Star Ratings and PDPM – A Proposal

UPDATE: As of today (6-25-2018) McKnight’s is reporting that CMS is including all PBJ information to the nursing home compare website. I consider this progress!

The current star rating system we use for skilled nursing is not compatible with PDPM. The reason for this is that staffing ratings depend upon expected nursing hours, which are based on the case-mix of your facility. That case-mix is based on RUG-IV RUGs calculated for every resident in your facility. Each RUG has an associated number of expected RN, LPN and Aide hours based on data from the STRIVE studies.

The problem is the STRIVE study is based on RUG-IV RUGs and those RUGs have been significantly modified for PDPM. For example, under PDPM, nursing gets its own RUG. Those RUGs do not include any rehab RUGs and several RUG categories have been combined. PE1 and PD1 are now combined into PDE1. (To see the expected minutes per day from the STRIVE study, see table A1 in the appendix of this document.) We don’t know how many nursing hours to expect with a PDE1 because there has never been one.

The most simple solution, without doing another STRIVE study would be to simply average the data from the combined nursing RUGs and use that for the new RUG. This makes sense, is inexpensive to do and won’t shake up the star ratings all that much.

The Proposal

Here’s where I would humbly like to suggest we could improve the star ratings and PDPM at the same time: Let’s introduce another star for therapy hours. Along with the RN and total nursing stars, we’d have a therapy star as well. (If you aren’t familiar with how the RN and overall nursing stars translate into a staffing star, see table 5 on page 11 of this document. I am NOT suggesting a sixth star.)


There are at least two ways to implement this. The first would be a new STRIVE study, but that would take a long time and cost a lot of money. The second would be to use the same 2017 data that CMS used to create the provider-specific impact file for PDPM and calculate the number of therapy minutes delivered on average. This would be significantly less expensive than another STRIVE study and be good enough to estimate expected average minutes for the new therapy categories.


Why is this a good idea? There are at least two reasons:

  • PDPM pays for therapy but does not require any therapy actually be done. A 5 Star facility could theoretically do no therapy at all. Users of the nursing home compare tool have no way of knowing that if they simply rely on the star rating. Since the entire purpose of the star rating is for simple comparisons, I expect a lot of people don’t look much further than the overall rating.
  • CMS seems to want to encourage therapy be done but does not want to provide a financial incentive to do it. A therapy star rating would encourage providers to maintain at least a minimum level of therapy or risk a lower star rating.

Thoughts? Am I too far out of the box? 

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