Department  of Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
PRESCRIPTION  DRUG  USE 
IN  NURSING  HOMES 
Report  1 
An  Introduction  Based  on  Texas 
JUNE GIBBS BROWN 
Inspector  General 
November  1997 
OEI-06-96-00080  EXECUTIVE  SUMMARY 
PURPOSE 
To describe  the extent and appropriateness  of drug use by Medicare  and Medicaid  residents 
of Texas nursing  homes. 
BACKGROUND 
Payments  for prescription  drugs represent  a large portion  of Medicaids  expenditures  for 
nursing  homes.  In fiscal year  1995, Medicaid  payments  for prescription  drugs reached $9.8 
billion.  Medicaid  provided  services  for  1.7 million  nursing home residents  in the same year. 
Prescription  drug costs are estimated  to range  from $600 to $1000 per resident.  This implies 
that between  $1 billion  and $1.7 billion  of those payments  went for prescription  drugs in 
nursing  facilities. 
Several recent  studies suggest that the use of inappropriate  or contraindicated  drugs is a 
contributing  factor to the high health care costs in the elderly  population.  The primary  goal 
of drug therapy  for nursing  home patients  is to maintain  and improve,  to the extent possible, 
the patients  functional  capacity  and quality  of life.  The Omnibus Budget Reconciliation  Acts 
(OBRA) of 1987 and  1990, in recognition  of this,  require  the regulation  of certain  drugs in 
nursing homes and the establishment  of drug utilization  review programs  for nursing home 
residents.  Provisions  of the OBRA 1990, while not required  for all nursing  homes,  also 
clearly  establish  Congress  desire to involve  pharmacists  more actively  in patient care. 
We undertook  this inspection,  using three different  approaches,  to provide  insight  into 
several  issues related  to prescription  drug use in nursing homes.  These issues are addressed 
in three reports,  of which this is the first.  To assess the extent of prescription  drug use for 
Medicare  and Medicaid  nursing home residents,  we obtained Medicaid  data for Texas for 
calendar  years  1992 through  1994 and the first six months of  1995.l  We report  total 
program  expenditures  by year and total expenditures  by drug class,  offering  a more detailed 
understanding  of precisely  what types of drugs are being used in nursing  homes and in what 
volume  they are being used.  We also consider  expenditures  on drugs regulated  by the OBRA 
1987 or deemed inappropriate  for use in elderly  populations. 
The second report  of this series,  An Inside  View by Consultant  Pharmacists,  presents the 
results of a national  survey of consultant  pharmacists  who perform  Federally-mandated 
monthly  drug regimen  reviews  in nursing  homes.  The third report,  A Pharmaceutical 
Review and Inspection  Recommendations  (OEI-06--96-00082),  discusses results from an 
independent  review  of drugs and medical  records  for a sample of Texas nursing home 
patients.  Recommendations  addressing  the issues and concerns  raised collectively  by all 
three  reports  are located  in the third  and final  report  of this inspection. 
i  FINDINGS 
Taken together,  the three reports of this inspection  show that while progress has been 
made in improving  pharmacy practices in nursing homes, some weaknesses and 
vulnerabilities  still exist which warrant attention.  Following  are the findings  from the 
first report: 
Prescription  drug payments for  Texas Medicare  and Medicaid nursing  home  residents have 
increased  rapidly, rising  by 20 percent from  1992  to 1994. 
0  The average  payment  per beneficiary  increased  20 percent  from  1992 to 1994, much 
faster than the one percent  increase  in beneficiaries  receiving  drugs and substantially 
greater  than the rate of inflation  for this period. 
  Drug payments  for this population  are a significant  portion  of State and Federal 
program  expenditures;  more than  17 percent  ($91 million)  of Texas total prescription 
drug payments  of $535 million  were for the Medicare  and Medicaid  nursing  home 
population. 
Some nursing  home  residents are receiving  drugs  which are potentially inappropriate  or not 
medically necessary,  raising  cost and quality of care  concerns. 
It is important  to understand  that reports  of possible  inappropriate  use of medications  are 
somewhat a matter of opinion.  Ultimately,  for nursing  home patients,  it is either  the 
patients  attending  physician  or the facilitys  medical  director  who determines  what is 
appropriate  care. 
  In  1994 almost 20 percent,  more than  16,600,  of Texas Medicaid  and Medicare 
beneficiaries  received  at least one of twenty drugs considered  by medical  experts to be 
inappropriate  for elderly  use due to side effects or other consequences. 
  It does appear that a slight reduction  has been achieved  for the twenty  most frequently 
discussed potentially  inappropriate  drugs.  The percentage  of beneficiaries  receiving  at 
least one of the drugs has shifted downward  from 21.2 percent  in 1992 to 17 percent 
for the first half of 1995.  However,  the rate of resident  use of contraindicated  drugs 
remains  high enough  to be a continuing  serious concern. 
Five drug  categories  account for  an expanding  majority of total payments for  prescription 
drugs. 
  Gastrointestinal  drugs,  drugs for cardiovascular  and cardiac care,  psychotherapeutics, 
and antiinfective  drugs combine  to total more than half of Medicaid  payments  for 
prescription  drugs in this population. 
  Total payments  for drugs in these categories  increased  at very high rates,  ranging 
from 60 percent  to 94 percent,  between  1992 and  1994.  Departmental  Comments 
Within  the Department,  we received  comments  on the draft  reports  from the Health  Care 
Financing  Administration  (HCFA)  and the Assistant  Secretary  for Planning  and Evaluation 
(ASPE).  Both agencies  concurred  with the recommendations;  HCFA  emphasized  the need 
for further  studies to assess the extent of continued  use of potentially  inappropriate  drugs, 
other  avenues of possible  cost savings  related  to drugs,  and the need to determine  and 
understand  the potential  sources of the escalating  costs and claims  for certain  types of drugs 
used in nursing  homes.  The final reports  reflect  several  clarifications  or changes  based on 
their  suggestions.  The full text of each agencys  comments  is provided  in the third and final 
report  of this inspection,  A Pharmaceutical  Review and Inspection  Recommendations  (OEI-
06-96-00082). 
Comments  from External  Organizations 
We also received  comments  from the following  external  organizations:  American  Health 
Care Association;  American  Association  of Homes and Services  for the Aging;  American 
Medical  Directors  Association;  American  Society  of Consultant  Pharmacists;  and National 
Association  of Boards of Pharmacy.  Most of the associations  concurred  with one or more of 
the recommendations  within  each of the inspection  reports.  All commentors  support the need 
for better communication  and coordination  between nursing  home staff and other healthcare 
providers,  training  nurse aides,  and understanding  the implications  of nursing home 
medication  services and associated  costs. 
