Star Ratings Are Rising—But Are Outcomes? Reframing CMS Changes Through the Lens of Real Quality and VBP Impact

On June 18, the Quality, Safety & Oversight Group alongside the Survey & Operations Group of CMS released memo QSO-25-20-NH titled Updates to Nursing Home Care Compare. The main changes are quoted as providing performance data for Nursing Home Chains, dropping third cycle survey results (that is the oldest survey results) from the rating calculation, incorporating an antipsychotic measure while removing the COVID-19 vaccination measures.

While on the surface, these may look like they’ll be good for the average nursing homes bottom line, and performance, they may only make lower performing facilities “feel good” without actually effecting the quality of provided or their “bottom-line”.

As the Nursing Homes are typically the tail that shakes the body, the all-encompassing Medicare Star Ratings were established initially in 2002 under the Nursing Home Compare umbrella, to detail quality of care from staffing to outcomes. They were ultimately shaped into the star ratings we’ve become accustomed to in 2008 to provide simpler information to residents and their families under three domains, that are the staffing ratio, clinical outcomes of residents and the results of the regulatory inspections by Survey Agencies.

Under the main driving force of triple aim, that is improving quality of care and the health of populations while reducing the per capita cost of care, as authorized by the PAM Act of 2014 CMS began incentivizing SNFs providing a high quality of care under the Value Based Purchasing program, the SNF VBP, in 2018. This program was new during the acute phase of the SARS-CoV-2 pandemic and was essentially “paused”, chiefly owing to pauses in ongoing certification and survey activities. Regardless, data during this period was clear that poor SNF-VBP performance, that is poor “care compare star ratings” was directly associated with worse COVID-19 outcomes for SNF residents. 1

In this sense, although several administrations had changed, lawsuits were fought over the star ratings in general, mainly for Medicare Advantage plans, the ratings for LTC and the VBP program stayed the course, with the VBP program expanding beyond the initial 30-day all cause readmission to incorporate most of performance metrics underlying the star ratings, to start include healthcare associated infections, total nurse staffing hours per resident day, total nursing staff turnover, discharge to community, percent of residents experiencing one or more major falls with major injury, discharge function score, number of hospitalizations per mil long stay residents and SNF potentially preventable readmission by FY 2028 as authorized by the CAA of 2021. In this sense although not 1 to 1 correlates, data has demonstrated that the VBP program performance is strongly correlated with the care compare results both longitudinally and contemporaneously. 2

In this sense, for example, removal of the COVID-19 metrics may make sense from a star rating perspective as the coverage was abysmal with less than 50% for the last two years. 3,4 However, COVID-19 alone has been in the top causes of death amongst LTC residents as well as the community at large, accounting to a higher mortality rate then breast cancer not accounting for COVID-19 leading to secondary causes of death such as increased mortality. 5 Further, it is no surprise in this context that LTC deaths have remained above the pre-SARS-CoV-2 baseline, and will peak up to 2 months after the initial infection as well as causing increased readmissions for LTC residents. 6-8 In light of such data, even if the DON and other administrative staff of an LTC may have sighed a relief seeing the SARS-CoV-2 vaccination based star rating “disappear” the effect of vaccination or lack thereof not just on the star rating but on the bottom-line via the SNF VBP will not disappear, but will only work towards facilities that are not purely guided by the “carrot” that is the star, but are able to continue delivering high quality care beyond delivering the bare minimum required by regulations.

From this perspective, it is thus no surprise that while the star ratings and the SNF VBP have been programs not to penalize, but to improve care, they have failed to achieve quality targets such as readmissions, but have tied poor performance directly to poor bottom-line, in a chicken and egg scenario with poorer facilities achieving worse outcomes and looking down the barrel of financial penalties. 9-11

Ultimately, while some DONs and Administrators alike may be sighing reliefs and expecting higher scores, the data is clear that this will have no drastic effect on their bottom-line, nor the quality of care, but possibly increase ratings as a whole while State Survey Agencies are playing catchup from the delayed surveys and recertifications during the acute phase of the SARS-CoV-2 era. One thing is clear, the population of US is getting older, and will continue requiring long term care with estimates of more than 2/3 of those reaching 65 requiring LTC services during their lifetime. 12 As such from the facility perspective, providing quality care and thus ensuring a healthy bottom-line is beyond aiming for “high-star” ratings but ensuring proactive vs. reactive care, that is preventing morbidity and mortality, not reacting to when residents are sick. And finally, from the patient perspective, the star ratings are just one aspect of “quality” and that a facility with a healthy bottom-line may actually be providing higher quality of care even if the star ratings are comparable.

