The mental health watchdog Citizens Commission on Human Rights (CCHR) applauded the recent Department of Justice health care fraud crackdown but says greater oversight is needed of Medicaid billing of psychotropic drugs prescribed children, which could reduce their use and increase protections.
In announcing a national health care fraud takedown by the U.S. Department of Justice (DOJ) on July 13, 2017, Attorney General Jeff Sessions said that, “Too many trusted medical professionals like doctors, nurses, and pharmacists have chosen to violate their oaths and put greed ahead of their patients.”1 CCHR, which has investigated abuses in the mental health system for 48 years, applauded the crackdown but says a key area of investigation should be the psychotropic drugging of children under Medicaid.
The number of children taking powerful antipsychotic drugs has nearly tripled over the last 10 to 15 years, according to a consumer report. The increase, the report says, comes from the drugs being increasingly prescribed to treat behavior problems, a use not approved by the Food and Drug Administration (FDA).2
CCHR says that prescribing patterns under Medicaid should be investigated to isolate where psychotropic drug prescriptions to children and adolescents is most prevalent, reduce that number to safeguard this population, and, in doing so help to reduce Medicaid costs. In one year alone, Medicaid spent about $8 billion in fee for service for psychotropic drugs for all age groups—30 percent of the program’s total fee-for-service drug spending for all age groups.3
In 2014, the Government Accountability Office (GAO) found the federal government and states had taken a multitude of steps to better oversee psychotropic drug prescribing for children in foster care.4 A GAO drug audit had uncovered a 2,200 percent increase in drug expenditures for atypical antipsychotic drug reimbursement to the state of Michigan alone between 2000 and 2008. The Michigan Medicaid system was billed an increase of $40 million during the eight-year period just for this one class of drugs for foster children.5
CCHR says that despite Federal plans for state oversight of foster care drugging, the problem persists—possibly because of the profits involved for prescribers and youth behavioral facilities. For example, in 2013, Missouri adopted a pilot “second opinion” program, in which a board-certified child psychiatrist was tasked with reviewing the prescriptions for 10 children and searching for trends in how these medications are used.
Three years later, however, in its 2016 report to the federal government, Missouri’s Department of Social Services admitted that “many foster care children are prescribed multiple psychotropic medications without clear evidence of benefit and with inadequate safety data. The use of multiple medications (psychotropic or otherwise) creates the potential for serious drug interactions.”6
In 2015, the Medicaid and CHIP Payment and Access Commission (MACPAC) report on “Use of Psychotropic Medications among Medicaid Beneficiaries” found nearly one-quarter (24 percent) of children eligible based on child welfare assistance used a psychotropic drug, almost five times the rate of children eligible on a basis other than disability or child welfare assistance (5 percent).7
“The high rates of psychotropic medication use in the Medicaid population, risks associated with these drugs, and research documenting inappropriate prescribing, have raised concerns, especially for children involved in the child welfare system,” according to the MACPAC report.8
Another 2015 report by the U.S. Department of Health and Human Services (HHS) Inspector General examined in depth nearly 700 claims filed in five of the biggest prescribing states—California, Florida, Illinois, Texas, and New York—and discovered that two thirds of all the prescribing with costly “second generation antipsychotics” raised high-risk “quality of care” concerns.9
The report noted several disturbing examples:
- A 10 year old given an antipsychotic—without any medical documentation—mixed in with other psych drugs;
- A 4 year old on four psychotropic drugs, including two antipsychotics;
- A 16 year old on six psychiatric drugs, including three antipsychotics.
In the latter case, among the side effects of this polypharmacy assault, The Huffington Post reported: “This child experienced paranoia, hostility, unstable mood, hallucinations, and suicidal thoughts. This child also experienced significant side effects potentially resulting from the prescribed drugs, including a 22-pound weight gain, insomnia, and edema (swelling) of hands and feet.”10
The report also noted that over half of kids receiving antipsychotics are victimized by “poor monitoring” of the drugs’ risky health side effects—which can include breast growth in boys, cardiac arrest, extreme weight gain and diabetes.11
CCHR emphasizes that oversight is also needed in the private-for-profit behavioral sector where children are treated often at a cost to Medicaid. One large behavioral health company has significant reimbursement (33 percent) from Medicaid, “substantially all” of which relates to the treatment of children and adolescents. The company estimated that the child and adolescent behavioral healthcare market was $11 billion in 2014.
According to the IMS, Vector One: National and Total Patient Tracker Database for 2013, more than 274,000 0-1 year olds were prescribed psychiatric drugs and a staggering 370,000 toddlers. Over 3,760 two to three year olds were on antipsychotics; 46,102 were taking antidepressants and 282,759 were on anti-anxiety drugs. Additionally, 500,948 four to five year olds were on prescription psychotropic drugs, more than 4.1 million six to twelve year olds and greater than 3.6 million aged between 13 and 17.12
CCHR says potential prescription abuse, such as off-label (prescribed for unapproved use) was also highlighted by a 2012 study where national data showed a dramatic rise in off-label and FDA-approved uses of these drugs. Of particular note was a twofold to fivefold increase in the use of antipsychotic drugs in preschool children, despite little information on their long-term effects.