Several organizations  questioned  the methodology  used in this inspection,  particularly  for the 
consultant  pharmacist  survey.  However,  as with any evaluation,  there are always  some 
limitations  in how data and information  can be obtained,  given  time and other resource 
constraints.  Further,  while  we acknowledge  that a survey  of this nature introduces  some bias 
and subjectivity,  we also believe  that the survey  of consultant  pharmacists  provides  us with 
an up-close view of what is happening  with prescription  drug use in nursing  homes. 
Moreover,  the results of the consultant  pharmacist  survey  are consistent  with our results from 
our two other methodologies. 
Some comments  expressed  concerns  about the use of the term,  inappropriate.  As 
explained  previously,  use of this term in reporting  concerns  with a patients  medication 
regimen  are somewhat a matter  of opinion.  The evidence  provided  in these three  reports 
does not prove that any one prescription  was improper,  but that closer  examination  is 
warranted.  Also,  while the use of such a drug may be supported by physician  orders  in 
individual  cases, use of the drug,  in general,  is likely  to be considered  inappropriate. 
Some comments  addressed  the implications  of broadening  Federal  oversight.  There  is clear 
concern  about the responsibility  for medication  issues being the responsibility  of the 
physician,  not the nursing  home.  Further,  some organizations  expressed  concern  that these 
particular  issues did not result  in direct  recommendations  about the physicians  role for 
nursing  home patients  medication  regimens.  We felt that further  examination  of this area is 
iv  warranted  before  recommending  changes  which  would impact so many entities  involved  in 
the process. 
In conclusion,  we believe  the three  reports  collectively,  and each using a different  approach, 
strongly  indicate  that the intent of the provisions  of the OBRA Acts concerning  prescription 
drug usage are not being clearly  fulfilled.  Further,  HCFA has authority  to correct  and 
enhance  quality  of care for nursing  home patients.  The recommendations  we present attempt 
to facilitate  the initial  steps of this effort,  and to address some concerns  evidenced  in the 
reports  and received  comments.  While  we recognize  that great strides have been made to 
meet the OBRA requirements,  we believe  further  effort  remains by all the players  involved 
(HCFA,  associations  and their members,  nursing  homes,  and residents  and their  families) to 
further  improve  quality  of care for nursing  home patients. 
The full text of each organizations  comments  is provided  in the third and final report of this 
inspection,  A Pharmaceutical  Review and Inspection  Recommendations  (OEI-06-96-
00082). 
V    More than 50 percent  of Medicare  and Medicaid  beneficiaries  received  drugs from at 
least three of these top five categories  in each of the years considered. 
Gastrointestinal preparations  comprise  an increasing  proportion  of the prescription  drugs 
used in Texas nursing  facilities.  Closer scrutiny of the medical necessity of these very 
expensive drugs  appears  warranted. 
  Almost 47 percent  of the residents  in our dataset  received  at least one gastrointestinal 
drug in 1994; their total cost to Medicaid  was over $15 million.  This single drug 
class accounted  for almost  17 percent  of all Medicaid  prescription  drug payments  in 
that year,  a substantial  increase  over the  1992 share of  12 percent. 
0  This class of drugs is one of the most expensive,  with average  payments  per 
beneficiary  of nearly  $385 and an average cost per day of $1.05. 
0  A 1992 study suggests that at least 40 percent  of nursing  home residents  who receive 
these drugs are receiving  them for conditions  other than those indicated  in the medical 
literature.  Therefore,  curtailing  unnecessary  or inappropriate  use of gastrointestinal 
drugs could result  in sizeable program  savings. 
Total prescription  drug payments,  average payments per  day, and average payments per 
beneficiary  vary quite widely by Texas nursing  home.  The reasons for  and appropriateness 
of these variations are  unclear. 
Average  1994 prescription  drug payments,  when arrayed  by nursing  home,  range from a high 
of more than $8 per day to as little as 17 cents per day.  Total payments  per beneficiary 
begin at just over $5 and increase  to more than $485. 
RECOMMENDATIONS 
Based on the concerns  raised  in this report,  the Health  Care Financing  Administration 
(HCFA) should work with the States and other responsible  entities  to understand  reasons  for 
the rapid escalation  in costs and claims  for certain  types of drugs used in nursing  homes. 
Specific recommendations  for HCFA to consider  in this endeavor  are provided  in our third 
report,  A Pharmaceutical  Review and Inspection  Recommendations  (OEI-06-96-00082). 
COMMENTS ON THE DRAFT REPORT 
We solicited  comments  from agencies  within  the Department  of Health  and Human  Services 
which have responsibilities  for policies  related  to Medicare  and Medicaid  and long term care. 
We also requested  input from  several  national  organizations  representing  the interests  of 
nursing homes,  patients,  or providers.  We appreciate  the time and efforts  of those providing 
comments. 
... 
111  TABLE  OFCONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION 
FINDINGS 
Total prescription  drug payments 
Some residents  receive  potentially  inappropriate  medications 
Five drug categories  account for most payments 
Most beneficiaries  receive  at least one of five drug categories 
Total payments  for the top five drug categories  have increased  significantly 
Gastrointestinal  drugs warrant  closer  scrutiny 
Payments  vary widely by nursing home 
RECOMMENDATIONS  10 
COMMENTS ABOUT DRAFT REPORTS  11 
ENDNOTES  13 
APPENDICES 
Twenty  Drugs Generally  Considered  Inappropriate  for the Elderly  A-l 
General  Classification  of Prescription  Drugs  B-l  INTRODUCTION 
PURPOSE 
To describe  the extent and appropriateness  of drug use by Medicare  and Medicaid  residents 
of Texas nursing homes. 
BACKGROUND 
Medicaid and Long  Term Care 
The Medicaid program,  created  in 1965 under Title XIX of the Social Security  Act, 
represents  the second largest health care expenditure  for the Federal government.  Funded 
jointly  by Federal  and State governments,  it is designed to provide  certain  basic medical 
services,  including  inpatient  hospital  care,  physician  services,  and nursing  home care.  More 
than 36 million  people received  $90.7 billion  in Federal  money  and another  $68.8 billion  in 
State funds for Medicaid  reimbursed  services during  fiscal year  1995. 
