TRIBUNE WATCHDOG Compromised Care
Tighter rules sought for anti-psychotic drug use in nursing homes
Report shows elderly, frail patients are being 'chemically restrained' with powerful medicationBy Sam Roe and Christina Jewett Tribune reporter ProPublica
December 20, 2009
Health advocates are calling for tough new rules on the use of anti-psychotic drugs in Illinois nursing homes, including tighter controls on doctors who prescribe the powerful medications.
"Medical care should help you get better, not get worse," said Wendy Meltzer of Illinois Citizens for Better Care, an advocacy group for nursing home residents.
A Tribune investigation recently showed how many frail and vulnerable Illinois nursing home residents have been unnecessarily dosed with anti-psychotics, leading to harm and an increased risk of death. One psychiatrist, the Tribune found in a joint investigation with ProPublica, provided assembly-line care to thousands of mentally ill patients.
The advocates want Gov. Pat Quinn's Nursing Home Safety Task Force to address these problems. While the task force has focused on violent felons housed in nursing facilities, chairman Michael Gelder said the group will also target the misuse of psychotropic drugs.
"We want people to be safe and cared for in nursing homes, not threatened or unwillingly sedated," he said.
Reforming the system likely will be challenging. The FDA has approved anti-psychotic drugs to treat serious mental illnesses, such as schizophrenia, but doctors may also prescribe them to geriatric patients with other conditions, such as dementia, in a common but controversial practice called "off-label" use.
Meltzer said one way to stop nursing home doctors from using the drugs to "chemically restrain" residents is for the state to refuse to pay for certain medications.
For example, if a nursing home doctor wrote a prescription for an anti-psychotic that can be injected -- suggesting the medication is being used to sedate a resident -- the pharmacist would not fill the order unless the physician received permission from the Illinois Department of Healthcare and Family Services. Meltzer also said the state should not pay for multiple antipsychotics for the same resident or for psychotropics at dosages over recommended limits without prior approval.
In addition, Meltzer called for Illinois to require nursing homes to use standardized consent forms for each psychotropic drug. Documents show that hundreds of nursing residents have been given psychotropics without their permission since 2001. In other cases, facilities downplayed the dangers.
Nursing homes, Meltzer said, should have a formal process of explaining the benefits and risks of taking psychotropics. Right now, she said, the goal of many nursing homes is to simply get residents to sign the forms as opposed to explain the options.
Other possible reforms address problems raised by the ProPublica-Tribune investigation of Chicago psychiatrist Dr. Michael Reinstein.
Illinois law requires psychiatric hospitals to report patient deaths, but three deaths of people under Reinstein's care were never reported, said Illinois Department of Public Health spokeswoman Melaney Arnold. The agency grants and revokes the licenses of psychiatric hospitals, but it cannot levy penalties for lax death reporting because that law is on another agency's books.
Advocates said this inconsistency should be fixed, but Arnold characterized the problem as beyond the scope of her agency. "If (legislators) want to make a change to the law, they are welcome," she said.
Mark Heyrman, a University of Chicago law professor and mental health advocate, called on Medicaid to consider a doctor's cumulative disciplinary record when weighing sanctions. The agency, records show, has taken repeated action against Reinstein but has not punished him as a repeat offender. Rather, it has looked at him one audit at a time.
Heyrman said he wondered if it was wise for Medicaid to give tax dollars to doctors who have had repeated run-ins with the agency. "It seems to me there should be a higher standard for that," he said.
But overall, he said, Medicaid pays psychiatrists too little. "If we want decent care we have to raise the payments," Heyrman said.
Advocates also said Illinois should require drugmakers to publicly disclose payments to doctors so that their patients can be aware of possible conflicts of interest. One pharmaceutical company gave Reinstein nearly $500,000 to promote a drug that Medicaid records suggest he prescribed 41,000 times. Reinstein has disputed Medicaid's prescribing figures.
State Rep. Jack Franks, D-Marengo, has pushed a bill since 2005 requiring drugmakers to report the amount of money and gifts they give to doctors, nursing homes and hospitals. The bill has not passed, but he said he plans to re-introduce it next session.
He called Reinstein "the poster child for why we need this law."
Reinstein, through his attorney, said he agrees that drugmakers should disclose payments. He said he no longer accepts payments from pharmaceutical manufacturers, and if any are sent to him, he donates them to charity.
He also said he would cooperate and assist the task force if asked.
Sam Roe is a Tribune reporter. Christina Jewett is a reporter for ProPublica, an independent, nonprofit investigative newsroom in New York. Funded primarily by the Sandler Foundation, ProPublica publishes its work at propublica.org and through partnerships with the Tribune and other media. firstname.lastname@example.org
Copyright © 2009, Chicago Tribune
FYI the pharma company mentioned is AstraZeneca and the product is Seroquel.