schizophrenia drugs in pill bottles

Three weeks after federal officials announced they would begin auditing nursing homes for overuse of schizophrenia diagnoses, providers are still looking for answers about what those investigations will look like and how far they might reach.

The Centers for Medicare & Medicaid Services has issued only a four-page memo announcing the new effort, the results of which could drive star ratings lower for facilities found to have diagnosed patients with schizophrenia without proper assessment or documentation.

But facilities have begun to receive letters saying they are being reviewed, a consultant told McKnight’s Long-Term Care News. Others are already working behind the scenes to understand exactly what information CMS might request, and whether the agency will seek supporting information from patients’ referring healthcare providers.

“Granted, we want to make sure that schizophrenia diagnoses are done appropriately and done the way they need to be done. Absolutely. But we also have to make sure that we’re involving the medical professions and the primary care providers or the physician extenders that are making these decisions in that [audit] process,” said Lisa Thomson, chief operating officer of Pathway Health.

“That’s the question the industry is looking at: You can do external audits based on the MDS data, but what other data are you looking at, and what other information are you gathering before you’re making these decisions?”

On Friday morning, CMS told McKnight’s that it might request the following documentation, which should not be considered all-inclusive:

  • MDS assessments
  • Behavioral health records
  • Medication orders and administration records
  • Other associated information related to the resident’s schizophrenia diagnosis

Whatever CMS asks for, the implications could be major for providers who get docked: Based on results of its targeted, off-site audits, the agency will drop overall and long-stay quality measure ratings to 1 star for six months, an adjustment that also will drive any affected facility’s overall star rating down by one star. The policy also will suppress two other measures for six to 12 months.

Why they’re worried

That approach has many providers and pharmacy partners concerned.

“I don’t think the focus is necessarily a bad thing,” said Rob Leffler, RPh, vice president of clinical services for Kentucky-based Synchrony Pharmacy.

“My concern would be more around the fact that, if they do this audit and they feel that the documentation is not sufficient with what they receive even in that off-site audit, that they would change somebody’s Five-Star rating to 1 star. We’ve not seen them adjust star ratings like that before based on one factor.”

Leffler, like others interviewed for this article, pointed out the longstanding issue of incomplete admission documentation for skilled nursing residents. Many of those patients might have been prescribed an antipsychotic medication to control dementia-related behaviors during a preceding hospital stay or as a method to keep them calm or help them sleep and enable them to stay in their home longer.

Other patients may have been accurately diagnosed years ago and continue to be treated with an antipsychotic. If that diagnosis isn’t on a chart at admission but is later added due to investigation by facility staff, CMS shouldn’t necessarily discount the diagnosis, Leffler said. 

He also noted that skilled nursing providers are required to try behavioral interventions before prescribing certain medications. But hospitals aren’t held to the same standard, so CMS must look beyond the numbers inside certain skilled nursing facilities to find broader patterns, he added.

“Is it happening at the hospital? Is it happening at the admission point? Is it happening when they’re somewhere down the road at the facility?” he asked.

In her comments following the CMS announcement in January, LeadingAge President and CEO Katie Smith Sloan urged the agency to apply the same attention to diagnoses and inappropriate drug prescribing among all provider types.

“Our members often tell us of having to admit residents who’ve been prescribed these meds while under the care of other providers,” she said. “Healthcare is a team sport; All providers in the system must be held to the same expectation.”

What’s in store

One lingering question is how many providers could be hit by the new audits. Is a single diagnosis enough of a trigger, or will CMS focus its efforts on buildings where it sees a high proportion of diagnoses or a specific pattern?

Colleen Toebe, MSN, director of consulting services, said the requests she’d seen so far had been based on tracking of a single patient’s added schizophrenia diagnosis based on comparison of MDS submission and previous Medicare Part A claims from other healthcare settings.

“They have every intention to find every situation where schizophrenia was used as a way to reduce the possibility of gradual dose reductions being necessary or don’t have proper clinical support for that,” Sara Deiter, vice president of consulting service for Health Dimensions Group, said on recent webinar mapping major regulatory changes for 2023.

“It’s something to use with real care, to make sure you don’t put yourself in a position where you’re going to wind up being cited for inaccuracy of your assessment and potentially have fines associated with using that diagnosis incorrectly,” she added.

CMS has said it is targeting schizophrenia diagnosis for several reasons. There is a patient outcome element, as CMS noted that nursing home residents given erroneous schizophrenia diagnoses are “subject to poor care and unnecessary antipsychotic medications, both of which can be very dangerous.” But nursing homes also have been accused of using the diagnosis to mask the use of antipsychotics by excluding affected residents from quality measure calculations.

“It’s surprising to a lot of us that it’s been done in a way that the federal government considers to be abusive, but that is what they believe,”  Deiter said. “And so we just need to be critically cautious about how we use it and make sure we have the clinical support we need to validate that diagnosis.”

Prescribing practices still in spotlight 

Outside of the audit process, CMS will continue to dig deeper into the use of antipsychotics. Late last year, the Office of Inspector General published a report criticizing the agency for losing sight of overall antipsychotic use even as the use of psychotropic drugs fell. CMS agreed to make improvements.

The updated Requirements of Participation also strengthen rules for non-medication interventions.

“No one’s telling you that they have to work, but you have to have attempted them, you have to have documented it, and you have to be able to track it for effectiveness. And, then, if it is ineffective, then of course you can do what you need to do to get that resident resting and get them out of distress,” Deiter said. “The idea is not to keep patients in distress. It’s simply not to use psychotropic medications in excess of what’s required.”

Leffler sees this as an ideal time for providers to work with their pharmacy partners and check their policies and procedures. For well-intentioned providers, he said, this should be a fairly routine refresh. He acknowledges that some facilities hyper-focused on quality measures may have overused schizophrenia codes, though he said he has not seen it among his clients.

“We have entered into this data world,” Thomson said. “Part of our due diligence and our quality improvement process is really making sure that we take the platforms that we have available to us through CMS and the quality measures and through policies and procedures in our EHRs, and really prioritize where we need to pinpoint and look at that data.”

She encouraged facility staff to lean on pharmacy, association and other partners for help understanding whether their policies and decision-support mechanisms are appropriate and identifying areas that need shoring up.

Given the bold move to target star ratings in this case, experts said they would not be surprised to see CMS expand that approach in the future. Whether that’s for specific prescribing activities, for example, gabapentin for bipolar diagnoses, or for failing to meet statistical requirements, say an hourly staffing minimum, providers must recognize federal regulators’ ability to use data to monitor activity.

“That data will drive audits and future conversation around what’s changed and what needs to happen,” Thomson said.

This story was updated to include new information from CMS.