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  1. Center for Medicare Advocacy Discusses Nursing Home Resident Protections with CMS Administrator Seema Verma
  2. Did CMS’s Partnership to Improve Dementia Care Reduce the Inappropriate Prescribing of Antipsychotic Drugs for Nursing Home Residents as Much as CMS Claims? Two Recent Studies Say No
  3. Health Care Sabotage: Another Attempt at ACA Repeal
  4. Free Webinar: Enhancing the Promise of Medicare – Oral Health, Audiology, Vision Benefits

Center for Medicare Advocacy Discusses Nursing Home Resident Protections with CMS Administrator Seema Verma

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Seema Verma, the Administrator of the Centers for Medicare & Medicaid Services (CMS), invited the Center for Medicare Advocacy and other advocacy organizations to meet with her on June 25, 2018. The Administrator asked our organizations to provide one to two recommendations for the Requirements of Participation that would reduce burdens on nursing facilities. However, recent actions by CMS have indicated that “burden reduction” may really translate to rolling back nursing home residents’ rights and protections. For instance, CMS placed an 18-month moratorium on the full enforcement of several resident protections, including standards dealing with antipsychotic drugs and baseline care plans.[1] This change also stemmed from CMS’s efforts to reduce provider “burdens.”

In accepting the Administrator’s invitation to meet, our organizations submitted a joint statement advocating that the nursing home Requirements of Participation should not be changed to reduce provider “burdens.” As our organizations expressed in the statement and during our meeting with Administrator Verma, many “issues that providers call burdens are very often resident protections.”


[1] Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare, CMS (Nov. 28, 2017), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-04.pdf.

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Did CMS’s Partnership to Improve Dementia Care Reduce the Inappropriate Prescribing of Antipsychotic Drugs for Nursing Home Residents as Much as CMS Claims? Two Recent Studies Say No

The Centers for Medicare & Medicaid Services (CMS) has ended its campaign to reduce the inappropriate use of antipsychotic drugs for long-stay residents in nursing facilities (formally called the National Partnership to Improve Dementia Care in Nursing Homes) for facilities that reduced their antipsychotic drug usage by 34% by the end of 2016 (from 23.9% of long-stay residents in the first quarter of 2012 down to 15.7% of long-stay residents in the first quarter of 2017).  No more is expected of these facilities; CMS encourages them to “continue their efforts and maintain their success.”[1]  Only facilities not yet achieving the reduction – facilities that CMS now calls “late adopters” – have new Partnership goals; CMS encourages these facilities to reduce antipsychotic drug use by 15% by 2019.[2]  The American Health Care Association (AHCA), the largest nursing home trade association, also touts the reduction of antipsychotic drugs by its member facilities.[3]  Are these claims of victory – of actually reducing the use of these drugs – true?  Two recent studies say no; the claims of success are grossly overstated.

A study in the Journal of the American Medical Association Internal Medicine debunks claims that the National Partnership achieved its goals.[4]  First, the rate of antipsychotic drug use in nursing facilities was declining before the Partnership began (from 29% in 2006 to 22% in 2009-2010) so that the Partnership did not “accelerate[] the decline that was already occurring.”  Second, researchers found a lot of drug substitution.  Instead of antipsychotic drugs, residents were given other drugs, particularly mood stabilizers that are not captured in CMS assessment data.  Reviewers based their analysis on 637,426 residents (a 20% sample of nursing home residents using traditional Medicare between January 1, 2009 and December 31, 2014) and the Part D drugs they received.

