RISE summarizes recent regulatory news from the Department of Health and Human Services (HHS) and the Office of Inspector General (OIG), as well as a new report from Urban Institute on Medicaid redeterminations.

HHS watchdog examines widespread use of psychotropic drugs in nursing homes

Nearly 80 percent of nursing home residents on Medicare received psychotropic drugs between 2011 and 2019, according to a new Health and Human Services (HHS) Office of Inspector General (OIG) report.

The Centers for Medicare & Medicaid Services (CMS) has been monitoring the use of antipsychotics in nursing homes for 10 years and last year OIG published a report that determined the agency’s method for monitoring the drug use didn’t always provide complete information. While CMS worked to reduce the use of antipsychotics, another category of psychotropic drug—anticonvulsants—increased. This resulted in the overall use of psychotropic drugs to remain constant, according to the watchdog.

Nursing homes with certain characteristics, such as lower ratios of registered nurse staff and those with a higher percentage of residents with low-income subsidies, were associated with the higher use of psychotropic drugs. The OIG also expressed concern that nursing homes could misreport residents as having schizophrenia, since CMS’ long-stay quality measure that tracks antipsychotic use in nursing homes excludes residents with this diagnosis. 

The report followed concerns raised in April by then-Senate Finance Committee chairmen Chuck Grassley (R-Iowa) and then-Ranking Member Ron Wyden (D-Ore.). 

“Nursing home residents deserve to be treated with dignity, and their loved ones ought to have the confidence that nursing homes are prescribing medicines appropriately. Unfortunately, this Inspector General report confirms many of our fears that serious medications are being administered without appropriate diagnoses or oversight,” Grassley said in a statement.

Wyden said he was also disturbed by the OIG findings. “This report makes it clear that more needs to be done to protect nursing home residents, and I will continue working to make that a reality,” he said.  

OIG determined CMS should evaluate the use of psychotropic drugs among nursing home residents, use data to focus oversight on nursing homes in which trends may signal inappropriate use, and expand the required data elements on Medicare Part D claims to include a diagnosis code.

Report: Most Medicaid enrollees don’t know eligibility may end when PHE expires

New research conducted by the Urban Institute and funded by Robert Wood Johnson Foundation, shows most adults who are enrolled in or have a family member enrolled in Medicaid were not aware that their eligibility for the program will be redetermined when the COVID-19 Public Health Emergency (PHE) ends.

The Families First Coronavirus Response Act prohibited states from disenrolling individuals from Medicaid during the PHE, but states will resume regular renewals when the PHE ends. The report used Health Reform Monitoring Survey data from June 2022 to assess awareness about Medicaid renewals and found:

  • Sixty-two percent of adults with family Medicaid enrollment said they haven’t heard anything about the upcoming eligibility redeterminations
  • Only five percent reported they heard a lot about the return to regular Medicaid renewals
  • The most common source of information for those who had heard about the resumption of renewals was media or social media (34 percent)
  • Twenty-one percent were told how to get assistance with the renewal process
  • Less than one-third were informed of coverage options available to them if they become ineligible for Medicaid 

OIG: BCBS RI owes nearly $5M in MA overpayments

The OIG has released the findings of its Medicare Advantage (MA) compliance audit of Blue Cross & Blue Shield of Rhode Island (BCBS RI). The audit focused on nine groups of high-risk diagnosis codes for payment years 2016 and 2017 and based on its sample, found that the organization received at least $4.8 million in net overpayments.

OIG said it sampled 270 unique enrollee-years with the high-risk diagnosis that resulted in higher payments for 2016 through 2017. The watchdog found that most of the selected diagnosis codes submitted to the CMS for its risk adjustment program weren’t supported by information in the medical record and couldn’t be validated. Based on the sample results, OIG estimated that BCBS RI received at least $4.8 million in net overpayments for 2016 and 2017.

The watchdog recommended the insurer return the overpayments to Medicare, identify similar instances of noncompliance that occurred before or after the audit period and refund any resulting overpayments, and review its existing compliance procedures and make necessary improvements.

HHS issues report on Long COVID

The federal government has released a new report that highlights patients’ experience of Long COVID to better understand its complexities so that government leaders, clinicians, and patient advocates can address them.

There are more than 50 conditions linked to Long COVID that impact nearly every organ system. Researchers estimate that between five percent and 30 percent of those who had COVID-19 may have Long COVID symptoms and roughly one million people are out of work at any given time due to Long COVID. This figure equates to approximately $50 billion annually in lost salaries, HHS said in an announcement.

The findings are based on more than 1,000 hours of interviews, workshops, and human-centered design research with the public. “Long COVID isn’t one condition,” said Rear Adm Michael Iademarco, M.D., M.P.H., deputy assistant secretary for science and medicine. “The Health+ Long COVID Report allows us to hear directly from patients so we can better understand the complexities of this multisystemic condition and enrich our understanding and response to Long COVID and its associated conditions.” 

The report, commissioned by HHS and produced by Coforma, an independent third-party design and research agency, offers recommendations on how to deliver high-quality care and relevant and intentional resources and supports to individuals and families impacted by Long COVID:

  • Health care providers should develop and share materials about Long COVID to educate patients.
  • Insurance providers should update plan guidelines that align coverage with medical treatments that improve health outcomes for people with Long COVID.
  • Educators and employers should support accommodations for people living with Long COVID that allow them to continue to work and study.
  • Federal agencies should disseminate Long COVID messaging to let people know Long COVID is real and is a serious public health issue.