Overburdened by Regulations in Long-Term Care: A Public Health Crisis in Need of Policy Solutions to Improve Care and Access

Abstract

The US population continues to age. with people over 65 years constituting 13# of the general population. By 2050, this percentage is expected to rise to nearly 25%. With the "Graying of America", the number of individuals with multiple physical and mental comorbidities requiring long-term care continues to rise sharply. Due to the deinstitutionalization of the state hospitals, the number of mentally ill patients has increased significantly in long-term care. Today, approximately 25% of newly admitted nursing home residents has mental illness (defined by schizophrenia, bipolar disorder, depression, or anxiety). With this, the need for high-quality care for these complex patients with mental illness who reside in long-term care is needed.

Centers for Medicare and Medicaid Services (CMS) has responded to this need with increasing regulations governing the use of psychoactive medications. While the intention of these regulations was undoubtedly to reduce the morbidity of overprescribing psychotropics, they too severely limit access of antipsychotics to a few diagnoses. Under the 5 star rating regulations, long-term care patients must carry a diagnosis of Huntington's Disease, schizophrenia, or Tourette's syndrome in order to meet compliance standards. Unfortunately, this excludes a huge population of patients that could stand to benefit from access to these medications. Patients particularly at risk are those with Alzheimer's with behavioral and psychological symptoms of dementia (BPSD). While the FDA approves brexpiprazole for the treatment of agitation associated with dementia due to Alzheimer's disease, access to this treatment for long-term care residents is still limited by 5-star rating regulations. Facilities also pose a unique barrier to access for patients who have antipsychotics on their medication list. Patients with severe mental illness are sometimes discriminated against because their needs cause the facilities to drop in their quality ratings/metrics, thus decreasing reimbursement.

State regulators use critical element pathways to monitor what they deem to be unnecessary psychotropic medication use. Fines and ratings are dependent on compliance with these documentation audits. Prescribers who understand the existing policies can learn how to accurately code and document for their patients and keep the facility in compliance. A special CMS audit is ongoing regarding excess/inappropriate use of schizophrenia as a diagnosis for patients on antipsychotics. It is imperative that documentation is up to date and accurate.

In order to improve access for appropriate antipsychotic use according to APA guidelines, state and federal policies require revision. Project Pause is a coalition of multidisciplinary stakeholders dedicated to this cause. This group contains psychiatrists, nursing home providers, pharmacists, National Minority Quality Forum representatives, and other relevant association members. Through discussion and advocacy efforts, we are working with CMS to achieve change.