No Conviction in the Code I Restriction

by Anthony Chicotel, CANHR Staff Attorney

Following the May 2011, Office of the Inspector General Report finding terrible misuse of antipsychotic drugs on nursing home residents, the Department of Health Care Services (DHCS) announced it was issuing a “Code I Restriction” on antipsychotics paid for by Medi-Cal to nursing home residents.  The restriction would prohibit the use of antipsychotics for non-FDA approved indications like dementia.

While most nursing home residents’ medication is paid for by Medicare Part D, not Medi-Cal, the effort was welcome.  The Department of Public Health (DPH) touted the Code I Restriction as one piece of the state’s overall effort to tamp down on antipsychotic misuse in nursing homes.  (See slide #5 of DPH’s presentation on reducing antipsychotic misuse: http://www.cdph.ca.gov/programs/LnC/Documents/CAHPS-Antipsychotic-CDPHPresentation-8-17-12.pdf)  CANHR applauded the move believing it could notably decrease the incidence of “treating” dementia with antipsychotics.

It turns out that Code I Restrictions may not be much of a help in the campaign to end antipsychotic misuse.  In an attempt to obtain data about the impact of the Code I Restriction, CANHR contacted DHCS for help.  We learned that DHCS does not track the number of antipsychotic prescriptions for which payment is declined due to a Code I Restriction.  In fact, we were told:

“Unfortunately, a provider’s noncompliance with this policy does not translate into a hard claim reject in the Medi-Cal system which in turn makes it difficult to track.  Essentially we rely on providers to adhere to the policy.  So in short, we do not track this code 1.”

It looks like DHCS uses an honor system for antipsychotics in nursing homes.  If honor was enough to prevent misuse, California would not continue to have over 23% of all residents on antipsychotic drugs.  While many nursing homes throughout the state are dedicating themselves to improved dementia care, others will require stronger policy incentives.  In those facilities, an honor system is not going to change the business-as-usual reliance on dangerous and enervating chemical restraints.

 

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About achicotel

Anthony Chicotel is a staff attorney for CANHR. His areas of expertise include the rights of long-term care residents, nursing home litigation, health care decision-making, and conservatorships.
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