BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON
          BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT
                              Senator Jerry Hill, Chair
                                2015 - 2016  Regular 

          Bill No:            SB 1174         Hearing Date:    April 11,  
          2016
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          |Author:   |McGuire                                               |
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          |Version:  |March 28, 2016                                        |
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          |Urgency:  |No                     |Fiscal:    |Yes              |
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          |Consultant|Sarah Mason                                           |
          |:         |                                                      |
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               Subject:  Medi-Cal:  children:  prescribing patterns:   
                              psychotropic medications


          SUMMARY: Adds to the list of cases that the Medical Board of California  
          (MBC) prioritizes for its investigative and prosecutorial  
          resources, the following:  "Repeated acts of clearly excessive  
          prescribing, furnishing, or administering psychotropic  
          medications to a minor without a good faith prior examination of  
          the patient and medical reason."  Requires the Department of  
          Health Care Services (DHCS) to provide quarterly data to MBC  
          related to prescriptions of psychotropic medications for foster  
          youth and requires the board to provide quarterly reports after  
          reviewing the information provided by DHCS and determine if any  
          potential violations of law or excessive prescribing of  
          psychotropic medications inconsistent with the standard of care  
          exist.

          Existing law:
          
         1)Provides for the licensure and regulation of physicians  
            and surgeons by the Medical Board of California (MBC)  
            pursuant to the Medical Practice Act (Act). (Business and  
            Professions Code (BPC) § 2000 et. seq.)

         2)Provides that the MBC shall take action against a  
            physician who is charged with unprofessional conduct, as  
            specified.  (BPC § 2234)








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         3)Requires MBC to prioritize its investigative and  
            prosecutorial resources to ensure that physicians and  
            surgeons representing the greatest threat of harm are  
            identified and disciplined expeditiously.  Requires cases  
            involving excessive prescribing, furnishing or  
            administering of controlled substances, or repeated acts  
            of prescribing, dispensing or furnishing of controlled  
            substance without a good faith prior examination of the  
            patient and medical reason to be handled as a high  
            priority.  States that physicians and surgeons shall not  
            be prosecuted for excessive prescribing when prescribing,  
            furnishing or administering controlled substances for  
            intractable pain as authorized under current law.  (BPC  
            §2220.05)

         4)Provides MBC with the authority to issue a probationary  
            physician's and surgeon's certificate to an applicant  
            subject to terms and conditions, including, but not  
            limited to practice limited to a supervised, structured  
            environment, continuing medical or psychiatric treatment,  
            ongoing participation in a specified rehabilitation  
            program, or abstention from the use of alcohol or drugs.   
            (BPC §2221)

         5)Authorizes a physician and surgeon to prescribe for, or  
            dispense or administer to, a person under his or her  
            treatment for a medical condition dangerous drugs or  
            prescription controlled substances for the treatment of  
            pain or a condition causing pain, including, but not  
            limited to, intractable pain.  Provides that a physician  
            and surgeon shall not be subject to disciplinary action  
            for prescribing, dispensing, or administering dangerous  
            drugs or prescription controlled substances according to  
            certain requirements.  Authorizes MBC to take any action  
            against a physician and surgeon who violates laws related  
            to inappropriate prescribing.  Provides that a physician  
            and surgeon shall exercise reasonable care in determining  
            whether a particular patient or condition, or the  
            complexity of a patient's treatment, including, but not  
            limited to, a current or recent pattern of drug abuse,  
            requires consultation with, or referral to, a more  
            qualified specialist.  
         (BPC § 2241.5)









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         6)Provides that only a juvenile court judicial officer shall  
            have authority to make orders regarding the  
            administration of psychotropic medications for a minor  
            who has been adjudged a dependent of the court and  
            removed from the physical custody of his or her parent.   
            Requires the Judicial Council to adopt rules of court and  
            develop appropriate forms.  (Welfare and Institutions  
            Code (WIC) § 369.5)

         7)Provides for the development of a statewide coordinated  
            training program designed specifically to meet the needs  
            of county child protective services social workers,  
            agencies under contract with county welfare departments  
            to provide child welfare services, and persons defined as  
            a mandated reporter pursuant to the Child Abuse and  
            Neglect Reporting Act.  (WIC §16206)

