Background:

Medicaid and Foster Children.

The Health Care Authority (Authority) administers the Medicaid program which is a state-federal program that pays for health care for low-income state residents who meet certain eligibility criteria. Persons under 19 years old who are in foster care and are under the legal responsibility of the state or a tribe located within the state are eligible for Medicaid. Persons under 21 years old who are either in foster care or eligible for continued foster care services may also enroll in Medicaid. In addition, persons between 19 and 26 years old may receive Medicaid if they either were in foster care and enrolled in Medicaid on their eighteenth birthday or were older than age 18 when their foster care assistance ended.

Antipsychotic Medications.

Antipsychotic medications were intended to help people with severe mental illnesses such as schizophrenia or bipolar disorder, but are now used for many other conditions. Early antipsychotics, commonly referred to as first generation antipsychotics, carried several side effects such as movement disorders and sedation. More recently developed antipsychotic medications, commonly referred to as second generation antipsychotics, have fewer side effects related to motor skills, although they have been associated with weight gain, type 2 diabetes, and other side effects. A 2012 report by the federal Agency for Healthcare Research and Quality noted the increased use of antipsychotic medications for children and youth despite the existence of few high-quality and longitudinal studies.

The Authority is required to review the psychotropic medications of all children under 5 years old and establish methods to evaluate the appropriateness of the medication for the children, including the use of second opinions from experts in child psychiatry. "Psychotropic medications" include the following drug classes: antipsychotic, antimania, antidepressant, antianxiety, and Attention Deficit Hyperactivity Disorder.

Evidence-Based Practice Institute.

The Evidence-Based Practice Institute (Institute) was established through legislation in 2007. It is located at the University of Washington School of Medicine. The Institute serves as a statewide resource to the Department of Social and Health Services and other entities for child and adolescent evidence-based, research-based, promising, or consensus-based practices for children's mental health treatment. The Institute also provides training and consultation to licensed children's mental health providers who are implementing evidence-based or research-based practices for treating emotional and behavioral disorders in children.

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Summary of Substitute Bill:

The Health Care Authority (Authority) must require that an expert in psychiatry provide a second opinion review for all prescriptions of one or more antipsychotic medications for any foster child under 18 years old on Medicaid. A 30-day supply of medications may be dispensed pending the second opinion review. The second opinion must address psychosocial interventions that have been or will be offered to the child and the caretaker to address the behavioral issues.

Each Medicaid managed care system must develop a list of evidence-based treatments and other behavioral health resources under contract with the managed health care system. The managed health care system must distribute the list to its health care providers who provide care to patients under 18 years old. The Evidence-Based Practice Institute at the University of Washington must be consulted in the development of the lists.

The Authority must promote the appropriate use of behavioral therapies in place of or in addition to prescription medications where appropriate and available, rather than merely encouraging their use.

Legislative findings are made that foster children are prescribed antipsychotic medication at a much higher rate than children in the general population and that requiring a second opinion for antipsychotic prescriptions and the use of behavioral interventions may reduce the number of children being prescribed antipsychotic medications while improving outcomes for children.

Substitute Bill Compared to Original Bill:

The substitute bill allows for the dispensing of a 30-day supply of prescriptions of antipsychotic medications pending the second opinion review.

The substitute bill changes the requirement that the Health Care Authority ensure the appropriate use of cognitive behavioral therapies where appropriate to requiring it to promote the appropriate use of cognitive behavioral therapies where appropriate and available.

The substitute bill requires managed health care systems serving Medicaid clients to develop and maintain a list of evidence-based treatments and other behavioral health resources under contract with the managed health care system. Managed health care systems must distribute the list to their health care providers and support staff who serve patients under 18 years old. The Evidence Based Practice Institute of Washington must be consulted during the development of the lists.

Staff Summary of Public Testimony:

(In support) While progress has been made, foster children are prescribed antipsychotics much more frequently than other children. Nationwide, a foster child is seven times more likely to be prescribed a psychotropic medication than a child who is on Medicaid. Stories from youth in foster care confirm the research that says that they are subject to significant levels of psychotropic medications and at a much higher rate than their peers from intact families.

The state has an obligation to assure that all of those prescriptions are appropriate and necessary and that there is a discussion of behavioral health interventions. Foster kids need love, not drugs. Many foster children and youth would benefit from medication management. This bill will reduce overmedication.

Overmedication and undermedication leads to youth leaving foster homes, running away from foster homes, inpatient care that should not happen, and ending up on the streets. Primary care physicians usually prescribe antipsychotic medications without a second opinion. Foster youth have identified medication management or overmedication as key youth-inspired solutions for real reform.

Foster children need to be provided with a range of services beyond just psychiatric medication. This bill creates a more collaborative approach to providing services to children. If somebody is in need of medication, it should always be done in combination with some other kind of psychosocial service. This bill encourages the integration of psychiatric and psychosocial services and provides appropriate services and psychiatric prescribing. Young people experiencing complex developmental trauma may appear to be suffering from disorders that are perfectly natural responses to trauma, grief, and loss and would be best served a combination of accruing normal developmental experiences, trauma-informed mental health services, and limited use of psychotropic medications, when absolutely necessary.

Requiring a second opinion could result in significant delays for children who need these types of medications and there should be an amendment allowing for an urgent medication fill. There must be some leeway if there is a crisis or immediate need. The use of cognitive behavioral therapies should be "encouraged," rather than "ensured."

(With concerns) From a clinical perspective, the prescribing of any psychotropic medicine, particularly to children, should be done deliberately, thoughtfully, and carefully. Because it takes time to get a second opinion review, there should be an allowance for prescribing prior to the second opinion being obtained. While it is imperative that children be offered psychosocial therapy, there are not necessarily enough providers to meet the standard of "ensuring" that children are provided those services.

(Opposed) None.