Prior Authorization Policies for Pediatric ADHD Medication Prescriptions

According to the Centers for Disease Control and Prevention, more than 6.4 million US children 4-17 years old have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The percentage of US children diagnosed with ADHD has increased by 3-5 percent per year since the 1990s. Relatedly, the percentage of children in this age group taking ADHD medication also has increased by about 7 percent per year from 2007-2008 to 2011-2012.

In response, some state Medicaid programs have implemented policies to manage the use of ADHD medications and guide physicians toward best practices for ADHD treatment in children. These policies include prescription medication prior authorization requirements that restrict approvals to patients above a certain age, or require additional provider involvement before approval for payment is granted.

In a new article published this afternoon in MMWR, CDC researchers compared Medicaid and employer-sponsored insurance (ESI) claims for “psychological services” (the procedure code category that includes behavior therapy) and ADHD medication among children aged 2–5 years receiving clinical care for ADHD.

The article references a newly released LawAtlas map that examines features of state Medicaid prior authorization policies that pertain to pediatric ADHD medication treatment, including applicable ages, medication types, and criteria for approval.

States with Medicaid programs that have a policy that requires prior authorization for ADHD medications prescribed to children younger than 28 years old.

States with Medicaid programs that have a policy that requires prior authorization for ADHD medications prescribed to children younger than 28 years old.

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Variability of US State Workplace Wellness Program Laws

A team of researchers led by Jennifer Pomeranz, JD, MPH, Clinical Assistant Professor of the College of Global Public Health at New York University, have released a new set of resources that detail characteristics of laws related to workplace wellness programs and identify trends in these laws across the United States: interactive maps for public and private employers at LawAtlas.org and a paper published in the American Journal of Public Health.

Workplace Wellness Program Laws in US

A few key findings:

  • Thirty-three states and the District of Columbia have laws related to workplace wellness programs.
  • Four states (Georgia, Indiana, Maine and Massachusetts) provide tax incentives for work place wellness programs.
  • State laws addressed public and private employers differently, for example, five states permit rewards (e.g., discounts, rebates and waivers) by public employers, whereas 16 states expressly permit positive rewards for participation in programs by private employers.

The research was funded by the Robert Wood Johnson Foundation’s Public Health Law Research Program.

New Federal Employee Drug Screening Guidelines to Include Opioid Testing

By Jonathan K. Larsen, JD, MPP

There is no denying that the United States is experiencing an opioid overdose epidemic. Drug overdose deaths generally in the United States have been associated, at least in part, with increasing mortality rates among white non-Hispanics, which is counter to trends in other wealthy nations. The Urban Institute’s Laudan Aron recently posted about the underlying causes of our current epidemic, paying special attention to aggressive marketing of painkillers, the related spike in opioid prescriptions, and the closely correlated increase in opioid abuse. The issue has even made it into the current Presidential campaign, however briefly. President Obama has sought increased funding to address the issue, as well as a focused private, state, and local effort to tackle prescription drug abuse. While opioid abuse has been on the rise, it is not typically part of employee drug testing, when employers choose or are required to test. This may be changing.

The Substance Abuse and Mental Health Services Administration (SAMHSA), the federal agency responsible for drug testing standards for federal agencies, is poised to release drug screening guidelines (see page 4 (28104 in the Federal Register) that would expand drug screening for opioid abuse to federal employees, and could influence employee drug testing policies across the nation. The US Department of Defense has been testing for hydrocodone and benzodiazepines (used to treat anxiety and seizures among other things) since May 1, 2012. SAMHSA cites sobering statistics about opioid-related deaths now outnumbering deaths from illicit drugs, as it prepares to test for oxycodone, oxymorphone, hydrocodone, and hydromorphone, all classified as Schedule II drugs, or drugs with high risk of abuse, by the United States Food and Drug Administration (FDA). The proposed guidelines were released May 15, 2015, so the final rules should be coming soon. Continue reading

Involuntary Outpatient Commitment in the US

Civil commitment laws in the United States variably give authority to mental health providers, law enforcement, and others to compel someone to receive treatment if they may be a danger to themselves or others because of mental illness. These laws have long been a topic of discussion, but there has been limited research on their impact to patients and their communities, largely because the laws have not been effectively or reliably catalogued. The Policy Surveillance Program has been actively collecting and coding state civil commitment laws and regulations to create an index.

