April 14, 2025
At its April 11, 2025, public meeting, “Regulations, star ratings, and FFS Medicare policies aimed at improving nursing home quality,” the Medicare Payment Advisory Commission (MedPAC) focused on the persistent challenges in nursing home quality oversight and the limitations of current Medicare policies aimed at improvement.
MedPAC staff highlighted widespread concerns with the current Five-Star Quality Rating System used to evaluate nursing home performance. They noted that while there have been isolated improvements in some quality measures, the overall quality of care remains problematic—particularly in areas such as staffing, resident experience, and treatment of neuropsychiatric symptoms.
The commission identified several critical gaps:
- Limited consumer utility: Awareness and use of the star ratings website remain low, and the system does not reflect key quality indicators like patient experience.
- Unintended consequences: The current system may worsen disparities by failing to adjust for social risk factors or account for specialized care models, such as Alzheimer’s-focused facilities.
- Overreliance on inspection data: Many commissioners criticized the weight given to survey inspections in the ratings, arguing they reflect regulatory compliance more than actual care quality.
This reinforces long-standing findings from the GAO and OIG that the nursing home survey and certification process is underfunded and inconsistently implemented. Survey backlogs, staffing shortages, and variability in state inspection practices have further undermined confidence in the system.
Several commissioners called for a complete redesign of the quality measurement framework. Suggestions included:
- Prioritizing staffing as a key driver of quality
- Removing inspection data from the ratings system
- Incorporating patient experience and social determinants into quality assessments
They also discussed the promise of alternative models like Institutional Special Needs Plans (I-SNPs) and the role of Accountable Care Organizations (ACOs) in improving outcomes for high-needs populations.
MedPAC’s June 2025 Report to Congress will include a whole chapter on this topic. In the meantime, stakeholders are encouraged to submit public comments to help inform the commission’s recommendations.
MedPAC will reconvene in the fall. See the full presentation here.
