CMS this month will begin auditing nursing homes to determine whether they're overdiagnosing schizophrenia to skirt reporting requirements for antipsychotic drugs—and organizations that misdiagnose patients could see their CMS quality score drop to just one star.

The controversy around antipsychotic drugs in nursing homes

In 2012, CMS began requiring nursing homes to report antipsychotic drug use data, which then became part of each nursing home's "quality of resident care" score that contributes to a facility's CMS star rating.

However, the reporting requirement excluded prescriptions related to three conditions: schizophrenia, Tourette's syndrome, and Huntington's disease. Since CMS implemented its requirement, Medicare data shows that the share of nursing home residents diagnosed with schizophrenia has increased by 70%.

In May 2021, a report from a federal oversight agency found that almost a third of long-term nursing home residents with a schizophrenia diagnosis in 2018 didn't have any Medicare record of being treated for the disease. Currently, one in nine nursing home residents has been diagnosed with the disease, despite the condition affecting just around one in 150 people in the general population.

In addition, a November 2022 report from HHS' Office of Inspector General (OIG) found that the number of nursing home residents reported as having schizophrenia without a corresponding diagnosis increased significantly between 2015 and 2019. In total, OIG identified 99 nursing homes that reported at least 20% of residents with schizophrenia.

The findings suggest that some understaffed nursing homes may use the drugs to subdue patients.

"People don't just wake up with schizophrenia when they are elderly," said Michael Wasserman, a geriatrician and former nursing home executive. "It's used to skirt the rules."

CMS to audit nursing home for their use of antipsychotics

CMS on Wednesday announced it will conduct "targeted, off-site audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis."

According to Modern Healthcare, if CMS finds that a nursing home has misdiagnosed a patient with a neurological condition during an audit, the organization's quality score will drop to one star, decreasing its rating overall.

Although nursing homes with inappropriate diagnoses will not be immediately fined, a senior CMS official said Medicare will share the information with state inspectors who routinely check the safety and quality of nursing homes.

"No nursing home resident should be improperly diagnosed with schizophrenia or given an inappropriate antipsychotic," said HHS Secretary Xavier Becerra. "The steps we are taking today will help prevent these errors and give families peace of mind."

In addition to the audits, CMS said it plans to post inspection citations, including those under dispute, to its Care Compare website, beginning on Jan. 25.

"While the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance," such as those that could lead to serious injuries, CMS said. "Displaying this information while it is under dispute can help consumers make more informed choices when it comes to evaluating a facility."

"We have made significant progress in decreasing the inappropriate use of antipsychotic medications in nursing homes, but more needs to be done," said CMS Administrator Chiquita Brooks-LaSure. "People in nursing homes deserve safe, high-quality care, and we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications."

Reaction

Overall, industry groups and patient advocates expressed support for CMS' efforts to increase transparency around antipsychotic prescriptions in nursing homes. However, several have also expressed concerns.

"We appreciate CMS's effort to enhance the Five-Star Quality Rating System. However, dramatically downgrading entire ratings based on a single measure results in misleading information and causes more consumer confusion," said David Gifford, CMO of the American Health Care Association/National Center for Assisted Living.

Separately, Chris Laxton, executive director of AMDA – The Society for Post-Acute and Long-Term Care Medicine, said that nursing homes may be more hesitant to accept patients with legitimate diagnoses because they may face increased scrutiny for their use of antipsychotics.

"There's certainly a question about inappropriate diagnoses of schizophrenia and antipsychotic prescribing," Laxton said. "On the other hand, we need measures that don't create a situation where nursing homes refuse to accept patients or where diagnoses are driven by a desire not to be penalized."

LeadingAge, an association of nonprofit aging service providers, commended CMS' efforts to improve nursing home safety, but also noted that antipsychotic prescribing needs to be addressed among all providers.

"We urge CMS to address the issue of inappropriate antipsychotic use among providers of all types," said LeadingAge president and CEO Katie Smith Sloan. "Our members often tell us of having to admit residents who've been prescribed these meds while under the care of other providers. Healthcare is a team sport; all providers in the system must be held to the same expectation." (Berryman, Modern Healthcare, 1/18; Alltucker, USA Today, 1/18; Seitz, Associated Press, 1/18; Frieden/Fiore, MedPage Today, 1/18)