The Centers for Medicare and Medicaid Services (CMS) has proceeded with changes to how it calculates rates of antipsychotic drug use in skilled nursing facilities (SNFs), but some of the new measurements have come without prior notice, leaving it to providers to realize what is taking place, according to analytic experts and consultants.

CMS’s updates to the long-stay antipsychotic measure now includes Medicare and Medicaid claims data and Medicare Advantage encounter data to supplement MDS data.

“This change means that providers need to re-check and download their January 2026 Five-Star Preview report to see if their performance on their long-stay antipsychotic medication changed,” said Jennifer Napier, practice director with Engage Consulting. “The values initially reported in the 1/21/26 release are now different when reviewing the report today. This could result in providers either gaining or losing total point values and ultimately losing or gaining a star in the Five-Star rating.”

She added that the national average for this antipsychotic quality measure has risen as a result from 14.5 percent (reported on the October 2025 Five-Star report) to 16.7 percent (reported on the January 2026 Five-Star report.)

The ramifications in states like Ohio that have a Quality Incentive Payment system, where point values are assigned based on performance in QM metrics, can have significant financial impacts when scores change in Five-Star performance,

Residents at the Forefront

Amy Greer, director of quality innovations, Zimmet Healthcare Services Group, said the changes leave her concerned that facilities will look to change how they prescribe medications, which could adversely affect the resident.

“Some facilities that are struggling with this measure could potentially discourage prescribing these medications for their residents,” she said.

In addition, Greer said the usage of these claims does not give a full picture of what is going on at the facility. “It will not reliably capture why the medication was prescribed, will not take into account any facility-initiated interventions to reduce antipsychotic usage, such as gradual dose reductions and tapering off of needed medications, or the facility focus on non-pharmacological interventions.”

She said it also will skew data on those SNF facilities that primarily have large populations with behavioral/mental health/dementia diagnoses and may look worse on the Five-Star rating due to this factor.

How to Prepare 

When asked what providers can do to prepare or manage the changes, Napier said:

• Providers should be reviewing their current MDS 3.0 Facility and Resident level reports to internally review the current residents triggering on the new hybrid measure.  
  

• If a resident meets exclusionary criteria (such as having a diagnosis of schizophrenia) and is still triggering on the report, that should be investigated.  
  

• Ultimately though, facilities should be internally looking at their residents that are on antipsychotic medication and work with their interdisciplinary teams, including care coordination with the physician and psychiatric services providers to reduce and eliminate the use of antipsychotics as clinically appropriate.
   

She added that the most immediate area affected will be Five-Star ratings and total QM point values changing.  “If you are right on the cusp in point values, this can take you from Quality Measure score of a 5 to a 4 or from a 2 star to a 1, both of which can impact your overall Five-Star rating,” Napier said. 

Greer echoed these concerns, noting that with the usage of claims now being included in the measure calculation, this can increase the providers rate of antipsychotic usage, which in turn can penalize them on their Five-Star Provider Report, and if providers do not fully understand how CMS is capturing this data they will continue to struggle.

“If their antipsychotic rates surge it will also leave them open to potential further auditing, [we have seen this with the previous and ongoing schizophrenia audits], and a downgrading of their Quality Measures star rating, which can also negatively impact their Overall Star rating,” she said.

Many facilities have arrangements with hospital providers to be a preferred facility and in turn most SNFs must have no less than three stars to be considered.

“If the QMs pull down the star rating to two this will have potentially disastrous impacts on their census, their admissions, their CMI, and possibly their reputation in the community, Greer said.

What CMS Is Doing

In January, CMS released the Care Compare Nursing Home Five-Star Quality Rating System Technical User’s Guide, but that only briefly touched on changes. The MDS 3.0 Quality Measures User’s Manual was released in December 2025 with a formal breakdown of the measure specifications to include claims data.

“When the January Five-Star Provider Reports were released late last month, we saw that the first three quarters of the look-back period for antipsychotic usage measure now displays ‘N/A’ instead of their previous rate and is now solely being counted for Quarter 3 2025 using both MDS data and claims data,” Greer said.

CMS has stated that additional guidance is forthcoming. “I would not be surprised if later this year in June or July, we will see another Five-Star Technical User’s Guide that will rescale the cut points for Star Ratings for Quality Measures,” she said. “So, those facilities that did have increases will see this as yet another way their Star Rating can be changed for the worse.”

Greer said she is sure once CMS has compiled more data, we will also see an update to the QM Manual with some measure FAQs and some clarifications from the previous manual. “I am sure that feedback from SNFs and stakeholders will also ensure CMS will have to continually clarify/revise/amend as needed,” she said.

Questions or comments? Contact Patrick Connole at pconnole@parkplacelive.com.