          8) Establishes a program of public health nursing in the  
             child welfare services program that provides  
             health-related case management services from a foster  
             care public health nurse to coordinate with child  
             welfare service workers to provide health care services  
             to children in foster care.  Includes among the duties  
             of public health nurses the monitoring and oversight of  
             psychotropic medications.  Requires public health nurses  
             to receive training related to psychotropic medications,  
             as specified.  (WIC § 16501.3)

          9) Requires Department of Social Services (DSS), in  
             consultation with DHCS, and other specified stakeholders  
             to develop county-specific monthly reports that describe  
             each child for whom one or more psychotropic medications  
             have been paid for under Medi-Cal, including authorized  
             medications, pharmacy data including the quantity and  
             dose of medications, other available information  
             regarding psychosocial interventions and incidents of  
             polypharmacy.  Requires DSS to develop training, in  
             consultation with DHCS, the Judicial Council, the County  
             Welfare Directors Association of California, the County  
             Behavioral Health Directors Association of California,  
             the Chief Probation Officers of California, and  
             stakeholders, that may be provided to county child  
             welfare social workers, probation officers, courts  
             hearing dependency or delinquency cases, children's  








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             attorneys, children's caregivers, court-appointed  
             special advocates, and other relevant staff who work  
             with children under the jurisdiction of the juvenile  
             court that addresses the authorization, uses, risks,  
             benefits, assistance with self-administration,  
             oversight, and monitoring of psychotropic medications,  
             trauma, and substance use disorder and mental health  
             treatments, including how to access those treatments  
          (WIC § 16501.4)  

          This bill:

          1) Adds repeated acts of clearly excessive prescribing,  
             furnishing, or administering psychotropic medications to a  
             minor without a good faith prior examination of the patient  
             and medical reason therefor to the list of cases that MBC  
             shall prioritize its investigative and prosecutorial  
             resources.

          2) Requires DHCS to provide quarterly data to MBC, in  
             collaboration with DSS that includes, but is not limited to,  
             the child welfare psychotropic medication measures and the  
             Healthcare Effectiveness Data and Information Set measures  
             related to psychotropic medications.  Specifies that data  
             provided to MBC shall include a breakdown by population of  
             the following and including rate and age stratifications for  
             birth to 5 years old, 6 to 11 years old and 12-17 years old:

             a)   Children prescribed psychotropic medications in managed  
               care and fee-for-service settings.

             b)   Children adjudged as dependent children and placed in  
               foster care.

             c)   Children in juvenile halls and children placed in  
               ranches, camps, or other facilities.

             d)   A minor adjudged a ward of the court who has been  
               removed from the physical custody of the parent and placed  
               into foster care.

             e)   Children with developmental disabilities.

          1) Requires MBC to review the information provided by DHCS on a  








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             quarterly basis in order to determine if any potential  
             violations of law or excessive prescribing of psychotropic  
             medications inconsistent with the standard of care exist and,  
             if warranted, to conduct an investigation.  Requires MBC to  
             take disciplinary action as appropriate if, after an  
             investigation, MBC concludes that there was a violation of  
             law, including a conclusion that there was excessive  
             prescribing of psychotropic medications inconsistent with the  
             standard of care.  Requires MBC to provide a quarterly report  
             to the Legislature, DHCS and DSS.


          FISCAL EFFECT:  Unknown.  This bill is keyed "fiscal" by  
          Legislative Counsel.  

          
          COMMENTS:
          
          1. Purpose.  This bill is sponsored by the  National Center for  
             Youth  and stems from a series of hearings held by the  
             California State Senate Committees on Health and Human  
             Services regarding the oversight and monitoring of  
             psychotropic medication and mental health services for youth  
             in foster care.
             
