To the Editor:It’s been 20 years since CMS launched Nursing Home Compare, now Nursing Home Care
Compare (NHCC), a web-based consumer resource outlining care quality in nursing homes
(NHs). Quality metrics are summarized in scorecards grading each facility using a
5-star rating. When the National Quality Forum developed the long-stay quality-measures,
they purposefully incorporated only minimal adjustments for resident risk with few,
well-defined exclusions.
1
A disadvantage of using unadjusted quality scores is the tendency to underestimate
the care quality provided to less healthy patients. Furthermore, an incentive is created
for facilities to artificially improve their scores by selecting healthier patients
and avoiding frailer individuals.
2
,3
Numerous metaphors describe this routine consequence of quality initiatives leveraging
public reporting, including cherry-picking—selecting for easy, straightforward admissions
likely to improve scores—and lemon-dropping—discharging difficult residents (usually
to the hospital) who negatively impact quality measures.
4
,5
Some estimates attribute as much as half of NHCC quality measure variation to unadjusted
risk.
2
,6
The unfair outcome of biased selection is worsening disparity as more desirable facilities
recruit more desirable patients, thereby increasing the appearance of quality and
thus their desirability.
7
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References
- National voluntary consensus standards for nursing home care 2004. Accessed August 22, 2022.
- Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming?.Health Serv Res. 2011; 46: 555-571
- Is there evidence of cream skimming among nursing homes following the publication of the Nursing Home Compare report card?.Gerontologist. 2009; 49: 793-802
- Outmigration for coronary bypass surgery in an era of public dissemination of clinical outcomes.Circulation. 1996; 93: 27-33
- The influence of public reporting of outcome data on medical decision making by physicians.Arch Intern Med. 2005; 165: 83-87
- The "Nursing Home Compare" measure of urinary/fecal incontinence: cross-sectional variation, stability over time, and the impact of case mix.Health Serv Res. 2010; 45: 79-97
- Nursing home 5-star rating system exacerbates disparities in quality, by payer source.Health Aff (Millwood). 2015; 34: 819-827
- Public reporting and demand rationing: evidence from the nursing home industry.Health Econ. 2015; 24: 1437-1451
- The White House briefing room fact sheet: protecting seniors by improving safety and quality of care in the nation's nursing homes.(2022. Accessed August 22, 2022)
- The role of socioeconomic status in nursing home quality ratings.Seniors Hous Care J. 2017; 25: 3-14
Article info
Publication history
Published online: September 29, 2022
Accepted:
August 30,
2022
Received in revised form:
August 29,
2022
Received:
August 17,
2022
Footnotes
This study was supported in part by the Commonwealth of Virginia's Alzheimer's and Related Diseases Research Award Fund [Awards 15-2, 18-3], Virginia Center on Aging, School of Allied Health Professions, Virginia Commonwealth University. The sponsor played no role in study design or preparation of this letter.
The authors declare no conflicts of interest.
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