The research breaks down civil commitment into three categories: short-term, long-term, and involuntary outpatient commitment.

Under involuntary outpatient commitment laws, individuals with mental illness who meet certain criteria, such as danger to self or others, are required to receive mandatory treatment in an outpatient setting. An individual may be placed directly into outpatient treatment with a court order or after the patient has already been placed in an inpatient treatment facility (more commonly referred to as conditional release). Continue reading

Is our legal commitment process an evidence-based model?

By Bryan Kozusko

The research methods used by the Policy Surveillance Program to develop datasets mapping health laws and policies include secondary research that provides context to the law, identifies the legal strategy it embodies, and uncovers any evidence to suggest whether it is improving health and well-being. While policy surveillance is meant to facilitate an evidence-building process by producing robust data for analysis, researchers attempt to uncover some indication that existing policies are evidence-based.

The Policy Surveillance Program has been mapping involuntary civil commitment laws at various levels: short-term inpatient commitment, long-term inpatient commitment, and outpatient civil commitment. So far, a literature review is inconclusive on the effectiveness of involuntary outpatient civil commitment.

Domestically, a handful of studies appear to exist. To date, only two systematic studies have been performed, both of which yield inconclusive or inconsistent results (see Kisely & Campbell, 2014, and Ridgely, Borum & Petrila, 2001). The Kisely and Campbell review shows an overall improvement in areas such as social functioning and quality of life; however, researchers acknowledge the sample size is very small and the quality of the trials range from low to medium. The Ridgely et al. review gathered similar unreliable data, inconsistent or conflicting results on quality of life after commitment. Continue reading

Changing How We Think (and Talk) About Public Health Law

By Scott Burris, JD

Marice Ashe, Donna Levin, Matthew Penn, Michelle Larkin and I have a new piece in the Annual Review of Public Health (also available on SSRN). We set out a “transdisciplinary model of public health law” that encompasses within the core of the field both the traditional public health law practice of lawyers and what we call “legal epidemiology” — all the important public health law functions (from policy design to evaluation) that are typically carried out by people without legal training. I hope you will take a look.

Why this article and a transdisciplinary model? The idea comes out of the experience that the authors have all had trying to promote public health law practice and research. We realized that in spite of the success of the field and its importance to public health, a lot of non-lawyers in public health training, practice and research were uncomfortable with law — even when their work had to do with enforcing it or evaluating its impact.

We realized that we as lawyers were making things worse, by adhering to a traditional view of public health law as purely a practice of lawyers. We found that acknowledging the work of non-lawyers in public health law, conceptualizing key public health law activities in scientific terms, and even borrowing some scientific practices for legal work, were effective ways to change attitudes and improve our impact. Many of us have articles in the pipeline on legal epidemiology, policy surveillance and “the five essential public health law services” that will show the model in action.

I don’t have to tell readers of this blog that public health law is a great field. I hope the concept of transdisciplinary model will help make it a truly integral part of public health.

Read the full article here.

Job Opportunity: Legal Research Associate

Come join our team!

The Public Health Law Research program is hiring legal research associates to work on our policy surveillance project. The legal research associate will conduct legal research using Lexis and Westlaw, build historical law using HeinOnline, and conceptualize legal domains for empirical research. The associate will also code law for the creation of quantitative legal datasets at LawAtlas.org, and write legal briefs and other materials for LawAtlas.org.

Learn more and apply today!

Tennessee: The Next State to Require Involuntary Outpatient Commitment?

By Bryan Kozusko, JD (Expected graduation: May 2016)

How will Tennessee address involuntary outpatient commitment hereon out? Currently, Tennessee is one of seven states that does not provide for direct involuntary outpatient commitment, pending a final disposition by a court with jurisdiction. According to general involuntary outpatient commitment law, whenever an individual is believed to require such commitment, a final hearing must be held allowing an adjudication on the merits and the establishment of grounds by clear and convincing evidence. The other states that do not allow for this process are Alaska, Connecticut, Kentucky, Maryland, Massachusetts, and New Mexico.

