If your facility is like many others across the country, your CMS 5-Star rating just took a negative hit. Read on to learn the details behind why this change happened, and how you can take proactive measures to improve your 5-Star rating.

Changes to the Quality Measures 5-Star rating

On July 1, 2016, CMS made some significant changes to the way the Quality Measures 5-star rating is calculated, which may have an equally significant effect on your facility’s rating.

There are five major changes worth your attention because they may have already negatively affected your Quality Measure 5-star rating. These include five new QMs (including three claims-based QMs), a new imputation strategy, new QM cutoffs and coefficients, a switch to a four-quarter average instead of three quarters, and new 5-Star cutoffs.

Five new Quality Measures (three claims-based)

There are five new measures that will be used when calculating the Quality Measure 5-star rating:

• Percentage of residents whose ability to move independently worsened (Long-Stay)
• Percentage of residents whose physical function improves from admission to discharge (Short-Stay)
• Percentage of residents who were re-hospitalized after a nursing home admission (Short-Stay, Claims-Based)
• Percentage of residents who have had an outpatient emergency department visit (Short-Stay, Claims-Based)
• Percentage of residents who were successfully discharged to the community (Short-Stay, Claims-Based)

For the first two quarters, July 1 – Dec. 31*, these measures will only have 50% the weight of the other 11 measures. You can find more information about how the MDS-based measures are calculated in the MDS 3.0 Quality Measures User’s Manual, and more information about how the claims-based measures are calculated in the New Measures Technical Specifications.

* Technically, these QMs are calculated using MDS/claims data from Jan. 1 – June 30 because CMS waits two quarters before calculating QMs.

New imputation strategy

“Imputation Strategy” refers to the methodology used to guess values or rates when there is not enough data to make an accurate calculation. Starting July 1, CMS made some significant changes to the way QM rates are imputed and when they are imputed.

A measure will have to be imputed if it cannot be calculated for at least 20 residents’ assessments summed across four quarters of data. Previously, the rates were imputed based only on statewide averages for a measure. After July 1, rates will be imputed based on a combination of the facility’s data and statewide averages.

Also, for facilities that don’t meet the requirements for imputation, scoring rules have changed for the missing data. Instead of rescaling with a multiplier, points will be assigned to missing measures based on the average points assigned to all other measures of the opposite stay type (short or long) in the same facility. Scores for claims-based measures will be imputed the same way, using the average points assigned to all of the short-stay measures for the same facility.

More information about how values are imputed can be found in the 5-Star Quality Rating System Technical User’s Guide.

New QM cutoffs and coefficients

Occasionally, CMS will recalculate cutoffs and coefficients for each quality measure. The cutoffs define how many points (20, 40, 60, 80 or 100) are assigned for a given rate and the coefficients that are used to calculate a risk-adjusted value of a measure.

Cutoffs are based on a national distribution for a QM. For example, for many of the QMs, facilities are broken into quintiles, so that the top 20% of facilities receive 100 points, the bottom 20% of facilities will receive 20 points, and the second, third and fourth quintiles receive 40, 60 and 80 points respectively.

The cutoffs are static for a period of time, making it possible for a facility to improve and receive 100 points even though they may not fall into the top 20%. However, every time the cutoffs are recalculated, that facility will be reverted to the points assigned to their quintile, possibly reducing the 5-Star point calculation.

Four-quarter average

Previously, rates were calculated based on a three-quarter average of a measure. Starting July 1, CMS will use a four-quarter average instead. This means that calculated rates will be a little more resistant to change, because MDS assessments will considered for a longer period of time. Depending on the situation, this could be a positive or a negative effect for your QMs.

New 5-Star cutoffs

Every year, the cutoffs for calculating the final quality measure 5-star rating are changed so that 25% of facilities are 5-Star, 20% are 4-Star, 20% are 3-Star, 20% are 2-Star, and 15% are 1-Star. For one year it is possible for a facility to jump up or down in their 5-Star rating, but if they do not move into a new percentile, the quality 5-star rating will be reverted when the cutoffs change again.

How can you proactively improve your 5-Star rating?

The importance of quality measures and the CMS 5-Star rating scale will only increase over time. That means that facilities with the ability to access and analyze their data will have an advantage when it comes to improving their quality ratings. Others will be left behind.

At SimpleLTC, we will continue to update and enhance the capabilities of SimpleAnalyzer™ to make it both easy and affordable for facilities to measure, analyze and make proactive decisions that improve quality ratings, as well as overall quality of care.