BILL ANALYSIS Ó
SB 1174
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Date of Hearing: June 28, 2016
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Rudy Salas, Chair
SB 1174(McGuire) - As Amended June 22, 2016
SENATE VOTE: 36-3
NOTE: This bill is double-referred, having been previously heard
by the Assembly Committee on Health on June 21, 2016 and
approved on a 13-0 vote.
SUBJECT: Medi-Cal: children: prescribing patterns:
psychotropic medications
SUMMARY: Requires the Medical Board of California (MBC) to
conduct an analysis of data regarding Medi-Cal physicians and
their prescribing patterns of psychotropic medications for
foster youth using data provided by the Department of Health
Care Services (DHCS) and the Department of Social Services
(DSS), as specified. Requires that the data be shared pursuant
to a data-sharing agreement and would require that, every 3
years, the MBC, DHCS, and the DSS consult and revise the
methodology, if determined to be necessary. Requires the DHCS
to disseminate guidelines on an annual basis via email to any
prescriber, as specified. Requires the MBC to handle on a
priority basis investigations of repeated acts of excessive
prescribing, furnishing, or administering psychotropic
medications to a minor, as specified.
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EXISTING LAW:
1)Establishes the MBC within the Department of Consumer Affairs
(DCA) to license and regulate physician and surgeons and the
Medical Practice Act (Act). (Business and Profession Code
(BPC) § 2000 et seq.)
2)Requires the MBC to take action against a physician and
surgeon who is charged with unprofessional conduct, as
specified. (BPC § 2234)
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. Prohibits physicians and surgeons from being
prosecuted for excessive prescribing when prescribing,
furnishing or administering controlled substances for
intractable pain as authorized under current law. (BPC §
2220.05(a)(3))
4)Requires the MBC to indicate in its annual report the number
of temporary restraining orders, interim suspension orders,
and disciplinary actions that are taken in each priority
category, including those in 3) above. (BPC § 2220.05(c))
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.
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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 the
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)
6) Provides that only a juvenile court judicial officer
shall have authority to make orders regarding the
administration of psychotropic medications for a minor
is 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)Establishes a program of public health nursing in the child
welfare services (CWS) program that provides health-related
case management services from a foster care public health
nurse to coordinate with CWS 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. (WIC § 16501.3)
8)Requires 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 paid
claims and managed care encounters. Requires DSS to develop
training, in consultation DHCS and various other agencies that
may be provided to county child welfare social workers and
others that addresses the use of psychotropic medications.
(WIC § 16501.4)
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THIS BILL:
9)Adds repeated acts of clearly excessive prescribing,
furnishing, or administering psychotropic medications to a
minor without a good faith prior examination and medical
reason therefor to the list of cases that MBC must prioritize
for investigation and prosecution.
10)Requires MBC to conduct on a quarterly basis an analysis of
Medi-Cal physicians and their prescribing patterns of
psychotropic medications and related services using data
provided quarterly by the DHCS in collaboration with the DSS.
11)Requires that analysis to include, but not be limited to, the
child welfare psychotropic medication measures and the
Healthcare Effectiveness Data and Information Set measures
related to psychotropic medications.
12)Requires the data concerning psychotropic medications and
related services to be shared pursuant to a data sharing
agreement meeting the requirements of all applicable state and
federal laws and regulations.
13)Requires MBC, DHCS, and DSS to consult and revise the
methodology every three years, if determined to be necessary.
14)Requires the data provided to the MBC pursuant to 4) and 5)
above include a breakdown by population of all of the
following:
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a) Children prescribed psychotropic medications in managed
care and fee-for-service settings;
b) Children adjudged as dependent children, as specified,
and placed in foster care; and,
c) A minor adjudged a ward of the court who has been
removed from the physical custody of the parent and placed
into foster care.
15)Specifies that the data provided to the MBC must include
total rate and age stratifications that include the following:
a) Birth to five years of age, inclusive;
b) Six to 11 years of age, inclusive; and,
c) Twelve to 17 years of age, inclusive.
