The Complex Relationship Between Quality Ratings and Pandemic Deaths in Nursing Homes

By Yaa Akosa Antwi, PhD
April 19, 2022

Yaa Akosa Antwi is an Assistant Professor of Economics and Management at the Johns Hopkins University Carey Business School. Her research focuses on understanding and quantifying how government policies and economic incentives affect health outcomes and the functioning of health care markets.

Mortality from COVID-19 among residents of nursing facilities has been among the highest of any group — 108 times higher than non-nursing home residents at the end of 2020. This grim reality reflects nursing home residents’ advanced age and physical closeness with staff and other residents, but mortality has varied across facilities, raising the question of whether some have done a better job at preventing death than others.

In a study recently published in the Journal of Health Economics, Christopher Cronin and William Evans used Centers for Medicare and Medicaid Services (CMS) data to look for a relationship between nursing home deaths during the pandemic and nursing home quality, as measured by the CMS quality rating system (five stars are the best; one is the worst). 

After controlling for the overall number of cases of COVID in the facilities, the researchers found that:

  • Five-star facilities had a lower death rate from COVID-19 — they had fewer staff shortages, tested residents and staff more frequently and received test results faster. 

  • Once vaccines became available, five-star facilities vaccinated residents and staff at a higher rate.

  • Five-star facilities had a higher death rate from non-COVID cases compared to one-star facilities. 

  • Because of the higher death rate from non-COVID cases, the overall death rate was higher in five-star facilities.

The researchers offer a possible explanation for these findings: higher quality nursing facilities followed CMS guidelines most closely by isolating residents and limiting visitors. This may have prevented infection, but perhaps, by following these guidelines, five-star facilities created new problems. The authors cite “an abundance of qualitative evidence” suggesting isolation in nursing homes led to loneliness, despair and “may have also expedited death.”

In looking at these findings, readers should be aware of some of the limitations of CMS’ star rating system for nursing facilities: Some of the data is self-reported, the measures may not capture all aspects of quality, and the system compares facilities to others in the state instead of to a national standard. 

While every quality rating system could be better, one conclusion from this research might be that yes, five-star nursing facilities were better at following CMS’ rules. But the rules were too myopically focused on the pandemic and not the whole person. This lesson will be important to keep in mind as policymakers, including the Biden administration, look to reform our clearly ailing nursing home system.

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