State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Positives and Negatives of Publicly Reported Information


Stakeholders with whom we spoke discussed the positive and negative implications of publicly reporting information on nursing home quality. State officials believe the greatest benefit of publicly available nursing home quality reports is to help nursing home residents, their families, and informal caregivers make informed decisions when selecting a nursing home or evaluating the care provided in a particular facility. Some stakeholders in most of the states indicated that the report cards had increased consumer access to public information. However, consumer advocates noted that consumers frequently do not know that the reports exist, may not have Internet access, or may not be proficient in navigating the Internet. There has been no analysis of how often report cards actually influenced decisions about nursing home placement.

  • In Florida, advocates noted that hospital discharge staff, rather than a family member who had taken the opportunity to review quality ratings, made most nursing home placements.

  • Particularly in states with lots of rural areas with a low population density (e.g., Iowa, Maine, Missouri, Texas), there are some parts of the state in which there may only be one facility within a reasonable distance of family members, rendering the report card of little value for facility selection.

Some stakeholders also expressed concern that websites may not be designed to optimize consumer access to, and use of, these sites. Some provider associations suggested that more collateral materials should be included on websites to aide consumer understanding of the information posted. States reported difficulties in balancing the provision of sufficient information to assist consumers in making more informed decisions, while not overloading consumers with data. For example:

  • In Iowa, the Ombudsman said consumers were misled because the website included complaints alleging poor care that were later found to be unsubstantiated.

  • Florida officials said they decided to post only regulatory compliance information on their website, out of concern that the Quality Indicators were too confusing to residents and families.

The websites were also reported to provide easy access to information on nursing home quality to advocates, the provider industry, legislators, and other public policy makers. The websites in Florida, Iowa, Texas and Maryland each includes a disclaimer that the information on their website should not be used as the sole basis for nursing home selection. However, some stakeholders expressed concern that users of these websites do not sufficiently explore the meaning of posted information. For example,

  • Consumer advocates and providers in Florida believe that users rarely looked behind the summary star rating to see the back-up information, even though it is available on-line.

  • In Iowa, facilities voiced concern with the posting of survey results that are under appeal. Provider associations said that even when deficiencies are later overturned, the damage from the initial posting can be difficult to reverse. Many providers in the state are opposed to the posting of complete, unedited Statement of Deficiencies survey findings on the state's public reporting system. They believe that the state should include additional information to aide consumer understanding of the information posted, perhaps with some type of summary rating like that used in other states.

While some stakeholders indicated that the information reported on a state's website was generally current and accurate, others expressed concern that some websites were designed to collect old information while other sites simply could not be kept current. For example:

  • In Florida, report card scores are derived from 45 months of survey results. The developers who created the scoring algorithm said this is important to avoid giving inaccurate ratings to facilities that cycle in and out of compliance. But providers complained that deficiencies corrected long ago are unjustly depressing their current scores. Florida providers (as well as consumers) were also distressed by the fact that report cards have not been updated according to the original quarterly schedule.

  • In Iowa, there is concern about the posting of survey findings going back as far as 1999 are included on the state's public reporting system, believing that this can punish providers for deficiencies that have long been corrected. In Iowa, the policy is to post survey results two days after they are mailed to facilities and, if they are appealed by the facility, to mark them as such on the website.

Consumer representatives were concerned that a good rating on a report card--or even a bad one--could misinform consumers. For example, some advocates in Florida believe that giving the worst facilities in the state even a one-star rating was misleading. In Texas, the lowest ranking indicates facilities that have the 'most disadvantages' with respect to quality indicators or a 'substandard quality of care' with respect to survey findings, so this is less of a concern.

Many providers indicated that greatest benefit of the public reporting was the ability afforded to them to use a good quality rating as a marketing tool. Providers in several states said the reports allow good nursing homes an opportunity to receive the praise they deserve and distinguish them from poorer performing facilities.

While CMS and some of the states have posted nursing home performance information for the last several years, providers expressed concern about the impact of posting this information on the availability and costs of nursing home liability insurance. Providers and their associations in Iowa, Florida, and Texas reported that some liability insurance companies were choosing not to write policies for facilities with a higher number of deficiencies or that have poor quality indicator scores, and others have increased rates to the point where facilities report they can no longer afford this insurance. While the survey deficiency information has always been public, the availability of this information on state public reporting systems makes it easier and less costly for insurers to identify poor performing facilities. The states of Iowa, Florida, and Texas have convened task forces to examine the liability insurance issue.

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