16)Requires the data provided to the MBC to include the
information in 7) above for each prescriber with a pattern of
prescribing that includes one or more of the following:
a) Prescriptions for any class of psychotropic medication
for a child who is five years of age or younger;
b) Prescriptions for concurrent administration of two or
more antipsychotic medications that exceed 60 days;
c) Prescriptions for concurrent administration of three or
more psychotropic medications exceeding 60 days; and,
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d) Prescriptions for a dosage that exceeds the amount
recommended for children.
9)Requires that the data provided to MBC pursuant to 2) above
include the following information on each identified
prescriber:
a) Prescriber name, specialty, location, and contact
information;
b) The child's gender and year of birth;
c) List of the psychotropic medications prescribed,
diagnosis, and the medication start and end date;
d) Unit of the medication(s), quantity of the
medication(s), the days supply, and prescription fill date:
and,
e) The child's weight.
10)Requires the MBC on a quarterly basis to review the data
provided pursuant to 1) through 5) above in order to determine
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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.
11)Requires the DHCS to disseminate guidelines on an annual
basis via email to any prescriber who meets the data
requirement threshold for prescribing of psychotropic
medications to children and adolescents, as specified.
12)Requires the MBC to take disciplinary action if after an
investigation, the MBC concludes that there was a violation of
law, as specified.
13)Requires the MBC to take action, as appropriate, if after an
investigation the MBC concludes that there was excessive
prescribing of psychotropic medications inconsistent with the
standard of care, as specified.
14)Requires, beginning July 1, 2017, the MBC to report annually
to the DHCS, DSS, and the Legislature the results of the
analysis of data.
FISCAL EFFECT: According to the Senate Appropriations
Committee, this bill will result in:
1)Ongoing costs up to $280,000 per year for the DHCS to analyze
prescription drug claims data and compile required information
for the Medical Board. The DHCS's information technology
systems contain prescription drug claims data (when combined
with information from the DSS on foster care placements) to
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provide the data required to fulfill the requirements in the
bill. The DHCS indicates that it will need two additional
staff positions to compile the required data, stratify it into
the required data categories, and report to the Medical Board.
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.
2)Uncertain costs for the MBC to review the information provided
by the DHCS and investigate instances where excessive
prescribing may be occurring. According to the MBC, its staff
is 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
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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.
COMMENTS:
Purpose. This bill is sponsored by the National Center for
Youth Law . 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. 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. The State of
California has not been monitoring over prescribing because the
data collection and data sharing system is not in place. Given
the State has a 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. SB 1174
will establish a formal process for the [MBC] to responsively
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review and confidentially investigate psychotropic medication
prescription patterns among California children."
Background. Psychotropic Medications Prescribed to Foster
Youth. According to information obtained from the Child Welfare
Indicator Project, 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.
A number of factors contribute to the potential for
inappropriate psychotropic prescribing practices including:
A lack of access to effective non-pharmacological
interventions and a reliance on medications to quickly
control difficult behaviors;
An inadequate supply of child behavioral health
specialists with training in evidence-based,
trauma-informed practices;
Limited clinical knowledge among child welfare case
workers about appropriate psychotropic medication use;
A lack of coordination across providers and
child-serving agencies; and,
Aggressive, effective pharmaceutical marketing and
financial incentives that drive prescribing.
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In November of 2011, the Centers for Medicare and Medicaid
Services (CMS), the Substance Abuse and Mental Health Services
Administration (SAMHSA), and the Administration for Children and
Families (ACF), wrote a joint letter encouraging states to
strengthen oversight of psychotropic medication use among the
foster youth population.
The MBC and the DHCS Data Use Agreement. In 2014, Senator Ted
Lieu, then chair of the Senate Committee on Business,
Professions, and Economic Development, sent a letter to the MBC
in response to several newspaper articles which asserted that
some doctors were prescribing drugs that have not been approved
for children, and without reviewing the children's medical
records or drug history (San Jose Mercury News, "Drugging Our
Kids", 2014). Senator Lieu requested that the MBC investigate
these medical professionals and develop recommendations to
minimize dangerous prescribing practices. In response, the MBC
and the DHCS adopted a one year trial Data Use Agreement that
allows for the sharing of prescriber data in order to identify
prescribing patterns of licensees.
