The GAO released a new report today, “Foster Children: Additional Federal Guidance Could Help States Better Plan for Oversight of Psychotropic Medications Administered by Managed-Care Organizations.” The report examines the extent to which psychotropic medication use was supported by foster and medical records for children in foster care, highlights state policies with regards to oversight of psychotropic medications and notes recent efforts undertaken by the Department of Health and Human Services (HHS) in informing the field and offering guidance to states on effective practice, oversight and monitoring.
Children who have been abused or neglected often have a range of unique physical and mental health needs, physical disabilities and developmental delays. Nearly 60 percent experience a chronic medical condition, and one-quarter suffer from three or more chronic health conditions. Roughly 35 percent have significant oral health problems. Nearly 70 percent have moderate to severe mental health problems, and 40 percent to 60 percent are diagnosed with at least one psychiatric disorder. For children in foster care, Medicaid is an essential program. It supports EPSDT and funds long-term mental health care for children, including those who need more intensive or restrictive services such as hospitalizations and residential treatments.
In recent years, Federal spending on prescription medications has taken up a greater portion of Medicaid budgets. This is in part due to growing Medicaid expenditures on new and more costly psychotropic medications for children, many of which have not been tested for use in children. Research has shown that children enrolled in Medicaid are more likely to be prescribed psychotropic medications than those who are privately insured; and, a greater proportion of Medicaid enrolled children are given prescriptions for multiple psychotropic medications, even though fewer receive outpatient mental health services.
In the Medicaid program, children in foster care are much more likely to use psychotropic medications than children who qualify for Medicaid through other aid categories. Studies have shown that children in foster care are prescribed psychotropic medications at a much higher rate than other children – 2 to 3 times higher. Children in foster care are also often prescribed two or three medications at once, the effects of which are often not known. Another growing concern is the utilization of atypical antipsychotics in children in foster care. Research suggests that these youth are being prescribed antipsychotics at a much higher rate today than ever, even though these drugs have limited FDA approval for use in older children and little is known of their impact on younger children.
State prescribing practices received considerable attention in 2011 with the release of a GAO report that reviewed medication use in the Medicaid program. The report found that 20-39 percent of children in state foster care received prescriptions for psychotropic medication in 2008, compared with only 5-10 percent of children on Medicaid not in foster care. The report also found that children in state foster care are prescribed dosages at far higher rates than their peers served by Medicaid, and often in amounts that exceed guidelines issued by the FDA.
The GAO report released today highlights new challenges, including the fact that many states have, or are transitioning to Managed Care Organizations (MCOs) to administer prescription-drug benefits, and states have taken only limited steps to plan for the oversight of drug prescribing for foster children receiving health care through MCOs. This is a concern and creates a risk that controls instituted in recent years under fee-for-service may not remain once states move to managed care.
In reviewing foster and medical records of 24 foster youth in Florida, Massachusetts, Michigan, Oregon, and Texas, the report also highlighted other key findings, including:
The use of evidence-based therapies remains limited. Experts found that 3 of 15 children who may have benefitted from such therapies were mostly provided such services, while 11 of 15 cases were scored partial in this category. In 1 of 15 cases there was no documentation that evidence-based therapies were provided.
Appropriateness of medication dosage is often not fully supported by documentation. Experts found appropriateness of medication dosages was mostly supported by documentation in 13 of 24 cases and partially supported in the other 11 cases. The rationale for concurrent use of multiple medications was mostly supported in 5 of the 20 cases where multiple medications were used, but 14 of 20 cases included documentation that partially supported concurrent use, and 1 case did not include documentation to support concurrent use.
Concurrent use of medications continues to be a concern. Experts found that for 5 of 20 applicable cases, concurrent use of multiple psychotropic medications was mostly supported based on documentation. However, 14 of 20 cases included documentation that partially supported the concurrent use of multiple medications, and one case did not include any documentation to support concurrent use.
The use of psychotropics in infants is troublesome. Experts found in 4 of 9 infant cases reviewed that the prescription of psychotropic medication was for non-mental-health purposes, based on documentation reviewed. However, experts found that in 2 of 9 cases the infants were prescribed psychotropic medications for psychiatric reasons, and the rationale and oversight for such medications were partially supported by documentation. In 3 of 9 infant cases, experts were unable to discern whether the psychotropic medications were prescribed to infants for mental-health purposes or for some other medical reason, based on documentation reviewed.
These findings highlight some of the practice and oversight challenges states face and suggest that more work remains to be done to significantly decrease the over-prescription of psychotropic medication to foster youth. One promising opportunity is the new five-year collaborative demonstration proposal in the President’s FY 2015 budget to reduce inappropriate prescribing practices and over-utilization of psychotropic medications. The proposal would invest $50 million a year, through ACF to fund state infrastructure and capacity building to ensure improved coordination between state Medicaid programs and child welfare agencies. In conjunction with the ACF investment, $100 million will be invested through CMS to provide incentives to states that demonstrate improvements in these areas.
Funding for the President’s proposal, along with additional guidance to states on the monitoring and oversight of psychotropics in MCOs and a continued commitment from states to addressing this issue are all critical to success as we work to reduce the overutilization of psychotropic medications in foster youth and ensure greater access to evidence-based therapeutic interventions.