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Medicare Ratings Allow Nursing Homes to Game the System

Only one-fifth of all 15,000 nursing homes in the nation hold the distinction of a five star rating by the Medicare system, but an examination into the process has found that many top ranked nursing homes have been given their rating due to incomplete information regarding the conditions at their homes. This misinformation has an effect on the facilities’ residents, potential consumers, and investors regarding the communities.

Medicare Nursing Home Ratings

The Medicare ratings system is considered one of the best ways to evaluate nursing homes in the country. When nurses and doctors discharge patients from the hospital, they often use the ratings in referral decisions. Insurers also look at the ratings when creating preferred insurance networks. Medicare ratings are also the first metric that investors and lenders look at when deciding whether a nursing home is a safe bet.

However, these ratings are accumulated through self-reported data given by the facilities that the government does not verify. In fact, only one of the three main criteria for rating a nursing home, the result of the annual health inspection, is verified by an independent source. Other criteria such as staff levels and quality statistics are reported by the nursing homes and accepted by Medicare at face value.

In addition, the Medicare ratings system does not take into account a variety of negative factors and information about the nursing home communities. Fines, enforcement actions by the state, and complaints filed against the facilities are not factored into the ratings system.

Gaming the System

Many nursing homes are now taking advantage of the rampant self-reporting and using it to their advantage in order to raise their rating in the Medicare system. Nationally, the number of nursing homes with above-average ratings has risen steadily. In 2009, around 37% had above-average marks, and by 2013 that percentage was closer to half.

Even nursing homes that have a history of poor care rate highly in the areas that rely on self-reporting. Of the more than fifty nursing homes in the country on a federal watch list for quality, nearly two-thirds of those communities have four or five star ratings in the Medicare system for self-reported staff levels and quality metrics. The worst facilities in the country can still self-report that their quality is the best while simultaneously being on watch lists for failing state health inspections.

Using the System as an Elder Care Resource

Some advocates agree that the current Medicare ratings system is the best option available, but other experts believe that the ratings are so inflated their only remaining purpose is to weed out the worst homes. A provision in the Affordable Care Act requires that Medicare use payroll data in order to ensure that nursing homes are not padding their staffing around inspections to receive a better rating, but Medicare has not implanted the system yet. The agency has said that it is still working on the verification system and hopes to have it running soon.

Until a better ratings system is introduced, experts encourage people looking into nursing home care to do their research and rely on more than just the Medicare rating. Check annual health inspection records, visit the facilities multiple times, talk to residents, and make sure that you are getting the true picture of the place before making a decision.

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