CMS to Part D Plans: “Curb Use of Antipsychotics in Nursing Home Patients”

Medicare Sponsors’ are failing to monitor the safe utilization of antipsychotic drugs among the elderly. CMS is stepping up its warnings to Medicare Plans to implement more effective management of these drugs. Plans can expect increased scrutiny. Will your plan meet the standard?

Patrick Conway, Chief Medical Officer and Director for the CMS Office of Clinical Standards and Quality, told lawmakers  that Medicare officials need to do more to stop doctors from prescribing powerful psychiatric medications to nursing home patients with dementia, an unapproved practice that has flourished despite repeated government warnings.

The antipsychotic medications are prescribed to treat people suffering from schizophrenia and bipolar disorder, but they’re also given to hundreds of thousands of elderly nursing home patients in the US to pacify aggressive behavior related to dementia. These medications increase the risk of death in seniors, prompting the Food and Drug Administration to issue multiple warnings against prescribing the drugs for dementia.

Medicare improperly paid about $116 million in the first half of 2007 for prescriptions filled in nursing homes for a class of drugs called atypical anti-psychotics, Daniel Levinson told the Senate Committee on Aging in a hearing. Nursing homes should be held accountable for inappropriately dispensing antipsychotic medications for Medicare beneficiaries and pay back the Part D program for those misused medicines.

Since the beginning of the Medicare Part D program, CMS regulations have instructed Part D sponsors to implement cost-effective drug utilization management processes to monitor and control for both under- and over-utilization §423.153(b). However, controls currently in place to address overutilization are largely limited to claim-level edits do not seem to effectively address the type of overutilization.

On September 28, 2011, CMS issued a bulletin entitled “Improving Drug Utilization Review Controls in Part D” stating that CMS expects Part D Sponsors to implement an enhanced retrospective drug utilization review process in which sponsors (and/or their PBM)  of opioids, antiretrovirals, and atypical antipsychotics, by:

• Establishing clinical upper thresholds for appropriate dosing consistent with clinical guidelines through sponsor Pharmacy and Therapeutics (P&T) committees.
• Creating and monitoring beneficiary-level utilization reports that could identify unusual patterns of drug use at or near the established clinical thresholds;
• Assigning clinical staff, such as case managers, to review these reports and the beneficiaries‟ medication histories, and determine whether interventions are warranted;
• Address any exception requests through the exceptions and appeal processes.

CMS has provided a roadmap to step up monitoring activity. Plans will face increased scrutiny by CMS for meaningful Drug Utilization Management (DUM) systems both concurrently and retrospectively to ensure appropriate use of antipsychotic drugs.