The system used to rate nursing homes’ quality needs to be given more oversight in order to discourage admission practices providers employ to pump up their ratings, said authors of a research letter published Thursday in JAMDA.
Spurred by evidence that facilities were prioritizing long-term care admission policies that would bolster facility ratings in the Centers for Medicare & Medicaid Services’ Nursing Home Care Compare database run by, a team of researchers surveyed four Virginia facilities and found that was indeed the case.
“Some estimates attribute as much as half of NHCC quality measure variation to unadjusted risk,” the researchers wrote. “The unfair outcome of biased selection is worsening disparity as more desirable facilities recruit more desirable patients, thereby increasing the appearance of quality and thus their desirability.”
CMS launched the Nursing Home Compare (now Nursing Home Care Compare) resource 20 years ago. The researchers said that when the National Quality Forum developed the long-stay quality-measures, they purposefully incorporated only minimal adjustments for resident risk with few, well-defined exclusions.
“A disadvantage of using unadjusted quality scores is the tendency to underestimate the care quality provided to less healthy patients,” said the letter. “Furthermore, an incentive is created for facilities to artificially improve their scores by selecting healthier patients and avoiding frailer individuals.”
The team surveyed 14 admissions- and retention-related staff from three urban and one rural facility. Participating facilities had enhanced staffing, were overwhelmingly white demographically, and in the highest quintile for both social determinants of health and antipsychotic use.
Respondents agreed in general on three admission and retention decision themes:
- Facilities are strategic in choosing the residents to admit.
“Goals were facility-centric,” wrote the researchers. “What was best for local populations or individual patients was not described. There was consensus that certain facilities have greater opportunity for selectivity whereas others are obliged to take residents no other nursing home wants.”
- NHCC quality measures influence admission decisions.
“Although ambivalence regarding the efficacy of quality measures to capture quality was universal, all participants endorsed scorecard awareness and described sincere facility-wide
effort to optimize scores,” the team wrote. “No decision maker reported difficulty forecasting the impact of individual admission decisions on quality measure scores. All interviewees reported cherry-picking admissions. Most described lemon-dropping problematic residents.”
- Staffing requirements are critical considerations.
“While acknowledging nuanced interplay between the competing elements influencing decisions, all participants emphasized the critical importance of an admission’s staffing needs,” said the letter. “Residents with few staffing needs were desirable; residents requiring challenging, time-consuming care were avoided.”
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The team said that it is common knowledge that publicly-reported quality initiatives lead to cherry-picking. In turn, cherry-picking increases disparities, and disparities have increased since NHCC’s scorecard debuted.
“Our results suggest these phenomena are linked, that quality reporting has created new selection incentives resulting in increased sorting and greater disparity,” said the researchers. “This finding should raise concern given the pandemic has witnessed a simultaneous surge in resident care requirements and a contraction in staffing availability, a trend potentially incentivizing even greater admission sorting and intensifying disparities.”
The researchers predict that quality-based compensation will increase and since they see no action to curb the NHCC effect on admission and retention, they suggest a hard look at admissions and retention policies.
“NHCC is growing, adding quality measures and increasing penalties for underperformers,” they wrote. “Thus, reflection on both successes and improvement opportunities in existing programs may be timely. If quality reporting impacts admission decisions and admission decisions drive disparities, then facility-centric admission processes require continued research attention and perhaps enhanced oversight to avoid increasing disparities in nursing home quality and access.”
