BILL ANALYSIS Ó SB 1174 Page 1 SENATE THIRD READING SB 1174 (McGuire) As Amended August 3, 2016 Majority vote SENATE VOTE: 36-3 ------------------------------------------------------------------ |Committee |Votes|Ayes |Noes | | | | | | | | | | | | | | | | |----------------+-----+----------------------+--------------------| |Health |13-0 |Wood, Maienschein, | | | | |Bonilla, Burke, | | | | |Campos, | | | | | | | | | | | | | | |Roger Hernández, | | | | |Lackey, Nazarian, | | | | |Ridley-Thomas, | | | | |Santiago, Steinorth, | | | | |Thurmond, Waldron | | | | | | | |----------------+-----+----------------------+--------------------| |Business & |16-0 |Salas, Brough, Baker, | | |Professions | |Bloom, Campos, | | | | |Chávez, Dahle, Dodd, | | | | |Eggman, Gatto, Gomez, | | | | |Holden, Jones, | | SB 1174 Page 2 | | |Mullin, Ting, Wood | | | | | | | |----------------+-----+----------------------+--------------------| |Appropriations |19-0 |Gonzalez, Bigelow, | | | | |Bloom, Bonilla, | | | | |Bonta, Calderon, | | | | |Daly, Eggman, | | | | |Gallagher, | | | | | | | | | | | | | | |Eduardo Garcia, | | | | |Holden, Jones, | | | | |Obernolte, Quirk, | | | | |Santiago, Wagner, | | | | |Weber, Wood, Chu | | | | | | | | | | | | ------------------------------------------------------------------ SUMMARY: Requires the State Department of Health Care Services (DHCS) and the State Department of Social Services (DSS), to provide the Medical Board of California (MBC) with information to conduct an analysis of Medi-Cal and managed care prescribing patterns of psychotropic medications to determine if excessive prescribing exists and, if so, to take appropriate action and adds repeated acts of clearly excessive prescribing psychotropic medications to a minor without a good faith prior examination to the list of cases that MBC must prioritize investigating and prosecuting. EXISTING LAW: 1)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 SB 1174 Page 3 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. 2)Provides that only a juvenile court judicial officer has the authority to make orders regarding the administration of psychotropic medications for a minor who is a dependent of the court. Requires that court authorization for the administration of psychotropic medications be based on a request from a physician, indicating the reasons for the request, a description of the child's diagnosis and behavior, the expected results of the medication, and a description of any side effects of the medication. Requires the Judicial Council, on or before July 1, 2016, to adopt rules and develop appropriate forms for implementing this requirement. Requires the rules and forms to address all of the following: a) The child and his or her caregiver and Court Appointed Special Advocate (CASA), if any, have an opportunity to provide input on the medications being prescribed; b) Information regarding the child's overall mental health assessment and treatment plan is provided to the court; c) Information regarding the rationale for the proposed medication, provided in the context of past and current treatment efforts, is provided to the court; and, d) Guidance is provided to the court on how to evaluate the request for authorization. 3)Requires that the court either approve or deny a physician's SB 1174 Page 4 request, pursuant to 2) above, within seven business days of its receipt. 4)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. 5)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. FISCAL EFFECT: According to the Assembly Appropriations Committee, costs to DHCS, MBC, and DSS are expected to be minor and absorbable, as this bill largely aligns with existing activities that are not likely to cease in absence of this bill. COMMENTS: According to the author, this bill stems from a growing and significant concern over the excessive prescribing of psychotropic medication to foster youth in California. It follows a series of hearings held by the California Senate Committees on Health and Human Services regarding the oversight and monitoring of psychotropic medication and mental health services for youth in foster care. Even with the growing attention to this situation, the problem is now more severe than ever and California's 63,000 foster youth are the ones who are suffering the consequences of our state's inaction and lack of oversight over the past 15 years. According to the author, SB 1174 Page 5 despite our current safeguards in place - the JV-220 process, whereby judges decide what medications and at what dosage are provided to foster youth, over the past fifteen years the rate of foster youth prescribed psychotropic medication has increased 14 fold. The author states that nearly one in four California foster teens are prescribed psychotropic drugs; of those nearly 60% were prescribed an anti-psychotic (an estimated 75% of them for an off label use) and 36% are prescribed multiple medications. The author states that, as reported by the San Jose Mercury News, the federal Food and Drug Administration authorizes