BILL ANALYSIS                                                                                                                                                                                                    Ó



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          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,        |                    |








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          |                |     |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      |                    |
          |                |     |                      |                    |
          |                |     |                      |                    |
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          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  








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            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  








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            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,  








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          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,  








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          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  








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          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  








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          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