BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 1174|
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UNFINISHED BUSINESS
Bill No: SB 1174
Author: McGuire (D), et al.
Amended: 8/19/16
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
SENATE FLOOR: 36-3, 5/31/16
AYES: Allen, Anderson, Bates, Beall, Berryhill, Block,
Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,
Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,
Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,
Moorlach, Nguyen, Nielsen, Pavley, Roth, Vidak, Wieckowski,
Wolk
NOES: Morrell, Pan, Stone
NO VOTE RECORDED: Runner
ASSEMBLY FLOOR: 80-0, 8/23/16 - See last page for vote
SUBJECT: Medi-Cal: children: prescribing patterns:
psychotropic medications
SOURCE: National Center for Youth Law
DIGEST: This bill adds the following causes of action to the
Medical Board of Californias (MBC) list of priority cases for
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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". This bill requires the
Department of Health Care Services (DHCS) to provide data to MBC
on psychotropic medications prescribed to foster youth and
requires the MBC to analyze prescribing patterns to foster
youth.
Assembly Amendments add sunset provisions to the requirement for
DHCS to provide MBC data and the requirement for MBC analysis of
prescribing data; and extend the timeframe for reporting from
quarterly to annual as well as included changes necessary for
implementation of the bill by DHCS, Department of Social
Services (DSS) and MBC.
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)
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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)
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
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 and DSS, until January 1, 2027, to provide data
to MBC regarding Medi-Cal physicians and their prescribing
patterns of psychotropic medications, including pharmacy
claims data for all foster children who are or have been on
three or more psychotropic medications for 90 days or more
that includes:
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a) A list of the psychotropic medications prescribed;
b) The start and stop dates, if any, for each psychotropic
medication prescribed;
c) The prescriber's name and contact information;
d) The child's or adolescent's year of birth;
e) Any other information that is deidentified and necessary
for MBC to exercise its statutory authority as an oversight
entity and;
f) The unit and quantity of the medication and the number
of days' supply of the medication.
3)Requires MBC, until January 1, 2027, to contract for
consulting services from, if available, a psychiatrist who has
expertise and specializes in pediatric care for the purpose of
reviewing the data provided in 2) above. Requires MBC to
analyze prescribing patterns by population children adjudged
as dependent children and placed in foster care and a minor
adjudged a ward of the court who has been removed from the
physical custody of the parent and placed into foster care.
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,
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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
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
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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.
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 DUA 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
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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 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.
SUPPORT: (Verified8/23/16)
National Center for Youth Law (source)
Bay Area Youth Center
California Youth Connection
California Youth Empowerment Network
Children Now
Consumer Attorneys of California
Consumer Watchdog
Contra Costa County
Family Voices of California
First Focus Campaign for Children
John Burton Foundation
Kids in Common
Madera County Department of Social Services
Peers Envisioning and Engaging in Recovery Services
San Luis Obispo County Department of Social Services
Sunny Hills Services
Therapists for Peace and Justice
Woodland Community College Foster & Kinship Care Education
Youth Law Center
Two individuals
OPPOSITION: (Verified8/23/16)
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California Academy of Child and Adolescent Psychiatry
ARGUMENTS IN SUPPORT: Numerous groups 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 Academy of Child and
Adolescent Psychiatry believes that initiating investigations as
proposed will ultimately target prescribing physicians who
specialize with patients with severe mental health difficulties.
The organization notes that it is unclear how MBC would make a
basis for an accusation of professional conduct on the date
proposed to be provided to the board and would like to see a
review panel made up of qualified providers who could review
outlying prescribing practices and discuss, educate and offer
advice to prescribers who are outside the community standard.
ASSEMBLY FLOOR: 80-0, 8/23/16
AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker,
Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke,
Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley,
Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth
Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto,
Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper,
Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim,
Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis,
Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte,
O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez,
Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting,
Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon
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Prepared by:Sarah Mason / B., P. & E.D. / (916) 651-4104
8/23/16 20:02:58
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