CMS/OIG Stepped-up Scrutiny of Psychotropic Drugs

In January of this year, CMS announced new efforts to reduce the use of antipsychotic drugs (APDs) that include targeted audits to determine whether Nursing homes are accurately assessing and coding individuals with diagnoses of schizophrenia. CMS administrator, Chiquita Brooks, in a recent press release, stated, “we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications.”

Scientific study has clearly shown that APDs are especially dangerous in the NH population due to their potentially devastating side effects, that includes death. And as CMS has implemented active initiatives to cut the use of APDs in the nation’s NHs, to the credit of the NH industry and the providers who prescribe these drugs, a significant reduction in their use has been achieved since the launch of these initiatives, starting in 2011. In the 4th quarter of 2011, 23.9% of long-stay NH residents received an APD, and seven years later in 2018, the national use dropped to 14.6%. Some states and regions achieved a greater reduction than others and one study showed an overall reduction in APD prescriptions by 34.1%.

Notwithstanding these significant achievements of reduction, other facilities also showed trends toward increased use of other classes of psychotropic drugs and increased diagnoses of schizophrenia that accommodate the use of APDs as FDA approved drugs vs. their off-label use when prescribed to residents with conditions of dementia, without schizophrenia.

In studies conducted by the OIG in recent years, a marked and questionable surge in NH residents identified as having schizophrenia was found between 2015 and 2019. This coincided with CMS’ inclusion of the rate of usage of APDs as a quality measure in affecting performance on Care Compare, the NHs 5-star Quality Rating System. Specifically, the reporting of residents with schizophrenia in the MDS and the number of residents who lacked a corresponding schizophrenia diagnosis in Medicare claims and encounter data increased by a staggering 194%. “That one was shocking,” exclaimed Brian Whitley regional inspector general for HHS’ Office of Evaluations and Inspections, “194% over a four-year period, that screams to us that there’s something that we need to look at further and deeper here.” Consideration was given to consistent statistical data that shows schizophrenia is most often diagnosed in the late teens – early 20’s of a person’s life and becomes increasingly rare later in life, with its occurrence after age 65 being 7.5 per 100,000 person-years (i.e., if 100,000 persons were followed over 1 full year, initial-onset schizophrenia would occur in 7.5 of them).

As noted, other findings of the OIG were that, with the main focus by CMS being on inappropriate and excessive usage of antipsychotic drugs, the agency lost sight of monitoring the use of other psychotropic drugs, which remained constant and specifically showed, a significant increase in the off-label use of anticonvulsants. The data further suggested that while APDs were being successfully reduced, they were being replaced with psychotropics from other classes, especially the anticonvulsants, possibly in the same non-appropriate manner, but averted formal CMS policy to prevent the use of unnecessary drugs. From 2011 – 2019, approximately 80% of long-stay nursing home residents were prescribed one or more psychotropics.

Moreover, the OIG also found that NHs with lower registered nurse (RN) staff-to-resident ratios were linked to higher use of psychotropic drugs, and facilities with higher percentages of residents with low-income subsidies were also found to utilize psychotropic drugs more. Virtually all psychotropic drugs carry dangerous side effects, such as falls, delirium, cognitive impairment, and many other serious adverse reactions, including death.

As mentioned, CMS recognizes the serious risks that the above trends of psychotropic drug usage create for NH residents and is redoubling its efforts to prevent the use of unnecessary psychotropic drugs. Targeted audits involving these issues have already commenced and if an audit specifically reveals a pattern of inaccurate coding of residents as having schizophrenia, the facility’s 5-Star Quality Measure Rating on Care Compare will be negatively impacted and downgraded to one star, which in turn would drop the overall Star Rating one star as well. In addition, the agency plans to begin publicly displaying survey citations that facilities are disputing on Care Compare, noting that, “displaying this information while it is under dispute can help consumers make more informed choices when it comes to evaluating a facility.”

On the other side of the issues of non-appropriate prescribing, some facilities while feeling compelled and on a mission to cut the use of APDs and other psychotropic drugs are doing so willy nilly to everyone, which not surprisingly can worsen outcomes and result in preventable hospitalizations. We are reminded that psychotropic medications also have their proper clinical indications and medical necessity for managing a broad range of psychiatric disorders and illnesses, in the absence of which significant emotional distress, dysfunction and reduced quality of life occur.

Potential solutions to these problems exist in such practices and interventions:

*Application of a Systematic, Integrated, Holistic, Person-Centered approach to professional care (e.g., The DICE Approach: Describe, Investigate, Create, Evaluate, developed by Helen Kale, M.D., et al, 2014)
*Reliable and accurate differential diagnosis, serving as a basis for medication optimization.
*Regular communication and coordination with primary care and the IDT, that emphasizes a team approach.
*Regular collaborative communication with the patient and/or significant others, including assigned 3rd party medical decision-makers, including discussions of informed consent and risk-benefit information.
*Utilization of appropriate first-line non-pharmacological interventions either before medication intervention or concurrently with urgent and necessary medication usage.
*Close and consistent monitoring of medications being used, including consideration of clinically indicated Gradual Dosage Reductions (GDRs).
*Documentation by the prescribing clinician that clearly states the proper clinical indications and rationale for use of selected drugs, consistent with professional practice guidelines and existing evidenced based science.
*Regular training of care staff on principles of person-centered, holistic care and recognition of unmet resident’s needs
*Daily occupation and involvement in meaningful personal and social activities
*Reliable and direct support for the aforementioned from facility management, administrators, and directors

Seniors Wellness Group, as the mental health care provider of your facility, is committed to these principles of resident care and is your professional resource for expert consultation, guidance, and collaboration on the same. Please do not hesitate to call upon us for discussion or assistance with these or any other matters pertaining to the mental health and well-being of your residents. Thank you.

For additional information please see the linked professional articles:

Management of Neuropsychiatric Symptoms of Dementia in Clinical Settings: Recommendations from a Multidisciplinary Expert Panel

Neuropsychological Profile and Phenomenology of Late Onset Psychosis

A case report of late-onset schizophrenia differentiated from a dementing disorder

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