The Fault in CMS’ Stars

The Centers for Medicare and Medicaid Services (“CMS”) spends considerable time and effort promoting their Five Star Quality Rating System for Nursing Homes (see here).  They even provide an extensive analysis of how they arrive at their ratings (see here).  The ratings are based on a complicated scoring system that involves multiple factors including: both state and agency health inspections, staffing levels and quality measures.  The stars shine brightly on the individual facility web pages along with all of the private pages covering the facilities.

There’s just one problem with this system.  It is not accurate.

All of the ingredients that I mentioned above plus many more are compiled by CMS into a single number which was called a “cycle score” and now is referred to as a “rating score”.  It’s what happens next that creates the problem.  Once they have that number they first group the facilities by state and then by rating score (lowest to highest).  

Did you catch that first step?  CMS first groups the facilities by state, then ranks them.  The top ten percent of the facilities in each state receive five stars while the bottom 20 percent receive one star.  And that how a facility earns its stars; it is simply a ranking of the facilities in a particular state by ratings score with the stars indicating what ranking the facility has achieved in the state.

What this means is that it is not accurate to compare a nursing home in one state to a nursing home in another state using CMS’s Five Star Quality Rating System.  It is comparing apples to oranges.  To further illustrate this oddity, we have put together a presentation of what CMS calls its “Cut Point Table”.   This table shows the range of ratings scores that a nursing home needs to qualify for the different star levels in each state.  At the opposite ends of the spectrum are New Hampshire and Nevada.  New Hampshire which only has 73 facilities is the most difficult state, requiring a ratings score of less than .667 to qualify for a five star rating.  Compare that to Nevada which has 62 facilities but only requires a 40 for a five star rating.  Worse still having a 39 rating in New Hampshire means that you would only be a one star facility.  In New Hampshire a ratings score of 20.667 was the lower limit for two stars. (Strangely too, the data for this tables comes from a CMS PDF document. The data is not actually available as structured data but only as an unstructured PDF.) Here is a page with the latest data.

So, a five star nursing home in Nevada could be worse than a one star nursing home in New Hampshire!  How does that make sense?

Piling on to this problem is the fact that CMS does not make it easy to find the rating score.  It is available in the data that they publish (and so we have it), but they do not provide it on their pages.  

So that’s it.  The Five Star Quality Rating System for Nursing Homes is tragically flawed. You cannot easily compared facilities from one state to another. There is a better system, but it is not easy to find.

Luckily, we can help.  Each of the nursing home pages that we present shows all of the rating scores.  The lists that we provide use the score to sort facilities, and we will be adding additional forms and reports as time provides.