What Medicare and Medicaid’s Ratings Say About Nursing Homes

For all of its flaws, Medicare and Medicaid’s Nursing Home Compare five-star rating system gives consumers a head-start when searching for a facility. Now, the Kaiser Family Foundation has taken a closer look at the ratings, and reached some interesting conclusions:

  • In a system that rates facilities from 1-5 stars, about one-third have low 1 or 2 star ratings, while about 45 percent received 4 or 5 stars.
  • Non-profits, which represent only about one-quarter of nursing facilities, generally get higher ratings than for-profits.
  • Smaller facilities score higher than larger ones.
  • Nursing homes affiliated with continuing care communities have higher overall ratings than those that are not.
  • Facilities in states with large numbers of low-income older residents rate more poorly than those in states with fewer poor seniors. Note: This looks at state residents, not residents of individual facilities.
  • There is a wide variation in quality among states. In 5 states, more than 20 percent of facilities received 1 star ratings. In 7 states, at least 30 percent received top scores.
  • About two-thirds of US counties have at least one 4 or 5 star facility, but one-third have none.

Let’s unpack a couple of results:

Non-profits versus for-profits. Non-profits achieve higher scores than for-profits. About 42 percent of for-profits received 1 or 2 stars while only 21 percent of non-profits received the lowest ratings. Similarly, 39 percent of for-profits scored 4 or 5 stars compared to 60 percent of not-for-profits. At least as measured by Nursing Home Compare, non-profits are clear winners.

Smaller facilities versus large:  Those with fewer than 60 beds did much better than their larger competitors. Only about one in five small sites received 1 or 2 stars compared to 37 percent of facilities with 60-120 beds, and 45 percent of those with more than 120 beds. It was the same story for the highest scores.  Almost two-thirds of small homes got 4 or 5 stars compared to only 43 percent of mid-sized facilities and one-third of the largest.

The study, done by Cristina Boccuti, Giselle Casillas, and Tricia Neuman,  is based on the February, 2015 Nursing Home Compare data base, which is compiled by the federal Centers for Medicare and Medicaid Services. About 15,000 nursing homes are included. Facilities that are not certified by either Medicare or Medicaid are not rated.

The Kaiser results are interesting and helpful, but the Five Star ratings are not the last word in quality. For example, I would not say that non-profit facilities are better than for-profits simply based on these ratings.

Medicare and Medicaid’s rating system includes information from 3 sources—state health inspections (which can vary widely in rigor), quality measures, and staffing levels—both self-reported by the facilities themselves.

In addition, the Five-Star system does a much better job measuring safety than quality. For long-stay residents, for example, it measures falls, urinary tract infections, pressure ulcers, self-reported pain, and the use of anti-psychotic drugs.  And, as I wrote last year, even some of these measures can be seriously misleading.

Worse, Nursing Home Compare doesn’t tell consumers much about the quality of life of residents. Do they feel comfortable? Does the staff seem caring and responsive? Do they have freedom to do what they want? Those are important questions that the rating system does not answer.

If I were looking for a nursing facility, either for rehab or for long-term care, I’d probably start with the Medicare rating system.  But I’d never stop there. I’d visit facilities, talk to staff, residents, and their families, and eat a meal or two in the dining room.

Still, the Five Star system is a useful screen for consumers. And, as the Kaiser studies shows, it provides valuable, if not definitive, information about the kinds of facilities out there.

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