Researchers have found that a new, complaint-focused quality metric would better represent the needs of residents and family consumers searching nursing home ratings.

Currently, inspections triggered by complaints are lumped into a single “health inspections” category on Medicare’s Care Compare website, along with results of routine recertification surveys. But that may inflate overall scores and obscure the kind of information consumers most want, researchers reported in JAMA Network Open Tuesday.

A new two-pronged metric would make it clearer to consumers just how much scrutiny providers had faced from both regulators and nursing home patients or their advocates.

“What we were looking at is how much of your star rating is really driven by those annual surveys vs. complaint inspections, and is there different information that you can obtain about a facility if you were to, say, decompose, or look at those two survey ratings separately?” explained co-author John Bowblis, PhD, professor of economics and research fellow at the Scripps Gerontology Center of Miami University. “What this paper shows is that, while there is a general correlation between the two, you actually get a lot of different information from complaint surveys.”

And by lumping the two score components together, the Centers for Medicare & Medicaid Services is blocking website users’ ability to measure how they should weigh the information.

“You’re limiting a consumer’s way of knowing, is this information that’s coming from the same regulatory process that some people have criticized? Or is this being initiated by complaints, which is more, how do consumers feel about this?” Bowblis told McKnight’s Long-Term Care News on Monday. 

If the lower rating is coming more from the complaint surveys, he added, “that means there are a lot of people who are finding, or at least alleging, that there are potential issues.”

One survey easier than another?

To understand how separating metrics on Care Compare might more accurately reflect quality, Bowblis and Lindsay Peterson, PhD, of the School of Aging Studies at the University of South Florida, calculated three sets of Five-Star ratings using inspection data from 2017. 

In one they combined recertification and complaint surveys; in another they used only recertification, or annual, survey results; and in the third they used only complaint investigation scores.

In their model, among the nearly 20% of nursing homes that garnered 1-star ratings based on complaints alone, most had higher recertification health inspection ratings. And the study found that overall scores were more likely to reflect that higher inspection rating score.

“This finding suggests that overall health inspection star ratings may be affected by recertification survey results and may mask the results of complaint investigations,” the researchers wrote.

In all, just 30.9% of nursing homes earned the same star rating for their annual survey and complaint inspection performance. The differences between the two scores could be critical for nursing home consumers who want to know more about how non-regulators view a specific facility.

“Somebody had to actually go to the state, complain about the quality or some issue,” Bowblis said. “The deficiencies that come from complaint inspections actually provide additional information because in some ways, they are reflecting what the consumer or the family members or an ombudsman feels about a particular survey.”

That may go beyond what surveyors key in on, or what particular regulations a state or federal agency has recently emphasized in its latest inspection guidance.

Two separate metrics also would make it clearer if a facility has no recent complaints, which raises another ongoing issue with the survey and inspection process. Bowblis and Peterson, citing previous federal reports, underscored a lack of consistency in complaint filing and investigations among various states. Some studies have found problems with oversight and management of states’ complaint-response processes.

“Complaints have the potential to identify quality gaps not identified during recertification surveys,” the researchers noted. “An absence of complaints may indicate that consumers are pleased with a nursing home’s care and service, but it also may indicate they are unaware of their complaint options, have difficulty reporting complaints, or fear retaliation.”