House committees hear concerns on managed care program, medically vulnerable Texans

Linda Badawo says she doesn’t know if managed care works or not — but it hasn’t worked for her family.

Sitting with her son D'ashon beside her in his wheelchair, Badawo told legislators during a joint hearing of the House General Investigating & Ethics Committee and a subcommittee of House Appropriations on Wednesday about how the managed care organization charged with caring for him failed.

That failure included cutting down the number of nursing hours available for him, using physical restraints on him and denying her when she appealed those decisions, she said. Then, when D'ashon was in temporary foster care while Badawo was traveling outside the country, he started choking. The incident left him brain dead.

Badawo said caseworkers didn’t come by her home until the situation became dire.

“I hate to say it, but I guess they were just trying to save money as much as they could,” Badawo said.

Dozens of people — including children and adults in wheelchairs, parents, insurance executives, state agency officials and representatives of advocacy groups — packed the room for the latest hearing in the aftermath of a Dallas Morning News investigation into Medicaid managed care companies' failure to provide care for vulnerable Texans. The private companies running the program are hired by Texas to coordinate health care for people on Medicaid, the joint federal-state health insurance program for the poor and disabled. The government-subsidized health care system has expanded in Texas in recent years, and money that the companies don’t spend caring for Texans can go toward paying lobbyists and executives’ bonuses, the Morning News reported.

Legislators expressed a mixture of frustration and angst during the all-day hearing as parents featured in the Morning News stories recounted their dealings with the companies responsible for providing care for their medically fragile children.

Caroline Cheevers, flanked by her four children in wheelchairs, came from Houston to tell legislators that her family is “limping along trying to manage the best we can” between making sure her children’s medication was approved, that nurses are coming in for their hours and finding providers to care for them. She said she’s filed more than 30 complaints to the Texas Health and Human Services Commission about her issues with the managed care program.

“It’s exceptionally frustrating having to spend this much time fighting for something they should be getting without an issue,” Cheevers said. “If they were still in foster care, the state would be paying a lot more for their care than they would be if they're adopted ... the kids that need forever homes are provided the medical care so families like mine can take these kids and give them a forever home.”

Later in the afternoon, a panel of insurance executives from Superior HealthPlan, Amerigroup, Cigna Health Spring, Molina Healthcare of Texas and United Healthcare Community Plan of Texas went in front of legislators to explain how their companies operated and answer for some of the allegations made against them in the Morning News articles.

The panel tried to give ideas on how to improve the managed care program, including using telemedicine, changing how provider network adequacy is calculated and beefing up dental benefits. But company representatives also endured some biting criticism from legislators and were warned they needed to provide more data on how many claims they’ve denied and how many former Texas Health and Human Services Commission employees are working for their companies.

State Rep. Sarah Davis, R-West University Place, chair of the two committees presiding, asked David Harmon, chief medical officer for Superior HealthPlan, if he believed the testimony from parents and the Morning News series shows a systemic problem when it comes to caring for medically complex or fragile patients. Harmon said he didn’t think so.

“There’s always opportunities for improvement,” Harmon said. “I really love that program, I think it’s a great program, I think it’s a high quality program.”

“But nothing is wrong from your perspective,” Davis said.

“That’s not what I’ve said, I think we can always do better,” Harmon said. “I do think that the folks from our managed care organization that work with children in foster care are very passionate about what they do and want the best for these children.”

Davis expressed frustration with Superior HealthPlan’s testimony, saying that "all I get from Superior, for the most part, is, ‘Well, we didn’t do anything wrong.’"

"There is just a complete lack of pointing of fingers and saying, ‘We didn’t do anything wrong,’ and, ‘We’ve got records that say this,’ ‘We’ve got records that say otherwise,’" Davis said. "That was a little speech there, but I really hope when we hear from the rest of the managed care organizations that you keep that in mind."

State Rep. Kevin Roberts, R-Houston, expressed frustration that the managed care companies’ fair hearing appeals process for patients doesn’t have someone who reviews the medical necessity of what was denied.

“How in the world can they review whether or not the decision was correct?” Roberts asked.

Texas Health and Human Services Commission officials were also brought in to testify about how they work with managed care organizations and hold them accountable. Legislators expressed skepticism over how much self-reporting the companies are allowed to do. Agency officials said in recent months they’ve started in-person visits to the managed care organizations to interview staff and monitor how they’re handling complaints and prior authorizations and making sure they’re telling customers about their right to appeal.

Badawo told legislators that there was no trigger for the managed care organization in charge of D'ashon to do something to help him. Instead, she said, they kept denying her appeal to get him round-the-clock care.

“The funny part of it is, they can make you appeal a hundred times, and they’ll keep telling you you have the right to appeal,” Badawo said. “But there are some situations that we can’t wait for that long, something has to be done right now, and that was the situation I had with my son.”

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