             According to the Author, over the past fifteen years, the  
             rate of foster youth prescribed psychotropic medication has  
             increased 1,400 percent.  Nearly 1 in 4 California foster  
             teens are prescribed psychotropic drugs; of those nearly 60  
             percent were prescribed an anti-psychotic - the powerful drug  
             class most susceptible to debilitating side effects.   The  
             Author states that while the Child and Family Services  
             Improvement and Innovation Act of 2011 requires each state to  
             oversee and monitor the use of psychotropic medications with  
             children in care, there are currently no requirements to  
             identify those who are over-prescribing medication to foster  
             youth.  According to the Author, the state has not been  
             monitoring over-prescribing because the data collection and  
             data sharing system is not in place but that given the  
             state's responsibility to monitor the administration of these  
             drugs and to ensure the health and well-being of foster  
             children, we should implement a process that provides the  
             appropriate oversight for these powerful medications.  The  
             Author states that by establishing a formal process for MBC  








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             to responsively review and confidentially investigate  
             psychotropic medication prescription patterns among  
             California children, the bill brings our state in line with  
             standard oversight practice in Washington, Illinois, and  
             Ohio, whose initiatives have shown a 25 percent decrease in  
             dangerous prescribing practices and have improved the overall  
             prescription frequency for medically acceptable reasons.

          2. Background.  

             a)   Psychotropic Medication.  According to background  
               information from recent Senate hearings on this issue,  
               concern over the use of psychotropic medications among  
               children has been well-documented in research journals and  
               the mainstream media for more than a decade. The category  
               of psychotropic medication is fairly broad, intending to  
               treat symptoms of conditions ranging from attention deficit  
               hyperactivity disorder (ADHD) to childhood schizophrenia.  
               Some of the drugs used to treat these conditions are U.S.  
               Food and Drug Administration (FDA)-approved, including  
               stimulants like Ritalin for ADHD, however only about 31  
               percent of psychotropic medications have been approved by  
               the FDA for use in children or adolescents.  It is  
               estimated that more than 
             75 percent of the prescriptions written for psychiatric  
               illness in this population are "off label" in usage,  
               meaning they have not been approved by the FDA for the  
               prescribed use, though the practice is legal and common  
               across all manner of pharmaceuticals. 
          
          Anti-psychotic medications, used to treat more severe mental  
          health conditions, include powerful brand-name drugs such as  
          Haldol, Risperdal, Abilify, Seroquel and Zyprexa.  They have  
          very limited approval by the FDA for pediatric use beyond rare  
          and severe conduct problems that are resistant to other forms of  
          treatment, such as Tourette's syndrome, behavioral symptoms  
          associated with autistic disorder, childhood schizophrenia, and  
          bipolar disorder.  However, the off-label use of these  
          anti-psychotics among children is high, particularly among  
          foster children. According to a study published in 2011,  
          children who took antipsychotic medications were likely to  
          suffer ill health effects including "cardio metabolic and  
          endocrine side-effects" as well as significant weight gain.  The  
          authors recommended that collaboration between child and  








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          adolescent psychiatrists, general practitioners and  
          pediatricians is essential to "reduce the likelihood of  
          premature cardiovascular morbidity and mortality." 

          Compounding the potential for unintended side effects is the use  
          of combinations of psychotropic medications, which foster youth  
          are particularly likely to be prescribed, despite limited  
          evidence of clinical efficacy.  Protecting the health and  
          well-being of children who are taking one or more psychotropic  
          medication requires extensive and ongoing health and metabolic  
          screenings to identify potential adverse effects quickly,  
          however in practice many children many fail to receive ongoing  
          screenings and adverse effects may go undetected causing  
          permanent injury or death.

             b)   Media Reports.  A recent series of stories published in  
               the San Jose Mercury News  and most recently in the Los  
               Angeles Times, highlighted growing concerns that  
               psychotropic medications have been relied on by  
               California's child welfare and children's mental health  
               systems as a means of controlling, instead of treating,  
               youth who suffer from trauma-related behavioral health  
               challenges.  The series detailed significant challenges in  
               accessing pharmacy benefits claims data held by the DHCS,  
               eventually overcome through a Public Records Act request  
               and lengthy negotiations, and demonstrated that prescribing  
               rates were far higher than had been anticipated by child  
               welfare system experts.

             c)   Court Oversight Mechanisms.   SB 543  (Bowen, Chapter 552,  
               Statutes of 1999) mandated that, once a child has been  
               adjudged a dependent of the state, only the court may  
               authorize psychotropic medications for the child, based on  
               a request from a physician that includes the following:  

                           The reasons for the request;
                           A description of the child's diagnosis and  
                    behavior;
                           The expected results of the medication; 
                           A description of any side effects of the  
                    medication. 

