Foster Children:

Additional Federal Guidance Could Help States Better Plan for Oversight of Psychotropic Medications Administered by Managed-Care Organizations

GAO-14-362: Published: Apr 28, 2014. Publicly Released: May 22, 2014.

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Stephen M. Lord
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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.

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 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.

For more information, contact Stephen M. Lord at (202) 512-6722 or

Recommendation for Executive Action

  1. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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, the Secretary of Health and Human Services should 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.

    Agency Affected: Department of Health and Human Services


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