"Gaming the 5 Star System"

By / Posted on September 3rd, 2014

It was disheartening to read the NY Times story this week about the CMS 5 Star rating system. Such reporting leaves both the providers and the consumers asking, “If a 5 Star nursing home isn’t a 5 Star nursing home … then does that mean that a 1 Star nursing home isn’t a 1 Star nursing home?” “Hip, hip hooray,” say the 1 Star homes. “I told you that those 5 Star homes weren’t better than us. They just game the system.” Wow!

The article asserts that nursing home leaders game the 5 Star system in two ways – 1) By falsely documenting better clinical outcomes via the Quality Measures; and 2) By staffing up during the survey and then reducing staff after the inspectors are gone. I would like to address both.

Regarding the accusation of gaming the Quality Measures (QMs) – consider that the QMs are calculated from each of the residents’ Minimum Data Set (MDS) assessments. The MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. MDS assessments are required on admission and then periodically throughout their stay. The participants in the assessment process are licensed healthcare professionals including RNs, therapists, dieticians and social workers. MDS assessments are legally signed by these professionals and submitted electronically to CMS. So … are these professionals falsifying the coding of the MDS in order to game the QMs? No way!

Regarding the accusation of staffing up – it may be happening. Let’s start collecting payroll data in order to ensure accurate reporting and that nursing homes are consistently, appropriately staffed.

Another solution is for providers to adopt innovative, evidence-based models like The GREEN HOUSE® model. One of the essential elements of the model is higher direct care staffing than traditional nursing homes. Traditional SNFs average about 2.50 C.N.A. hours per resident, per day (HPPD) compared to Green House homes that average 4.00 HPPD. Green House homes are able to provide this consistent, high level of staffing by utilizing a versatile caregiver service approach. And organizations that follow The Green House staffing and organizational model can deliver high quality care at a cost that is no more than a traditional institutional nursing home.

The elders depicted in the article were in need of short-term rehabilitation with a plan to get back home. Green House homes focused on short-term rehabilitation are achieving great results. Elders rehabilitating in Green House homes experience fewer rehospitalizations and typically get back home 10 days sooner than the elders in traditional, post acute SNFs. The Green House model, with its’ unique approach to care and staffing, plays a key role in these outcomes.

The vast majority of Green House model adopters are 4 and 5 Star nursing homes and they deserve the high ratings. But, if the goal of the Five Star rating system is to guide consumers to the best performing homes, perhaps CMS should add a specific mark of excellence designed to identify providers that have adopted innovative, evidence-based models like The Green House model.

CMS currently cautions consumers to be wary of certain nursing homes that have had consistently low performance via a Special Focus Facility designation next to their name on the CMS site. I’m sure consumers appreciate the chance to steer clear of the lowest performers. Let’s find a better way to direct them to the best.