               Under the statute, psychotropic medications are defined as  
               those "administered for the purpose of affecting the  








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               central nervous system to treat psychiatric disorders or  
               illnesses.  These medications include, but are not limited  
               to, anxiolytic agents, antidepressants, mood stabilizers,  
               antipsychotic medications, anti-Parkinson agents,  
               hypnotics, medications for dementia, and psychostimulants."

               In accordance with this statute, the Administrative Office  
               of the Courts established a series of court documents  
               generally referred to as "the JV 220", which includes a  
               statement completed and signed by the prescribing physician  
               that includes the child's diagnosis, relevant medical  
               history, other therapeutic services, the medication to be  
               administered, and the basis for the recommendation. 

               In addition, a form must be included indicating notice has  
               been provided to the parents or legal guardians, their  
               attorneys of record, the child's attorney of record, the  
               child's guardian ad litem, the child's current caregiver,  
               the child's Court Appointed Special Advocate, if any, and  
               if a child has been determined to be an Indian child, the  
               Indian child's tribe.  The procedure for notification  
               varies by county - the responsibility may fall primarily to  
               the child welfare agency, or it may be shared with the  
               juvenile court clerk's office that may be responsible for  
               notifying the attorney and the Court Appointed Special  
               Advocate.

               Within four court days after notification, a parent or  
               guardian, the child, the attorney for either, the guardian  
               ad litem, or the Indian child's tribe may file an objection  
               to the application.  Following this period, the court files  
               a final order.

             a)   Oversight Concerns.  Stakeholders have expressed  
               concerns about the efficacy of oversight mechanisms, given  
               that in many counties the court lacks access to medical  
               experts to assist in evaluating medical information.  Child  
               welfare advocates and clinicians reported that in many  
               instances a prescribing physician who fills out the JV 220  
               form may not have a history of treating the child, and thus  
               may not be aware of prior medications or alternative  
               treatments that have (or have not) been tried.  Such  
               information is frequently left blank on the JV 220.   
               Additionally the California Drug Use Review recently found  








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               that fewer than four in ten children had received the  
               required baseline laboratory screenings prior to being  
               administered a psychotropic medication.  In theory, a  
               health and education passport - a paper file of the youth's  
               medical history - is supposed to be provided to a new  
               caregiver, who might provide important information to a  
               prescribing physician; however it is common for a child to  
               move between placements without the requisite records,  
               leaving the foster parent also unaware of the child's  
               medical history.
          
          The JV 220 form offers little opportunity for input from the  
          community of representatives and caregivers involved with the  
          youth except to offer a short window of opportunity to formally  
          object.  Furthermore, the form does not include information  
          related to baseline or ongoing screening, it does not require  
          consideration of alternative treatments (though it provides a  
          field inquiring about them), nor does it offer substantive  
          opportunities for relevant parties to weigh in with important  
          information that may be worthy of consideration by the court.  

          In 2012, DHCS and DSS convened a statewide Quality Improvement  
          Project (QIP) to design, pilot, and evaluate effective practices  
          to improve psychotropic medication use among children and youth  
          in foster care. Three workgroups were established for the  
          project-the Clinical Workgroup, the Data and Technology  
          Workgroup, and the Youth, Family, and Education Workgroup to  
          jointly conduct analysis of child welfare data, develop tools to  
          assist prescribers, pharmacists, and juvenile courts, as well as  
          develop and disseminate training materials and information about  
          psychotropic medications for youths and caregivers. 

          QIP's Data and Technology Workgroup released a summary report in  
          December 2014 matching data from Child Welfare Services/Case  
          Management System (CWS/CMS) and DHCS that detailed  
          fee-for-service and Medi-Cal managed care encounter data  
          pharmacy paid claim records for psychotropic medication for  
          children in foster care during Federal Fiscal Year (FFY)  
          2012-13.  The report found that of 10,557 children (under the  
          age of 21) in California who received at least one paid claim  
          for psychotropic medication during FFY 2012-13, 10,419 (or 98  
          percent) of these children were identified as youth in an active  
          out-of-home placement. The report further broke down the data  
          based on age, gender, ethnic group, placement type, responsible  








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          agency, time in care, and time in placement.

