August 06,2015

Press Contact:

Taylor Harvey (Wyden): 202-224-4515
John Rizzo (Casey): 202-228-6367

Wyden, Casey Call for GAO Report Into Federal Government’s Nursing Home Rating System

Recent News Reports Have Raised Concerns About Integrity of So-Called ‘Five-Star’ Rating System

Washington DC- Today, U.S. Senators Bob Casey (D-PA) and Ron Wyden (D-OR) called for an GAO Report on the federal government’s nursing home rating system. Recent news reports have raised questions about the integrity of the federal government’s ‘Five-Star’ rating system that millions of families rely on when selecting a nursing home for their loved one. Casey and Wyden released a new letter to Gene Dodaro, Comptroller General of the United States, requesting that the Government Accountability Office (GAO) conduct an assessment of the general accuracy and reliability of the Five-Star Quality Rating System for nursing homes and its usefulness as a consumer tool. Casey and Wyden are both members of the Senate Finance Committee. Senator Wyden serves as Ranking Member.

“We owe our families the peace of mind in knowing that the rating system they’re using to make a critical decision about the future of their loved ones is accurate,” Senator Casey said. “The Five Star rating system has the potential to make a substantial difference in the lives of vulnerable seniors but the Administration has to make sure the rating system is working. A GAO review will put the Five Star Rating program on a stronger footing.”

“Seniors and their families must be able to make well-informed choices when it comes to nursing care, and being able to compare quality among nursing homes is a key part of making that a reality,” Wyden said. “Back in 2008, I asked CMS why it was easier to compare the quality of home appliances than the nursing homes that play such a critical role in our health system today. The Five Star rating system is a step in the right direction, but there is more to do to ensure seniors and their families are able to make this important decision with the best information possible.”

The Nursing Home Compare tool is a public website consumers can use to search for and compare nursing homes. The Nursing Home Compare site features the Five-Star Rating System that rates nursing homes on a scale of one to five in three major performance areas – health inspections, staffing and quality measures – as well as one overall rating. The rating system, along with a federal watch list of the lowest performing providers (Special Focus Facilities), is important to nursing homes, not only because consumers use the ratings to evaluate nursing home options, but also because doctors often base their referral decisions on the ratings and insurers do them same when designing their networks.

The full text of Casey and Wyden’s letter can be seen below:

The Honorable Gene Dodaro

Comptroller General of the United States

Government Accountability Office

441 G Street, N.W.

Washington, D.C. 20548

Dear Mr. Dodaro:

The quality of care in nursing homes remains an issue of concern for the millions of people who reside in them, as well as their families. The Government Accountability Office (GAO) has a long history of identifying concerns with the quality of care in the nursing home industry and has called for improvements to be made. We are writing to request that GAO undertake a specific review of the Five-Star Quality Rating System, which is part of the Nursing Home Compare web tool administered by the Centers for Medicare and Medicaid Services (CMS). 

The Five-Star system assigns each nursing home an overall rating and three component ratings based on the extent to which the nursing home meets CMS’s quality standards and other measures.[1] The component ratings include results on annual inspections, self-reported staffing data[2], and self-reported performance on selected quality measures. Each nursing home is assigned from one to five stars, with more stars indicating higher quality. In 2012, GAO reported on how the Five-Star system was developed, how the information in it gets updated, and how CMS ensures that the system’s goals are met.[3]

As part of the Nursing Home Compare web tool, the Five-Star system is intended to be a valuable tool that helps millions of Americans and their families make smart care choices and helps doctors and insurers make informed referral and network decisions. By increasing transparency and inspiring competition, the rating system is also intended to help improve overall nursing home quality. 

While we acknowledge recent CMS steps to update the Five-Star ratings and improve nursing home quality on a broader scale, media reports continue to raise questions about the system’s integrity. Choosing a nursing home can be one of life’s most important and consequential decisions, so it is vital that the information the government provides be as accurate and robust as possible. An inaccurate rating system would put at risk individuals who choose a substandard nursing home based on false or incomplete information. It also would put at risk good nursing homes that may be mischaracterized, especially because the rating system ranks them not only on their own merits, but also in comparison to other facilities. Many nursing homes provide quality care in good faith, and it is important that the rating system reflects that without giving cover to bad actors.

We are requesting that GAO conduct an assessment of the general accuracy and reliability of the Five-Star Quality Rating System for nursing homes. Given the recent changes to Medicare regulations governing nursing homes and the Five-Star system, we ask that GAO use the most recent data available in completing this assessment. Specifically, we would like GAO to examine:

  1. What steps does CMS take to ensure the reliability and timeliness of the data used in the Five-Star Quality Rating System? Are these practices consistent across CMS regions?
  2. Are there meaningful differences/distinctions between the star levels in the Five-Star Quality Rating System (e.g. between four and five star nursing homes)?
  3. How do the number and type of substantiated complaints align with the star ratings?
  4. What do stakeholders see as the strengths and weaknesses of the Five-Star Quality Rating System as a tool for consumers? What is reported by ombudsmen, watchdog groups, state agencies and others? Are there opportunities for improvement?
  5. To the extent possible, determine the extent to which patients and their families are using Nursing Home Compare and provide recommendations to improving knowledge of, and access to, nursing home quality information.   

As part of a larger effort to ensure the fairness and accuracy of healthcare quality rating systems, we look forward to your assessment and thank you for your attention to this matter. Going forward, the staff contacts for this work will be Ben Schwartz (Senator Casey) and Polly Webster (Senator Wyden).

[1]See a description of the Five Star system in: Government Accountability Office, Nursing Homes: CMS Needs Milestone and Timelines to Ensure Goals for the Five-Star Quality Rating System Are Met, March 23, 2012, GAO-12-390.

[2] Section 6106 of the Affordable Care Act requires nursing homes to submit payroll data in order to calculate measurements under the staffing domain.  To date, however, nursing homes have not transitioned from self-reported staffing data to payroll submissions.  Nationwide mandatory reporting is not scheduled to begin until July 1, 2016.

[3] GAO-12-390.