There’s an article in the New York Times today about Nursing Home Compare, the website run by the Centers for Medicare and Medicaid Services (CMS) that provides quality ratings for nursing homes nationwide. CMS rates nursing homes on a five-star scale based on staff levels, self-reported quality information, and annual inspections. As someone who works in the field of patient and family engagement, I’m all for making this kind of quality information publicly available. Increasing transparency helps patients and family members make better health care decisions, right?
Ideally, yes – but the real answer is more complicated. We put a lot of faith in star ratings, particularly in the absence of other available information. Need to find a good restaurant in an unfamiliar area? I don’t know about you, but when I look on Yelp, I’ll probably choose a four- or five-star rated restaurant over the three-star one. More stars = better food, service, and overall experience. So if you need to find a nursing home for a parent or loved one, it’s logical to take the information at face value and assume that more stars = better quality. But the picture isn’t that simple.
One problem is the effect of increasing emphasis on star ratings. For nursing homes, the star ratings can affect referral patterns, market share, and network status with insurance companies. As a result, it’s not surprising that some nursing homes have started to “teach to the test.” The NYT article disturbingly reports evidence that some nursing homes game the system—for example, by gearing up staffing levels before their annual inspection, only to decrease them again as soon as the inspectors are gone.
Another issue is that star ratings can’t reflect all aspects of quality, nor do they always speak to personal preferences. When I needed to find a day care center for my first child, I accessed our state’s online rating system, where day care centers are rated from one- to five stars based on three dimensions of quality. Armed with information, we visited several four- and five-star centers. As a comparison point, we also visited a three-star center. Ultimately, we decided that how the state defined quality didn’t always align with what we thought was important—and for us, the three-star center was a better choice.
Does all of this mean that health care quality ratings, like those available from CMS’s Compare sites, aren’t valuable? Absolutely not. I’m a big believer in public reporting of quality information (there’s a good chunk of my resume devoted to it). I’ll also be the first to admit that the system isn’t perfect.
We can make it better by helping people understand what aspects of quality are covered by publicly-reported ratings (like those on Nursing Home Compare) – and more importantly, what aspects aren’t. We can explain the potential differences between a five-star nursing home and a three-star nursing home, and what this means for the care your loved one might receive. We can provide people with decision tools and discussion guides to help them navigate the emotional and confusing decision of selecting a nursing home. We can work with patients and families to promote public discussion around issues of health care quality and improve the information that’s available. And, we can keep the spotlight on the need for transparency – because despite the challenges, it’s still a critical part of helping all of us make better health care decisions.