Just a few years ago it seemed that advocates for health care transparency had scored a big victory. The Centers for Medicare & Medicaid Services (CMS) announced that they would rate nursing homes by awarding five stars to the best and fewer stars to lower-quality facilities. Families searching for care for loved ones would have access to a familiar rating system to help them make choices. After all, star ratings for restaurants, hotels and other services are common, so using stars for checking out nursing homes would not be a big leap for most consumers.
It turns out, though, that five-star nursing homes may not be delivering five-star quality. A New York Times report recently let the air out of inflated nursing home scores, finding that when the ratings began in 2009, 37% of the country’s 15,000 or so nursing homes received a four- or five-state rating. Last year, nearly half did.
I know a thing or two about nursing homes, having rated them for two major Consumer Reports investigations, one in 1995 and the other in 2006. I know about yo-yo compliance — when a nursing home cleans up for awhile and then reverts to old ways that wouldn’t pass muster. I know about the temptation to skimp on care to help the bottom line. Most nursing homes are for-profit businesses. I also know how hard it is to keep good staff. Nursing home residents can be difficult to handle, and the pay is almost always low.
So it wasn’t surprising, then, that some homes have learned to game the system, as the Times reported. Although nursing home operators first fought government attempts to award stars to the best, they now say the ratings have had a positive effect on the industry — they’ve “helped move us along in the right direction,” was how Dr. David Gifford, a top official at the American Health Care Association, put it.
And that brings me to my rule for judging the value of consumer information. How much the industry protests providing information is directly proportional to its usefulness as a quality indicator. These CMS nursing home ratings are not very useful. That’s quite disappointing given that the stakes are so high when a family places a vulnerable loved one in a nursing home.
The industry has long been a target for newspaper exposes; the Times piece is just the latest. Yet the Times report found big discrepancies between “self-reported” information from the nursing homes (which contribute to star rankings) and actual on-site inspections by reviewers. Some CMS-ranked four- or five-star homes even show up on the government’s own watch list of homes with oodles of violations. Of the more than 50 homes on the CMS watch list, two-thirds have four- or five-star ratings for staff levels and quality statistics. How can that be? I’m sure officials at CMS had every intention of making it easier for families to make a good choice.
What’s a family to do if they can’t trust the government’s ratings? The same advice I gave years ago still stands: The best thing to do is get your hands on the state inspection survey — the real thing — not the summary of deficiencies found on the government’s website. That document describes in detail the kind of care a facility gives — the good, the bad and the ugly. A facility with a 63-page survey is one that families might want to avoid. One with no deficiencies may also be suspect. It could mean inspectors aren’t looking very hard.
There’s no substitute for visiting a prospective home at different times of the day. If you find that residents are not pleased with their meals or that there are no activities that interest them, that’s a bad sign. Watch how the staff interacts with the residents.
Once I saw an aide wheeling a half-naked woman backwards in her wheelchair. Contrast that with staff members who engage residents by giving them manicures or playing ball with them. And, of course, don’t forget the sniff test. If the facility smells like residents are sitting in their urine, look elsewhere. In my experience, the good ones don’t smell.
Being a good shopper with on-the-ground experience can give you the best chance of finding a good nursing home. It may be better than relying on a rating scheme that doesn’t tell you much, except that questionable nursing homes have learned to ace the test.
Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College, New York, NY. She blogs on the Prepared Patient blog.