          Although the data produced a wide scope of the breakdown  
          surrounding psychotropic drug prescriptions to foster youth, the  
          report also cautions that there are a number of key analytical  
          considerations when reviewing the data. The report states that  
          the figures presented are not necessarily representative of  
          youth for whom court authorizations for psychotropic medications  
          are required, as it includes youths aged 18-20 years old placed  
          with non-dependent legal guardians and other non-foster care  
          placements as well as youth for whom court authorizations for  
          psychotropic medications are required.  In addition, the report  
          states that since only the most recent paid claim for youth  
          under 21 years old was used to examine the case and placement  
          information, this data might not necessarily be reflective of  
          their experience in care or the experiences of youth before and  
          after the period of study.

             b)   Guidelines.  The QIP's Clinical Workgroup released a set  
               of guidelines to assist prescribers and caregivers in  
                                                                          maintaining compliance with State and county regulations  
               and guidelines pertaining to Medi-Cal funded mental health  
               services and psychotropic prescribing practices for foster  
               homes, group homes, and residential treatment centers.  In  
               addition, the guidelines include prescriber and caregiver  
               expectations regarding developing and monitoring treatment  
               plans for behavioral health care, principles for informed  
               consent to medications, and governing medication safety.
          
          These guidelines are designed as a statement of best practice  
          for the treatment of children and youth in out-of-home care and  
          include:

                           Prescribing standards for psychotropic  
                    medication by age group;
                           Parameters for psychotropic medication  
                    indications, dosing, and monitoring;
                           Recommendations to address challenges in the  
                    management of complex cases; and
                           Decision "algorithm" to be used by  
                    prescribers.

             a)   Efforts in Other States.  According to information  
               provided by the Author, a number of other states have taken  








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               action to address concerns about psychotropic medication.   
               Alabama provides a focused mailing to prescribers of any  
               antipsychotics to children under 18, as well as telephone  
               outreach by child psychiatrists to prescribers of  
               antipsychotics to children under age five.  Colorado sends  
               educational alerts and letters to prescribers detailing  
               information about the psychiatric medication utilization of  
               their patients.  In Colorado, if post-intervention changes  
               are not observed, follow-up letters and face-to-face  
               meetings with peer consultants are conducted.  Illinois  
               maintains a watch-list of high-risk prescribers, utilizing  
               this data to assess the impact of changes in consent  
               policies on prescriber behaviors.  Michigan created a  
               system whereby child psychiatrists follow-up with  
               prescribing physicians based on established triggers to  
               review the case and provide consultation.  Missouri uses  
               the Behavioral Pharmacy Management System to analyze  
               prescribing patterns for children and adolescents and send  
               letters to prescribers offering consultation on best  
               prescribing practices.  An analysis of this intervention  
               showed a significant reduction in the percentage of outlier  
               prescriptions.

          1. Medical Board Efforts to Provide Guidance to Licensees on  
             Prescribing.  
          MBC utilizes guidelines for prescribing controlled substances  
             for pain that the board established.  In 1994, MBC  
             unanimously adopted a policy statement entitled "Prescribing  
             Controlled Substances for Pain" stemming studies and  
             discussions about controlled substances which was designed to  
             provide guidance to improve prescriber standards for pain  
             management, while simultaneously undermining opportunities  
             for drug diversion and abuse.  The guidelines outlined  
             appropriate steps related to a patient's examination,  
             treatment plan, informed consent, periodic review,  
             consultation, records, and compliance with controlled  
             substances laws.  Guidelines are used by physicians as well  
             as MBC in its regulation of licensees. 

             Subsequent to MBC's 1994 action, legislation that took effect  
             in 2002 (AB 487, Aroner, Chapter 518, Statutes of 2001) that  
             created a task force to revisit the 1994 guidelines to  
             develop standards assuring competent review in cases  
             concerning the under-treatment and under-medication of a  








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             patient's pain and also required continuing education courses  
             for physicians in the subjects of pain management and the  
             treatment of terminally ill and dying patients.  As a result,  
             the task force amended the guidelines from referencing only  
             intractable pain to all kinds of pain.  

