B. Agency Oversight
The Parameters provide recommendations for the appropriate use of psychotropic medications for children served in the public behavioral health system, including children in foster care. They include criteria indicating the need for review of the child's clinical status. Medical consenters, caregivers, judges, attorneys, and advocates also use the Parameters as they fulfill their duties of advocacy and oversight.
1. Medication Review
The STAR Health managed care organization (MCO) oversees automated reviews of pharmacy claims data for all children in foster care receiving psychotropic medications to identify medication treatments which appear to be outside the Parameters. Additionally, STAR Health MCO clinical staff routinely conduct telephonic health screenings when children newly enter DFPS conservatorship or change placements.
The telephonic health screening includes screening of the child's psychotropic medications treatment. The screening process includes criteria such as:
• Does the child have a documented mental health diagnosis?
• What is the child's age? (Prescriptions might need further review if the child is under age 3 or 4, depending on the class of medication.)
• Is the child taking two or more medications from the same drug class? (Two mood stabilizers and long and short acting stimulants from the same “family” are allowed, but two or more medications from the same class call for further review.)
• Is the child prescribed four or more psychotropic medications regardless of the class?
2. Psychotropic Medication Utilization Review [141]
The Psychotropic Medication Utilization Review (PMUR) process is designed to determine whether a child's psychotropic medication treatment is outside of the Parameters and, if so, whether a consultation call from a STAR Health child psychiatrist to the prescribing physician is indicated. A PMUR can be initiated by the STAR Health MCO if indicated by a health screening or pharmacy claim review. A PMUR may also be triggered by a request from any judge, attorney, caseworker, advocate, foster parent, medical consenter, or other concerned person working with the child. The PMUR examines child-specific clinical information about a child's diagnoses, medication dosage, and whether the medication treatment is in compliance with the Parameters. The STAR Health MCO has committed to prioritize responses to inquiries from judges concerning children under their supervision. PMUR findings are usually sent to the child's caseworker or can be faxed or emailed directly to the court, if requested.
All PMUR requests are reviewed by one of five STAR Health Licensed Behavior Health Clinicians who gather medical records and screen children's psychotropic medication treatment for compliance with the Parameters. If the treatment is outside the Parameters, the clinician refers the case to a STAR Health child psychiatrist to conduct a PMUR. The child psychiatrist outreaches to the treating physician, works with the treating physician to reduce polypharmacy if indicated, and prepares a PMUR report. The PMUR report will contain a formal determination about the foster child's medication treatment. The possible determinations are as follows:
• Medication treatment within Parameters;
• Medication treatment outside Parameters. Medication treatment reviewed and found to be within the standard of care;
• Medication treatment is outside Parameters and there is opportunity to reduce polypharmacy; or
• Medication treatment is outside Parameters and there is risk for or evidence of significant side effects.
The STAR Health MCO is in a good position to intervene and educate the prescribing physician because it holds a contract with these providers to participate in STAR Health. Physicians and other clinicians who appear to consistently prescribe outside the Parameters despite risk for or evidence of significant side effects, or when there is an opportunity to reduce polypharmacy, are referred to the Quality of Care (QOC) review process. Additional records are examined for pervasive patterns of over-prescribing or dangerous prescribing. Qualifying cases may be referred to the Peer Review Committee for further investigation and action. The Peer Review Committee is established by the MCO and consists of network providers to review PMUR concerns for STAR Health Members that exceed the QOC thresholds. Superior HealthPlan also utilizes consultant physicians as needed to review specific specialist issues if a need is identified. The results of Quality Improvement and Peer Review Committee investigations and actions are confidential and may not be released to or discussed with the public. All QOC issues are tracked and trended. Any practitioner showing a pattern or trend may be placed on corrective action and/or face disciplinary action up to and including termination of contract, if warranted.
A PMUR cannot address whether other medications might be effective, and this process is not the appropriate avenue to address immediate concerns about new medications or medication side effects. Instead, the informed consent process is considered the appropriate avenue to inquire about new medications and side effects. In these situations, the STAR Health MCO recommends that the Medical Consenter contact the prescribing physician directly. DFPS also employs CPS Nurse Consultants in each administrative region to assist CPS staff with children's health issues, including questions about psychotropic medications.
Please see the PMUR Process for STAR Health Members FAQ and Stakeholder Manual for more information on the process.[142]
3. Effect of Texas' Oversight Process
As a result of the various improvements to Texas' oversight process, including hiring a Medical Director at DFPS, implementing the Parameters as a statewide monitoring system, and launching managed care and clinical consultation by the STAR Health programs, the prescription patterns of psychotropic medications for Texas children experiencing foster care have improved significantly. Since implementation of the Parameters in 2005, the use of psychotropic medications in Texas foster care has decreased substantially from a high of 31.4% in 2004 to 17% in 2021 for children prescribed psychotropic medications for 60 days or more.[143] It should be noted in 2020, HHSC revisited the foster care prescription data from State Fiscal Years 2002 to 2021 using the new psychotropic drug list and other methodological changes to provide a single consistent historical timeline. Previous versions of the cited report incorporated changes as they occurred. Due to programming code changes, additional data becoming available, and additional medications being added to the list of psychotropic medications, the data have changed from previous versions of the report.[144] When reviewing the chart below, please note that it contains a new data measurement regarding “any psychotropic medication prescription,” as indicated by the blue line. The use of any children prescribed psychotropic medications in Texas foster care has decreased substantially from a high of 37.7% in 2004 to 23.2% in 2021.
Percentage of Children and Youth in Texas Foster Care
Receiving Psychotropic Medications by Measure*
**Please note that psychotropic medications may be used off label for medical reasons.