For six years Tennessee legislators have tried, but failed, to successfully implement a permanent statute authorizing direct involuntary outpatient commitment following the disposition of a final commitment hearing. In 2009, Bill H.R. 0297 of the 106th General Assembly passed through the Senate unanimously. Once received by the House, no further action was taken and the bill was never voted on. In 2012, the 107th General Assembly authorized the creation of an involuntary outpatient pilot program to operate two years in Knox County, Tennessee. In 2014, the 108th General Assembly amended their law to terminate the pilot program on June 30, 2015, citing the public welfare of their citizens.

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Second Amendment Rights and Mental Illness

By Mariam Ahmed, JD/MSPP (2016)

In recent years, there have been a multitude of state- and federal-level discussions about how to use law to minimize gun violence as active shooter events increase. During these deliberations, one point that has repeatedly been debated is whether people with mental illness should have their gun possession rights limited.

Here’s how the legal landscape currently looks.

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A needle in a haystack – finding the elusive solution to Indiana’s HIV Outbreak

By Nicolas Wilhelm, JD

Scott County, Indiana, which only has a few thousand residents, has historically had an average of five HIV cases per year. Since December 2014, however, the county has seen an outbreak, with more than 140 newly diagnosed cases. Dr. Jonathan Mermin, the director of the National Center for HIV/AIDs, Viral Hepatitis, STD and TB Prevention at the Center for Disease Control (CDC) calls this “one of the worst documented outbreaks of HIV among IV users in the past two decades.” Dr. Joan Duwve, the chief medical consultant with the Indiana State Department of Health, explained that the abuse of the prescription drug Opana was one of the catalysts for the increase in HIV cases, with some residents injecting it as frequently as 10 times a day, and sharing syringes with other members of their community.

HIV is mainly spread either by sexual contact with another person with HIV, or by sharing needles or syringes with someone who has HIV. One way to reduce the spread of the disease is to implement syringe exchange programs (SEPs) that reduce the transmission of blood-borne pathogens like HIV by providing free sterile syringes and collecting used syringes from injection-drug users (IDUs).

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Webinar, 5/6: Policy Surveillance and Public Health

May 6, 2015 at 12 p.m. ET

Policy surveillance is the ongoing, systematic collection, analysis, and dissemination of data about laws and policies. There is a long tradition of conducting “50 state surveys” to identify laws of public health significance, but the methods for creating these surveys are largely unscientific. Unlike this traditional legal research, policy surveillance uses systematic quantitative and qualitative coding to create scientific datasets and track policies over time. Throughout the past year the Robert Wood Johnson Foundation’s Public Health Law Research program, the Network for Public Health Law, ChangeLab Solutions and the CDC Public Health Law Program have been exploring policy surveillance through a Delphi process and within their programs. This webinar will present the findings from that Delphi study and will explore the role of policy surveillance in understanding the impact of law on public health.

Presenters include:

  • Jennifer Ibrahim, PhD, MPH, Associate Director, Public Health Law Research program, Associate Professor, College of Public Health at Temple University
  • David Presley, JD, Policy Surveillance Manager, Public Health Law Research program
  • Matthew Penn, JD, MLIS, Director, Centers for Disease Control and Prevention, Public Health Law Program
  • Donna Levin, JD, Director, Network for Public Health Law (Moderator)

Register here.

Building on 20 Years of Success: The Future Role of Law

By Scott Burris, JD

On this, the last day of National Public Health Week 2015, we’re looking forward by looking backward. There is nothing new about using law and policy to promote healthier environments, products and behavior. There is no good future for public health that does not include even more, and more effective, legal interventions.

Evan Anderson and I wrote in 2012 about the legal regulation of health-related behavior over the past half-century. The story we told offered several reasons for unabashed optimism about what law can do for health. The record is clear that law works, and works across a wide range of different health threats. We pointed to CDC lists of Great Public Health Achievements from the last century and the first decade of the 21st.   Every one of them — from high levels of vaccination, through motor vehicle safety and cancer prevention to maternal and child health – could not have been successful without law and policy. Continue reading

Making Connections & Collaborating for the Future of Public Health

As part of the Public Health Law Research program’s participation in National Public Health Week 2015, we have been sharing materials and resources under the daily themes. Today’s theme, Building Broader Connections, is about expanding partnerships and making connections to benefit public health.

