HHS Inspector General Finds CMS Data Understates Antipsychotic Drug Use in Nursing Home

A serious and longstanding quality of care problem in nursing homes is the inappropriate use of antipsychotic drugs with residents who have dementia.  A decade ago, the HHS Office of Inspector General (OIG) reported that 83% of claims for atypical antipsychotic drugs were associated with conditions other than those approved for their use by the Food and Drug Administration (FDA) and that 88% of antipsychotic drugs prescribed for residents were associated with the highest level of warning from the FDA (that use of such drugs could cause the death of residents with dementia).[1]  In response, the Senate Special Committee on Aging held a hearing on November 30, 2011 – “Overprescribed: The Human and Taxpayers’ Costs of Antipsychotics in Nursing Homes”[2] – and the Centers for Medicare & Medicaid Services (CMS) launched a National Partnership to Improve Dementia Care in Nursing Homes in 2012.[3]

A new report by the Inspector General[4] finds that significant problems remain.[5]  First, the resident assessment (MDS) data that CMS uses as the sole source of information to report antipsychotic drug rates in nursing homes is incomplete and understates antipsychotic drug rates.  CMS’s use of only MDS data misses many residents who are taking antipsychotic drugs.  OIG finds that 249,135 residents (23% of long-stay residents in nursing homes) had a Part D claim for an antipsychotic drug in 2018, but that 12,091 of the residents (5%) were not reported in their MDS assessments as receiving antipsychotic drugs.

Second, CMS excludes from reporting of antipsychotic drug use in the quality measure on the federal website Care Compare any residents with one of three diagnoses, including schizophrenia.  In other words, if residents are diagnosed with schizophrenia, their use of an antipsychotic drug is not flagged as inappropriate.  OIG reports that of the 98,227 residents that nursing facilities report as having schizophrenia, more than 29,000 residents (30%) did not have any evidence of a diagnosis of schizophrenia in their Medicare claims (and 71% of them had at least one Part D claim for an antipsychotic drug).  These 29,000 residents are not included in the quality measure for antipsychotic drug use.  Facilities’ assessments of schizophrenia appear false in too many instances.  A study published in 2017 found that in the two years following the introduction of the National Partnership, diagnoses of schizophrenia in nursing home residents nearly doubled.[6] 

CMS concurred with OIG’s two recommendations: “to validate the information reported in MDS assessments” and to “supplement the data it uses to monitor the use of antipsychotic drugs in nursing homes.”

While CMS’s concurrence with OIG’s recommendations is significant and could lead to meaningful changes, the OIG report raises serious broader concerns.  First, too many resident assessments that CMS uses in the quality measure domain, which is largely based on self-reported data, are fraudulent and misstate residents’ conditions and needs.  The Center for Medicare Advocacy has long described the quality measure domain on the federal website as inaccurate and self-serving.  Second, the National Partnership is not the success that CMS and the nursing home industry claim.[7] The real disgrace is that far too many residents continue to receive antipsychotic drugs when use of the drugs is dangerous and life-threatening for them.

Although OIG reports that facilities’ self-reported MDS data miss many cases of antipsychotic drug use, Tony Chicotel, an attorney with California Advocates for Nursing Home Reform, finds that even these self-reported data, as reported by CMS,[8] document a dramatic increase in antipsychotic drug use during the coronavirus pandemic.[9]  For example, California’s antipsychotic drug rate reported by facilities was 23% in the first quarter of 2021, nearly the same as the 24% reported by facilities prior to the National Partnership.  Chicotel also finds that facilities nationwide report that more than 11% of all residents have diagnoses of schizophrenia.  The rate is almost 18% in California, compared to a 9% rate reported in 2011. 

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[1] OIG, Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents, OEI-07-08-00150 (May 2011), https://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf.
[2] https://www.aging.senate.gov/hearings/overprescribed-the-human-and-taxpayers-costs-of-antipsychotics-in-nursing-homes includes the written statements of Senator Herb Kohl (D-WI) and the witnesses.  Center attorney Toby S. Edelman testified and included in her testimony a longer history of concerns about the inappropriate use of antipsychotic drugs in nursing homes and its causes (insufficient numbers of appropriately trained staff; reduced use of physical restraints; some drug companies’ illegal off-label marketing of antipsychotic drugs, as documented in False Claims Act lawsuits; consultant pharmacists’ working for long-term care pharmacies; and the designation of antipsychotic drugs as a protected class under Part D).  See statement at https://www.aging.senate.gov/imo/media/doc/hr240te.pdf.
[3] https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National-Partnership-Dementia-Care-Resources.
[4] OIG, CMS Could Improve the Data It Uses To Monitor Antipsychotic Drugs in Nursing Homes, OEI-07-19-00490 (Issue Brief, May 2021), https://oig.hhs.gov/oei/reports/OEI-07-19-00490.pdf
[5] Problems are documented in Committee on Ways and Means Majority, Under-Enforced and Over-Prescribed: The Antipsychotic Drug Epidemic Ravaging America’s Nursing Homes (Jul. 2020), https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/WMD%20Nursing%20Home%20Report_Final.pdf, and Human Rights Watch, “They Want Docile” How Nursing Homes in the United States Overmedicate People with Dementia (2018), https://www.hrw.org/report/2018/02/05/they-want-docile/how-nursing-homes-united-states-overmedicate-people-dementia.
[6] Jonathan D. Winter, J. William Kerns, Katherine M. Winter & Roy T. Sabo (2017), “Increased Reporting of Exclusionary Diagnoses Inflate Apparent Reductions in Long-Stay Antipsychotic Prescribing,” Clinical Gerontologist DOI: 10.1080/07317115.2017.1395378 (published online Dec. 5, 2017), summary of article in journal is at https://www.tandfonline.com/doi/full/10.1080/07317115.2017.1395378.
[7] “Did CMS’s Partnership to Improve Dementia Care Reduce the Inappropriate Prescribing of Antipsychotic Drugs for Nursing Home Residents as Much as CMS Claims? Two Recent Studies Say No” (CMA Alert, Jun. 28, 2018), https://medicareadvocacy.org/did-cmss-partnership-to-improve-dementia-care-reduce-the-inappropriate-prescribing-of-antipsychotic-drugs-for-nursing-home-residents-as-much-as-cms-claims/.
[8] NDS 3,0 Frequency Report, https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Minimum-Data-Set-3-0-Public-Reports/Minimum-Data-Set-3-0-Frequency-Report.
[9] Email from Tony Chicotel, May 10, 2021.