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Medicare Introduces It's New 5 ""Star"" Rating System for Nursing Homes

December 20, 2008

CMS Introduces Its New 5 Star Rating System for Nursing Homes

By Julie Appleby, Steve Sternberg and Jack Gillum, USA TODAY

Jacquelyn McCarthy, who runs a nursing home in Framingham, Mass., credits the five-star rating it's getting from the government today to its focus on caring for both residents and staff.

The Bethany Health Care Center, a 169-bed non-profit home sponsored by the Sisters of St. Joseph, is one of 33 nursing homes nationwide to earn top ratings across all categories in scores posted on a federal government website. McCarthy says giving workers health insurance, pensions and low-cost meals pays off. Turnover is low, and nursing assistants care for the same people each day, allowing them to get to know residents.

""If the resident doesn't seem as alert or if it looks like they're more agitated, we know immediately and can get right on it,"" says McCarthy, whose facility earned five stars overall and in categories on staffing, inspection results and quality measures. The Centers for Medicare & Medicaid Services (CMS) scored nearly 16,000 nursing homes for the first time.

Lower in the ratings is Oakwood Healthcare in Philadelphia, one of six nursing homes nationwide regarded as so troubled by Medicare that it was tagged as one of the nation's worst for nearly four years. Eight months of improvements helped net the home two stars.

""I think the reputation was deeply deserved,"" says Irene Contino-Kosyla, who became Oakwood's administrator in April as part of an overhaul by new owners. The 148-bed facility was run-down, badly managed and dealt with difficult patients by putting far too many on mood-altering drugs, she says.

The new ratings reflect a Bush administration effort to promote openness about quality, aiming to increase competition among nursing homes and give consumers more choice.

Nursing homes face daunting challenges: finding and keeping staff, caring for frail patients, complying with a host of federal and state rules and doing it all under financial constraints imposed by limited government payments that vary from state to state. As a result, quality varies widely among individual homes and among states, according to an analysis of the Medicare ratings by USA TODAY.

In 14 states, residents choosing a home randomly have a more than 25% chance of picking a nursing home that, overall, rates one star, the lowest ranking on Medicare's new system.

USA TODAY also found that:

• Louisiana led the nation in the percentage of one-star homes: 39% of its 285 homes are in that category.

• Nationally, 23% of homes received one-star ratings for overall performance.

• Homes associated with hospitals ranked higher than those that were not.

• Delaware had the largest percentage of five-star homes, 13 of 45, or 29%. Alaska, New Hampshire, Maine, Hawaii and Alabama also topped the five-star list, having at least 20% of their homes in that category.

Basis for system

The simple ratings are based on complex data drawn from state inspections and reports on staffing and other measures provided by the nursing homes.

The overall rating was heavily influenced by how well homes scored on staffing and on 10 quality measures, including how well a home responds to residents' declining mobility, high-risk bedsores and pain. They also factor in whether facilities use excessive physical restraint.

View our searchable database of ranked nursing homes

To get a five-star rating on staffing, homes had to provide at least four hours a day per patient of care by registered nurses and other nursing staff. A home could score low on the overall ranking but have higher scores on individual categories, such as quality.

Nursing home officials say state inspections, which play a major role in the ratings, give a skewed picture of care at a home by focusing mainly on problems.

""I would challenge almost any organization to be perfect in 150 categories,"" 24 hours a day, seven days a week, says Stephen Morrisette, president of the Virginia Health Care Association, which represents long-term care facilities. ""There is no provision in the survey process to note ”¦ areas where nursing facilities are doing an excellent job.""

Joe Donchess, executive director of the Louisiana Nursing Home Association, says a shortage of nursing staff and low Medicaid payments ”” about $115 per patient a day ”” make it hard for the homes to hire enough workers to achieve high scores on staffing, he says. Medicaid, the health program for the poor, is administered by the states and overseen by Medicare.

A 2008 report for the American Health Care Association, the industry's trade group, shows Medicaid's daily payment rates ranged from $108 in Texas to $225 in Delaware. Medicaid spends more than $125 billion on nursing home care nationally, or about 43% of the total tab, says the Kaiser Family Foundation, a research group.

State ombudsmen, who advocate for nursing home residents, dismiss some industry concerns about the ratings, saying the homes provide much of the information. ""CMS is using their data,"" says Illinois ombudsman Sally Patrone. ""If they're poorly rated, they need to improve.""

No substitute for a visit

Kerry Weems, acting Medicare administrator, says the website ( can help narrow the search for a home but ""is not a substitute for actually visiting.""

Nursing home resident advocates agree. ""We hope that nobody looks at the five-star rating system and bases their decision entirely on it,"" says Janet Wells of the National Citizen Coalition for Nursing Home Reform.

Contino-Kosyla, Oakwood's administrator, says the facility has changed dramatically since the new owners bought it.

""We have a wound-care specialist, a preventive wound program ”¦ an anti-fall program, new social service directors, whole new admissions and activities departments,"" she says. ""It's a totally different facility.""