CMS Nursing Home Ratings System to be Reviewed by GAO at Senators’ Request

The Goverment Accountability Office (GAO) has announced that it will conduct a review of the Centers for Medicare and Medicaid Services (CMS) nursing home rating system, following concerns raised by lawmakers about the accuracy of the information.

The investigation comes in response to a request by several members of the U.S. House and Senate, including Senators Bob Casey and Ron Wyden, and representative Elijah E. Cummings. Wyden, an Oregon Democrat, is ranking member on the Senate Finance Committee, and Cummings, a Democrat from Maryland, is ranking member of the House Committee on Oversight and Government Reform.

Casey and Wyden wrote a letter to the GAO on August 6, calling for the review of the rating system, which ranks nursing homes nationwide on a five-star system based on a number of factors. Cummings wrote a similar letter to CMS on August 26, 2014, asking to be briefed on the rating system, which was revised in February.

“The GAO’s decision to conduct a review is the first step towards ensuring the accuracy of this system that millions of families rely on,” Casey and Wyden said in a statement issued last week. “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. We have to get this right.”

The senators said they asked for the probe following news reports that questioned the rating system’s accuracy.

Most of the questions come from a New York Times investigative report published in September 2014, which found that the ratings are largely based on self-reported data by nursing homes, with little or no confirmation by regulators to even gauge whether the information is close to accurate.

Of the three categories used to find the ratings, which include annual health inspections, staffing levels and quality statistics, only annual health inspections come from independent reviewers. Everything else is based on how well the nursing home tells CMS it is doing.

In addition to the questions raised by the lack of confirmation for self-reported data, the report outlined a number of factors that should be considered in rating the quality of a nursing homes, which the CMS system does not consider, including enforcement actions by state regulators, fines, or customer complaints.

Nursing Home Neglect Concerns

A report issued in 2014 by the U.S. Department of Health & Human Services’ Office of Inspector General (DHHS-OIG) found that about a quarter of all U.S. nursing home residents experience adverse events and that about 11% are harmed by mistakes, most of which are preventable.

Preventable nursing home mistakes result in additional costs for Medicare, often leading to a nursing home or hospital receiving additional reimbursements for treating the damage caused. Reducing such events could result in large savings for the federal government.

Researchers used the study to estimate the national incidence rate, the cost of such mistakes, and whether they could have been prevented. They found that 22% of Medicare beneficiaries suffered adverse events while in nursing homes, and another 11% were harmed temporarily during their time in such facilities, meaning that a third of all nursing home patients are affected by adverse events. About 59% of those medical mistakes were found to be certainly or most likely preventable.

The study found that more than half of those who were harmed by mistakes had to be hospitalized, costing Medicare $2.8 billion in 2011 alone.