In  1995, Medicaid  was the primary  payment  source for the personal  health care for 4.4 
million  Americans  over 65.  Long term care is one of the largest and fastest growing  needs 
of the elderly.  Medicaid  is the primary  public program  for long term care assistance  for the 
elderly  and disabled.  In fiscal year  1995, of $39 billion  in program  expenditures  for care for 
this population,  $29 billion  went for nursing home stays.3 
Prescription Drug  use in Nursing  Homes 
Payments  for prescription  drugs represent  a large portion  of Medicaids  expenditures  for 
nursing homes.  Estimates  of the average cost per bed range from $600 to $1000 per year.4 
In fiscal year  1995, Medicaid  payments  for prescription  drugs reached  $9.8 billion. 
Medicaid provided  services  for  1.7 million  nursing  home residents  in the same year.  This 
suggests that Medicaid  paid between  $1 billion  and $1.7 billion  to provide  prescription  drugs 
to residents  of long term care facilities.  This could be as much as 16 percent  of total 
Medicaid prescription  drug expenditures.  But, health  care costs associated  with inappropriate 
use of prescription  drugs add to these estimates. 
Potential Problems  and  Costs 
Several recent  studies suggest that inappropriate  use of prescription  drugs by the elderly  is a 
potentially  serious health  problem  and could be adding hundreds  of millions  of dollars  each 
year  in unnecessary  drug and hospitalization  costs.  The inappropriate  use of these drugs can 
take a number of the following  forms: 
  drug-age contraindication, 
0  drug-allergy  contraindication, 
a  drug-disease  contraindication, 
1  0  incorrect  drug dosage, 
0  incorrect  duration  of drug therapy,  and 
  less effective  drug therapy. 
While  approximately  3 percent  of all hospital  admissions  are caused by adverse drug 
reactions,  the percentage  is much higher  for the elderly.  One study estimated the percentage 
of hospitalizations  of elderly  patients due to adverse  drug reactions  to be as high as 17 
percent,  almost six times greater  than for the general  population.  The Food and Drug 
Administration  (FDA) estimates  that the annual cost of hospitalizations  due to such 
inappropriate  drug use is 20 billion  dollars.6  Much of this cost is in the elderly  population 
and a large portion  of it is borne by government  health  care programs,  including  Medicare 
and Medicaid. 
Not only do the elderly  use more prescription  drugs than any other age population,  they also 
tend to be taking  several drugs at once,  increasing  the probability  of adverse drug reactions. 
The elderly  also tend to eliminate  these drugs from their  system less efficiently  due to 
decreased  bodily  functions.  Studies also suggest more  subtle effects of inappropriate  drug 
use, such as loss of cognitive  or physical  function  and the potential  for an increased  risk of 
falls among the elderly.  Researchers  have concluded  that a number of prescription  drugs 
used for the general population  should not be prescribed  for elderly  patients  (See Appendix 
A).  Frequently,  other equally  effective  drugs which present  fewer risks are 
recommended .7r8 
Regulation and  Control of Prescription  Drug  Use in Nursing  Homes 
As part of the Omnibus Budget Reconciliation  Act of  1987 (OBRA 1987), Congress  required 
regulation  of the use of .certain drugs in nursing homes.  On October  1, 1990, the Health 
Care Financing  Administration  (HCFA)  implemented  regulations  which hold nursing homes 
accountable  for monitoring  drug use. 
Additionally,  physicians  must now justify  the use of antipsychotic  drugs based on specific 
diagnoses  and observe  specific parameters  within which these drugs may be used.  While 
recent  studies indicate that the OBRA 1987 regulations  may have had a positive  effect on 
reducing  antipsychotic  drug use in this population,  there  is some evidence  of continuing 
problems  of inappropriate  prescriptions,  multiple  presgriptions,  and possible drug-drug 
interactions.  For example,  a July  1995 study of 21,884  nursing  home residents  found that  12 
percent  of residents  in the study were prescribed  one or more of 10 nonpsychotropic 
medications  that are considered  inappropriate  for use in the elderly.  Thirty-one  percent  of 
those residents were receiving  more than seven prescription  drugs,  and 19 percent  of this 
group had prescriptions  for at least one inappropriate  medication. 
METHODOLOGY 
This report  documents  prescription  drug expenditures  and identifies  the types of drugs being 
used in Texas nursing  homes.  As part of preinspection,  we reviewed  1) current  literature 
related  to prescription  drug use by the elderly  and 2) Medicare  and Medicaid  policies 
2  associated  with payment  and monitoring  drug use.  To assess the extent of prescription  drug 
use by Medicare  and Medicaid  residents,  we obtained  Medicaid  data for Texas nursing home 
residents  eligible  for Medicare  and Medicaid  for calendar  years  1992-94 and the first six 
months  of  1995.  The selection  of Texas was purposive  based on 1) the availability  of 
Medicaid  data and planned  identification  of the Medicare  and Medicaid  population  in the 
State by HCFA  and the Office of the Inspector  General  (OIG), 2) designation  as a 
demonstration  site for Operation  Restore Trust (see description  below),  and 3) the large 
number  of nursing  facilities  in Texas,  approximately  eight percent  of long term care facilities 
in the nation.  Texas also ranks third  in the nation  for total Medicaid  spending. 
This  inspection  provides  insight  into several  issues related  to prescription  drug use in nursing 
homes.  First,  we report  total program  expenditures  by year and total expenditures  by drug 
class,  offering  a more detailed  understanding  of precisely  what types of drugs are being used 
in nursing  homes and in what volume they are being used.  We also consider  expenditures  on 
drugs regulated by OBRA or deemed inappropriate  for use in elderly  populations. 
For ease of analysis  and understanding  we have compressed  the several thousand different 
drugs in our study into 32 general  categories.  Drugs are combined  based on therapeutic 
function  and pharmacological  makeup.  For example,  the category  for which Federal 
programs  paid the most in 1994, gastrointestinal  preparations,  include such types of drugs as 
those intended to treat ulcers,  limit the secretion  of certain  gastrointestinal  fluids,  or to treat 
gastrointestinal  reflux.  Some of the most common brand names in this category  include 
Zuntuc and Pepcid.  Other categories  include:  cardiac,  psychotherapeutic,  cardiovascular  and 
antiinfective  drugs.  A complete  list of the categories  and the types of drugs each contains 
appears in Appendix  B.  Although  we collected  and analyzed  Texas prescription  drug data 
for the years  1992 through  the first six months of 1995, much of the discussion  in this report 
is focused on the most current  year for which we have complete  data,  1994, with 
comparisons  to the other years  where appropriate.  Because of the difficulty  in estimating  the 
nursing  home population  for the full year of 1995, no attempt was made to project these 
figures beyond June 30,  1995. 
