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Study says some nursing homes gaming the system to improve their Medicare star ratings

January 17, 2018

For families faced with the difficult decision of placing a loved one in a nursing home, a government rating system is often the only source of information to determine which facilities are the best. However, a new study of nursing homes in California, the nation's largest system, by faculty at Florida Atlantic University and the University of Connecticut, found that some nursing homes inflate their self-assessment reporting to improve their score in the Five-Star Quality Rating System employed by Medicare to help consumers.

"We were able to empirically demonstrate that inflation does exist in the current system," said Xu Han, assistant professor in the Department of Information Technology & Operations Management within FAU's College of Business, who co-authored the study with Niam Yaraghi and Ram Gopal from UConn's School of Business. "So many nursing homes have a five-star rating; they look like they're luxury hotels, but it's difficult to see through that and determine what kind of service they're actually providing. In reality, many of them are not really providing five-star services."

The five-star rating system that Medicare uses to compare nursing homes is made up of three components: employing a base score from an objective, on-site inspection, along with two scores from information on staffing and quality reported by the facility. Patients, physicians and payers rely heavily on these overall ratings, which have climbed higher as self-reported scores have trended upward.

The study, recently published in the journal, Production and Operations Management, investigates whether these rating improvements reflect actual quality gains or unjustified ratings inflation. Among the study's findings:
  • Nursing homes that have more to gain financially from higher ratings are more likely to improve their overall rating through self-reporting.

  • Little direct correlation exists between self-reported measures and on-site inspection results, either contemporaneously or over time.

  • The number of resident complaints is similar for nursing homes with the same inspection rating but varies noticeably between facilities with the same overall rating, which suggests inflation in self-reported measures.

  • At least 6 percent of the nursing homes inflate their self-reported measures, which include quality measures on patient health, as well as staffing numbers.

The study provides systematic evidence that some nursing homes are inflating the self-reported measures in Medicare's star rating system. By showing that there is a manageable number of facilities that are likely inflators and identifying key predictors of being an inflator, the researchers said the findings can help Medicare focus its future audits more strategically and improve its inspection process and ratings system.

"We know there are issues with the rating system, but what can we do to improve it?" asked Han, who continues to study nursing home ratings. "We need an effective audit system and to conduct more research on how we can use technology to improve nursing home operations and the rating system."

The study uses data from 2009 to 2013, the first five years after the rating system was implemented in 2008. The researchers examined data from more than 1,200 nursing homes in California, the largest system in the U.S., including the facilities' star ratings and other characteristics from Medicare files and information on facility finances and resident complaints from other databases maintained by the state.
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About Florida Atlantic University

Florida Atlantic University, established in 1961, officially opened its doors in 1964 as the fifth public university in Florida. Today, the University, with an annual economic impact of $6.3 billion, serves more than 30,000 undergraduate and graduate students at sites throughout its six-county service region in southeast Florida. FAU's world-class teaching and research faculty serves students through 10 colleges: the Dorothy F. Schmidt College of Arts and Letters, the College of Business, the College for Design and Social Inquiry, the College of Education, the College of Engineering and Computer Science, the Graduate College, the Harriet L. Wilkes Honors College, the Charles E. Schmidt College of Medicine, the Christine E. Lynn College of Nursing and the Charles E. Schmidt College of Science. FAU is ranked as a High Research Activity institution by the Carnegie Foundation for the Advancement of Teaching. The University is placing special focus on the rapid development of critical areas that form the basis of its strategic plan: Healthy aging, biotech, coastal and marine issues, neuroscience, regenerative medicine, informatics, lifespan and the environment. These areas provide opportunities for faculty and students to build upon FAU's existing strengths in research and scholarship. For more information, visit http://www.fau.edu.

Florida Atlantic University

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