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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