On May 31, 2012, the Centers for Medicare & Medicaid Services (CMS) announced an initiative to reduce the rampant misuse and overuse of antipsychotic drugs in
nursing home facilities. The Center for Medicare Advocacy has been working to educate policy makers, advocates, and the public about the misuse of antipsychotic drugs for many years, and is part of an
ad hoc coalition of advocates working with CMS and Congress to address the problem that both
harms nursing home residents and costs the Medicare program billions of dollars.
CMS's press release announcing the "Partnership to Improve Dementia Care" describes several steps that CMS is taking:
- Enhanced training: CMS has developed "Hand in Hand," a training series for nursing homes that emphasizes person-centered care, prevention of nursing home abuse, and high-quality care for residents. CMS is also providing training focused on behavioral health to state and federal surveyors;
- Increased transparency: CMS is making data on each nursing home's antipsychotic drug use available on Nursing Home Compare starting in July of this year, and will update the data;
- Alternatives to antipsychotic medication: CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities.
At the May 31, 2012 press briefing announcing the initiative, Shari M. Ling, M.D., CMS's Deputy Chief Medical Officer, identified additional CMS strategies – raising public awareness, strengthening regulatory oversight, and research. Dr. Ling said that residents' advocates working on the issue of antipsychotic drugs for many years had brought the issue to the forefront of public attention. She said, "We would not be here today without them."
Antipsychotic Drug Deficiencies Are Cited, But Enforcement Is Timid
Speaking earlier this month at a symposium on dementia care without drugs, sponsored by California Advocates for Nursing Home Reform (CANHR), Jonathan Evans, M.D., a geriatrician and president-elect of the American Medical Directors Association, described the CMS plan as reasonable but primarily “‘an effort to try to educate people rather than to regulate.’” CANHR attorney Tony Chicotel agreed with the need for increased enforcement. The Center for Medicare Advocacy agrees with their concerns.
Since the Nursing Home Reform Law (enacted in 1987) was implemented in October 1990, federal law and its implementing regulations and guidance have contained strong restrictions on the use of antipsychotic drugs. Two survey and enforcement issues, however, undercut the law's effectiveness.
1. "Level of Harm" Coding Assigns a Value to Deficiencies that is Too Low Either to Provide a Meaningful Sanction for Poor Care or to Lead to Better Facility Practices.
Although some drug deficiencies are cited each year, their significance is understated and undercoded. The federal enforcement system assigns a scope and severity level to each deficiency that is cited, using a federal scope and severity grid. The grid was published in 1994 as part of the final enforcement regulations. There are four levels of severity. Two levels indicate no harm (substantial compliance and no harm) and two indicate harm (harm and immediate jeopardy). Generally, when states cite deficiencies at a no-harm level, no financial penalty is imposed.
State survey agencies typically cite antipsychotic drug deficiencies at the no-harm level. In fiscal year 2012, 1,213 unnecessary drug deficiencies, 42 C.F.R. §483.25(l), (F329), were cited nationwide. (F329 is the tag where antipsychotic drugs are cited.) However,
- 1185 (98%) nationwide were cited at a no-harm level;
- Only 13 deficiencies nationwide (0.01%) were cited at a harm level; and
- Only 12 deficiencies nationwide (0.01%) were cited at the highest level of harm, immediate jeopardy.
As a consequence of the no-harm, no-penalty practice,
FY2012 data show that most facilities cited with unnecessary drug deficiencies are unlikely to have had any financial penalty imposed.
2. The Financial Remedies that Have Been Imposed Are Trivial, In Light of the Seriousness of the Harm that Residents Suffered.
Recognizing Elder Abuse Awareness Day: Working Together to Curb Misuse of Powerful Antipsychotic Drugs in Nursing Homes || CMA