             Guidelines were further updated following the passage of AB  
             2198 in 2006 (Houston, Chapter 350, Statutes of 2006),  
             clarifying that health care professionals with a medical  
             basis, including the treatment of pain, for prescribing,  
             furnishing, dispensing, or administering dangerous drugs or  
             prescription controlled substances, may do so without being  
             subject to disciplinary action or prosecution.  AB 2198  
             stemmed from MBC's efforts to better reflect the current  
             state of treating pain, as well as the current manner of  
             investigating and disciplining physicians who treat patients  
             with pain, who often require large quantities of medication.   


             MBC currently encourages all licensees to consult the policy  
             statement and Guidelines for Prescribing Controlled  
             Substances for Pain.  MBC also highlights that while it is  
             lawful under both federal and California law to prescribe  
             controlled substances for the treatment of pain, including  
             intractable pain, there are limitations on the prescribing of  
             controlled substances to or for patients for the treatment of  
             chemical dependency.  MBC expects that a licensee follow the  
             same standard of care when prescribing and/or administering a  
             narcotic controlled substance to a "known addict" patient as  
             he or she would for any other patient.  

             MBC has made available to all licensees on its website as  
             well as through an email to its licensee listserv the QIP's  
             Guidelines for the Use of Psychotropic Medication with  
             Children and Youth in Foster Care which states that "the use  
             of psychotropic medication for children and youth is  
             considered a non-routine intervention, used under specified  
             circumstances and as only one strategy within a larger, more  
             comprehensive treatment plan to provide for that child's  
             safety and well-being".  MBC's responsibilities in overseeing  
             their licensees' prescribing habits of psychotropic  
             medications to foster youth are also a component of an audit  
             currently being conducted by the California State Auditor  
             pertaining to the oversight and monitoring of children in  








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             foster care who have been prescribed psychotropic  
             medications.

             At the October 2015 MBC meeting, the Board discussed  
             strategies to help identify physicians who may be  
             inappropriately prescribing psychotropic medications to  
             foster youth as well as identify additional information  
             needed from DHCS and DSS. However, there were concerns raised  
             about the expectations of physicians based on the quality of  
             information in the QIP's Psychotropic Data Match Report.  The  
             MBC has expressed concerns that the data presented in the  
             report may not be sufficient to make a decision as to  
             appropriate prescribing practices for physicians working with  
             foster youth. 

             The Board has, in the meantime, developed a notification  
             process whereby individuals in the healthcare delivery system  
             for foster youths can directly contact MBC staff if they  
             believe a physician is inappropriately prescribing medication  
             to children in foster care.  After a complaint or  
             notification is made, MBC staff will directly contact DSS to  
             obtain all de-identified patient information for the foster  
             child and the prescriber. The Board can then determine  
             whether or not it will need patient records. DSS and the MBC  
             can then obtain these patient records through a court order  
             so that the Board can proceed with an investigation into the  
             prescribing physician.

          4.Data Sharing Efforts.  MBC currently has a data user agreement  
            (DUA) with DHCS and DSS in order to allow the MBC to receive  
            information that does not breach the confidentiality of a  
            patient.  The agreement is based on conversations dating back  
            to 2014 regarding the data needed for the MBC to identify  
            physicians who may be inappropriately prescribing psychotropic  
            medications to foster children.  Upon receipt of its first set  
            of data under the DUA, MBC enlisted a pediatric psychiatrist  
            review the data.  The physician determined that the  
            information provided through the agreement was not substantive  
            enough to allow MBC to identify instances of any inappropriate  
            prescribing and noted that additional information to assist in  
            this effort would include the diagnosis associated with  
            medication prescribed, the dosage of medication prescribed,  
            the schedule or timing of dosage of medication prescribed and  
            the weight of child or adolescent.








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          5.Prior Related Legislation.   SB 238  (Mitchell, Chapter 534,  
            Statutes of 2015) required certification and training programs  
            for foster parents, child welfare social workers, group home  
            administrators, public health nurses, dependency court judges  
            and court appointed council to include training on  
            psychotropic medication, trauma, and behavioral health, as  
            specified, for children receiving child welfare services. The  
            bill also required Judicial Council to amend and adopt rules  
            of court and develop appropriate forms pertaining to the  
            authorization of psychotropic medication for foster youth, on  
            or before July 1, 2016.  
           