Recent reports by CNN also confirm that drug substitution is occurring.  In October 2017, CNN reported that Avanir, the manufacturer of Nuedexta – a drug approved by the Food and Drug Administration to treat pseudobulbar affect, or PBS (uncontrollable laughing or crying), a condition affecting less than 1% of the population – targeted advertising at nursing facilities that had high rates of antipsychotic drug use.[5]  Since 2012, “more than half of all Nuedexta pills have gone to long-term care facilities” and “The number of pills rose to roughly 1.4 million in 2016, a jump of nearly 400% in just four years.”[6]  CNN reported that in March 2018, the Centers for Medicare & Medicaid Services issued a memorandum to Part D plans, reminding them, as described by CNN, that “Nuedexta is only approved to treat PBA” and that “Part D insurers are legally required to ensure the drug is only being covered when prescribed for medically-accepted uses.”[7] 

A second study found that the 20% reduction in the use of antipsychotic drugs was overstated because of the increased reporting of exclusionary diagnoses, chiefly schizophrenia.[8]  CMS excludes residents with schizophrenia (and also Tourettes and Huntingtons) from the publicly-reported quality measure that define inappropriate antipsychotic drug use.  Consequently, by including one of the three excluded diagnoses in residents’ assessments, facilities avoid being cited as administering inappropriate antipsychotic drugs.  The researchers conclude, “since antipsychotics prescribed to patients with schizophrenia, Tourette's syndrome, and Huntington's disease is not reported to CMS's quality measure, these findings suggest that a significant portion, perhaps as much as l/5th, of the apparent reduction in inappropriate antipsychotic use in nursing homes, is due to this trend in diagnosis reporting rather than an actual decrease in medication use.”  Researchers based their findings on resident assessment data for Medicaid beneficiaries in Virginia.  The National Institute of Mental Health reports that schizophrenia “is typically diagnosed in the late teen years to early 30s.”[9]  Consequently, the “new” diagnoses of schizophrenia in nursing home residents is likely to be false and fraudulent.    

Conclusion

Human Rights Watch reported in February that 179,000 nursing home residents are receiving antipsychotic drugs now.[10]  Other reports describe other rates of antipsychotic drug use.  Reports vary dramatically, depending on which residents are reviewed (long-stay, short-stay, all) and whether analysts look at residents during a Medicare Part A stay or residents receiving medications under Medicare Part D.[11]  

Regardless of how the numbers are calculated, however, there is no question that many tens of thousands of residents are getting antipsychotic drugs who should not be.  This problem is not solved, despite CMS’s, and the industry’s, claims of victory.


[1] CMS, “Data show National Partnership to Improve Dementia Care achieves goals to reduce unnecessary antipsychotic medications in nursing homes” Fact Sheet (Oct. 2, 2017), https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-02.html.
[2] Id.  See also CMS, “National Partnership to Improve Dementia Care in Nursing Homes: Late Adopter Data Report (April 2018),” https://www.nhqualitycampaign.org/files/Late_adopter_package_20180416.pdf
[3] AHCA, New CMS Data Show Half of AHCA Members Hit 30 Percent Antipsychotics Reduction Goal Ahead of Schedule Association’s Quality Initiative drives drop in usage in skilled nursing centers nationwide” (News Release, May 5, 2016),  https://www.ahcancal.org/News/news_releases/Pages/New-CMS-Data-Show-Half-of-AHCA-Members-Hit-30-Percent-Antipsychotics-Reduction-Goal-Ahead-of-Schedule.aspx.
[4] Donovan T. Maust, H. Myra Kim, Claire Chiang, Helen C. Kales, “Association of the Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care With the Use of Antipsychotics and Other Psychotropics in Long-term Care in the United States From 2009 to 2014,” JAMA Internal Medicine (published online Mar. 17, 2018), summary of article in May journal is at https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2674245
[5] Blake Ellis and Melanie Hicken, “The little red pill being pushed on the elderly: CNN investigation exposes inappropriate use of drug in nursing homes,” CNN (Oct. 12, 2017), https://www.cnn.com/2017/10/12/health/nuedexta-nursing-homes-invs/index.html.
[6] Id.
[7] Blake Ellis and Melanie Hicken, “Government issues warning about pill pushed on elderly,” CNN (Jun. 5, 2018), https://www.cnn.com/2018/06/04/health/nuedexta-government-warning-insurers-invs/index.html.
[8] Jonathan D. Winter, J. William Kerns, Katherine M. Winter & Roy T. Sabo (2017), “Increased Reporting of Exclusionary Diagnoses Inflate Apparent Reductions in Long-Stay Antipsychotic Prescribing,” Clinical Gerontologist DOI: 10.1080/07317115.2017.1395378 (published online Dec. 5, 2017), summary of article in journal is at https://www.tandfonline.com/doi/full/10.1080/07317115.2017.1395378.
[9] National Institute of Mental Health, Schizophrenia, https://www.nimh.nih.gov/health/statistics/schizophrenia.shtml.
[10] Human Rights Watch, “They Want Docile How Nursing Homes in the United States Overmedicate People with Dementia” (Feb. 5, 2018), https://www.hrw.org/report/2018/02/05/they-want-docile/how-nursing-homes-united-states-overmedicate-people-dementia
[11] “Antipsychotic drugs and nursing home Residents: What Do the Different Numbers Mean?” (CMA Alert, Mar. 15, 2015), https://www.medicareadvocacy.org/antipsychotic-drugs-and-nursing-home-residents-what-do-the-different-numbers-mean/

