PolicyLab

We were encouraged to see that President Barack Obama’s budget announcement yesterday included at least $750 million* for a five-year, Centers for Medicare & Medicaid Services (CMS) demonstration project in partnership with the federal Administration for Children and Families (ACF) to address the over-prescription of psychotropic medications for children in foster care. And yet, we have to ask ourselves how we ever landed in a place where, by 2008, a near majority of foster care youth who received psychotropic medications during mental health-related visits received antipsychotics to control their behavior, and nearly a quarter received a cocktail of medications of uncertain benefit.

The need for alternative therapies to medication

Many view this crisis as a consequence of “big pharma” pushing lucrative medication at vulnerable Medicaid youth, or of clinicians seeking an easy way out to subdue very challenging behaviors in children. Our work at PolicyLab at The Children's Hospital of Philadelphia (CHOP) has recognized both the complexity of this crisis and the urgency of action needed in response to the safety implications of exposure to powerful drugs with known side effects. But, the problems related to the overprescribing of psychotropic medications for children in foster care will not be addressed by simply placing the blame on the clinicians or “big pharma.” Rather, as the President’s proposal acknowledges, they will be only be addressed by creating a pipeline that assures that proven therapeutic alternatives to medication are available and funded.

Prescription medications have a very capable and well-tested engine to get their product to the market: the pharmaceutical industry. The designers of alternatives to prescription medications, on the other hand, have no such engine. The therapeutic interventions that we know work for children with behavioral health issues, such as Multi-Systemic Therapy and Parent-Child Interaction Therapy, are created in small research shops that do not have the capacity to package their therapies for national public sector distribution. The reality is that there is no non-pharmaceutical intermediary industry that provides this support. Thus, while we can point to small “gem-like” evidence-based programs that provide alternative therapies to medication with great success, the programs have never been scaled for broader replication, owing largely to lack of resources. Further complicating replication efforts are licensing issues and costs of interventions that are not “open source,” even if created through public research dollars, and that, despite their success rate, are often not billable through Medicaid.

There are solutions to this market failure, and the President’s budget creates a path towards innovation

As cities and states grapple with how to create this pipeline, we offer Philadelphia as a blueprint for consideration. Over three years ago, PolicyLab, in partnership with our city agencies and non-profits, came together to demonstrate how alternative therapies to medication could be made available to children in foster care. We did not want to build another “gem” program that could end after the one-time grant funding ran out. Instead, we insisted that we first obtain state approval to use Medicaid dollars for the intervention (the state, another partner, agreed) and that the agencies chosen to provide the intervention be selected through a formal Request for Proposal (RFP) purchasing process so that capacity was built in the field, rather than siloed within an academic institution. Today, we have positive preliminary program data, and our public sector partners are beginning to purchase and roll out the intervention citywide.

That is not to say there have not been glitches or logjams. There have been many, and many remain. But, as a city, Philadelphia is committed to creating a pipeline for getting alternative therapies to medication to our local market, so that clinicians who are asked to help a child with behavioral health needs have something other than pills in their toolbox. It is a positive first step in the right direction and paves the way for a future where foster youth have access to safer, more appropriate treatment. 

The President’s budget proposal provides the opportunity to support these kinds of innovations and efforts, and we applaud the focus and priority that has been placed on this issue in this year’s budget. Our nation’s foster youth deserve no less.

* Most reports we’ve seen thus far mention the $750 million figure, however, if you look at the actual budget document, it appears that over $1 billion could be appropriated over the next 6 years.  See Table S-9 on e-page 185 (page 181 of the hard copy document). The Fact Sheet and FAQs from HHS provide more information on the $750 million figure.

Kathleen Noonan, JD, is the co-founder of PolicyLab and former senior legal advisor at PolicyLab.