We spoke with Laura Hitchcock, JD, Policy Research & Development Specialist for Public Health – Seattle & King County and the King County Executive/Department of Executive Services Partnerships Initiative Lead. We asked her to offer some insight from her work as a lawyer and researcher in a public health department.

PHLR: What role can researchers play in building partnerships with health departments and contributing to the policy-making discussion?

Laura Hitchcock, JD

Laura Hitchcock, JD

LH: Public health researchers can help to support development and refinement of evidence-based policies. Because policies are created in a political process, it is important for public health departments to continue to offer their scientific knowledge to support creation of effective policies, including repeal of ineffective policies or refinement of existing policies to better result in a healthy population by 2030. Health departments may need help to define local or state-focused areas for policy evaluation by working together with researchers, and should contribute to development of research agendas by identifying areas where policy makers, communities, medical professionals and others have concerns about the public’s health, and are likely to need support from researchers to know how to ‘plug in’ to research agenda development. Continue reading

Short-Term Emergency Commitment Laws Require Police to Assess Symptoms of Mental Illness

By Leslie Allen, JD

On November 20, 2014, the Public Health Law Research program released a new 50-state dataset analyzing state law governing the short-term emergency commitment process. These laws give law enforcement officers and others the right to involuntarily admit someone into a mental health care facility if they are in danger of harming themselves or others because of a mental illness.

In 47 states, police may take a person into custody without a warrant, and may initiate an emergency psychiatric hold – essentially committing them to a mental health institution without their consent. Recently, the media has increasingly examined how the police interact with the mentally ill (for example, “Police Taught to Spot Signs of Psychiatric Crisis” from FoxNews, republishing from the  Associated Press, “Police Confront Rising Number of Mentally Ill Suspects” from The New YorkTimes, and see “Where the Police are Part of Mental-Health Care” from The Atlantic). Much of the police forces’ relationship with the mentally ill is established by the laws governing civil commitment.

Police officers serve as first responders for mental health crisis treatment by legislation in nearly every state. Continue reading

Medical Marijuana Delivery May Not Be As “Eazy” As It Seems

By Arielle Lusardi, BA, JD/MPH (’17)

As state medical marijuana laws proliferate throughout the country, companies are trying to secure their own piece of the action. In July 2014, a San Francisco-based start-up company, called Eaze, launched a mobile application that facilitates the delivery of medical marijuana in California. Continue reading

Being Blunt About Product Safety: The problems with the lack of uniformity in medical marijuana laws

By Holly Jones, BA, JD candidate

How can the federal government ensure consumer safety in an industry that distributes a substance the federal government classifies as an illegal drug? The federal government effectively banned the use of marijuana nationwide with the Controlled Substance Act of 1970, classifying marijuana as a Schedule I substance according. Regardless of this federal prohibition, 23 states and Washington, DC have legalized marijuana for medical use. A lack of federal legalization allows states to independently enact their own distinct medical marijuana laws.

In a dataset released yesterday on LawAtlas.org, the distinctions become clear — there are currently 24 variations of medical marijuana program product safety guidelines in the United States, some of which bear little, if any, resemblance to one another. While some states, like Connecticut and Massachusetts, provide incredibly comprehensive guidelines for their medical marijuana programs, others provide skeletal legislation and instead grant a great deal of autonomy to local jurisdictions.

While variation may allow researchers to more effectively evaluate the approaches, from a patient-safety perspective, uniformity has its advantages. Continue reading

McCullen and New York Statewide Coalition: The Erosion of Public Health as a Legal Norm

At first glance, last Thursday’s decisions by the Supreme Court in McCullen v. Coakley and the New York Court of Appeals in New York Statewide Coalition of Hispanic Chambers of Commerce v. New York City Department of Health and Mental Hygiene, have little in common. McCullen, which struck down a Massachusetts law establishing a 35 foot buffer zone around reproductive health clinics, was a First Amendment case that dealt with the always contentious issue of abortion. In contrast, N.Y. Statewide Coalition, which upheld a lower court decision striking down a regulation of the New York City Board of Health barring the sale of large portions of sugary soda, was decided on state administrative law grounds, with the court finding that the Board exceeded its authority.

