The Centers for Medicare & Medicaid Services will be increasing its oversight of the use of psychotropic drugs to pay closer attention to certain classes, warned the lead author of a federal report identifying gaps in the agency’s current monitoring approach.
While CMS met a 2011 goal of lowering the use of antipsychotics in nursing homes, it lost sight of the use of other psychotropic drugs, the Office of the Inspector General for the Department of Health and Human Services found in a report issued this week.
The use of anticonvulsants, often prescribed to epileptics, increased, leaving the overall use of all psychotropic drugs unchanged. From 2011 through 2019, about 80% of Medicare’s long-stay nursing home residents were prescribed some type of psychotropic drug.
Those findings echo recent academic research that pointed to psychotropics being replaced by other drug classes that were possibly being used in the same, non-appropriate manner.
OIG also discovered that the number of unsupported schizophrenia diagnoses increased and, in 2019, was concentrated in a small number of nursing homes.
“Specifically, we found that from 2015 through 2019 both 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 194%,” the report read.
The CMS long-stay quality measure of antipsychotic use excludes residents who are reported as having schizophrenia in the MDS. Nursing homes could misreport residents as having schizophrenia in the MDS to drive up their success on the quality measure, the OIG explained.
CMS leaders have acknowledged an increasing rate of schizophrenia diagnoses, and warned providers about trying to hide the true rate of prescriptions for antipsychotics, which have often been relied upon to control patient behavior.
“We saw the rates kick up just a bit, so we are very concerned that residents are not on these dangerous drugs,” CMS Nursing Homes Division Chief Evan Shulman said at a national event this summer. “People who are 80 don’t generally develop schizophrenia. And … it’s not contagious. These antipsychotics are very dangerous. Labeling someone as having schizophrenia to justify these drugs is simply unacceptable.”
In response to OIG recommendations, CMS said it is now using data to analyze the use of psychotropics and other drugs that affect brain activity, such as anticonvulsants. Changes to the survey process and guidance in effect since late October “specifically target inappropriate use of anticonvulsants,” CMS noted.
“At this time, CMS has reviewed and is actively analyzing data to identify nursing homes with a higher rate of diagnosed schizophrenia amongst residents admitted between January 2020 and June 2021 with a new claim of schizophrenia within the last five years,” the agency said. “CMS is also reviewing data to identify any possible trends or anomalies among nursing home residents, facilities and prescriber levels.”
Other missed opportunities
The OIG said that by not collecting diagnoses on Medicare Part D claims, CMS is limiting its ability to effectively conduct oversight of all psychotropic drug types. The absence of diagnoses on claims stunts the agency’s ability to detect patient risk and patterns of potentially inappropriate drug use. Also, the lack of diagnoses challenges CMS to systematically determine whether claims meet the payment requirement that the drugs are used for medically accepted purposes.
“What we found is very concerning,” report team lead Andrea Staples told McKnight’s Long-Term Care News. “CMS guidance states that the ‘use of psychotropic medications, other than antipsychotics, should not increase when efforts to decrease antipsychotic medications are being implemented, unless the other types of psychotropic medications are clinically indicated.’
“We find the trends in psychotropic drug use concerning because of the serious potential side effects, such as increased risk of death, suicidality, or falls among the elderly. We would like to see CMS broaden its oversight to not only include antipsychotics, but to include the use of all psychotropic drugs among residents.”
That risk may be further enhanced depending on the number of other medications being taken regularly. Staples added that the Federal Drug Administration has issued boxed warnings on multiple psychotropic drugs since they can result in severe adverse effects.
CMS agreed to increase its oversight efforts in general, and especially in regards to data collection, but the agency said it was prevented from changing Part D prescriber rules because it did not have statutory authority. State laws govern what is required to be included on prescriptions, the agency responded.
