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May 15, 2019 Readers Write No Comments

Three Reasons to Look Beyond the SNF Five-Star Rating When Assessing Potential Hospital Partners
By Tom Martin

Tom Martin is director of post-acute analytics for CarePort Health of Boston, MA.

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Last month, the SNF Five-Star Rating program underwent major changes in all three domains. As a result, many SNFs saw their ratings drop on Nursing Home Compare, and many hospitals and health systems questioned whether these facilities could continue to meet their high standards for quality.

A close look at the program’s methodology revealed that CMS’s changes in measurement were the root cause of the decline in ratings, as opposed to a true dip in quality. As tempting as it is to use the star ratings as the primary criteria for adding or keeping SNFs in a preferred post-acute network, there are a few compelling reasons for hospitals to look beyond these general statistics and consider alternative strategies.

The first reason is that the quality domain carries the least weight though it includes some of the most important measures.  The survey domain is the most heavily weighted in the calculation of a facility’s overall star rating.

While surveys are certainly an important indicator of quality, they’re not the most relevant or timely markers for hospitals that are assessing SNFs as potential partners. The results are subjective, standard surveys only happen once a year, and the forced distribution of ratings in this domain makes it difficult to know if a provider is truly improving or if other SNFs in their state are just getting worse.

In contrast, CMS is constantly adding new measures to the quality domain, some of which are highly relevant to hospitals. In fact, for a few key measures such as 30-day readmissions, ER visits, and successful discharge to the community that really matter to hospitals, the period of time that patients are followed has been extended beyond discharge from the SNF. These longer measurement windows are especially helpful to hospitals that are part of an ACO or involved in other value-based programming that holds them accountable for patient outcomes across the entire care continuum.

Unfortunately, with a total of 17 quality measures currently included in the quality domain, a SNF’s performance on these critical measures has a limited impact on its quality star rating and minimal impact on its overall star rating.

The second reason to look beyond the star ratings is that the claims-based quality measures are limited to the Medicare fee-for-service population. Even if a hospital or other acute entity such as an ACO focuses on the measures that are most relevant to them, as mentioned above, and ignores the composite star ratings, the data on these measures are confined to a facility’s Medicare fee-for-service population, which may or may not make up a significant portion of its current population. And looking ahead, the percentage of Medicare beneficiaries choosing to receive their benefits under a Medicare Advantage plan will only continue to rise, making these fee-for-service claims-based measures even less representative of the quality of care provided at a SNF—ironic given that they would otherwise have the potential to provide the most valuable information in the program.

The third reason to look beyond the star rating system is that changes in measurements, such as those made this April, have occurred many times over the 10 years the program has been in place and will likely continue to occur. But as we saw in April, they skew the data and can mask true trends in quality, making it hard for hospitals to get a complete and accurate picture of the performance of participating SNFs. What hospitals really need are objective means of measuring performance, and that’s not a given with the Five-Star Rating program. For example, in April CMS changed the cut points for the various star levels in the staffing domain, so even though a provider may have actually increased staffing levels in April, that provider may still have received a lower rating due to these new higher thresholds.

Selecting a few measures from the Five-Star Rating program to focus on when assessing potential SNF partners is a reasonable strategy, but one that doesn’t quite go far enough in the era of value-based care. In today’s climate, where hospitals and health systems are being held responsible for patients long after their inpatient stays are over, these acute entities need to be much more closely connected to their downstream partners. They need access to real-time patient data from SNFs, and not just on their Medicare FFS patients, but on their entire population.

All stakeholders—acutes, post-acutes, and most importantly, patients—benefit when providers break down data siloes and exchange healthcare information freely. Simple alerts stemming from ADT (admissions, discharge, and transfer) data can go a long way toward helping providers stay on top of what’s going on with their patients. The star ratings have their place, but to truly understand the quality of care that is being provided by their post-acute partners and ensure patients are receiving high-quality care at every point in the continuum, hospitals need to get proactive and start collecting their own data.

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