- By Editorial Board
Faced with mounting anecdotal evidence that some foster children in Texas aren’t getting the medical services they need under the state’s Medicaid system, officials have started to quantify the scope of the problem.
The early numbers are distressing — and they underscore the need for the Legislature to provide more funding and better safeguards for foster children in this critical program.
Superior HealthPlan, the for-profit company that serves as the gatekeeper to Medicaid-funded services for Texas foster kids, denied medical services to those children 394 times between June 7 and July 13, according to reporting by the American-Statesman’s Julie Chang. The Texas Department of Family and Protective Services started tracking the denials to see how Superior’s decisions are affecting foster children, many of whom have severe disabilities, though state officials noted that most patient service requests during that period were approved.
Superior says the denials were only for treatment that was not medically necessary or covered by Medicaid, but foster parents say the children in their care need the therapies and medical equipment that Superior denied.
These figures come in the wake of the Dallas Morning News’ Pain & Profit series that chronicled the shortcomings of Texas’ Medicaid system in great detail, starting with Superior’s unconscionable decision in 2016 to skimp on the hours of nursing care for a severely disabled 1-year-old boy who kept pulling out his breathing tube. The child, D’ashon Morris, later became brain dead after dislodging his tube in the hours before his part-time nurse arrived.
Superior saved up to $500 a day by denying the round-the-clock nursing care that doctors had recommended for D’ashon.
The profit motive should have no place at the table when providers make medical decisions for Texas’ most vulnerable children. Yet, that is the financial reality of the system Texas lawmakers created by channeling foster children and other Medicaid patients into managed care organizations over the past two decades. Texas provides these firms a predetermined payment based on a patient’s overall condition, regardless of how many services that patient requests or receives each month.
Lawmakers shifted the Medicaid system to private companies to save money. The only way that works is if managed care companies, who are also trying to post a profit, deny some of the costly care patients need.
Even when care is approved, it can be difficult for patients to get it: Many doctors won’t accept Medicaid managed care patients because the payments are too low to cover their costs, a problem magnified by the state’s overall shortage of doctors and specialists, particularly in rural areas.
We recognize the managed care model can be successful in the general population, where programs that promote preventative care can lower costs and produce better health outcomes.
But a mountain of reporting has shown that model does not meet the needs of foster children or other medically vulnerable Texans who require expensive, long-term care. More than half of Texas’ foster children — many of whom are pulled from homes wracked by drug abuse, violence or neglect — have special needs.
Just as lawmakers two years ago confronted a systemic underfunding of the state’s child protective services, they must take an honest look next session at the funding needed to provide proper health care to foster children and other medically fragile residents. Simply wishing the state didn’t have to spend so much money on these costly services doesn’t make the need go away. Legislators face not only a moral imperative to provide for these hurting children but a financial one, as failing to provide the care needed early on can lead to more expensive health problems down the road.
Lawmakers should also craft meaningful changes to the appeals process for families who’ve been denied services by a Medicaid managed care organization. Appeals should be triaged so the most urgent cases are heard quickly. Additionally, while patients appeal the company’s refusal to pay for a new level of nursing or therapeutic care a doctor has recommended, those patients should temporarily receive those services, so their health is not jeopardized while the administrative process plays out.
Some lawmakers have already shown a willingness in hearings this summer to confront the problem. We’re also encouraged that the Texas Health and Human Services Commission, which oversees the state’s Medicaid contracts with managed care companies serving foster children and other residents, plans to hire 98 employees over the next two years to increase that oversight. As part of its efforts to ensure patients get the care they need, the commission must also press the Medicaid companies to expand their network of providers to serve the 34,000 foster children statewide.
Lawmakers who’ve heard from struggling families and seen the media reports can no longer be blind to the problems in the state’s Medicaid managed care system. Next session they must fix it.