This bill would codify the Data Use Agreement allowing the MBC
and DHCS to continue identifying licensees who appear to be
incorrectly prescribing medication to foster youth and flag them
for investigation.
State Auditor Report. The California State Auditor (CSA) is
currently engaged in an audit of foster youth and psychotropic
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medication. It is expected to be released in July or August of
2016. According to information obtained from the CSA website,
the audit will select and review four county CWS agencies-two
counties identified as having a high prevalence of the use of
psychotropic medications for foster children and two counties
with a correspondingly low prevalence. The audit will provide
independently developed and verified information related to the
DSS, DHCS, and a selection of county CWS agencies' oversight and
monitoring of foster children who have been prescribed
psychotropic medications, as well as a review of the
availability and adequacy of other supportive services, such as
mental health and substance abuse counseling. The audit will
also determine whether any other states have implemented
innovations or oversight systems that have successfully reduced
the use of psychotropic medications in foster children or
improved their access to non-pharmacological supports, and
evaluate whether California could benefit from similar policies
or practices.
Other States. 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. 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.
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Michigan created a system whereby child psychiatrists follow-up
with prescribing physicians when indicated 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.
ARGUMENTS IN SUPPORT:
The National Center for Youth Law (sponsor), Children Now , John
Burton Foundation , and the Bay Area Youth Center similarly write
in their letters of support, "Last year, the [DHCS] and the
[MBC] adopted a one-year trial Data Use Agreement that allows
for the sharing of prescriber data in order to identify outlying
prescribers. Such data sharing practices should not be on a
one-time basis, but rather an ongoing process for improving the
quality of prescribing for our children."
Advokids writes in their letter of support, "We demand high
quality, accessible mental health services for foster children
and the careful collection of data surrounding psychotropic
medications to ensure the physical and emotional safety of our
foster youth."
The Children's Partnership writes, "TCP strongly supports SB
1174, which will establish a formal process for the MBC to
responsively review and confidentially investigate psychotropic
medication prescription patterns among California children."
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Consumer Watchdog writes in support, "Over the last year, the
legislature has taken important steps to protect the health and
safety of foster youth. SB 1174 provides the [MBC] with the
information it needs to ensure that physicians' prescribing
patterns are shifting in response to those reforms."
The Medical Board of California supports the bill if amended and
writes, "This bill will further the [MBC's] mission of consumer
protection for a very vulnerable population. The [MBC] is
actively working with the author's office and the sponsors on
amendments, as the [MBC] would like a sunset date included in
this bill so the [MBC] can determine if the data provided is
useful to the [MBC]."
The Pacific Juvenile Defender Center writes in support, "This
bill enables the 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 Child Academy of Child and Adolescent Psychiatry has an
opposed unless amended position and writes, "We would like for
this bill to require the MBC to contract with a Board Certified
Child and Adolescent Psychiatrist for the purposes of reviewing
the data that is proposed; We believe that a more refined data
set will help further the goals for this legislation? the LA
County Parameters? are a more appropriate starting point for the
MBC to review prescribing practices?If the investigation [of a
licensee] should not result in disciplinary action, questions
regarding whether or not a physician has ever been investigated
by the MBC come up often?[W]e believe the envisioned process
will have a negative impact on the ability of the Medi-Cal
system to recruit and retain high quality providers."
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REGISTERED SUPPORT:
National Center for Youth Law (sponsor)
Advokids
Bay Area Youth Center
Children Now
The Children's Partnership
Consumer Watchdog
John Burton Foundation
Medical Board of California (support if amended)
Pacific Juvenile Defender Center
REGISTERED OPPOSITION:
Child Academy of Child and Adolescent Psychiatry
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Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301