Think Tank

Reviews Mixed for New Law on Nursing Home Ratings

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California nursing homes have one year to get ready for a new law that will require them to publicly display grades they receive on federal report cards.  A new law – authored by Assembly member Mike Feuer (D-Los Angeles) and Cameron Smyth (R-Santa Clarita) and recently signed by Gov. Arnold Schwarzenegger (R) — requires all nursing homes certified by Medicaid or Medicare to post their scores from CMS’ Five-Star Quality Rating System, beginning Jan. 1, 2011.

The grading system ranks facilities based on quality measures, surveys and staffing rates.  It has been praised as a valuable consumer tool by some and criticized by others as misleading and inaccurate.

The law also requires nursing homes to provide consumers with a detailed explanation of the ratings along with instructions on how to get more specific information and nursing home comparisons online.

We asked stakeholders how the new law might change California’s nursing home system for consumers and for nursing home operators.

We got responses from:




System Provides Easily Understood, Useful Information

Assembly members Mike Feuer (D-Los Angeles) and Cameron Smyth (R-Santa Clarita)

When our elderly loved ones need round-the-clock, specialized care, we want to make sure that they are safe and well-attended.  We want to learn everything we can about the places they might live and the people who might care for them. 

But the process to find the right skilled nursing facility is frequently difficult, always emotional and sometimes swiftly decided. We should have easy access to information that may affect our choices about the best facility for our loved ones.

Unfortunately, the amount and format of the information available to consumers can be overwhelming and confusing.  That is why we jointly authored AB 215, bipartisan legislation that has been signed into law to require skilled nursing facilities to post federal quality of care ratings prominently. 

CMS has created a nursing home quality rating system that is simple to understand and provides useful information to consumers.  Currently in California, however, consumers can access that system online only — not directly at the long-term care facilities. 

Now that AB 215 has been signed into law, facilities that accept Medicare or Medicaid will be required to post the federal CMS star rating in a visible, public location, helping ensure that families are aware of this valuable information about facilities they are considering.

In its passage through the Legislature, AB 215 enjoyed strong bipartisan support in both houses, as well as support from a broad coalition of senior advocacy groups, legal service organizations, and local governments. 

The governor signed the bill into law in October, and its provisions will go into effect in 2011. This bill proves that good public policy that protects Californians can be the result when Democrats and Republicans work together.


Five-Star System Inaccurate, Not User Friendly

Jim Gomez
President, CEO California Association of Health Facilities

Over the past several years, California nursing facilities have made significant strides in the area of quality improvement.  Staffing has increased, wages are up, resident satisfaction is high and turnover is down.

Why then would a consumer rely solely on a ranking system that uses outdated information on staffing levels and enforcement actions to make a decision about choosing a skilled-nursing facility instead of considering factors like the quality of care and quality of life?

The California Association of Health Facilities strongly believes that consumers should have access to credible, accurate information when choosing a skilled-nursing facility.

Unfortunately, the five-star system, designed and adopted by CMS, is seriously flawed and misleading. In fact, CMS called five-star a “work in progress” and has issued a “caution” to consumers about relying solely on the five-star ranking system to determine if a facility is the right place for a loved one. 

Here are some reasons why five-star is inaccurate and not consumer-friendly:

  • The five-star system pre-determines that 20% of all facilities get a one-star rating while just 10% get five stars.  That’s like telling a class of 100 students that 20 of them will automatically fail.
  • Facilities get marked down for accepting the most chronically ill, obese patients, patients with wounds, post-surgical patients and those with pain and diabetes.  The scoring is not risk-adjusted for populations like those with Alzheimer’s, where a decline is expected and unavoidable.
  • The staffing requirement in California is 3.2 hours per patient day. Although most facilities have achieved an average staffing level of 3.6 hppd, a facility cannot receive a five-star rating for the staffing component unless it meets a threshold of 4.08 nurse staffing hours per resident day (including a minimum of .55 RN hours).

CMS had indicated it will launch Phase II of the rating system to address some of these concerns, and Rep. Henry Waxman (D-Calif.), chair of the House Committee on Energy and Commerce, has asked the U.S. Government Accountability Office for a comprehensive evaluation of the five-star program. 

Nothing can replace a personal visit to a skilled-nursing facility to see how it looks and feels. Visit during mealtime.  Talk to the staff.  And be sure to inquire whether the facility conducts confidential patient and family satisfaction surveys to help you make the best informed decision for you and your family. 


New Law Aimed at Off-line Californians

Michael Russo
Health care advocate and staff attorney, California Public Interest Research Group

When Zagat recently released its 2010 restaurant guides, they were greeted by a flurry of discussion among bloggers: in this age of restaurant ranking Web sites like Yelp and CitySearch, are the venerable guides still relevant, much less necessary?

Those bloggers had a point — there’s rarely been more information available online about, well, anything — but at the same time, they missed it entirely.  For diners who wouldn’t know what a Yelp is if it came out and yelped at them, the paper guidebooks provide a valuable service.

And that service is what this new requirement is all about. 