This  is the first in a series of three reports  detailing  our inspection  of issues related to 
prescription  drug use in nursing  facilities.  The second report,  An Inside View by consultant 
Pharmacists  presents the results of a national  survey of consultant  pharmacists  who perform 
Federally-mandated  monthly  drug regimen  reviews  &rnursing  homes.  The final report,  A 
Pharmaceutical  Review and Inspection  Recommendations  presents  the findings  from a 
pharmaceutical  review  of the records  of a number of Texas nursing  home residents  and the 
collective  recommendations  of all three reports. 
This  inspection  was conducted  as a part of Operation  Restore Trust (ORT).  The initiative, 
focused  in five States (California,  Florida,  Illinois,  New York,  and Texas),  involves  multi-
disciplinary  teams of State and Federal  personnel  seeking to reduce fraud,  waste, and abuse 
in nursing  homes and home health  agencies,  and by durable  medical  equipment  suppliers. 
This  inspection  was conducted  in accordance  with the Quality  Standards  for  Inspections 
issued by the Presidents  Council  on Integrity  and Efficiency. 
3  FINDINGS 
Prescription  drag payments for  Texas Medicare  and Medicaid nursing  home  residents have 
increased  rapidly, rising by 20 percent  between 1992  and 1994. 
II  ,I 
Table  1:  Increasing  Prescription  Drug  Payments  for  Texas 
Medicare  and  Medicaid  Nursing  home  Residents 
IL-
I! 
TOTAL  AVERAGE  PAYMENT  ,/ 
TOTAL  BENEFICIARIES  PER BENEFICIARY  8' 
YEAR  PAYMENT  RECEIVING 
'II 
DRUGS  !I 
. 
1992  $75,501,900  83,891  $900  I 
1993  $82,517,940  84,895  $972 
1994  $91,584,609  85,111  $1076 
Percent Change  +21.3%  +1.45%  i-19.6% 
* 1992 figures  projected  using  calculations  based  upon  1994 Medicare  and Medicaid  to 
total  beneficiary  ratio. 
From  1992 to  1994 total drug payments  have increased  each year,  rising  much faster than the 
rate of increase  in the number of beneficiaries  receiving  drugs (+ 1.5 percent)  and at a 
substantially  greater  rate than the rate of inflation  during this period.  As a result,  there 
was a significant  increase (20 percent)  in the average payment  per beneficiary  during this 
period.  The  1994 total represents just over  17 percent  of the total Texas drug claims.  A 
portion  of this growth may be attributable  to changes  in treatment  and practice  patterns over 
this period.  Recognition  that older patients  may benefit  from a more aggressive  diagnosis  and 
treatment  of depression,  combined  with higher costs of newer and potentially  safer 
antidepressants,  as well as increased use of more expensive  cardiovascular  and cardiac drugs, 
may have contributed  to the increase. 
In 1994,  almost 20 percent,  or more  than 16,600,  of  Texas  Medicare  and Medicaid 
benejkiaries  received  at least one of the twenty dmgs  experts consider potentially 
inappropriate for  elderly use. 
This is 19.6 percent  of all beneficiaries  in our dataset.  Note, however,  that although  there  is 
an overall  increase  in beneficiaries  receiving  all drugs in the five major  cost categories  (see 
Table 4), there  is a downward trend in the percentage  of beneficiary  claims for 
contraindicated drugs (see Table 2).  The rate of potentially  inappropriate  claims has 
declined  from 2 1.2 percent  in 1992 to 20.8 percent  in 1993 to  19.6 percent  in 1994.  The 
trend appears to continue  in 1995, as only  17 percent  of Medicare  and Medicaid  beneficiaries 
receiving  drugs had claims for one or more  items on the list of contraindicated  drugs.  While 
this is encouraging,  it is important  to remember  that the 1995 figures  represent  only claims 
from the first  six months  of the year,  and it is likely  that the final figure  will be somewhat 
4  higher  for the full year.  Regardless,  the rate of resident  use of contraindicated  drugs remains 
high enough  to be a continuing,  serious concern. 
/  Table  2:  Beneficiaries  with  Claims  for Contraindicated  Drug  (by Year)  /
I 
Ii 
BENE WITH  BENE WITH  ~I 
Jo  YEAR  CONTRAINDICATED  DRUG  ANY DRUG  % OF TOTAL  I 
,  I 
II
Jo  1992  15,623  73,814  21.2%  ~~ 
t 
1993  17,617  84,584  20.8%  :~ 
,i 
1994  16,670  85,111  19.6% 
1995 
(first  6 
months)  12,460  73,328  17.0% 
We searched our  1994 dataset for Medicaid  payments  for several  specific drugs experts 
generally  consider  inappropriate  for elderly  use.  The following  discussion  illustrates  some of 
the concerns  with these problematic  drugs. 
Examples  of contraindictied  drags  being  used in Texas nursing  facilities: 
Dipyridamole 
Just over ten percent  of all the Medicare  and Medicaid  beneficiaries  receiving  any 
prescription  drug in 1994 received  dipyridamole.  This drug falls  into the cardiac  category 
and is used to reduce blood clot formation.  It is often prescribed  in cases of cardiac  valve 
replacement  or to help prevent  recurrence  of myocardial  infarction,  or heart  attack. 
Dipyridamole  is also prescribed  as treatment  for transient  ischemic  attacks  (TIAs) which can 
lead to blindness,  paralysis,  speech disturbance,  or coma.  Some experts express concern  that 
the effectiveness  of this drug at low doses is in doubt and that higher  doses may lead to 
toxicity.  They  suggest that other,  safer drugs are available.12  Our data show Medicaid 
programs  paid $346,639  for this drug in Texas nursing  facilities  in 1994. 
Psychotherapeutic  Drugs 
Of particular  concern  to medical  experts and to Congress  and the HCFA  are drugs that fall 
into the psychotherapeutic  class.  Despite regulatory  changes  in the late 1980s mandating  the 
reduction  of the use of psychoactive  drugs in nursing  home patients,  several  recent  studies 
indicate  that about half of all residents  were still being  given  one or more of these drugs as 
late as the mid  1990s.13 Consistent  with this literature,  in Texas nursing  facilities  55.8 
percent  of Medicare  and Medicaid  residents  received  at least one of the drugs in 1994. 