            SB 253  (Monning) of 2015 was also intended to respond to  
            troubling reports about overprescribing of psychotropic  
            medication to foster youth and would have provided a detailed  
            framework the court must use when determining whether to  
            approve the administration of psychotropic medication to wards  
            and foster children, and required judicial oversight of any  
            ongoing treatment to help ensure that these powerful drugs are  
            only used when medically necessary and appropriate for the  
            particular child and that such usage is very carefully  
            monitored to ensure any benefits of the medication are not  
            outweighed by its short- and long-term risks.  The bill also  
            would have required an order of the juvenile court authorizing  
            psychotropic medication to require clear and convincing  
            evidence of specified conditions and would have prohibited the  
            authorization of psychotropic medications without a second  
            independent medical opinion under specified circumstances, as  
            well as would have prohibited the authorization of  
            psychotropic medications unless the court was provided  
            documentation that appropriate lab screenings, measurements,  
            or tests have been completed, as specified.  (  Status:   The  
            bill was placed on inactive in the Assembly.)
             
            SB 484  (Beall, Chapter 540, Statutes of 2015) required DSS to  
            establish a methodology for identifying group homes that have  
            levels of psychotropic dug utilization warranting additional  
            review, and to inspect identified facilities at least once a  
            year, as specified. The bill permitted DSS to share  
            information and observations with the facility and to require  
            the facility to submit a plan within 
            30 days to address identified risks, as specified.  
             








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            SB 319  (Beall, Chapter 535, Statutes of 2015) expanded the  
            duties of the foster care public health nurse to include  
            monitoring and oversight of the administration of psychotropic  
            medication to foster children, as specified. 
          
          6.Arguments in Support.  Numerous groups such as the  Youth Law  
            Center  ,  Consumer Attorneys of California  , and  First Focus  
            Campaign for Children  support SB 1174, citing the frequency of  
            psychotropic drug prescription among foster youth. These  
            groups call for an appropriate oversight mechanism that can  
            help identify outlying prescribers. They argue that SB 1174  
            will enable MBC to confidentially collect and analyze data,  
            and, when warranted, conduct investigations of physicians who  
            frequently prescribe over the recognized safety parameters for  
            children.

          7.Arguments in Opposition.  The  California Medical Association   
            (CMA) is concerned that SB 1174 adds another bureaucratic  
            layer to a process that is already highly regulated and are  
            concerned that the bill will delay or prevent some youth from  
            receiving appropriate treatments as well as discouraging  
            physicians from working within the Medi-Cal program.  CMA  
            notes that because the medical records are protected, the data  
            that provided to the MBC will provide an incomplete picture  
            without the underlying medical records which can only be  
            obtained through a court order or if the patient waives  
            confidentiality.  CMA believes that investigations will target  
            physicians working specifically within the Medi-Cal system or  
            mental health professionals who specialize with patients with  
            severe mental health difficulties.  CMA cites the example of a  
            psychiatrist who works exclusively in Juvenile Hall or group  
            homes as potentially having a much higher rate of psychotropic  
            prescriptions to children than a psychiatrist providing  
            services to the general population which will trigger that  
            physician being investigated. 
            
            CMA believes that this bill has the potential to discourage  
            physicians from working within the Medi-Cal program which is  
            already suffering from access problems as well as cause some  
            physicians not to prescribe psychotropic medications even if  
            they feel it is an appropriate treatment option.

             CMA is requesting an amendment to ensure that educational  
             outreach be required before MBC could initiate an  








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             investigation based on the data received from DHCS. They  
             suggest that the guidelines could be a useful tool as the  
             centerpiece of educational outreach.  
          
          SUPPORT AND OPPOSITION:
          
           Support
           Bay Area Youth Center
          California Youth Connection
          Consumer Attorneys of California
          Consumer Watchdog
          Family Voices of California 
          First Focus Campaign for Children
          John Burton Foundation
          Kids in Common, a program of Planned Parenthood Mar Monte
          Madera County Department of Social Services
          Peers Envisioning and Engaging in Recovery Services 
          Therapists for Peace and Justice
          Woodland Community College Foster and Kinship Care Education
          Youth Law Center
          One individual
          
          Oppose
           
          California Medical Association

                                      -- END --