Five-Star Nursing Homes, Zero-Star Caregivers?

zero star caregivers

The Medicare rating system for nursing homes is just about as legitimate as the MPAA film rating system, according to an article published in the New York Times. For the past five years Medicare has been giving nursing homes star ratings, with five stars being the highest mark that any such establishment can aspire to. Only 3,000 of more than 15,000 nursing homes in the United States have a perfect rating, but the way the system work it’s a wonder that number isn’t larger. As it turns out, of the three criteria upon which ratings are based, two are self-reported. The annual health inspections the government conducts are the basis for the overall rating, but when the other two criteria (staffing levels and quality indicators) are accounted for, “the share of homes with the better ratings has increased to nearly half,” the NY Times reports.

In addition to being mostly based on self-reported data, the ratings do not take into account negative factors such as fines and enforcement actions applied by state as opposed to federal authorities. The article singles out Sacramento, California’s Rosewood Post-Acute Rehab nursing home, a five-star establishment as per Medicare, but which has been the target of 102 consumer complaints and reports of problems according to the California Department of Public Health, and of 164 complaints according to California Advocates for Nursing Home Reform. Moreover, the home has been sued about a dozen times by patients and their families for below-average care. “It looks nice when you walk in,” Bonnie Nathan said. Mrs. Nathan put her mother in Rosewood in 2010 mostly on the strength of Medicare’s five-star rating. She’s currently suing the home because its workers allegedly did not treat her mother for a respiratory condition that resulted in her death.

When it comes to staff most of the top-rated nursing homes seem to aim for quantity instead of quality. As a matter of fact, the administrators of these establishments have fond a loophole to improve their scores. As the annual inspection draws nearer – and they are fully aware of when that will be – they add workers just long enough to merit a four- or five-star rating on the staffing levels measure – and thus an extra star overall – only to drop them shortly after. That’s how the number of nursing homes had a four- or five-star rating for staff levels has gone from 39% in 2009 to 52% in 2013, and it has also contributed to the fact that by 2013 almost half of homes got a four- or five-star rating from only 37% in 2009. An Affordable Care Act provision mandates that Medicare verify the accuracy of staff levels by looking at payroll data, but the agency says it’s still working on the verification system that will enable it to comply with the requirement. 

Nevertheless, chief executive of North American Health Care (the chain that operates Rosewood) John L. Sorensen said that the quality of the home is such that he “would put (my) parent there.” He added that “while we have had a few problems, they’re pretty minor compared to the overall accomplishments and tremendous customer satisfaction that’s being provided,” and that the lawsuits against Rosewood could be chalked up to Sacramento’s “very litigious marketplace.” Curiously, recent interviews showed that half dozen current and former residents said that the home didn’t deserve a five-star rating, and The Times found that “many residents live three to a room, and there is often a scarcity of basic supplies like washcloths, as well as a shortage of quality staff, according to interviews with current and former patients, their families and statements from former employees.”

 Unfortunately, quality measures can be as easily manipulated as staffing levels, although senior vice president of quality and regulatory affairs at nursing home trade group the American Health Care Association said “I think (the ratings) helped move us all along in the right direction. I have not seen any evidence of (facilities manipulating their ratings) or heard any evidence of it.” The problem is, though, that these star ratings that should be a mean to an end (improving the well-being of residents) have become an end in itself. “It’s everything to us,” Sorensen says. “If you create a product that people can trust and admire, the profits that you hope for — they follow as a result of excellence.”

Sadly, the ratings may be more about politics than anything else. Nurses and doctors use them in referral decisions when discharging patients from hospitals, and insurers also consider them when establishing preferred networks. Furthermore, Medicare is planning to expand the system to cover hospitals, dialysis centers and home-health-care agencies as well. Hopefully the agency will straighten out a few details first, including how nursing homes that have historically offered poor care are high scorers in self-reported data areas, getting four- or five-star ratings for their staff levels and quality statistics and only one or two stars for the health inspection. “These are among the very worst facilities, and yet they are self-reporting data that gives them very high staffing and very high quality measures,” senior policy lawyer with the Center for Medicare Advocacy Toby S. Edelman said. “It seems implausible.” This is certainly not the kind of fibbing in caregiving that can be condoned.

“We’re in this business because we want to do the right thing for our patients,” Sorensen said as he dismissed the lawsuits against Rosewood. “That is our agenda.” It’s like that early 90’s Joe Pesci movie where a judge condemns him to live in his own dilapidated apartment building so that he can experience first-hand how his tenants live. Somehow it doesn’t seem like such a far-fetched premise anymore, and one that many people in the nursing home industry could profit from.

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