BILL ANALYSIS Ó
SB 1174
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SENATE THIRD READING
SB
1174 (McGuire)
As Amended August 19, 2016
Majority vote
SENATE VOTE: 36-3
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|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, Mullin, Ting, | |
SB 1174
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| | |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. Requires, on or before January 1, 2022, the MBC to
conduct an internal review of its data review, investigative,
and disciplinary activities and to revise its procedures
relating to those activities if necessary and sunsets the
provisions of this bill on January 1, 2027.
EXISTING LAW:
1)Requires MBC to prioritize its investigative and prosecutorial
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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.
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.
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3)Requires that the court either approve or deny a physician's
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
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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,
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
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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,
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
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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
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.
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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
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:
0004665