As the Centers for Medicare & Medicaid Services continues its rapid-fire audits of schizophrenia diagnosing, some providers and quality experts are questioning why the agency hasn’t done more to review its quality measure for antipsychotic drug use.

CMS has been tracking use of antipsychotic drugs as a quality measure since 2012. In that time, the agency has consistently excluded three conditions from required antipsychotic reporting, viewing them as valid reasons to prescribe an antipsychotic. Those three conditions are schizophrenia, Huntington’s disease and Tourette syndrome.

But in that same period, experts told McKnight’s, the Food and Drug and Administration has approved antipsychotics for additional conditions that can be common among nursing home patients. Nursing homes also have taken on more patients with severe behavioral health needs for whom antipsychotic drugs are often deemed appropriate.

Yet, providers using antipsychotics for patients in either of those categories may appear to be less responsible to consumers simply because their antipsychotic QM measures are higher than their peers.

“The Physician’s Desk Reference actually shows indications for using antipsychotics for bipolar disease I and II, neurocognitive symptoms associated with borderline personality disorder, Lewy body neuropsychotic symptoms. We even have Nuplazid, which was approved by the FDA in 2016 specifically for the treatment of Parkinson’s psychosis,” said Melanie Tribe-Scott BSN, vice president of Quality Initiatives at Zimmet Healthcare Services Group. 

“I know if my loved one needed an antipsychotic in the community and then they were to be placed in a long-term care facility, my concern is that that facility might try to take them off that medication to avoid this quality measure,” she added.

Policy conflict?

Tribe-Scott has clients working with a high proportion of special needs patients, and they haven’t been able to drive their antipsychotic use below the national average. They were placed years ago in a special program for “late adopters” and have never been able to get off that list. They could face civil monetary penalties for any kind of Immediate Jeopardy offense or, ultimately, denial of payments for new admits. 

That may represent a policy conflict as CMS continues its pressure on prescribing reductions and simultaneously pushes nursing homes to take more residents with severe behavioral health needs.

Tribe-Scott said an agency official told her it is removing late adopters notations from the Five-Star ratings systems within weeks, though the agency has not made that information widely known. She estimates about 1,500 providers have been placed in the program over the years.

That could be reason to think that CMS is reconsidering its broad view of antipsychotic usage.

So could the fact that the agency recently brought together a group of experts to look at the antipsychotic quality measure. During an Open Door Forum earlier this month, one caller asked if CMS might consider expanding excluded diagnosis.

An agency spokeswoman last week confirmed a panel had met on that topic but declined to give more details about the scope of the panel’s tasks or its makeup.

“The Refinement of the Nursing Home Antipsychotic Medication Measures Technical Expert Panel (TEP) convened at the end of February, and the final TEP report is not yet available. We anticipate the report becoming available soon,” the agency said in an email to McKnight’s Long-Term Care News March 23.

Tough choices

Being torn between taking patients off needed medications and being penalized for it, or choosing another diagnosis that would be excluded from the quality measure “is kind of where this whole issue is coming from now, partially,” said Alicia Cantinieri, vice president of MDS policy and education for Zimmet.

The “whole issue” now is, of course, a series of schizophrenia audits that CMS launched in January to identify providers who may have used schizophrenia diagnoses without proper assessment or documentation.

They have many providers on edge, with Tribe-Scott and Cantinieri noting that some requests for documentation have gone back as far as 2014 and ask for information on patients released long ago or even deceased. Most providers don’t hold records that long, and many have lost staff members who would have the needed institutional memory about specific patients.

At this point, the effort feels to some observers that regulators are concentrating on the wrong concern.

“They’re focusing on the diagnosis of schizophrenia rather than who’s getting an antipsychotic,” Cantinieri said. “It would help if CMS really looked at the exclusions because there are other approved uses for these medications and also zero in on the gradual dose reductions to make sure that the residents are on the lowest effective dose that they need.”

She also called on the agency to provide solid examples of sufficient documentation so that providers can comply with expectations moving forward.

Both experts said CMS should consider the narrow confines the focus on specific diagnosis has placed providers in and try to create a measure that more accurately reflects changing needs of today’s nursing home population.

“I don’t think anybody would condone misdiagnosing or including a diagnosis on the MDS that there isn’t medical back up for,” Tribe-Scott said, “but you can see how you’re damned if you do or you’re damned if you don’t.”