Administration officials spoke for the first time about President Barack Obama’s proposal for a 10-year, $750 million effort to “address over-prescription of psychotropic medications for children in foster care,” on a Friday conference call with child welfare advocacy, research and member organizations.
The plan was first made public in Obama’s 2015 budget request, released on Tuesday, and you can read about it with context by clicking here.
Youth Services Insider listened in on the Friday call about the plan, which featured envoys from both the two relevant Health and Human Services (HHS) federal agencies: JooYeun Chang, who heads the Children’s Bureau at the Administration for Children and Families (ACF), and John O’Brien, a senior advisor at the Centers for Medicare and Medicaid Services (CMS).
There was little detail that accompanied mention of the plan in Obama’s budget. On the call, we learned why: because there isn’t much detail yet about the plan. Here are some notes on the discussion.
It’s less about over-prescription, more about under-using anything else
How would one define “over-prescription”? An educated health professional could certainly lean on the “know it when I see it” approach, but that is no good when it comes to counting.
Would HHS submit that any foster youth with two psychotropic prescriptions was “over-prescribed?” Or a certain weight measurement of psychotropic drugs? There are some that would argue any prescription of an anti-psychotic to a child is over-prescribing.
It would be virtually impossible to pin down, and it does not appear that the administration is interested in attempting to do so.
“We want a full array of choices for foster youth with mental health challenges,” said Chang. “It’s important for medications to be an option, but not the only option.”
Part of that, said O’Brien, is dispelling some “urban myths” about what the feds won’t reimburse for, and in other cases green-lighting more options for agencies.
Set ‘Em Up, Knock ‘Em Down Strategy
The way Chang and O’Brien described it, the idea is for ACF funds to build the capacity of some states to better screen, assess and refer foster youths for mental health services.
Then, Medicaid would provide pay-for-performance incentives to those states as they got better at serving both foster youths and Medicaid-eligible children in general.
“In an ideal world, the $250 million is meant to help states be in a position to access some of the $500 million in incentives,” said Chang.
Better capacity and funding to bolster non-drug options will drive down the number of children who are prescribed psychotropic medication, or so the theory goes. It will be set up in a way that basically forces a participating state to improve the communication and integration of child welfare and Medicaid services.
“Nothing causes collaboration like cash,” O’Brien said. (We add parenthetically that nothing causes anything quite like cash.)
There will be a list, with flexibility.
Expect CMS to put together a list of allowable strategies for serving youths. O’Brien ticked off a few on the call:
- Parent Child Interaction Therapy
- Multi-Dimensional Foster Care
- Functional Family Therapy
- Multi-Systemic Therapy
- Cognitive Behavioral Therapy
It did sound like supportive services not directly related to mental health – like respite care for families or supportive employment for youths – could be included.
And if states are passionate about an unlisted option, and can provide “some evidence” of its efficacy, they will be allowed to spend on it, O’Brien said.
Incentives may extend beyond demonstration
The ACF portion of the plan ($250 million given out in five-year grants) will be a competitive process. There will be competition to identify the states involved in the CMS demonstration project portion of this, but at least some of the proposed $500 could go to states that are already developing better options using state dollars.
“They may not need to be a demonstration grant,” O’Brien said. “We wouldn’t want to penalize states that are early adopters.”
Feel free to chime in
Chang and O’Brien encouraged call attendees on multiple occasions to weigh in on how this might work. Among the details that are still in discussion:
- What strategies and service delivery options should be included?
- What entities should receive the ACF grants: State agencies? Others?
- Benchmarking: How should CMS gauge the success of these states’ efforts? It will likely be a combination of process outcomes (think “how many more youths are referred to new or existing options”) and performance-based outcomes (think permanence, well-being indicators).
Youth Services Insider is written mostly by Chronicle Editor-in-Chief John Kelly.