When CMS rolled out its new nursing home ranking Web site last year, it gave consumers a powerful new tool.  The ability to look up details on nursing home staffing and programs, as well as the results of inspections, means that patients and their families can make better-informed choices.  When what’s at stake isn’t merely where to eat out but the quality of care a loved one will receive for potentially years to come, it’s hard to overstate the importance of information.

And it’s not just about quality.  Research has shown that in nursing homes, as in most areas of health care, facilities that take quality seriously by ensuring that patients get effective care also have lower costs than their competitors.  We spend more than $8 billion annually on nursing home care in California, so this is hardly small potatoes. 

Of course, online rankings are only useful to those who know that they’re available, and who have the capacity and technical fluency to take advantage of them.  Requiring nursing homes to post their rankings, explain them to visitors, and point them towards the full online resource will greatly expand the number of Californians who will be able to use them.

To be sure, there’s room for improvement in the rankings — both in increasing their accuracy, so there’s less reliance on self-reported data, and also in expanding the inspection-related information that’s available.

But the bottom line is that if more Californians are aware of, and use, these rankings, not only will the quality of care our seniors receive improve, it will also help make long-term care more affordable.  Bridging the digital divide so that these rankings are more accessible is a common-sense, pro-consumer move. 


CMS System ‘Seriously Flawed and Misleading’

Michael Torgan
Executive Vice President, Country Villa Health Services

There are a number of things that have become clear to me over the past 22 years observing and participating in the skilled-nursing profession. Most people do not think about health care until they need it, and when the need arises, it is a crisis. 

Health care professionals are compassionate and caring individuals who want to make a positive difference every day. Quality of care is uniquely defined by the experience an individual has had while receiving care. 

Making health care decisions is emotional. 

California nursing facilities have made tremendous gains in the quality care provided.

I strongly support consumers accessing accurate, understandable and meaningful information about skilled-nursing facilities. I also believe in the concept of a quality rating system as a useful consumer tool and a motivator for nursing facilities to strive to provide the best possible services.

But the CMS five-star rating system significantly misses the mark.  It is seriously flawed and misleading. Skilled-nursing care is complex, and providers are not all similar in the patient population they serve or the services they specialize in. 

The five-star system has disguised itself as a rating system, but is nothing more than an imposter.  Applying the logic of the five-star system would be like grouping sprinters and long-distance runners in a broad category called track runners and rating them together.  The focus and skills of each group are very different and cannot be comparatively measured in any meaningful way.

The five-star system automatically says that the bottom 20% of skilled nursing facilities will get the lowest rating, while only the top 10% can get the highest rating, a skewed bell curve. 

Individual facility ratings are subject to frequent change without any change in the facility’s own performance as ratings are based on the performance of other providers in the group. 

As a result, overall and survey “star” ratings can change for a facility even though there has been no updated certification survey, complaint survey, staffing, or resident assessment information for the facility. 

The five-star system penalizes providers that care for clinically complex patients. 

The five-star system imposes a wishful staffing ratio that was expressly rejected by CMS as too costly for Medicare to reimburse and does not consider the roles of other skilled professionals who provide complex care.  

Nothing should replace a personal visit to a skilled-nursing facility.  That includes meeting with staff and patients.  Even CMS recognizes this in its cautionary warning on its Web site. 

I completely endorse having a system that helps consumers better understand the quality of skilled-nursing providers — it is important. But CMS’ simple stars do not shed meaningful light for those seeking such information. 


Five-Star System Valuable, but Limited

Gary Passmore
Executive Assistant to the State President, Congress of California Seniors

Assembly Bill 215 will add another resource for patients and their families to learn about nursing homes, the quality of care they provide and how government regulatory agencies have evaluated their performance.

Because the information provided under AB 215 is available in several other places, the new law may be of limited value to consumers, but it is, nonetheless, important.

The information will be posted in a prominent location at each facility and will display the current rating, using the five-star system developed by CMS. Because the information is to be posted at the facility, prospective patients or their families might not see the information until after they become residents.

Ironically, its greatest advantage is also its greatest shortcoming: the rating system allows for a quick comparison by condensing a great deal of information into a familiar format similar to ones used for restaurants or lodging. But it also limits the observer to a very limited comparison.

The star rating system summarizes results of inspections for compliance with federal standards, staffing levels, and various measures of “quality.”  The ratings do not reflect the different levels of patient acuity among institutions which can influence ratings.

The ratings also force comparisons among institutions in the community (rather than against a broad standard) so that results may be skewed in the same way that grading on a “curve” in an academic setting can distort performance to fit the ranking within a narrow cohort. A mediocre facility in a community with many poor facilities could look better than a fairly good one in a place with many high quality facilities.

Other Web sites by the federal and state governments and several not-for-profit organizations (including the California HealthCare Foundation) provide far more detailed information for consumers.

(Editor’s note: CHCF is the publisher of California Healthline.)

Ideally, consumers and their families will use the posted rating to engage in a conversation with facility staff, and their questions will lead them to use other Web-based resources with more information. Over time, we hope that greater consumer awareness will lead to greater concern and demand for quality care.

The Congress of California Seniors has always supported strong regulation and wide reporting of information on quality nursing home care, and we supported AB 215.