BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 1174| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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 SB 1174 Page 2 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) SB 1174 Page 3 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: SB 1174 Page 4 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, SB 1174 Page 5 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 SB 1174 Page 6 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 SB 1174 Page 7 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) SB 1174 Page 8 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 SB 1174 Page 9 Prepared by:Sarah Mason / B., P. & E.D. / (916) 651-4104 8/23/16 20:02:58 **** END ****