On closer inspection, however, the two cases share several features in addition to their date of decision. One is the failure to give substantial weight to the state’s interest in protection health. In his opinion for the Court in McCullen, Chief Justice Roberts accepted that the buffer zone law was content neutral and therefore not subject to strict scrutiny. Nevertheless, a unanimous Court held that the Massachusetts law was not narrowly tailored to serve the government interests of protecting public safety and access to health care. In reaching this decision, the Court focused on the “toll” that the buffer zone placed on the abortion opponents who tried to dissuade woman from having abortion, rather than the impact of the lack of such a zone on woman seeking reproductive health care. Equally important, the Court showed no willingness to defer to the state’s contentions that alternative regulatory approaches had proved unsatisfactory. Rather the Court insisted that given “the vital First Amendment interests at stake, it is not enough for Massachusetts simply to say that other approaches have not worked.”

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A Tale of Two Polities (Revisited)

By Hosea H. HarveyPh.D., JD

About a year ago, my colleague Scott Burris blogged on this forum about the two polities of public health that compete for our visions – one view sees public health as “incredibly popular with citizens and lawmakers” and the other as the despised “nanny state.” Burris suggested that the former view is largely the truth, but the latter view is driving budgets and policymaking. His action plan centered on mobilizing public support for public health initiatives rooted in sound science, and engaging battles over public health law budgets and lawmaking. To do so, he recommended, among other things: a) that ideological or economic arguments against public health initiatives be challenged with data and science, including collaborations with state public health agencies, b) that legislators be supported more vigorously with real public opinion data and evidence, and c) improved normative work by law professors to develop a proactive intellectual, cultural, and political framework to evaluate, and perhaps influence, public health law interventions.

With respect to my own area of expertise, three recent developments seem designed to provide responses to Burris’s clarion call. First, the LawAtlas policy surveillance web portal has expanded significantly over the past year and has become a one-stop shop for public health law advocates and lawmakers to objectively evaluate existing public health law interventions and to learn about key elements of such laws. LawAtlas, as readers of this blog know, has expanded from an initial public health law surveillance of four broad public health law regimes to more than 20 datasets covering laws at a variety of levels – some statewide, as in my work on youth sports TBI laws, and some at a county or community-level such as the Seattle and King County public health law surveillance tool, which tracks policies adopted by local governments, public sector institutions, and private organizations in King County, Washington. My own policy surveillance portal, which has been substantially revised and re-launched this week, is one tool that contributes data to conversations that can too often be overrun by politics and emotion. Whether on LawAtlas, or in other forums, perhaps countering political noise with raw data will help reduce the level of misinformation in this policy space and promote a more reinvigorated evidence-based approach to public health lawmaking.

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National Conference on HIV Criminalization

By Sterling Johnson, JD

Grinnell College in Iowa will host the first National Conference on HIV Criminalization next week, June 2-5 on its campus.

One of the stated goals of the conference will be to discuss the recent legislative changes in Iowa and how to apply the lessons to other states with laws that apply specifically to people with HIV.

Currently, 43 states criminalize actions by HIV-positive individuals. Check out our map at LawAtlas.org for more details.

US states with HIV criminalization laws

In 2009, Iowa became the center of this battle when Nick Rhoades, who is HIV-positive, had a one-time sexual encounter with another man, Adam Plendl. Three months after, Mr. Rhoades was arrested on suspicion of engaging in intimate contact without disclosing his HIV-positive status. At the time of the sexual encounter, he used a condom, had an undetectable viral load and his sexual partner did not contract HIV; however, Nick Rhoades was sentenced to 25 years in prison and classified as a sex offender. The case is now is now on appeal and being argued by Lambda Legal. The Iowa court of Appeals affirmed the conviction and the case is now under review by the Iowa Supreme Court. Mr. Rhoades’s case led to community organizers lobbying to reform the HIV criminalization law in Iowa. Continue reading