During the first half of  1995 48.3 percent  of beneficiaries  received  psychotherapeutics, 
indicating  continued  high usage of drugs in this category. 
5  One of these psychotherapeutic  drugs  is diazepam,  better known  by its brand name,  Valium. 
It is a long-acting  benzodiazepine  often used to treat dementia,  anxiety  disorders,  and 
insomnia.  A number  of studies cite expert claims  that there  are other,  shorter  acting drugs in 
the same class that are more appropriate  for use in the elderly.  One concern  about the use 
of diazepam  in this population  is the tendency,  because  it remains  in the system for quite a 
long time,  for older folks  to become  oversedated  and uncoordinated  when given  regular  adult 
doses.  Such effects are likely  to result  in injuries  associated  with falls.  The HCFA 
guidelines,  as well as the experts,  recommend  that physicians  attempt to reduce the dosage of 
these drugs in elderly  people until a minimal  effective  dose is reached.  In  1994, Medicaid 
programs  paid $8 1,890 for Diazepam  for a total of 2,911 Medicaid  and Medicare  Texas 
nursing home beneficiaries. 
In the same year,  Medicaid  programs  also paid $159,630  for amitriptyline  for 6,459 
residents.  Also within the psychotherapeutic  classification,  amitriptyline  is used to treat 
depression.  While  there  is some concern  about the possible  underuse  of antidepressants  in 
elderly  individuals,  experts  worry  about the number  and severity  of side effects  associated 
with this particular  drug.  Moreover,  some of these side effects can be misinterpreted  as 
symptoms whose treatment  might require  additional  psychoactive  drugs.  Finally,  another 
long-acting  benzodiazepine  in the psychotherapeutic  class,  flurazepam,  was the object of 953 
claims for a total of $19,317  in 1994. 
Five drag  categories  account for  an expanding  majority of total payments for  prescription 
drags. 
These drug categories  consistently  rank in the top five  in terms of total payment  for all of the 
years for which we have complete  data.  Also,  their  share of total payments  has grown 
significantly  from  1992 through  the first half of  1995. 
Table  3: Five  Drug  Categories  Account  for the  Majority  of Total  Prescription  Drug  Payments 
GENERAL  CLASSIFICATION 
1992  1993  1994  d 
GASTROINTESTINAL  PREPARATIONS  11.9%  15.3%  16.7%  +40.3% 
CARDIAC  DRUGS  10.4  11.5  12.1  + 16.3 
PSYCHOTHERAPEUTIC  DRUGS  8.9  10.4  11.4  +28.1 
CARDIOVASCULAR  DRUGS  6.5  7.8  7.6  + 16.9 
ANTIINFECTIVES  4.6  5.7  5.5  + 19.5 
El 
TOTAL  42.3  50.7  53.3  //I 
Gastrointestinal  preparations  include drugs which are intended to treat ulcers, limit the 
secretion of certain gastrointestinal fluids, or to treat gastrointestinal reflux.  Some of the most 
common brand names in this category include Zanfac and Pepcid. 
6  Cardiac  drugs  include  recognizable  brand  names  such  as Procardia.  This  class  of drugs  is used 
in treatment  of chronic  angina  pectoris  and hypertension  and  in prevention  of angina  symptoms, 
such  as chest  pain  and  shortness  of breath,  as well  as reduction  of blood  pressure. 
Psychotherapeutic  drugs,  including  Prozac, Zolof,  and Paxil, are  used  to treat  a number  of 
problems  ranging  from  anxiety  and depression  to insomnia  and  agitation  associated  with  dementia. 
Cardiovascular  drugs  such  as Capoten and  Vasotec are used  to treat  blood  pressure  related 
ailments  and congestive  heart  failure. 
Finally,  antiinfective  drugs  are  used  to treat  a wide  range  of problems  including  urinary  tract 
infections,  bone  and joint  infections,  pneumonia,  infectious  diarrhea,  and skin and soft  tissue 
infections,  such  as bed  sores. 
Additionally, more  than 50 percent  of all beneficiaries  received  drags from  at least three  of 
the top five  classifications in each year for  which we have data. 
From  1992 through  1994 over 50 percent  of all Texas Medicare  and Medicaid  nursing home 
residents  were reimbursed  for at least one prescription  from the cardiac,  psychotherapeutic, 
and antiinfective  drug categories. 
I 
Table  4:  Percent  of Total  Beneficiaries  Receiving  Prescription  Drugs 
I 
GENERAL CLASSIFICATION  1992  1993  1994 
ANTIINFECTIVES  58.8%  63.9%  63.5%   
I 
PSYCHOTHERAPEUTIC  DRUGS  50.8  53.2  55.8  / 
/ 
CARDIAC  DRUGS  50.2  51.4  51.5  I 
GASTROINTESTINAL  PREPARATIONS  40.5  44.9  46.8  I 
1 
CARDIOVASCULAR  DRUGS  27.7  28.2  28.9 
Total payments for  the top five  categories  of drags  increased  very rapidly from  1992 
through  1994.  The proportion  of total beneficiaries  who receive  them also grew. 
From  1992 to the end of  1994 the proportion  of total beneficiaries  receiving  gastrointestinal 
drugs rose more than  15 percent.  With this increase  in use came a major  increase  (94 
percent)  in the total payments  for these drugs.  Similarly,  total payments  for 
psychotherapeutic  drugs rose nearly  92 percent,  while the percent  of total beneficiaries 
receiving  these drugs increased  by about  10 percent.  Though  not as high,  the other three top 
categories  also saw an increases  of 60 percent  or more in payments,  coupled with moderate 
growth  in the percent  of total beneficiaries  receiving  them.  To place this change  in 
perspective,  recall  from Table  1 that total drug payments  increased just over 21 percent  from 
1992 through  1994. 