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Health Care Sabotage: Another Attempt at ACA Repeal

Last week, the Health Policy Consensus Group released a plan to repeal the Affordable Care Act (ACA). It is reported that this group, led by longtime ACA critic, former Senator Rick Santorum, has been working with Senate Republicans and the White House on this “new” plan. Make no mistake; as we noted in a joint statement with the Medicare Rights Center on June 22, 2018, the plan is essentially a redo of the Graham-Cassidy bill that was overwhelmingly rejected last summer.   

After last year’s defeat of the Graham-Cassidy bill, Senator Graham said “We’re coming back to this after taxes.” And here they are. This new effort looks like the first step toward reviving the earlier plan that would cause millions of Americans to lose their health coverage, raise costs for people who are older or sicker, and further destabilize the ACA Marketplace. Equally as troubling, the plan would weaken protections for people with pre-existing conditions and would end Medicaid expansion – hurting low-income people, vulnerable older adults, children, and families throughout the country.      

According to the Center for American Progress, this “new” proposal could cut funding for ACA coverage by 31 percent by 2028 and funding for Medicaid by $649 billion from 2022 to 2028. These cuts would be devastating to older people and people with significant health care needs who need comprehensive coverage, including approximately 11 million people with Medicare who rely on Medicaid to help cover costs and obtain care not covered by Medicare.

This plan is yet another effort to undermine the ACA, disrupt the Marketplace and raise premiums. It comes on the heels of the Administration’s recently-released final rule expanding the use of Association Health Plans that would draw in younger healthier people and raise costs for older people left in ACA plans. Further, as discussed in a previous Alert, the Santorum plan builds on the Administration’s recent announcement that it will not defend the ACA against a lawsuit seeking to repeal it, siding against provisions of the ACA that guarantee coverage to people who are older, sicker, or have pre-existing conditions. These cumulative efforts to repeal and undermine the ACA will harm older adults not yet eligible for Medicare through increased costs and, in some cases, will bar access to coverage altogether. This will further strain Medicare finances, as more people who have gone without adequate health care will age into the program. 

The Affordable Care Act made it possible for older people with pre-existing conditions to gain access to quality, often life-saving, coverage. Millions of people gained access to essential health benefits such as prescription drugs, preventive services, emergency services and hospital care. It is time for attempts to sabotage health care to come to an end.

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Free Webinar: Enhancing the Promise of Medicare – Oral Health, Audiology, Vision Benefits

July 18, 2018 @ 3 PM ET

Presented By Center Attorneys David Lipschutz and Wey-Wey Kwok, and Diane Lifsey, Senior Policy Analyst for the National Committee to Preserve Social Security & Medicare

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