Nursing home providers and pharmacy groups reacted with a mix of surprise and cautious optimism Friday, after federal regulators confirmed they are reexamining a policy that strongly discourages the use of antipsychotic medications for most patients.<\/p>\n
A spokeperson for the Centers for Medicare & Medicaid Services late Friday confirmed the review, telling McKnight\u2019s Long-Term Care News the agency is \u201cactively reviewing the antipsychotic [quality] measure with the goal of supporting clinically indicated use while continuing to discourage inappropriate prescribing.\u201d<\/p>\n
\u201cCMS will remain committed to ensuring quality measures are evidence-based, clinically appropriate, and support transparency for residents and families,\u201d the spokesperson added in an email.<\/p>\n
The agency did not respond to specific questions about how it would move forward with the review, or when providers might see some, if any, relief from what is largely seen as one of the most challenging metrics helping to determine ratings available to consumers.<\/p>\n
Two sector representatives said they had participated in recent conversations with agency experts, who expressed some willingness to reevaluate the antipsychotic measure.<\/p>\n
The Washington Post reported<\/a> first Friday that Congress instructed the agency to better distinguish between appropriate and inappropriate prescribing in skilled nursing policies as part of budget negotiations last month.<\/p>\n But CMS told McKnight\u2019s its review of the antipsychotic measure was \u201calready underway prior to the appropriations report.\u201d<\/p>\n \u201cCMS continuously reviews its quality measures to ensure they are based on the best available evidence and reflect appropriate clinical care. In this case, it is important to balance resident access to necessary treatment with the critical need to protect against inappropriate prescribing.\u201d<\/p>\n Nursing homes have significantly reduced use<\/a> of antipsychotics since 2012, but CMS has pushed them to further limit use through a series of audits<\/a>, penalties and ratings reductions<\/a>.<\/p>\n Meanwhile, the medications have continued to evolve without review of their \u201cblack box\u201d warnings or exemptions of new drugs being designed specifically for patients with dementia and other conditions commonly treated in nursing homes.<\/p>\n Providers across the country have bemoaned the tension between a quality measure that strictly discourages the use of antipsychotics, the knowledge that agitation and other quality-of-life issues are often resolved by careful prescribing, and even family members who want their loved ones on the same drugs they took before entering the nursing home.<\/p>\n Big pharma role?<\/p>\n The Post article overlooked many of those nuances in favor of a storyline that made it appear pharmaceutical companies were the driving force behind the administration\u2019s reconsideration.<\/p>\n Amy Stewart, chief nursing officer for the American Association of Post-Acute Care Nursing, was quoted extensively by the Post article but told McKnight\u2019s she was disappointed in the tack the newspaper took.<\/p>\n \u201cNot all nursing homes provide poor care, and some people do need antipsychotics to keep their placement for the safety of themselves and others,\u201d said Stewart, who shared her own father\u2019s dementia journey and his need for an antipsychotic. \u201cCan the medications be sedating? Yes. As a clinician, I worked to lessen the sedation by working with the physician to titrate the dose. Medications aren\u2019t the first intervention. In most cases other interventions have been tried.\u201d<\/p>\n Stewart said that the current measure \u2014 which dings providers for any antipsychotic prescribed to a patient without one of three rare diagnoses \u2014 runs counter to CMS\u2019 own support for patient-centered care in nursing homes. She told McKnight\u2019s that if a patient\u2019s physician determines he or she needs antipsychotics, \u201ca prescriber should be allowed to prescribe them without a facility saying, \u2018That will hurt my QM.\u2019\u201d<\/p>\n AAPACN, LeadingAge and the American Society of Consultant Pharmacists are all aligned with Project PAUSE<\/a>, which has been working on the issue for more than five years. The ad hoc coalition of national patient and professional organizations operates under the Alliance for Aging in Research and receives some support from drug companies. But the Alliance has a 35-year track record in research and advocacy for patient protections and healthcare affordability.<\/p>\n LeadingAge Vice President of Health Policy Jodi Eyigor told McKnight\u2019s Friday afternoon that her organization \u201cabsolutely does not support the use of antipsychotics as chemical restraints or any other inappropriate prescribing practices.\u201d<\/p>\n \u201cHowever, we know that there are residents who can benefit from appropriate use of antipsychotic medications to lessen the distress caused by neuropsychiatric symptoms in dementia,\u201d she added in an email. \u201cWhile CMS continues its work to reduce the use of antipsychotic medications in nursing homes, we urge them to reconsider ways to more appropriately distinguish between appropriate and inappropriate use of the medications.\u201d<\/p>\n The coalition recently pushed for the language from Congress, according to ASCP Chief Executive Chad Worz. He said that the current CMS quality measure doesn\u2019t do enough to help consumers understand when higher usage rates might be appropriate, or when a rogue nursing home might truly rely too much on medication as a solution.<\/p>\n \u2018Some movement\u2019<\/p>\n Worz said CMS had only been open to discussion around measure reconsideration in the last year, and especially after a new methodology went into effect. The inclusion of patients\u2019 Medicare claims from outside of nursing homes in their scores has confused the issue further<\/a> and given facilities less ability to predict their performance and target reductions, Worz said.<\/p>\n \u201cFor the eight years I\u2019ve been here, seven of those years have been a CMS that is stubborn and unwilling to even consider altering that measure,\u201d he said. \u201cThis year there seems to be some movement. \u2026 We\u2019re cautiously optimistic that we will see some activity on this measure.\u201d<\/p>\n Worz said he would like to see a measure based only on MDS data that does not penalize providers for antipsychotic prescriptions if the facility also has documentation from a doctor on the patient\u2019s need for a specific drug. That could also be supported by a \u201cconcordant\u201d finding from the long-term care pharmacist, allowing the public and surveyors to focus on nursing homes where that consensus is often missing.<\/p>\n Worz also underscored that the movement may not be connected to the Trump administration at all, noting that the science behind antipsychotics and the conversation around them has been shifting for years.<\/p>\n Still, one advocate told McKnight\u2019s that a new CMS review was \u201cnews to me.\u201d As recently as November<\/a>, the agency had defended curbing the \u201coveruse\u201d of such drugs as a top priority.<\/p>\n