7  __-
!!  Table  5:  Percent  Change  1992-1994,  Percent  of Total  Beneficiaries  Receiving  Prescription  Drugs  and  ~ 
11  Total  Payment  for Five  Drug  Classifications 
GENERAL  CLASSIFICATION  Percent Total Beneficiaries  Total Payment 
(% change)  (X  change) 
,  GASTROINTESTINAL  PREPARATIONS  +15.5%  +  93.6% 
1 
~  PSYCHOTHERAPEUTIC  DRUGS  +  9.8  +  91.8  Ii 
I 
~  CARDIOVASCULAR  + 4.3  +  60.2 
I 
,  i 
ANTIINFECTIVES  +  8.0  + 63.8  ,~ 
in 
II 
/  CARDIAC  DRUGS  +  2.5  +  59.6 
Gastrointestinal preparations  comprise  an increasing  proportion  of the prescription  drugs 
used in Texas nursing facilities.  Closer scrutiny of the medical necessity of these very 
expensive  drugs  appears  warranted. 
Some experts  in elderly  health  care are concerned  about the increasing  use of certain 
gastrointestinal  drugs.  Within  this classification,  Histamine-2  receptor  antagonists  have 
become a very popular  treatment  for many acid related gastrointestinal  disorders  including 
peptic ulcers and gastroesophegeal  reflux.  Two of the most common  of these drugs are 
cemetidine  and ranitidene,  better known  as Tagamet  and Zantac,  respectively.  A 1992 study 
conducted  in a large long term care facility  indicated  that more than 40 percent  of patients 
receiving  these drugs were receiving  them for reasons unsubstantiated  by the medical 
literature. l5 
Because there are relatively  few side effects associated with these drugs when prescribed  in 
proper  doses the concern  about their use is not a major quality  of care issue.  However,  it 
can become a significant  cost issue.  These particular  drugs are very expensive.  In fact,  in 
1994 Federal  programs  paid $15,325,877  for gastrointestinal  drugs.  A total of 33,575 or 
almost 47 percent  of all Texas nursing  home beneficiaries  received  at least one 
gastrointestinal  drug.  Zuntuc accounted  for $5,921,810  of those payments  while  $751,588 
was for Tugamet.  At more than $380 per year per beneficiary,  gastrointestinal  drugs are 
also among the most expensive  types of drugs covered  by Federal  programs.  Thus,  if 40 
percent  or more of these claims are not medically  necessary,  there  should certainly  be an 
economic  benefit  from reducing  their  inappropriate  use. 
Total prescription  drug payments,  average payments per  day, and average payments per 
beneficiary  vary quite widely by Texas nursing  home.  The reasons for,  and 
appropriateness  of,  these variations are unclear. 
Average  1994 prescription  drug payments,  when arrayed  by nursing  home,  range from a high 
of more than $8 per day per facility  to as little as 17 cents per day.  Payments  per 
beneficiary  in a particular  facility  begin at just  over $5 and increase  to more than $485.  The 
8  1994 data  also  reveal  that  the  average  total  payment  aggregated  at the  nursing  home  level  is 
just  over $82,000.  Total payments  per facility  range from under $10 to more than $335,000 
for that year.  Almost  10 percent  of facilities  had total resident  reimbursements  under 
$10,000,  while  30 percent  of  facilities  had  total  reimbursements  of more  than  $100,000. 
Table 6 illustrates  the variation  in prescription  drug payments  when considered  at the facility 
level. 
Ii  7 
~~  Table  6:  1994  Average  Prescription  Drug  Payments;  ,I 
Totals,  Per Beneficiary,  and  Per  Day 
I 
pi  (by Nursing  Home) 
7 
MINIMUM  MAXIMUM  MEAN  1 
I 
TOTAL  PAYMENT  9.89  336,539  82,939  ~ 
(per facility) 
AVERAGE  PAYMENT  PER BENEFICIARY  5.26  487.23  158.95 
/  (per facility) 
1 
I 
/ AVERAGE  PAYMENT  PER DAY  0.17  8.82  0.73  1 
1 (per facility) 
1  I 
*For this analysis,  facilities with fewer than 5 beneficiaries  were excluded.  Also, one 
extreme case, whose average payment  per day value is 60 percent higher than the next 
lowest value, was omitted. 
While  some of these differences  are certainly  attributable  to the number of beneficiaries 
residing  in a particular  facility,  it is likely  that other factors  also contribute  to the variation. 
However,  our existing  data does not reveal  a relationship  that explains  these differences. 
When claims data for a particular  class of drugs are arrayed  by nursing home,  no 
characteristics  consistently  differentiate  those with high costs per beneficiary  or per day from 
those with lower costs.  Following  the compilation  of additional  data,  we plan further 
analysis  to determine  what other variables,  such as facility  type,  severity  of resident  illness, 
and types and numbers of other services,  contribute  to these wide differences  in payments  at 
the nursing home level. 
9  RECOMMENDATIONS 
Based on the concerns  raised in this report,  more  work is necessary  to understand  reasons for 
the rapid escalation  in costs and claims for certain  types of drugs used in nursing  homes. 
Specific recommendations  for HCFA to consider  in this endeavor  are provided  in our third 
report  of this inspection,  A Pharmaceutical  Review and Inspection  Recommendations  (OEI-
06-96-00082). 
10  COMMENTS  ABOUT  DRAFT  REPORTS 
We solicited  comments  from  agencies within the Department  of Health and Human Services 
which have responsibilities  for policies  related  to Medicare  and Medicaid  and long term care. 
We also requested  input from several  national  organizations  representing  the interests of 
nursing homes,  patients,  or providers.  We appreciate  the time and efforts  of those providing 
comments. 
Departmental  Comments 
Within  the Department,  we received  comments  on the draft reports  from the Health Care 
Financing  Administration  (HCFA) and the Assistant  Secretary  for Planning  and Evaluation 
(ASPE).  Both agencies concurred  with the recommendations;  HCFA emphasized  the need 
for further  studies to assess the extent of continued  use of potentially  inappropriate  drugs, 
other avenues of possible cost savings related  to drugs,  and the need to determine  and 
understand  the potential  sources of the escalating  costs and claims for certain  types of drugs 
used in nursing  homes.  The final reports  reflect  several clarifications  or changes based on 
their suggestions.  The full text of each agencys comments  is provided  in the third and final 
report of this inspection,  A Pharmaceutical  Review and Inspection  Recommendations  (OEI-
06-96-00082). 
Comments  from External  Organizations 
We also received  comments  from the following  external  organizations:  American  Health 
Care Association;  American  Association  of Homes and Services  for the Aging;  American 
Medical Directors  Association;  American  Society  of Consultant  Pharmacists;  and National 
Association  of Boards of Pharmacy.  Most of the associations  concurred  with one or more of 
the recommendations  within  each of the inspection  reports.  All commentors  support the need 
for better communication  and coordination  between nursing  home staff and other healthcare 
providers,  training  nurse aides,  and understanding  the implications  of nursing  home 
medication  services  and associated  costs. 