antipsychotics for children only in cases of severe mental illness, but evidence suggests medical professionals often prescribe them to California foster children for behavior problems. According to the author, California spends more on psychotropic drugs for foster children than on any other kind of medication. In the last decade, the state spent more than $226 million on psychotropic meds for foster children, 72% of total drug spending for this population. Additionally, there are substantial long-term costs of treating side effects associated with these medications. Furthermore, teens in foster care are three and a half times more likely to be prescribed psych medication than their peers who are not in foster care. While the federal Child and Family Services Improvement and Innovation Act of 2011 requires each state to oversee and monitor the use of psychotropic medications, California currently has no requirements to identify those who are over-prescribing medication to foster youth. California has no system for evaluating the medical soundness of high rates of prescribing; and no way to measure the efficacy of these practices. The California State Auditor (CSA) is currently engaged in an audit of foster youth and psychotropic medication. It is expected to be released in July or August of this year. According to the CSA Web site, the audit will provide independently developed and verified information related to DSS, SB 1174 Page 6 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 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 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 some of these policies or practices. The National Center for Youth Law (NCYL), the sponsor of this bill, argues that nearly one in four California foster teens are prescribed psychotropic drugs; of those nearly 60% were prescribed an anti-psychotic - the powerful drug class most susceptible to debilitating side effects. While the vast majority of doctors prescribing medication are doing so appropriately, California still needs an oversight mechanism (among other reforms including funding robust trauma care services). Currently, California has no system for evaluating the medical soundness of high rates of prescribing; and no way to measure the efficacy of these practices. NCYL noted that last year, DHCS and MBC adopted a one-year trial Data Use Agreement (DUA) that allows for the sharing of prescriber data in order to identify outlying prescribers. NCYL argues that 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. This 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. Advokids, states in support of this bill that it operates the only free statewide telephone hotline providing legal information to SB 1174 Page 7 anyone concerned about a foster child, and receives a high volume of calls from caregivers who are concerned about the lack of mental health services available to their foster children, many of whom have experienced multiple traumas in their lives. Advokids argues for 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 foster youth and when warranted to investigate physicians who frequently prescribe over the recognized safety parameters for children. MBC has a support if amended position on this bill. MBC requests additional information (included in the most recent version of this bill) and a sunset date so MBC can determine if the data provided is useful. MBC also has requested that the author amend this bill so that the education component is handled by DHCS since they are the Medi-Cal prescribers and the guidelines were created by DHCS and DSS. MBC notes that any information that can help MBC identify inappropriate prescribing can be utilized as a tool for MBC to use in its complaint and investigation process. However, once a possible inappropriate prescriber is identified, MBC will still have to go through its normal complaint and investigation process. The California Academy of Child and Adolescent Psychiatry (CACAP) believes that initiating investigations as proposed will ultimately target prescribing physicians who specialize with patients with severe mental health difficulties. CACAP argues that it is unclear how MBC would make a basis for an accusation of unprofessional conduct on the data that is proposed to be provided. Additionally, this process would also discourage physicians from prescribing a psychotropic medication even when, in their professional judgement, it is in the best interest for the child. An investigation by MBC is a significant event. Even if the investigation should not result in disciplinary action, questions regarding whether or not a physician has ever been investigated by MBC come up often in interviews and SB 1174 Page 8 credentialing reviews. While these red flag aren't as serious as a filed accusation, we believe the envisioned process will have a negative impact on the ability of the Medi-Cal system to recruit and retain high quality providers for Medi-Cal and Foster youth. Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097 FN: 0003936