Clearpol’s agentic AI platform makes that proactive mindset possible. Our regulatory‑intelligence engine ingests every CMS QSO memo, Federal Register update, and state bulletin the day it is released; automatically refreshes our rule set; and instantly pushes workflow updates, policy revisions, and compliance alerts to facility dashboards—so your team never scrambles to interpret changes. Let Clearpol shoulder the regulatory upkeep while you focus on resident care. Contact us today for a live demonstration and see how effortlessly your facility can stay ahead of every star‑rating tweak, SNF‑VBP metric, and CMS mandates.

Reference:

1.         Hefele JG, Aldag M, Elmor R, Kaushik C, Ballard JS. Poor Performance in SNF-VBP Program is Associated with Worse COVID-19 Outcomes in Nursing Homes. Innovation in Aging. 2021;5(Supplement_1):1013-1014. doi:10.1093/geroni/igab046.3632

2.         Andersen D, Binu S, Sacca M. Correlates of Skilled Nursing Facility (SNF) Performance in the SNF Value-Based Purchasing Program. Innovation in Aging. 2020;4(Supplement_1):83-83. doi:10.1093/geroni/igaa057.273

3.         Franklin D, Barbre K, Rowe TA, et al. COVID-19 Vaccination Coverage, and Rates of SARS-CoV-2 Infection and COVID-19–Associated Hospitalization Among Residents in Nursing Homes — National Healthcare Safety Network, United States, October 2023–February 2024. MMWR Morbidity and Mortality Weekly Report. 2024;73(15):339-344. doi:10.15585/mmwr.mm7315a3

4.         Reses HE, Segovia G, Dubendris H, et al. Coverage with Influenza, Respiratory Syncytial Virus, and COVID-19 Vaccines Among Nursing Home Residents — National Healthcare Safety Network, United States, November 2024. MMWR Morbidity and Mortality Weekly Report. 2024;73(46):1052-1057. doi:10.15585/mmwr.mm7346a2

5.         Maqsood MH, Talha KM, Minhas AMK, et al. CDC-WONDER Database Analysis of COVID-19 and Cardiovascular Disease-Related Mortality. Journal of the American College of Cardiology. 2023;81(17):1743-1745. doi:10.1016/j.jacc.2023.02.044

6.         Ballin M, Ioannidis JP, Bergman J, Kivipelto M, Nordström A, Nordström P. Time-varying risk of death after SARS-CoV-2 infection in Swedish long-term care facility residents: a matched cohort study. BMJ Open. 2022;12(11)doi:10.1136/bmjopen-2022-066258

7.         Bogin MH, Chandra A, Manggaard J, Thorsteinsdottir B, Hanson GJ, Takahashi PY. Telehealth Use and Hospital Readmission Rates in Long-term Care Facilities in Southeastern Minnesota During the COVID-19 Pandemic. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2022;6(3):186-192. doi:10.1016/j.mayocpiqo.2022.03.001

8.         Zazzara MB, Colloca GF, Maraschini A, et al. Causes of deaths in long-term care and hospice care facilities during the first year of COVID-19 pandemic: a snapshot of Italy during 2020. Aging Clinical and Experimental Research. 2023;35(6):1385-1392. doi:10.1007/s40520-023-02426-7

9.         Burke RE, Hutchins F, Heintz J, et al. Skilled Nursing Facility Value-Based Purchasing Failed To Achieve Hospital Readmission Reductions And Other Targets. Health Affairs. 2025;44(6):722-730. doi:10.1377/hlthaff.2024.01402

10.       Burke RE, Xu Y, Rose L. Skilled Nursing Facility Performance and Readmission Rates Under Value-Based Purchasing. JAMA Network Open. 2022;5(2)doi:10.1001/jamanetworkopen.2022.0721

11.       Sharma H, Hefele J, Xu L, Conkling B, Wang X. SNF‐VBP Penalizes Skilled Nursing Facilities with Negative Profit Margins. Health Services Research. 2020;55(S1):14-15. doi:10.1111/1475-6773.13341

12.       What is the lifetime risk of needing and receiving long-term services and supports (2019).