The Office of Inspector General (OIG) conducted a follow-up study on how the Centers for Medicare & Medicaid Services (CMS) monitors nursing home use of antipsychotic drugs to treat residents various conditions. The OIG found that although CMS has taken important steps to reduce the use of antipsychotic drugs in nursing homes, it can also make further progress by collecting more complete data on residents’ use of these drugs.
The OIG’s study found that CMS’s use of the Minimum Data Set (MDS) as the sole data source to count the number of nursing home residents using antipsychotic drugs may not always provide complete information. The OIG concluded that that some residents’ use of antipsychotics may not have been detected by CMS’s quality measure that is intended to monitor these drugs.
Previous OIG work in 2011 raised quality and safety concerns regarding the high use of antipsychotic medications among nursing home residents. Since then, CMS has taken important steps to monitor the use of these drugs in nursing homes. However, CMS has acknowledged the potential for inconsistencies in the data—self-reported by nursing homes—that it uses to monitor nursing home quality and to monitor the safety of the use of antipsychotic drugs.
The recent OIG study analyzed Medicare claims and found that using the MDS did not always result in a complete assessment of the number of residents who are prescribed antipsychotic drugs. Specifically, in 2018, 12,091 Part D beneficiaries who were long-stay residents aged 65 and older—5 percent of all such beneficiaries—had a Part D claim for an antipsychotic drug but were not reported in the MDS as receiving an antipsychotic drug.
Further, nearly one-third of residents who were reported in the MDS as having schizophrenia—a diagnosis that excludes them from CMS’s measure of antipsychotic drug use—did not have any Medicare service claims for that diagnosis. Finally, even for those residents included in the MDS counts, the MDS does not provide important details about the drug use (e.g., which antipsychotic drugs were prescribed, at what quantities and strengths, and for what durations).
The OIG recommendations to CMS include:
- Take additional steps to validate the information reported in MDS assessments. The OIG would like CMS to consider using additional data analysis tools to ensure the accuracy of what nursing homes report in the MDS. The OIG suggests that CMS consider creating automated comparisons of claims and MDS information to detect inconsistencies between a Medicare Part D claim and the MDS data.
- Supplement the data it uses to monitor the use of antipsychotic drugs in nursing homes. OIG recommends that CMS reconsider whether the current MDS measure provides sufficient information to effectively monitor nursing homes, and CMS should take steps to supplement it. OIG asks CMS to consider using Part D data to enhance its monitoring of overall and concerning prescribing patterns in nursing homes. For a subpopulation of nursing home residents (those enrolled in Part D), Part D data could provide additional information, such as which specific drugs are being dispensed, at what quantities and strengths, and for what duration.
CMS concurred with both of the OIG recommendations. In response to the first recommendation, CMS will take additional steps to validate the information reported in MDS assessments. CMS stated that it would take steps to consider using additional data analysis tools to ensure the accuracy of what is reported on the MDS, as may be feasible.
In response to the second recommendation, CMS to supplement the data it uses to monitor the use of antipsychotic drugs in nursing home, CMS stated that it would consider whether alternative measures could be used to monitor the use of antipsychotics more effectively in nursing homes. CMS did provide an example of action it has already taken to use Part D claims to calculate a related measure.
The full OIG brief can be accessed at: CMS Could Improve the Data It Uses to Monitor Antipsychotic Drugs in Nursing Homes, OEI-07-19-00490 (hhs.gov).
Issue:
Although antipsychotics can be effective in treating many conditions, this classification of drugs carries a risk to the geriatric resident and should be used only when necessary. The use of antipsychotics should be monitored closely by medical and nursing staff. Medical staff and nursing staff should be communicating routinely about residents who are receiving antipsychotics, and a plan of care should be developed for gradual dose reduction or to discontinue the use of antipsychotics when appropriate.
Discussion Points:
- Review your policy and procedure on psychotropic medication use. Update your policy and procedure if needed.
- Train all clinical staff about your psychotropic medication policy and procedure, including the risks and benefits of this classification of drugs and how to conduct appropriate monitoring of residents receiving these medications. Document that the trainings occurred and file the signed document in each employee’s education file.
- Periodically audit to ensure that each psychotropic medication that is prescribed has a plan of care that addresses decreasing or discontinuing the medication. IF decreasing or discontinuation of the psychotropic medication is not feasible, ensure that there is complete documentation of interventions that have been tried and were unsuccessful with a rationale for continuing use.
