Medicare to Look More Closely at Antipsychotic Use in Nursing Homes

WASHINGTON — The Centers for Medicare & Medicaid Services (CMS) announced actions on Wednesday that would put greater scrutiny on antipsychotic prescribing in nursing homes as well as let consumers know about citations the homes are disputing.

“President Biden issued a call to action to improve the quality of America’s nursing homes, and HHS is taking action so that seniors, people with disabilities, and others living in nursing homes receive the highest quality care,” HHS Secretary Xavier Becerra said in a press release. “No nursing home resident should be improperly diagnosed with schizophrenia or given an inappropriate antipsychotic. The steps we are taking today will help prevent these errors and give families peace of mind.”

CMS said that beginning this month, it will “conduct targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care and prescribed inappropriate antipsychotic medications,” which are “especially dangerous” to nursing home residents because the side effects can be devastating, and can even lead to death.

Chris Laxton, executive director of AMDA — The Society for Post-Acute and Long-Term Care Medicine, an association of nursing home medical directors, told MedPage Today that while his group has “always supported accountability around the appropriate use of antipsychotic medications,” capturing overall antipsychotic use is a crude measure of appropriate care.

“We know that no two facilities are alike in terms of their patient population,” Laxton said. “Some may have a greater need for appropriate antipsychotic prescribing.”

He added that there “are patients with dementia and psychosis for whom antipsychotics are helpful and not categorized as inappropriate.” He also warned that facilities may become hesitant to take patients with legitimate diagnoses and need for antipsychotics because it will make their overall rate go up and cause increased scrutiny.

“There’s certainly a question about inappropriate diagnoses of schizophrenia and antipsychotic prescribing,” Laxton said. “On the other hand, we need measures that don’t create a situation where nursing homes refuse to accept patients or where diagnoses are driven by a desire not to be penalized.”

David Gifford, MD, MPH, chief medical officer of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), said in a statement that antipsychotic use in nursing homes has fallen by 40% over the last decade, and noted: “In many cases, physicians not directly affiliated with the long-term care facility are diagnosing patients and prescribing these medications.”

LeadingAge, a group representing more than 5,000 nonprofit aging services providers, applauded CMS’s action. “LeadingAge supports efforts to address the issue of inappropriate antipsychotic drug use among providers of all types,” Katie Smith Sloan, the organization’s president and CEO, said in a statement. She noted that LeadingAge led the creation of the National Partnership to Improve Dementia Care in Nursing Homes, a program that CMS supervised.

“Much has been achieved since the program’s start in 2012, and nursing homes deserve a lot of the credit for the progress,” she said.

“There is more work to be done, however,” she continued. “We understand the challenges of implementing alternatives to drugs, particularly if programs that reduce the use of antipsychotics require more or specialized staff … However, this is a serious quality of care and quality of life issue for residents. Inappropriate use of potent drugs can compromise a person’s overall health. If stepped-up enforcement is needed, we support that approach. At the same time, we urge CMS to address the issue of inappropriate antipsychotic use among providers of all types … Healthcare is a team sport; all providers in the system must be held to the same expectation.”

On another front, CMS also announced that it is going to include disputed citations — in addition to those not in dispute — in its Care Compare nursing home database. “Currently, when a facility disputes a survey deficiency, that deficiency is not posted to Care Compare until the dispute process is complete,” CMS said in the release. “This process usually takes approximately 60 days; however, some cases can take longer. While the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance” including those that could lead to serious injury.

“Displaying this information while it is under dispute can help consumers make more informed choices when it comes to evaluating a facility,” the agency said. “This new information will begin appearing on Care Compare on January 25, 2023.”

Laxton lamented that the policy would create a “guilty until proven innocent” situation for nursing homes.

In his statement, Gifford said that while AHCA/NCAL appreciates CMS’s efforts to enhance its rating system, “dramatically downgrading entire ratings based on a single measure results in misleading information and causes more consumer confusion. It is becoming increasingly difficult for consumers to use Care Compare to see and understand what is most important when searching for a nursing home.”