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CMS nursing home star ratings overhaul sees 37% of skilled nursing facilities losing 1 or more stars

Hospitals use the ratings on quality measures as they seek skilled nursing facilities for inclusion in their preferred networks.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services this week released a major overhaul to the 5-star rating program for Nursing Home Compare that has resulted in an estimated 37 percent of skilled nursing facilities losing one or more stars.

The reason for the drop is not related to quality of care, but due to CMS methodology changes, according to Tom Martin, director of Post Acute Care Analytics for CarePort. CMS has raised the bar in the three domains used for the ratings in quality, staffing and survey results.

The agency has basically pushed the reset button as facilities have improved their ratings over the past 10 years.

"Every domain has undergone some methodology changes, pretty substantial changes," Martin said. "No one's going to be happy they lost a star rating because CMS changed the methodology." 


Hospitals use the star ratings, especially the measures in the quality domain, as they seek skilled nursing facilities for inclusion in their preferred networks.

Nursing Home Compare now displays two new quality ratings, one based on short-stay care and one for long-stay care, which will prove useful to hospitals that are primarily concerned with short-stay populations, Martin said.

Consumers also use the Nursing Home Compare website to find providers.

Another concern for SNFs is the potential loss of eligibility to participate in the skilled nursing facility three-day stay rule waiver program with next generation ACOs, Martin said. By losing this eligibility, SNFs lose access to this pool of patients and their affiliated ACOs.


Nursing Home Compare shows data gathered on nursing homes, skilled nursing facilities, rehab centers, and other long-term care settings.

Martin, who works with SNFs, said the changes released on Wednesday show that about 47 percent of skilled nursing facilities saw no change; 37 percent saw a decline of one or more stars; and 16 percent saw an increase in their overall star rating.

Star ratings are also used for hospitals, Medicare Advantage and part D plans. CMS proposed updates to the hospital star ratings in February and finalized policy changes for MA and Part D plans in April. 

For Nursing Home Compare, the update represents the first major change to the rating system since the program's inception in 2008.


Of all the domains, providers should look at the quality domain to increase their star ratings, Martin said. This is where the majority of changes have occurred and the domain most important to hospitals. Some measures have been retired. For other measures, CMS has  changed the definition for how they're calculated.

Providers need to determine on which of the 17 measures they scored poorly, and these can range from pressure ulcer rates to falls with injuries.

On the staffing domain, CMS raised the number of staffing hours per resident per day required for each level of star rating.

The survey domain is the most heavily weighted. It is based on the annual standards survey from surveyors who come into the facility. CMS grades on a curve, so the same number of providers gaining or losing stars in this domain remains relatively the same.

The main issue for skilled nursing facilities is that the providers are held responsible for quality measures, such as readmissions, that happen after the patient has left their care.


"From our point of view at CarePort, what we have seen are providers will often struggle with are quality measures for patients outside of their (care),  but facilities will get dinged for readmissions," Martin said.

Twitter: @SusanJMorse
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