Health care flaws aired

Legislators hear of denial of aid by insurers in Medicaid plan

AUSTIN — Texas lawmakers grilled private medical insurers and state leaders at a hearing Wednesday over reported deficiencies in the Medicaid managed care program, which provides health care to medically fragile children and adults with disabilities.

One Houston-area mother told lawmakers her son landed in the hospital with digestive failure, roughly a month after he was denied a prescription drug to treat an infection that costs $3,000 out-of-pocket.

“I can’t pay for that. He was put in the hospital ... that costs a lot more now,” Caroline Cheevers told House members about

her son Tyler. She adopted Tyler from Texas foster care after he was shaken as a baby. He now suffers hundreds of seizures a day that require constant care.

“We’re just limping along, trying to do the best we can,” Cheevers said.

The hearing, chaired by Rep. Sarah Davis, R-West University Place, comes after an investigation by the Dallas Morning News revealed the government paid private companies billions of dollars to manage care, but the contractors denied essential services medically fragile Texans.

Representatives for five of the companies — Superior HealthPlan, Amerigroup, Cigna HealthSpring, Molina Healthcare of Texas and United Healthcare Community Plan of Texas — mostly denied wrongdoing. They did point to some areas for improvement, including network adequacy in rural areas. But few disclosed the rate at which they deny care or how much they’ve paid in fines to regulators at Health and Human Services Commission, despite pressing from lawmakers. Nurse says fines curbed

Nancy Toll, a nurse who used to work for the commission, told lawmakers that millions of dollars in fines should have been levied. But Toll said she was told that if the fees were imposed, managed care organizations would be put out of business.

“That’s a problem,” she said. “If we can’t punish them monetarily ... then how are any changes going to take place?”

Toll also said lobbyists for managed care companies complained to the Legislature about fines and that many commission members aspired to secure jobs at managed-care companies, which she said paid better.

The Morning News found that when state inspectors recommended fines for the providers, the fees were routinely slashed by top leaders at the Health and Human Services Commission. The agency’s former leader, Charles Smith, told the Morning News the fees were meant as a way to enforce contracts, not inflict punishment.

Smith retired in May after several contracting errors surfaced at the agency that oversees public health and Medicaid. The program covers roughly 4 million Texans, including low-income children and pregnant mothers, though the hearing focused primarily on those who are medically fragile.

Under questioning from lawmakers, the five managed care companies denied contesting fines with lawmakers.

The head of Superior HealthPlan, Mark Sanders, said he wasn’t sure how many former commission employees now work at the managed care company, nor could he say exactly how much the organization had paid in fines.

LeAnn Behrens with Amerigroup said the company has paid fines of $20 million over the last two years and has seen little reduction to that total.

“I think the system worked,” she said. “We have corrected the systems causing the problems, and we’ve paid the penalties for it.” ‘Didn’t do anything wrong’

Much of the hearing focused the case of D'ashon Morris, whose nursing services were reduced by his managed care organization. The foster baby eventually pulled out a tube in his throat that helped him breath, leaving him in a persistent vegetative state, his adoptive mother Linda Badawo told lawmakers. D’ashon sat by her side, strapped into a medical scooter affixed with a large oxygen tank, almost taller than D’ashon.

When the nursing services were scaled back, Badawo told lawmakers Superior recommended putting the boy in a “soft splint,” which would have restricted his movements to keep him from removing the tube.

Lawmakers repeatedly questioned Superior executives over that decision, which chief medical officer David Harmon explained gets into an issue “of what is happening, versus what might happen.”

“There’s a solution for what might happen, which is the soft splint,” he said.

The answer displeased some lawmakers on the committee, especially Davis.

“All I get from Superior, for the most part, is ‘well, we didn’t do anything wrong,’” Davis said, during the daylong hearing. “I think that is probably one of the most frustrating things I am experiencing.”

Representatives from the Health and Human Services Commission, which holds the contacts for managed care, promised to beef up its oversight staff.