Researchers from Johns Hopkins University concluded that although an increase in the off-label use of antipsychotic medications in children and adolescents had occurred, no standardized oversight exists to guide such use.13
A New York Times article on the risk of antipsychotics in children said, “Many doctors say prescribing them for younger and younger children may pose grave risks to development of both their fast-growing brains and their bodies. Doctors can legally prescribe them for off-label use, including in preschoolers, even though research has not shown them to be safe or effective for children.”14
“What’s not known about the long-term effects is very troubling,” Christopher Bellonci, M.D., assistant professor at Tufts University School of Medicine in Boston, said. “The younger you go, the more you can affect the developing brain.”15
CCHR wants to see the oversight of the drug prescription practices increased, especially when it relates to children and adolescents who need greater protections. As Edward Opton with the National Center for Youth Law’s PsychDrugs Action Campaign, said: “Foster children are a lucrative market for psychotropic drug sales. Unlike adults, they can’t say, ‘No, I won’t take any more of that drug.'”16 The same can be said for all children, CCHR adds. Frequently, parents are not fully informed of psychotropic drug risks, according to the group.
1 “Sessions announces ‘largest health care fraud takedown’ in U.S. history,” CBS News, 13 July 2017, http://www.cbsnews.com/news/sessions-announces-largest-health-care-fraud-take-down-in-us-history/
2 “Are too many kids taking antipsychotic drugs?: Use is climbing despite questions about how safe the drugs are and how well they work” Consumer Reports, Dec. 2013 http://www.consumerreports.org/cro/2013/12/are-too-many-kids-taking-antipsychotic-drugs/index.htm
3 Chapter 5, “Use of Psychotropic Medications among Medicaid Beneficiaries,” Medicaid and CHIP Payment and Access Commission (MACPAC), June 2015, https://www.macpac.gov/wp-content/uploads/2015/06/Use-of-Psychotropic-Medications-among-Medicaid-Beneficiaries.pdf
5 Frank J. Granett, R.ph, Director of Clinical Pharmacy Operations at Behavioral Center of Michigan Psychiatric Hospital, Author: Over Medicating Our Youth & The American Epidemic “The Price of ADHD Business,” Op Ed News.com, 9 Feb., 2014, http://www.opednews.com/articles/The-Price-of-ADHD-Business-by-Frank-J-Granett-R-Children_Children-Teens_Depression_Diagnosis-140209-373.html
7 Chapter 5, “Use of Psychotropic Medications among Medicaid Beneficiaries,” Medicaid and CHIP Payment and Access Commission (MACPAC), June 2015, https://www.macpac.gov/wp-content/uploads/2015/06/Use-of-Psychotropic-Medications-among-Medicaid-Beneficiaries.pdf
8 Chapter 5, “Use of Psychotropic Medications among Medicaid Beneficiaries,” Medicaid and CHIP Payment and Access Commission (MACPAC), June 2015, https://www.macpac.gov/wp-content/uploads/2015/06/Use-of-Psychotropic-Medications-among-Medicaid-Beneficiaries.pdf
9 “Feds Pay for Drug Fraud: 92 Percent of Foster Care, Poor Kids Prescribed Antipsychotics Get Them for Unaccepted Uses,” Huffington Post, 30 May, 2015, http://www.huffingtonpost.com/art-levine/feds-pay-for-drug-fraud-9_b_6966454.html
10 “Feds Pay for Drug Fraud: 92 Percent of Foster Care, Poor Kids Prescribed Antipsychotics Get Them for Unaccepted Uses,” Huffington Post, 30 May, 2015, http://www.huffingtonpost.com/art-levine/feds-pay-for-drug-fraud-9_b_6966454.html
11 “Feds Pay for Drug Fraud: 92 Percent of Foster Care, Poor Kids Prescribed Antipsychotics Get Them for Unaccepted Uses,” Huffington Post, 30 May, 2015, http://www.huffingtonpost.com/art-levine/feds-pay-for-drug-fraud-9_b_6966454.html
12 IMS, Vector One: National (VONA) and Total Patient Tracker (TPT) Database, Year 2013, Extracted April 2014
13 “Antipsychotic Medication Prescribing Trends in Children and Adolescents, J Pediatr Health Care. 2012 Mar; 26(2): 139–145; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778027
14 “Child’s Ordeal Shows Risks of Psychosis Drugs for Young,” The New York Times, 1 Sept., 2010, http://www.nytimes.com/2010/09/02/business/02kids.html
15 “Are too many kids taking antipsychotic drugs?: Use is climbing despite questions about how safe the drugs are and how well they work” Consumer Reports, Dec. 2013 http://www.consumerreports.org/cro/2013/12/are-too-many-kids-taking-antipsychotic-drugs/index.htm