BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 1174|
|Office of Senate Floor Analyses | |
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THIRD READING
Bill No: SB 1174
Author: McGuire (D), et al.
Amended: 3/28/16
Vote: 21
SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 8-0, 4/11/16
AYES: Hill, Berryhill, Block, Galgiani, Hernandez, Jackson,
Mendoza, Wieckowski
NO VOTE RECORDED: Bates
SENATE APPROPRIATIONS COMMITTEE: 6-0, 5/27/16
AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza
NO VOTE RECORDED: Nielsen
SUBJECT: Medi-Cal: children: prescribing patterns:
psychotropic medications
SOURCE: National Center for Youth
DIGEST: This bill adds the following causes of action to the
Medical Board of California's (MBC) list of priority cases for
investigation and prosecution: "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;" and requires the Department of
Health Care Services (DHCS) to provide quarterly data to MBC on
psychotropic medications prescribed to foster youth and requires
the MBC to provide quarterly reports on violations of the law or
standards of care.
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ANALYSIS:
Existing law:
1)Provides for the licensure and regulation of physicians
and surgeons by the MBC pursuant to the Medical Practice
Act (Act). (Business and Professions Code (BPC) Sections
2000 et seq.)
2)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
substances without a good faith prior examination of the
patient and medical reason to be handled as a high
priority. Specifies 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)
3)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.
(Welfare and Institutions Code (WIC) § 369.5)
4) 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)
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5) 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, other available information regarding psychosocial
interventions and incidents of polypharmacy. (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 for which
MBC must prioritize its investigative and prosecutorial
resources.
2) Requires DHCS, in collaboration with DSS, to provide
quarterly data to MBC 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 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.
Background
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
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authors recommended that collaboration between child and
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
medications 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.
Medical Board Efforts to Provide Guidance to Licensees on
Prescribing. The MBC made available to all licensees on its Web
site, as well as through an e-mail to its licensee listserv, the
DHCS and DSS's statewide Quality Improvement Project (QIP)
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 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.
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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.
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 to
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.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee:
Ongoing costs up to $280,000 per year for the DHCS to analyze
prescription drug claims data and compile required information
for the MBC (General Fund and federal funds). The DHCS's
information technology systems contain prescription drug
claims data (when combined with information from the DSS on
foster care placements) to provide the data required to
fulfill the requirements in the bill. DHCS indicates that it
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will need two additional staff positions to compile the
required data, stratify it into the required data categories,
and report to the MBC.
However, as part of recent efforts to reduce overprescribing
of psychotropic medications to foster youth, the DHCS has been
working with the DSS and counties to identify foster youth
being prescribed such medications. The Governor's budget
proposal includes an additional permanent position to continue
this work. If approved by the Legislature, that new position
may be able to also perform some or all of the requirements of
this bill as well.
Uncertain costs for the MBC to review the information provided
by the DHCS and investigate instances where excessive
prescribing may be occurring (Contingent Fund of the MBC).
According to the MBC, its staff are already reviewing data
provided by the DHCS to look for cases of excessing
prescribing. However, to the extent that such data analysis
does uncover instances of excessing prescribing, this would
lead to increased costs for investigations and potential
disciplinary action by the MBC. While those instances of
excessing prescribing may already be actionable by the MBC
under current law and regulation, the data analysis required
in the bill makes such investigations more likely to occur.
Unknown potential cost savings in the Medi-Cal program due to
reduced inappropriate utilization of psychotropic medications
by foster youth. To the extent that this bill contributes to
ongoing efforts to reduce inappropriate use of those drugs by
Medi-Cal beneficiaries, the bill is likely to reduce spending.
Ongoing efforts in other states to reduce inappropriate
prescribing have substantially reduced the use of these
frequently expensive medications. The amount of any decrease
in spending that could be attributed to this bill is
uncertain, in part because there are several efforts underway
by the state and the counties to reduce inappropriate
prescribing of psychotropic drugs to foster youth.
SUPPORT: (Verified5/27/16)
National Center for Youth (source)
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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
OPPOSITION: (Verified5/27/16)
California Medical Association
California Academy of Child and Adolescent Psychiatry
ARGUMENTS IN SUPPORT: Numerous groups such as the Youth Law
Center, Consumer Attorneys of California, and First Focus
Campaign for Children support this bill, 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 this bill 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.
ARGUMENTS IN OPPOSITION:The California Medical Association (CMA)
is concerned that this bill 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
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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 investigation
based on the data received from DHCS. They suggest that the
guidelines could be a useful tool as the centerpiece of
educational outreach.
Prepared by:Sarah Mason / B., P. & E.D. / (916) 651-4104
5/28/16 16:46:01
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