The Financial and Societal Costs of Medicating America’s Foster Children Testimony of Matt Salo Executive Director National Association of Medicaid Directors Before the Senate Homeland Security and Government Affairs Committee Subcommittee on

Pharmaceutical   coverage   and   expenditures   have   been   a   large   and   growing   concern   of   the   Medicaid   Directors   for   a   number   of   years.   Psychotropics   pose   a   unique   concern   primarily   because   the   trends   in   costs   and   utilization   are   far   outstripping   every   other   baseline.   Careful   analysis   of   the   data   implies   that   this   is   a   result   of   many   factors,   some   legitimate,   others   less   so.   Concerns   include   both   overutilization   and  inappropriate  utilization,  and  this  is  true  for  adults,  seniors,  and,  unfortunately,  children  as  well.  

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   The Financial and Societal Costs of Medicating America’s Foster Children Testimony of Matt SaloExecutive DirectorNational Association of Medicaid DirectorsBefore theSenate Homeland Security and Government Affairs CommitteeSubcommittee on Federal Financial Management, Government Information, Federal Services, andInternational SecurityDecember 1, 2011  Good morning Chairman Carper, Ranking Member Brown, and distinguished members of theCommittee. My name is Matt Salo, and I am the Executive Director of the National Association of Medicaid Directors (NAMD). We appreciate the opportunity to testify before you today on an issue of critical importance in our health care system.MedicaidMedicaid is the nation's health care safety net. Jointly financed by the states and the federalgovernment, Medicaid will spend more than $400 billion this year to provide health care to more than60 million Americans. The program is administered by the states within a broad federal frameworkwhich leads to enormous variation across states in terms of who is covered, what services are provided,and how those services are delivered and paid for. Furthermore, within any given state, Medicaid's roleis broad, varied, and complex. Medicaid funds more than 40 percent of all births, and the majority of allpublicly financed long-term care in this country. It also provides most of the nation's funding forHIV/AIDS related treatments, mental health services, and others. It is therefore very difficult to talksimplistically about Medicaid (either nationally, or within a state), despite its incredible importance inthe U.S. health care system.NAMD is a newly formed organization created with the sole purpose of providing a home for thenation’s Medicaid Directors and we represent all 56 of the state, territorial and DC agency heads. Ourtwo broad objectives are to give the Medicaid Directors a strong, unified voice on national and federalmatters as well as helping develop a robust body of technical assistance and best practices for them toimprove their own programs. While no two programs look exactly alike, the Directors are unified in theirheartfelt desire to improve the health and health care of the growing number of Americans who rely onthe program.Pharmaceutical coverage for children in foster carePharmaceutical coverage and expenditures have been a large and growing concern of the MedicaidDirectors for a number of years. Psychotropics pose a unique concern primarily because the trends incosts and utilization are far outstripping every other baseline. Careful analysis of the data implies thatthis is a result of many factors, some legitimate, others less so. Concerns include both overutilizationand inappropriate utilization, and this is true for adults, seniors, and, unfortunately, children as well.As noted in the GAO report, this is also true, and especially concerning for one particularly vulnerablepopulation, children in foster care. While psychotropic medications show enormous promise in treatinga wide variety of serious conditions, there are clearly concerns about how current prescribing patternscan negatively impact the foster care population. The GAO report pointed out serious potentialproblems in three primary areas: the concomitant use of five or more psychotropics; prescribing doseshigher than the maximum levels cited by FDA guidelines; and the prescribing of psychotropics to infantsunder 1 year old.There is no question that subjecting our most vulnerable citizens to bad medicine is unacceptable andthat we can and should and will do better by them.  But there is also no question that this problem is the result of a range of serious flaws in the US healthcare system: from the prescribing patterns of physicians to the lack of oversight of a variety of levels of government, the lack of effectively promulgated health information technology, and the fragmentednature of the relationship between acute care and behavioral health in this country. As such, solutionswill require coordinated efforts from states, the federal government, mental health professionals,primary care practitioners, researchers, and others.By definition, children in foster care are covered primarily by Medicaid, and, as noted in the report,“they tend to have more numerous and serious medical and mental health conditions than do otherchildren.” While this does not excuse the delivery of substandard care, it does help to explain whypsychotropic prescribing patterns for this population are higher than for the general population. We alsonote a recent study in the medical journal Pediatrics that shows