Administration Plans Major Improvements to Nursing Home Compare

The federal nursing home website, Nursing Home Compare, is about to undergo major changes that should significantly improve the accuracy of information about nursing homes that is provided to the public.  The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014), signed by President Obama on October 6, 2014, supports one of the key changes – providing funding to implement a provision of the Affordable Care Act (ACA) that requires nursing home staffing data reported on Nursing Home Compare to be electronically-submitted and “based on payroll and other verifiable and auditable data.”[1]

Nursing Home Compare

Nursing Home Compare provides information on all nursing homes that participate in Medicare, Medicaid, or both.  For the past five years, the federal website has separately rated facilities on a five-point scale in each of three domains (health survey, nurse staffing, and quality measures) and also on a composite scale that combines the ratings for the three domains.

For many years, advocates for residents have criticized the Centers for Medicare & Medicaid Services (CMS) for reporting data on nurse staffing and quality measures as submitted by facilities, without performing any audits or edits of the information that is reported.[2]  In August 2014, The New York Times reported that nursing facilities “game” the five-star system and “that even nursing homes with a history of poor care rate highly in the areas that rely on self-reported data.”[3]   The Times reported that nearly two-thirds of 50 facilities on CMS’s watch list (i.e., the Special Focus Facilities) achieve four and five stars (on a five-star scale) in staffing and quality measures, confirming findings reported by the Center for Medicare Advocacy in 2011.[4]

State information is also excluded from the federal website.  The Times cites a California nursing home that received five stars on Nursing Home Compare, even though the state of California imposed a state fine of $100,000 against the facility for causing the death of a resident.

Planned Revisions to Nursing Home Compare

On October 6, the White House and CMS announced plans to revise Nursing Home Compare in five distinct ways, as described by a White House Fact Sheet and a CMS News Release:[5]

Change White House and CMS Description of Change Center for Medicare Advocacy Comments
Nationwide Focused Survey Inspections Beginning in January 2015, “CMS and states will implement focused survey inspections nationwide for a sample of nursing homes to enable better verification of both the staffing and quality measure information.”  CMS piloted special surveys in Fiscal Year 2014. A major criticism of Nursing Home Compare is that the staffing information and quality measure scores are self-reported by facilities and not audited by states or CMS to ensure accuracy.  Improving the accuracy of the information is an important change.
Payroll-Based Staffing Reporting With funding provided by IMPACT of 2014, “CMS will implement a quarterly electronic reporting system that is auditable back to payrolls to verify staffing information.”  The White House Fact Sheet reports that pilot testing will occur in FY 2015 and that all nursing homes nationwide will be required to implement payroll-based staffing reporting requirements by the end of FY 2016. Nurse staffing is a key factor determining quality of care in nursing homes.  Section 6106 of the ACA required facilities, by March 2012, to submit, electronically to HHS, direct care staffing information (including agency and contract staff), “based on payroll and other verifiable and auditable data in a uniform format.”  Staffing information is required to: (1) specify the category of worker; (2) include information on resident census and case mix; (3) include a regular reporting schedule; and (4) include information on employee turnover and tenure and hours of care per resident per day for each category of worker.

This provision has not been implemented.  The White House and CMS have now committed to implementing the provision, with funding from the IMPACT Act of 2014.

Additional Quality Measures CMS will increase the number and type of quality measures that are used to determine the quality measure score.  Beginning in January 2015, antipsychotic drugs will be included in the quality measure star rating.  Future additions will be Medicare claims-based data on residents’ rehospitalizations and discharge to the community. CMS has focused a great deal of attention on the reduction of antipsychotic drugs in nursing homes through its National Partnership to Improve Dementia Care.  Although Nursing Home Compare reports facilities’ (self-reported) antipsychotic drug use rates, the rates have not been used in calculating the rating for quality measures.  Quality measure star ratings will include antipsychotic drug use, effective January 2015.
Timely and Complete Inspection Data “CMS will also strengthen requirements to ensure that States maintain a user-friendly website and complete inspections of nursing homes in a timely way and accurate manner for inclusion in the rating system.” Section 6103 of the ACA requires states to maintain “a consumer-oriented website providing useful information to consumers” and to submit timely survey and certification information to CMS, for inclusion on Nursing Home Compare.
Improved Scoring Methodology Revisions to the scoring methodology “will place more emphasis on data that is verified by independent sources rather than data that is self-reported by nursing homes.” Nursing homes report that quality is improving, as evidenced by high scores on staffing and quality measures.[6]  Improving the scoring methodology should help reduce facility gaming.

IMPACT Act of 2014

The new law expressly transfers $11 million from the Medicare Trust Fund to CMS to implement the payroll-based staffing requirement.

Conclusion

The Center for Medicare Advocacy applauds the Administration for recognizing the need to revise Nursing Home Compare to ensure that its information is accurate, timely, and meaningful for prospective residents, residents, and their families and advocates.  The Center and other advocates will closely monitor implementation of these changes.


[1] IMPACT is at: http://thomas.loc.gov/cgi-bin/query/D?c113:3:./temp/~c113cRJI8N::
[2] For example, CMA, “The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again” (Weekly Alert, Apr. 17, 2014), http://www.medicareadvocacy.org/the-myth-of-improved-quality-in-nursing-home-care-setting-the-record-straight-again/.
[3] Katie Thomas, “Ratings Allow Nursing Homes To Game System; Medicare’s Five Stars; Data Taken at Face Value Often Fails to Reflect Real Conditions,” The New York Times, page 1 (Aug. 25, 2014), http://www.nytimes.com/2014/08/25/business/medicare-star-ratings-allow-nursing-homes-to-game-the-system.html?module=Search&mabReward=relbias%3As%2C%7B%221%22%3A%22RI%3A6%22%7D&_r=0.
[4] CMA, “Special Focus Facility Study: Nursing Facilities’ Self-Regulation Cannot Replace Independent Surveys” (Weekly Alert, Dec. 22, 2011),  http://www.medicareadvocacy.org/special-focus-facility-study-nursing-facilities-self-regulation-cannot-replace-independent-surveys/.
[5] White House, “Administration Announces New Executive Actions to Improve Quality of Care for Medicare Beneficiaries” (Fact Sheet, Oct. 6, 2014),  http://www.whitehouse.gov/the-press-office/2014/10/06/fact-sheet-administration-announces-new-executive-actions-improve-qualit; CMS, “CMS Announces Two Medicare Quality Improvement Initiatives” (Press Release, Oct. 6, 2014), http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-10-06.html.
[6] In its 2013 Quality Report, http://www.ahcancal.org/qualityreport/Documents/AHCA_2013QR_ONLINE.pdf, the American Health Care Association (AHCA), the trade association of for-profit providers and multi-state chains, reports that quality of care in nursing facilities is improving. Among other evidence, AHCA cites improvements in almost all of the quality measures from 2011 to 2012 and higher star ratings in the Centers for Medicare & Medicaid Services’ (CMS’s) Five-Star Quality Rating System.  Id. 22, 23-25.   AHCA reports that between 2009 and 2013, the proportion of five star facilities increased from 11.8% to 19.6% and the proportion of one-star facilities decreased from 22.5% to 13.5%.  Id. 24.