Several organizations  questioned  the methodology  used in this inspection,  particularly  for the 
consultant  pharmacist  survey.  However,  as with any evaluation,  there are always  some 
limitations  in how data and information  can be obtained,  given time and other resource 
constraints.  Further,  while we acknowledge  that a survey  of this nature introduces  some bias 
and subjectivity,  we also believe  that the survey  of consultant  pharmacists  provides  us with 
an up-close  view of what is happening  with prescription  drug use in nursing homes. 
Moreover,  the results of the consultant  pharmacist  survey are consistent  with our results from 
our two other methodologies. 
Some comments  expressed  concerns  about the use of the term,  inappropriate.   As 
explained  previously,  use of this term in reporting  concerns  with a patients  medication 
regimen  are somewhat  a matter of opinion.  The evidence  provided  in these three reports 
does not prove  that any one prescription  was improper,  but that closer examination  is 
11  warranted.  Also,  while  the use of such a drug may be supported  by physician  orders  in 
individual  cases, use of the drug,  in general,  is likely  to be considered  inappropriate. 
Some comments  addressed  the implications  of broadening  Federal  oversight.  There  is clear 
concern  about the responsibility  for medication  issues being the responsibility  of the 
physician,  not the nursing  home.  Further,  some organizations  expressed concern  that these 
particular  issues did not result  in direct recommendations  about the physicians  role for 
nursing  home patients  medication  regimens.  We felt that further  examination  of this area is 
warranted  before  recommending  changes  which would impact so many entities  involved  in 
the process. 
In conclusion,  we believe  the three  reports collectively,  and each using a different  approach, 
strongly  indicate that the intent of the provisions  of the OBRA Acts concerning  prescription 
drug usage are not being clearly  fulfilled.  Further,  HCFA  has authority  to correct  and 
enhance quality  of care for nursing home patients.  The recommendations  we present  attempt 
to facilitate  the initial  steps of this effort,  and to address some concerns  evidenced  in the 
reports and received  comments.  While  we recognize  that great strides have been made to 
meet the OBRA requirements,  we believe  further  effort  remains  by all the players  involved 
(HCFA,  associations  and their members,  nursing homes,  and residents and their families)  to 
further  improve quality  of care for nursing home patients. 
The full text of each organizations  comments  is provided  in the third and final report of this 
inspection,  A Pharmaceutical  Review and Inspection  Recommendations  (OEI-06-96-
00082). 
12  ENDNOTES 
1.  Once we identified  the dually-eligible  population,  we extracted  Medicaid payments 
for drugs provided  during  a nursing home stay from data currently  maintained  by 
HCFA  or the OIG.  Only the first six months of claims data were available  for 
1995.  These figures are included  in our analysis  where appropriate.  Due to the 
difficulty  in estimating  the nursing  facility  population  for the full year,  no attempt 
was made to project  these figures beyond  June 30,  1995. 
2.  Health  Care Financing  Administration,  BDMS Division  of Medicaid  Statistics, 
1996. 
3.  HCFA,  BDMS, OSM, Division  of Program  Systems,  12/19/1996. 
4.  Keitz,  Todd.  10 Things  You Should Know About the Long Term Care Market. 
Medical  Marketing  and Media.  30(5):42-46.  May  1995. 
5.  Beard,  Keith.  Adverse Reactions  as a Cause of Hospital  Admission  in the Aged, 
Drugs  & Aging,  Vol.  2, No.  4 (July/Aug.  1992), pp. 356-67. 
6.  General  Accounting  Office.  Prescription  Drugs and the Elderly:  Many Still 
Receive Potentially  Harmful  Drugs Despite Improvements.   Letter Report 
GAO/HHES-95-152.  July 24,  1995. 
7.  Spore DL, Mor V, Larrat  P, Hawes C, Hiris J,  Inappropriate  Drug Prescriptions 
for Elderly  Residents of Board and Care Facilities.  American  Journal  of Public 
Health,  Vo1.87, No. 3 (March  1997), pp. 404-409. 
8.  Beers, Mark,  Joseph G. Ouslander,  Irving  Rollingher,  et al.  Explicit Criteria  for 
Determining  Inappropriate  Medication  Use in Nursing  Home Residents.  Archives 
oflnternal  Medicine,  Vol.  lSl(Sept.  1991), pp.  1825-32. 
9.  42 CFR Set 483.60. 
10.  Ukens,  Carol. Warning  Sign.   Drug  Topics.  139 (13); 56 July  10, 1995. 
11.  The inflation  rate based on the Consumer  Price Index was just  over 6 percent  for 
this period  and 6.7 percent  based upon the CPI:  Medical  Index  for Prescription 
Drugs.  Thus,  the adjusted growth rate for average payments  per beneficiary 
remains  approximately  13 percent based upon either  index. 
Source:  Bureau of Labor  Statistics,  U.S.  Department  of Labor 
12.  Beers, et al.  1991; Avom  and Gurwitz,  1995. 
13.  Avom  and Gurwitz,  1995.,  Beers,  Ouslander,  et ai.,1992. 
13  14.  GAO, July 24,  1995; Beers, et al,  1991; Avom,  Jerry  and Jerry  H. Gurwitz. 
Drug Use in the Nursing Home.  Annals  of Internal  Medicine,  Vol  123 (August, 
1995), pp.  195-204. 
15.  Gurwitz,  JH, JP Noonan,  and SB Soumerai.  Reducing the Use of H2-Receptor 
Antagonists  in the Long-Term-Care  Setting,  Journal  of the American  Geriatric 
Society  1992; Vol 40 pp.359-64. 
14  APPENDIX  A 
20 Drugs Generally  Considered 
Inappropriate  for the Elderly 
The 20 drugs listed below were judged  generally  inappropriate  for elderly  patients  by a panel of 
experts.  The panels results and methodology,  published  in 1991, indicate that these drugs should 
normally  not be used with elderly  patients.  However,  they stress that there could be some medical 
situations  in which use of these drugs would be appropriate. 