that psychotropic prescribing patternsfor children in foster care are even higher than those in the SSI population, who are by definition facingmuch more serious disabilities than the general population. This is likely true because many of thechildren who qualify for SSI do so because of physical, as opposed to behavioral/mental disabilities. Tothat extent, the foster care population may legitimately require more significant behavioral interventionthan the overall SSI population.There are other reasons to make sure we are making valid comparisons before drawing conclusions. Inconversations with the medical and behavioral health experts in the states surveyed for the report,questions that warrant exploration were raised about the survey. For example, multiple prescriptionsmight reflect a prescriber legitimately cycling through a variety of potential medications in order to findthe one that works best for an individual. Similarly, there are instances where multiple psychotropicsmay well be in the best medical and behavioral needs of a given individual. Further analysis of prescribing patterns for infants show that many examples are for Benadryl. This is not to excuseunacceptable behavior, or rationalize away serious problems where they exist, simply that more analysisis needed to figure out the nature and scope of the real underlying problems.ChallengesThere are unfortunately a number of reasons why state oversight policy, or medical practice may havefailed to keep up with the ever changing literature or other developments. These are not meant to beexcuses for failure to act, but indicative of the breadth of the challenges that face systemic reform.Furthermore, it cannot be stressed enough how unique are the challenges faced by the children in thefoster care system.While government has an obligation to lead, doing so in violation of clear community opposition isfraught with risk, and pyrrhic victories are often short lived. As states grapple with finding solutions tothe epidemic of over- and misuse of psychotropics in general, they often face opposition from themanufacturers of these products, from mental health advocates (who in many cases are funded in largepart by these same manufacturers), and from the community at large, who tend to resist governmentintrusion into a doctor-patient relationship often viewed as sacrosanct.  In some states, this has resulted in state legislative action that has placed absolute prohibitions on priorauthorization of psychotropics like atypical antipsychotics. These laws place significant barriers on statepharmacy managers in their efforts to ensure compliance with the latest practice guidelines. While statelegislative barriers are not permanently set in stone, resolving them does require different strategiesthan in addressing state-level executive branch policy.These challenges also play out in the complicated relationship between state foster care workers, thechildren in the system, and the prescribers themselves. A lot of behavioral problems in foster care kidsare as a result of trauma which is under-diagnosed and requires specialized treatment approaches.As a practical matter, in an emergency, most prescribers are more likely to add medications thandiscontinue them, and effectively minimizing medication use requires a stable ongoing treatmentrelationship with a prescriber – a relationship that is rare, especially among older children who canchange placements frequently, seeing a different prescriber each time.State agencies also face challenges in recruiting and retaining sufficiently trained staff who possess theclinical expertise necessary to challenge a prescriber’s recommendation to treat with psychotropics. Onestate in particular had to abandon an attempt to strengthen the hand of foster care workers in thesesituations, when it became clear that BA/BS or MSW educated workers would face significant liabilityissues when disagreeing with prescribers.SolutionsIn the short term, I would note that in my conversations with the states that were a part of the GAOstudy, all were undertaking efforts to address the identified shortcomings. I know that your staff havehad extensive conversations with many, if not all, of these states, but we would be happy to continue towork with you if there is any further outstanding follow up required.But above and beyond these individual efforts, there is also a need for broader systemic reform. Thereare a number of solutions that can and should be implemented to help improve this situation. 1) TheGAO report recommends promulgating additional federal guidance from HHS to the states; 2) Moreclinical research is needed on the effects and implications of treating children of any age and in anysituation with psychotropics that have only been tested on adults; 3) More work needs to be done tobreak down the barriers to coordinating and integrating care for vulnerable populations in Medicaid,with an added focus on the varied, complex and challenging behavioral health conditions experiencedby children in foster care; 4) While Medicaid coverage and payment policy can and should change, manyof the challenges in this issue are medical policy issues, and as such, require the broader medicalcommunity to also adapt; and 5) NAMD, working collaboratively with key partners such as the MedicaidMedical Directors and the State Mental Health Program Directors can develop and disseminate bestpractices in this area and work with states to implement them; More HHS Guidance
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