Tim Mullaney
Tim Mullaney

The provider community can sound downright oxymoronic when it comes to the five-star rating system for nursing homes. Provider advocates defend the ratings (which show positive trends) while saying practically in the same breath that consumers need to take them essentially with a grain of salt. But my understanding of this seemingly fractured viewpoint has grown in recent weeks, because I’ve been trying to choose a new tennis racquet.

The five-star system has been much analyzed lately, due to a recent New York Times takedown. I spoke with a leader at the nation’s largest long-term care association about that article. David Gifford, M.D., senior vice president of quality and regulatory affairs at the American Health Care Association/National Center for Assisted Living, began by talking about the limitations of the ratings, and the Times’ failure to explain how they ought to be used.

The system could appear to be “misleading” to a consumer, because other available information could suggest that a nursing home’s rating is “incorrect,” Gifford said. He used a healthcare analogy: Everyone would like to have low cholesterol, but just because you have high cholesterol doesn’t mean you’ll develop heart disease. Similarly, four- and five-star facilities might be “less likely to have problems,” but issues can crop up there. At the same time, there are “many people” who have excellent experiences in places with one or two stars, he explained.

That said, the ratings do provide valuable information and in fact should be expanded to include even more data, Gifford told me.

So, on the one hand, don’t steer clear of a facility just because it has only one star. On the other hand, do take the ratings seriously and let’s double-down on them. You could be forgiven for taking a cynical view that associations like AHCA want to tout positive ratings trends while simultaneously protecting members with few stars.

A few days after talking with Gifford, I rented a few tennis racquets from my local pro shop and took them on the court to test them out. The results made me think harder about what the AHCA leader had told me. The Head racquet that had the best overall rating on my go-to website (tenniswarehouse.com) was my least favorite. I played terribly and it hurt my arm. I did much better with a Babolat racquet with a significantly lower overall rating.

The key word is overall. When I looked back at the ratings, I saw that the Head racquet had received a 79 in the “comfort” category while the Babolat earned an 86. As someone who’s experienced tendinitis since high school, I should have paid special attention to the comfort scores, I realized.

I also realized that I had not used the ratings in a very smart way. Since then, I’ve focused less on the overall scores and more on the specific categories that are most important to me. This might seem like “Being a smart consumer 101” stuff, and maybe it is. But it required me to do something a little bit difficult — namely, think harder about my specific needs and get over a lazy and impractical “I just want an all-around great racquet” mindset.

Basically, I experienced in miniature what Gifford was saying about the Nursing Home Compare ratings. The overall rating for the Head racquet might have seemed misleading to me, because it seemed like a terrible racquet once I got it on the court. But, actually, it was only in one specific area that it fell short — comfort — and it so happened that this is an area of very high importance to me. Gifford had made a similar point, saying that someone coming into a nursing home for a short-stay rehab probably should not get too hung up on how the facility performs on pressure ulcers.

The wrinkle here is that the ratings currently do not include many metrics relevant to short-stay residents. Hence AHCA’s position that the ratings need to be expanded: They want to see more of this short-stay data as well as customer satisfaction and other information to be included. (If Tennis Warehouse had not included a “comfort” category, I might have thought that its ratings were bunk.)

When I was talking to Gifford, I was a bit surprised at how much he focused on the importance of educating consumers about how to use the ratings. This seemed peripheral to me, as opposed to some of the other issues raised by the Times, such as accusations that facilities are “gaming the system” by staffing up for surveys. (An accusation that Gifford challenged. See the upcoming print issue of McKnight’s Long-Term Care News for more of the AHCA viewpoint.)

I’ve come to credit Gifford for emphasizing this piece of the equation so heavily. It was easy for me to learn from my early mistake and make better use of the tennis racquet ratings. Consumers can’t learn how to use nursing home ratings through trial-and-error, and it’s their wellbeing and the reputation of the whole sector at stake. And if you believe, as Gifford does, that the ratings are more accurate than the Times depicted, then teaching people how to use them becomes paramount in proving that the system is not fatally flawed.

Legislators responded to the Times article with indignation and called for changes, but there’s some reason to hope that the government also is taking provider input seriously. Shortly after the Times piece appeared, the Medicare agency announced a delay of the planned five-star system for dialysis facilities, to allow for more robust consumer education efforts called for by providers. Nursing Home Compare is well established, but the time may be ripe to clamor for more consumer education in this arena as well.

Tim Mullaney is McKnight’s Senior Staff Writer. Follow him @TimMullaneyLTC.