On January 22, Richard E. Neal, the Chairperson of the Ways and Means Committee of the House of Representatives, took aim at the Centers for Medicare & Medicaid Services’ nursing home antipsychotic reduction campaign – calling the recent data on antipsychotic use “extremely disappointing.” Representative Neal’s letter is remarkable not only for its clear disapproval of the campaign’s lack of progress, but also for its insightful understanding of why the campaign is failing.
The letter begins by pointing out that progress in reducing the use of antipsychotics in nursing homes has stalled. Drugging data back that up: in 2016 approximately 20.6% of nursing home residents received an antipsychotic drug. Two years later, the percentage is approximately 20.1%. As Representative Neal states, drugging remains a “major problem.”
Additional data are equally troubling. When nursing homes are cited for inappropriately administering psychotropic drugs to residents1, less than one percent of the issued deficiencies are identified as causing harm to the resident. In fiscal year 2019, 503 nursing home deficiencies have been issued nationwide for inappropriate psychotropic drug use (F758) and only one of them was identified as causing harm. In California, enforcement is even worse: of the 355 deficiencies since fiscal year 2018, zero were cited for harm. Representative Neal flatly explains the data mean “nursing homes are getting away with this practice.” [emphasis in original]
Perhaps the most alarming data indicate nursing homes are falsely diagnosing residents as having schizophrenia in order to conceal antipsychotic use from CMS’s antipsychotic quality measure. When CMS started its campaign, it made the poor choice to exclude some antipsychotic use by diagnosis (like schizophrenia), which has resulted in a predictable increase in residents with excluded diagnoses. For example, the percentage of residents “with” schizophrenia has increased by 42% since the national campaign began in 2012.
Representative Neal’s letter ends with a number of requests for CMS to explain its choices and describe its future plans for the campaign. Among the requests is for CMS to describe how state surveyors will more effectively identify when antipsychotics lead to resident harm. The answer to this is simple. CMS needs to take the position that antipsychotic use for people with dementia is presumptively harmful and force nursing homes to explain why it’s not harmful in each case. This presumption is justified by the psychopharmacology of antipsychotics and their insidious impact on the lives of people with dementia. In order for the antipsychotic reduction campaign to move forward, CMS needs to try some real enforcement.