Medication  Use  Comment 
Amitriptyline  To treat  Other antidepressant 
depression  medications  cause 
fewer side effects 
Carisoprodol  To relieve  severe  Minimally  effective 
pain caused by  while causing 
sprains and back  toxicity;  potential 
pain  for toxic reaction 
is greater  than 
potential  benefit 
Chlordiazepoxide  As a (minor)  tranquilizer  Shorter-acting 
or antianxiety  benzodiazepines  are 
medication  safer alternatives 
Chlorpropamide  To treat diabetes  Other oral medications 
(a hypoglycemic  agent)  have shorter  half-lives 
and do not cause 
inappropriate 
antidiuretic  hormone 
secretion 
Cyclandelate  To improve  blood  Effectiveness  is in 
circulation  doubt;  no longer  available 
in the U.S. 
A -1  Medication  Use  Comment 
Cyclobenzaprine  To relieve  severe  Minimally  effective 
pain caused by  while causing 
sprains and back  toxicity;  potential 
pain  for toxic reaction 
is greater  than 
potential  benefit 
Diazepam  As a (minor)  tranquilizer  Shorter-acting 
or antianxiety  benzodiazepines  are 
medication  safer alternatives 
Dipyridamole  To reduce blood- Effectiveness  at low 
clot formation  dosage is in doubt; 
toxic reaction  is 
high at higher 
dosages;  safer 
alternatives  exist 
Flurazepam  As a sleeping pill  Shorter-acting 
(a hypnotic)  benzodiazepines  are 
safer alternatives 
Indomethacin  To relieve  the  Other nonsteroidal 
pain and  anti-inflammatory 
inflammation  of  agents cause less 
rheumatoid  toxic reactions 
arthritis 
Isoxsuprine  To improve blood  Effectiveness  is in 
circulation  doubt 
Meprobamate  A (major) tranquilizer  Shorter-acting 
(used for anxiety)  benzodiazepines  are 
safer alternatives 
Methocarbamol  To relieve  severe  Minimally  effective 
pain caused by  while causing 
sprains and back  toxicity;  potential 
pain  for toxic reaction 
is greater  than 
potential  benefit 
A -2  Medication  Use  Comment
Orphenadrine  To relieve  severe  Minimally  effective 
pain caused by  while causing 
sprains and back  toxicity;  potential 
pain  for toxic reaction 
is greater  than 
potential  benefit 
Pentazocine  To relieve  Other narcotic 
moderate  to severe  medications  are 
pain  safer and more 
effective 
Pentobarbital  As a sleeping pill  Safer sedative-
and to reduce  hypnotics  are 
anxiety  (hypnotic)  available 
Phenylbutazone  To relieve  the  Other nonsteroidal 
pain and  anti-inflammatory 
inflammation  of  agents cause less 
rheumatoid  toxic reactions 
arthritis 
Propoxyphene  To relieve  mild to  Other analgesic 
moderate  pain  medications  are more 
effective  and safer 
Secobarbital  As a sleeping pill  Safer sedative-
and to reduce  hypnotics  are 
anxiety  (hypnotic)  available 
Trimethobenzamide  To relieve  nausea  Least effective  of 
and vomiting  available 
antiemetics 
Source: 
Beers,  Mark,  Joseph  G.  Ouslander,  Irving  Rollingher,  et  al.  Explicit  Criteria  for  Determining 
Inappropriate  Medication  Use  in  Nursing  Home  Residents.  Archives  of  Internal  Medicine,  Vol. 
lSl(Sept.  1991), pp.  182532. 
A -3  APPENDIX  B 
General Classification of Prescription  Drugs 
Analgesics 
Analgesics,  narcotic 
Analgesics,  non-narcotic  general 
Antidotes 
Anesthetics 
Anesthetic  local/topical 
Antiarthritics 
Antiasthmatics 
Bronchial  dialators 
Xanthine  derivatives 
Antihistamines 
Antihistamines 
Antipruritics 
Antiinfectives 
Tetracyclines 
Penicillins 
Streptomycins 
Sulfonamides 
Erytrhomycins 
Cephalosporins 
Antibacterials,  urinary 
Chloramphenicol 
TB preparations 
Antiinfectives,  miscellaneous 
Antimalarials 
Trimethoprim 
Vaginal  cleaners 
Antineoplastics  (anti-tumor) 
Antiparkinson  drugs 
Autonomic  drugs 
Cardiovascular  preparations,  other 
Parasympathetic  agents 
Blood 
Antigoagulants 
Hemostatics 
B-l  Cardiac  drugs 
Vasodilators,  coronary 
Digitalis  preparations 
Cardiovascular 
Aldosterone  antagonists 
Lipotropics 
Cholesterol  reducers 
Rauwolfias 
Hypotensives,  other 
Vasodilators,  peripheral 
CNS drugs  (central  nervous  system) 
Anticonvulsants 
Contraceptives 
Cough  and cold  preparations 
Antitussives-expectorants 
Cough  and cold  preparations 
Adrenergics 
Diuretics 
Electrolyte,  caloric  and fluid  replacement 
Iodine  therapy 
Protein  lysates 
Electrolytes  & miscellaneous  nutrients 
Hematinics 
EENT  preparations-(eye,  ear,  nose,  and throat) 
Nasal and otic preparations,  topical 
Ophthalmic  preparations 
Gastrointestinal  preparations 
Anti-ulcer/other  gastrointestinal  preps 
Antidiarrheals 
Antispasmodic-anticholinergics 
Bile therapy 
Laxatives 
Antinauseants 
Digestants 
Hemorrhoidal  preparations 
Hormones 
Corticotropins 
Mineralocorticoids 
Anabolics 
Androgens 
Estrogens 
Progesterone 
Other  hormones 
Oxytocics 
B-2  Hypoglycemics 
Misc.  Med.  Supplies,  devices  & other  non drug 
Medical  supplies,  devices  and other  non-drug  products 
Muscle  relaxants 
Psychotherapeutic  drugs 
Ataractics-tranquilizers 
CNS  (central  nervous  system)  stimulants 
Psychostimulants-antidepressants 
Sedative  and hypnotics 
Sedative,  barbiturate 
Sedative,  non-barbiturate 
Skin preparations 
Antibiotics,  other 
Antiparasitics 
Antivirals 
Antibacterials  and antiseptics,  general 
Glucocorticoids 
Enzymes 
Emollients,  protectives 
Fungicides 
Dermatologicals,  all other 
Thyroid  preps 
Thyroid  preparations 
Antithyroid  preparations 
Biologicals 
Pre-natal  vitamins 
Multivitamins 
Vitamins,  all others 
Vitamins,  fat soluble 
Folic  acid preparations 
B complex  with  vitamin  c preparations 
Vitamin  k preparations 
Unclassified  drug  products 
B-3