self-flagellation might be in play —  for not setting high enough goals in the first place. And it’s still not entirely clear why providers in a given area have to be so finely calibrated against one another. Why must citizens have to find the absolute best when “good enough” truly should suffice when seeking levels of health and functionality? Is the town’s second- (or third-, or fourth- …) best steak not good enough on any given night, provided it sends the diner home with a smile on his face and a healthy spring in his step?

Nonetheless, CMS has vowed to continually increase benchmarking levels — or “move the goalposts” as more than one provider has lamented.

“CMS expects nursing homes to continue making quality improvements over time, and we have periodically raised QM thresholds to promote further progress,” is how the agency explained it in a recent memo.

I agree wholeheartedly with the concept of not resting on one’s laurels. Striving for continued improvement should be encouraged in virtually any endeavor.

But it’s still hard grasping the idea that the delicious Chef’s Special that filled so many bellies and sent people home so happy and healthy one day isn’t going to be worthy of the same praise and satisfaction in the future. Pity the poor restaurant owner who suffers because of it.

Follow Editor James M. Berklan @JimBerklan.