Officials: Antipsychotic Drug Payments Erroneous, Prescribing Needs to Be Limited

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By Nathaniel Weixel

Medicare is spending too much money erroneously reimbursing claims for antipsychotic drugs, officials from the Centers for Medicare & Medicaid Services and the Department of Health and Human Services Office of Inspector General Nov. 30 told a Senate panel, and more needs to be done to stop physicians from prescribing them.

OIG Inspector General Daniel Levinson told the Senate Special Committee on Aging that all too often, nursing home patients receive antipsychotic drugs in ways that violate federal standards designed to prevent overmedication and inappropriate use.

According to Levinson, atypical antipsychotic drugs are intended for the treatment of psychoses and mood disorders. Physicians are not prevented from prescribing these drugs, either for approved indications or for off-label uses, even if they might carry a high risk to a patient's health.

“When properly prescribed, antipsychotics can offer beneficial treatment for individuals suffering from mental illness,” the panel's chairman, Sen. Herb Kohl (D-Wis.), said. “However, we have a responsibility to patients and their families to ensure that elderly nursing home residents are free from all types of unnecessary drugs, and we have a responsibility to taxpayers to be certain that they are not paying for drugs that are not needed.”

Levinson cited a report OIG released in May that found that 83 percent of all reviewed Medicare atypical antipsychotic drug claims for elderly nursing home residents were for off-label uses (91 HCDR, 5/11/11).

According to the report, from Jan. 1 through June 30, 2007, 51 percent of the Medicare reimbursement claims for atypical antipsychotic drugs were also erroneous, and they cost the program $116 million. Medicare Part D requires that drugs must be prescribed for “medically accepted indications” to qualify for reimbursement.

OIG in the report recommended that CMS could require nursing homes to reimburse the Part D program when claimed drugs violated quality and safety standards.

Report Finds Information Lacking

Levinson also cited a more recent report, posted Nov. 14, which found that Part D prescription drug plan (PDP) sponsors lack access to the information necessary to ensure appropriate reimbursement of Part D drugs, including antipsychotics (221 HCDR, 11/16/11).

Medicare is paying for drugs that it should not, and Part D prescription drug plans are not able to adequately prevent inappropriate payments for drugs, including antipsychotics, for uses that do not meet coverage requirements, Levinson said. In addition, nursing homes often fail to comply with regulations designed to prevent overmedication of these powerful and at times dangerous drugs, he said.

Levinson said the report also found that the PDP sponsors do not routinely collect diagnosis information, except when using prior authorization. The PDP sponsors indicated that prior authorization is the best tool they have to compare the diagnosis provided by the prescriber to the medically accepted indications contained in the compendia.

However, Levinson said, CMS disagreed that the solution to inappropriate drug use lies with the PDP sponsors' utilization management tools, including prior authorization.

Appropriate Prescribing

Patrick Conway, CMS chief medical officer and director for the Office of Clinical Standards and Quality, told the panel that CMS and OIG have a shared goal of encouraging appropriate prescribing by nursing home physicians.

Conway said that although the off-label prescribing of antipsychotic drugs for treatment of dementia is a complex problem, it can be solved.

A solution “will need collaborative quality improvement, and emphasis on nonpharmacological options to treat dementia and behavioral disturbances in patients with dementia,” Conway said.

He said CMS is continuing to explore new ways to strengthen enforcement of current rules by eliminating conflicts of interest that may influence prescribing and better educating providers, prescribers, and patients' families to eliminate inappropriate prescribing.

“Improper prescribing not only puts patients' health at risk; it also leads to higher costs,” Kohl said. “We can do better.”