Research Claims that Under Competitive Pressure, Nursing Homes Appear to Game Rating System

Nov 30, 2019 | Nursing HPRD & Turnover, Studies & Research of PBJ Data


Under pressure: Reputation, ratings, and inaccurate self-reporting in the nursing home industry

This paper examines firms’ strategic responses to reputational pressures in a critical healthcare domain—the U.S. nursing home industry. We investigate whether organizations improved in terms of care quality following an exogenous change in the required number of nursing hours associated with star-based ratings to which nursing homes are subject. We show that although firms at risk of losing a star tended to self-report higher staffing levels after the policy change, these reported increases were not associated with improvements in an important patient outcome—bedsores. These findings are consistent with false reporting of staffing data, or insufficient or ineffective hiring practices. Although we cannot definitively establish the existence of false reporting, supplementary analyses offer little support for the latter two possibilities.


Ody‐Brasier, Amandine, and Amanda Sharkey. “Under Pressure: Reputation, Ratings, and Inaccurate Self‐reporting in the Nursing Home Industry.” Strategic Management Journal, vol. 40, no. 10, 2019, pp. 1517–44. Crossref,


Under Competitive Pressure, Nursing Homes Appear to Game Rating System

Research co-authored by Yale SOM’s Amandine Ody-Brasier shows that when nursing homes increased reported staffing in response to a change in Medicare ratings, care didn’t improve, especially in competitive markets. The study suggests that ratings based on self-reporting may be unreliable, and offers a solution: hide the thresholds for jumping to higher ratings.


Walsh, Dylan. “Under Competitive Pressure, Nursing Homes Appear to Game Rating System.” Yale Insights, 12 Nov. 2019,


SNFs Appear to Have Gamed the System When Staffing Was Self-Reported

The federal government has spent the last few years focusing on staffing as a key area of improvement for nursing homes, requiring operators to provide payroll-based evidence of their labor hours and tightening the requirements for achieving the top scores — all based on the assumption that there’s a direct line between staffing and quality.

But a recent study argues that when SNFs had to self-disclose that information, care did not improve even when the facilities reported increased staffing.

When the Centers for Medicare & Medicaid Services (CMS) increased the level of staffing required to maintain star ratings in 2012, facilities that reported an increase in staffing did not see a corresponding decline in bedsore rates.

Specifically, SNFs in competitive markets were more likely to report such staffing boosts without an improvement in care quality, according to an article published in Strategic Management Journal by Amandine Ody-Brasier of Yale University and Amanda Sharkey at the University of Chicago.


Flynn, Maggie. “SNFs Appear to Have Gamed the System When Staffing Was Self-Reported.” Skilled Nursing News, 19 Nov. 2019,