Case Studies Varied in Quality of Documentation Supporting the Use of Psychotropic Medications

Expert reviews of 24 foster children’s foster and medical files in five  selected states found that the quality of documentation supporting the  prescription of psychotropic medication usage varied with respect to (1)  screening, assessment, and treatment planning; (2) medication  monitoring; and (3) informed and shared decision making. As shown in table 1, experts found that the  quality of screening, assessment, and treatment planning varied among  selected cases according to documentation reviewed. Experts found that medical pediatric examinations were mostly supported  by documentation for 22 of 24 cases. Experts found in 2 of 24 cases the  medical pediatric examinations were partially supported, such as when  the medical pediatric exams were mentioned in the documentation, but  not actually included in the records, preventing experts from evaluating  what the examinations consisted of, and whether monitoring for  psychotropic agents, such as assessing height, weight, or laboratory  functions, was conducted. In one example, whereby experts scored the  medical pediatric exam category as mostly supported in documentation, a  child with a history of behavioral and emotional problems—including  aggression and hyperactivity—was prescribed multiple ADHD  medications. In this case, experts noted the child’s records had thorough  psychological and pediatric assessments, with comprehensive  discussions of diagnostic issues and medication rationale as well as good  case-management summaries. Evidence-Based Therapies

Experts found that documentation reviewed supported that evidence- based therapies were mostly provided in 3 of 15 applicable cases where  the child may have benefited from such treatment. In 1 of 15 cases, there was no documentation that  evidence-based therapies were provided. For example, experts  found in one case with partially supporting documentation that the  monitoring of height, weight, vital signs, and metabolic effects of  antipsychotic medications was lacking and that the records did not  provide an adequate overview of medication risks and concerns regarding  concurrent use of multiple psychotropic medications. Appropriate Dosages Used

For 13 of the 24 cases, experts found that the dosages were mostly  supported for the children’s medications based on documentation  reviewed. However, 14 of 20 cases included documentation that partially supported  the concurrent use of multiple medications, and 1 case did not include  any documentation to support concurrent use. Selected States Have Policies and Procedures Intended to Address Oversight of Psychotropic Medications to Foster Children, and HHS Issued Guidance for Monitoring Psychotropic Medications

Selected states have policies and procedures that are intended to provide  oversight of psychotropic medications given to foster children. In Texas there is a single MCO used  to coordinate all prescription claims and medical services for children in  foster care, and this organization works closely with the state foster-care  agency to identify and monitor psychotropic medication use among  children in foster care. Justification for Concurrent Use of Multiple Medications

All five of the selected states have designed measures to review  prescriptions for concurrent use of multiple medications to a varying  extent. HHS Has Issued Guidance, Provided Technical Assistance, and Facilitated Information Sharing

In response to concerns and our December 2011 report recommendation  related to the need for additional guidance for the prescribing of  psychotropic medications for children in foster care, HHS’s ACF has  taken actions to improve the capacity of states’ child-welfare agencies to  effectively respond to the complex needs of children in foster care. Additional Guidance Could Help Officials Manage Psychotropic Medications as States Transition Prescription-Drug Benefits to Managed Care

Three of five states included in our review use, or are transitioning from  fee-for-service to, MCOs to administer prescription-drug benefits for  mental-health medications; however, Medicaid officials from two of those  three states reported that their states had conducted limited planning to  ensure appropriate oversight of MCOs administering psychotropic  medications—which creates a risk that state controls instituted in recent  years under fee-for-service may not apply to managed care—and could  benefit from additional federal guidance. However, this guidance does not address oversight within the  context of a managed-care environment, in which states rely on a third  party to administer benefits such as psychotropic medications. Recommendation for Executive Action

To assist states that rely on or are planning to contract with an MCO to  administer Medicaid prescription benefits, and to help provide effective  oversight of psychotropic medications prescribed to children in foster  care, we recommend that the Secretary of Health and Human Services  issue guidance to state Medicaid, child-welfare, and mental-health  officials regarding prescription-drug monitoring and oversight for children  in foster care receiving psychotropic medications through MCOs.
Why GAO Did This Study

In December 2011, GAO reported that foster children in selected states were prescribed psychotropic medications at rates higher than nonfoster children in Medicaid in 2008. GAO was asked to further examine instances of foster children being prescribed psychotropic medications.
For the five states included in GAO's 2011 report—Florida, Massachusetts, Michigan, Oregon, and Texas—this report: (1) assesses the extent that documentation supported the usage of psychotropic medication for selected cases; and (2) describes states' policies related to psychotropic medication and assesses HHS actions since GAO's 2011 report.
GAO contracted with two child psychiatrists who conduct mental-health research and work on issues related to foster care, to provide clinical evaluations of 24 cases that GAO selected from the population of foster children prescribed psychotropic drugs in GAO's 2011 report. The case selections were based, in part, on potential health risk indicators, and the findings are not generalizable. GAO obtained medical and child-welfare documentation spanning children's time in foster care, and redacted personally identifiable information prior to experts' review of cases. GAO also analyzed federal guidance and selected states' policies and interviewed federal and state officials.

What GAO Found

Two experts GAO contracted with reviewed foster and medical records for 24 cases in five selected states and found varying quality in the documentation supporting the use of psychotropic medications for children in foster care. Experts examined documentation related to several categories, such as (1) screening, assessment, and treatment planning; and (2) medication monitoring.
Screening, Assessment, and Treatment Planning. Experts' evaluation of this category included whether medical pediatric exams and evidence-based therapies—which are interventions shown to produce measureable improvements—were provided as needed, according to records. Experts found in 22 of 24 cases that medical pediatric exams were mostly supported by documentation. For example, in one case with mostly supporting documentation, experts found that a child with a history of behavioral and emotional problems had records documenting a medical pediatric exam and thorough psychological assessments, with comprehensive discussions of diagnostic issues and medication rationale. With regard to evidence-based therapies, 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 as partial in this category, and in 1 of 15 cases there was no documentation that evidence-based therapies were provided.
Medication Monitoring. Experts' evaluation of this category included the appropriateness of medication dosage and the rationale for concurrent use of multiple medications, according to records. 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. For example, experts found for one case that a child was prescribed four psychotropic drugs concurrently, when nonmedication interventions could have been considered. The rationale for the actions taken was partially supported by documentation.
All of the five selected states—two of which pay health care providers directly through fee-for-service, and three of which use or are transitioning to a third-party managed-care organization (MCO) for prescription-drug benefits to some extent—have policies intended to address oversight of psychotropic medications for foster children. According to state officials, all five of the states require medical examinations for children in foster care. Since GAO's 2011 report, the Department of Health and Human Services' (HHS) Administration for Children and Families (ACF) has, among other things, worked with other federal agencies to provide informational webinars and technical guidance for states to improve oversight of psychotropic medications, but this guidance does not address third-party MCOs administering medications. Officials from two of the three states relying on MCOs described limited state planning for MCOs to monitor psychotropic medications. Because there are indications MCO use is increasing, additional HHS guidance that helps states implement oversight strategies within the context of a managed-care environment could help ensure appropriate monitoring of psychotropic medications prescribed to children in foster care.

What GAO Recommends

GAO recommends that HHS issue guidance to states regarding oversight of psychotropic medications prescribed to children in foster care through MCOs. HHS agreed with GAO's recommendation.