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)
SB 1174 (McGuire) Page 3
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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 --