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Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State

Executive Summary
  1. Institute of Medicine, “Improving the Quality of Care in Nursing Homes.” Washington: National Academy Press, 1986; Institute of Medicine, “Improving the Quality of Long-Term Care.” Washington: National Academy Press, 2001; Government Accountability Office, “Nursing Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight.” GAO-03-561, July 2003; Government Accountability Office, “Nursing Homes: Federal monitoring Surveys Demonstrate Continued Understatement of Serious Care Problems and CMS Oversight Weakness.” GAO-08-517, May 2008; Government Accountability Office, “Nursing Homes: CMS’s Special Focus Facility Methodology Should Better Target the Most Poorly Performing Homes, Which Tend to Be Chain Affiliated and For-Profit.” GAO-09-689, August 2009; Government Accountability Office, “Poorly Performing Nursing Homes: Special Focus Facilities Are Often Improving, but CMS’s Program Could Be Strengthened.” GAO-10-197, March 2010; Government Accountability Office, “Nursing Homes: CMS Needs Milestones and Timelines to Ensure Goals for the Five-Star Quality Rating System are Met.” GAO-12-390, March 2012; Department of Health and Human Services, Office of the Inspector General, “Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.” OEI-06-11-00370, February 2014; Wiener JM, Freiman MP, Brown D. “Nursing Home Quality: Twenty Years After the Omnibus Budget Reconciliation Act of 1987.” Kaiser Family Foundation, December 2007; Werner RM, Konetzka RT. “Advancing Nursing Home Quality Through Quality Improvement Itself.” Health Affairs. 1(2010): 81-86.

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  2. Harrington, C., H. Carrillo, M. Dowdell, P. Tang, B. Woleslagle Blank, “Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2005 Through 2010, University of California San Francisco, October 2011; IOM 2001.

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Issue Brief
  1. Kaiser Commission on Medicaid and the Uninsured, Overview of Nursing Facility Capacity, Financing, and Ownership in the United States in 2011, June 2013; Harris-Kojetin L, et al., Long-term care services in the United States: 2013 overview. National health care statistics reports; no 1. Hyattsville, MD: National Center for Health Statistics. 2013.

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  2. The average number of Medicare-covered SNF days for a beneficiary was 27 in 2010. The Medicare SNF benefit covers up to 100 days of skilled nursing and skilled rehabilitation services per spell of illness. No beneficiary copayment is required for the first 20 days, but a daily copayment is required for the 21st through the 100th day of SNF care. Congressional Research Service, 2012 Greenbook.

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  3. Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Expenditures, 2013.

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  4. IOM (2001).

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  5. In 1980, as part of OBRA ’80, Congress passed the Boren Amendment to require Medicaid nursing home payments to be reasonable and adequate to provide quality care consistent with federal and state standards. The Boren amendment was repealed as part of the Balanced Budget Act of ’97, but the OBRA ’87 amendments have remained intact.

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  6. As part of the federal minimum staffing standards, nursing homes must have a licensed practical nurse (LPN)—a nurse with less academic training required than an RN—on duty at all times when an RN is not on duty. GAO (2011).

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  7. Wiener (2007). IOM (2001).

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  8. GAO (2008, 2009, 2010, 2012); OIG (2014).

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  9. Thomas, K. “In Race for Medicare Dollars, Nursing Home Care May Lag.” The New York Times, April 14, 2015.

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  10. Center for Medicare Advocacy, “The Myth of Improved Quality in Nursing Home Care: Setting the Record Straight Again.” April 2014. Thomas, K. “Medicare Star Ratings Allow Nursing Homes to Game the System.” The New York Times, August 24, 2014.

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  11. Centers for Medicare & Medicaid Services, Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide, February 2015. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf

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  12. Some states require a registered nurse (RN) to be on duty 24 hours a day for nursing homes with 100 or more residents—higher than the federal minimum standard which requires an RN on duty for at least at least 8 consecutive hours per day, 7 days per week, regardless of the number of residents in the nursing home.

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  13. Authors’ analysis of December 2014 Nursing Home Compare data.

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  14. Stated by Patrick Conway: “Rating the Quality of America’s Nursing Homes,” The Diane Rehm Show, March 11, 2015.

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  15. Government Accountability Office, “Nursing Homes: Private Investment Homes Sometimes Differed from Others in Deficiencies, Staffing, and Financial Performance.” GAO-11-571, July 2011; Donoghue C. “The Percentage of Beds Designated for Medicaid in American Nursing Homes and Nurse Staffing Ratios,” Journal of Health and Social Policy, 22(2006): 19-28.

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  16. GAO (2009).

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  17. GAO (2011).

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  18. More generally, nursing homes that participate in Medicare and Medicaid are required to have sufficient nursing staff to provide nursing and related services to allow each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being (GAO 2011).

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  19. Harrington C. “Nursing Home Staffing Standards in State Statutes and Regulations” Report. Department of Social and Behavioral Sciences, University of San Francisco. December, 2010.

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  20. The District of Columbia has only 19 nursing homes, which may compromise the ability to compare the star ratings among its nursing homes with those in other states.

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  21. Research based on star ratings from 2010 found that Medicare beneficiaries who had Medicaid coverage (health coverage for people with low-incomes) tended to reside in nursing homes rated with fewer Overall stars: Konetzka, T., D. Grabowski, M. Coca Perraillon, and R. Werner, “Nursing Home 5-Star Rating System Exacerbates Disparities in Quality, by Payer Source.” Health Affairs, May 2015.

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  22. Harrington (2011).

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  23. Span, P. “Nursing Homes are Starting to Supplant Hospitals as Focus of Basic Health Care” The New York Times, April 24, 2015.

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  24. Jacobson, G., T. Neuman,  A. Damico, “ Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Homes and Other Long-Term Care Facilities: A Potential for Achieving Medicare Savings and Improving the Quality of Care,”  The Henry J. Kaiser Family Foundation, October, 2010;  Perry, M., J. Commings, G. Jacobson, T. Neuman, J Cubanski, “To Hospitalize or Not to Hospitalize? Medical Care for Long‐Term Care Facility Residents A Report Based on Interviews in Four Cities with Physicians, Nurses, Social Workers, and Family Members of Residents of Long‐Term Care Facilities,”  The Henry J. Kaiser Family Foundation, October, 2010.

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