Officials: More additions and rebasings of nursing home ratings to come

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David Gifford, M.D., senior vice president of quality affairs at AHCA
David Gifford, M.D., senior vice president of quality affairs at AHCA

Nursing homes entered a controversial new era of tougher government ratings Friday when officials released rebased Five Star ratings that caused nearly one-third of the nation's skilled nursing facilities to lose a rating star due purely to administrative changes.

Regulators also gave providers plenty of reason for concern after emphasizing in a media conference call Friday that more quality measures will be added next year, when another round of Five Star scores rebasing also could take place.

Providers were flummoxed Friday at the thought of seeing Five Star ratings made unfit for historical comparisons yet again next year.

“We anticipate they will add lots of new measures, and every time it will make the system before not valid,” criticized David Gifford, M.D., vice president for quality affairs for the American Health Care Association.

Federal officials acknowledged that providers' graded performances in February should not be compared with earlier months'.

“There have been huge improvements, almost 20 percent reduction of antipsychotics in two years — 20 percent — and they add [antipsychotics reduction] measures to the Five Star rating system [Friday] and all of a sudden one-third lose a star and 61% dropped in the quality component,” Gifford told McKnight's. “If there was a change in quality, we'll take our lumps, but there was no drop. That's confusing and that's why providers are upset.”

The anxiety is liable to remain high. Gifford said quality measures for rehospitalization and discharge rates are “fully expected” to be added in 2016, although he says regulators have not yet announced a suitable methodology for tabulating them. Staffing and retention rates also are expected to be published on the Nursing Home Compare website in 2016. Consumers used the website to judge nursing homes about 1.4 million times in 2014, federal officials said.

Changes that went into effect Friday included: the inclusion of quality measures pertaining to antipsychotics use by short-stay and long-stay residents; increased performance expectations; and adjusted staffing algorithms aimed at verifying nurse staffing levels via payroll records.

Officials with the Centers for Medicare & Medicaid Services also announced Friday that after today they are releasing results of pilot surveys that checked “adequacy” of resident assessments and “accuracy” of provider information self-reported to help calculate quality measures. The pilots were conducted in five states in 2014.

“Many nursing homes will see a decline in quality ratings until they make further improvements,” Patrick Conway, M.D., the Deputy Administrator for Innovation and Quality and Chief Medical Officer at CMS, told a media gathering Friday. “Changes reflect CMS raised the bar for performance.

“For continuous improvement, you do need to raise the bar to incentivize improvement,” he added. “We've gotten to a place where a vast majority of nursing homes have five stars, so we do need to raise the bar so care does continue to improve.”

LeadingAge President and CEO Larry Minnix disputed the notion.

“The increase in the number of nursing homes scoring high on quality measures does not mean the quality bar was previously too low,” he said in a prepared statement. “Thousands of nursing homes are participating in Advancing Excellence in America's Nursing Homes and other programs to improve quality. We see this work paying off.”

CMS's Conway said that rebasing was announced as a planned event when the original system began in 2008 and refined in 2012.

“It's fair to say we want a more frequent process [of recalibrating thresholds] over time,” noted CMS Director of Survey and Certification Thomas Hamilton. He explained that while regulators didn't want to rebase this year using base levels from 2008, next year “will see a change” when new quality measures are added.

Conway and Hamilton told reporters that nursing homes “have worked very hard to make improvement” but added more needs to be done.

“The level of performance that we expected that was prevalent in 2008, we don't think suffices for 2015, and we expect improvement over time,” Hamilton said. “Just as the Model A in its day — I'm told — was an excellent car, it wouldn't measure up today.”

Providers feel that improvement goals are fine, but it's the Five Star system that doesn't measure up.

“We hope CMS will more aggressively pursue fixing the fundamental flaws behind Five Star because the public deserves a tool that is easy to understand and is supported by reliable criteria,” Minnix said. “But we aren't there yet.”

A request Friday morning for comment from CMS about how it was assisting providers who want to emphasize to consumers and other sources that changed star ratings are a result of the government's rebasing of the entire system, and not necessarily a drop in quality performance, was not responded to by Sunday evening.