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The Human Services Committee met on June 20 continue hearings on Interim Charge 2, an overview of Medicaid managed care as well as discuss recent news articles concerning MCOs in Texas. The committee also heard from witnesses on the unposted issue of border detention centers.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. This report is not a verbatim transcript of the hearing; it is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Review of Managed Care & Recent Events

Opening Comments

  • Chair Raymond – Would take issue with any saying that legislature has not stayed on top of managed care & are not ensuring that they provide proper care
  • Chair Raymond – Will be hearing testimony to recent items in the news as well

 

Mark Sanders, CEO Superior Health Plan

  • Chair Raymond – I would like you to speak to recent news events & to 2 patients in the Dallas Morning News; obtained a waiver to let you do so
  • Sanders, Superior – Many Texans in managed care programs, emphasizes the importance of managed care
  • Articles make many incorrect statements about how managed care operates in Texas, including about Superior health plan
  • Superior has an extensive client base, most chose Superior due to quality of care
  • Superior has conducted an internal review of issues in the DMN articles, have concluded that almost all assertions are unfounded; invited the OIG in to review conclusions
  • Have been working on obtaining releases from members to address specific concerns, will be speaking to 2 members identified in the article & 1 unidentified
  • Unidentified member – Was in foster care & on antipsychotic medications; DMN claimed psychiatrist was not on network and not practicing, also that parent was provided with inadequate information leading to her being unable to find an appointment, & that child had an outburst in school due to lack of medication leading to an inpatient admission
    • All of these assertions are inaccurate, confirmed that all prescriptions are being filled, physician was in-network during the entire course of care, inpatient admission was due to trauma in the foster home & child was cared for by a Superior psychiatrist after release
    • Psychiatrist began weaning member off of medications, parent contacted Superior and wanted the psychiatrist changed as he was not prescribing Zoloft, Superior contacted other offices to help meet the parent’s request
  • Chair Raymond – Were you able to give this info to the reporter? Did he ever ask?
    • We have releases to be able to discuss these cases with the legislature, also focused more on accountability to HHSC & the state
  • Frank – Did the reporters reach out to you to validate the claims?
    • They did reach out late in the process and with limited info
  • Frank – But you could not have answered due to HIPAA?
    • Correct
  • Also want to address issues related to behavioral health network and foster care network from the DMN article, our findings are much different than those reported
  • Behavioral health is a challenge in the state in general
  • Klick – I think this would be true nationally, we have a provider shortage, many psychiatrists now will not file on any insurance regardless of plan; does this affect your ability to recruit?
    • It is a challenge for us, in Austin have been exploring pre-payment to secure and hold appointments for members
    • This is something managed care has the flexibility and creativity to do
  • Klick – Do you assist members in finding physicians in network?
    • We absolutely do
  • Klick – But this would not help in the fee for service world?
    • In my experience no
  • Article also spoke to audiology network issues in San Antonio, we did experience these issues; issues stemmed from reductions in the Medicaid fee schedule for audiology services
  • Also found that contracts were based on fee schedule & that contracts were not sufficient to cover the cost of new, advanced hearing aids & devices
  • Moved to work outside of the fee schedule and establish agreements; managed care was able to respond quickly & faster than fee-for-service
  • Always willing to hear constructive criticisms for the managed care model
  • Chair Raymond – Would like to ask about the D’ashon Morris case
    • Refers to David Harmon, CMO Superior

David Harmon, Chief Medical Director Superior Health Plan

  • Before speaking to Morris, the unidentified client has been a member since 2008, records of continuous care are freely available & contest the allegations in the DMN article
  • Chair Raymond – We can look at these specific records, though not in open hearing
  • Regarding D’ashon Morris case
    • Received a request to increase 1-to-1 hours from 12 hours to 24 hours per day, Superior found another child in the home receiving 24-hour care and that D’ashon could be taken care of in a 2-to-1 ratio with this other child
    • Also found that 17 hours/day was appropriate, received an appeal and during the appeal D’ashon continued to receive 12 hours/day
    • Fair hearing needed to be rescheduled, case was dismissed as care had already been delivered during the authorization period in question
    • Superior then received a new authorization request and approved for 17 hours/day @2-to-1 ratio
    • Care also needed use of a soft splint, decision to use soft splint was supported by physician, but was not used
    • We did receive an appeal asking for >160 hours at 1-to-1, was approved at 1-to-1 17 hours/day due to trach tube pulling
    • Article also mentioned that child was being suctioned 2-7 times per hour, this is not normal
    • Never saw outreach to the treating pulmonologist about these issues
  • Chair Raymond – To your knowledge, why was it never used?
    • No documentation, there was an issue with CPS and a question of whether it was a ‘restraint’
  • Chair Raymond – I know the reporter noted that the soft splint is mostly not used; is it your understanding that it was not used because someone alleged it was illegal?
    • Not sure, left discussion with understanding that treating pulmonologist
  • Klick – Is it not common to sue these types of devices in acute care to prevent tube pulling?
    • Correct, in many times usage of a true restraint to prevent tube pulling
  • Rose – You said it was “unfortunate” that there are too many kids in the program, concerned that this avoids accountability; also concerned that you are dismissing the claims of the parents, this many complaints would not be made if there were no issues
  • Rose – You didn’t find any issues with either case identified in the DMN?
    • Sanders, Superior – Apologize if I misspoke, there are too many vulnerable children in Texas; did not mean to imply there were too many in the program
    • Articles are very one-sided, only trying to clarify the misrepresentations
    • As far as the two identified cases, we found that almost all assertions were unsubstantiated
  • Rose – Could you talk about the dismissal for the fair hearing for the appeal?
    • Harmon, Superior – Yes, in Medicaid cases the fair hearing is used to examine determinations made by treating physicians
  • Rose – Explain why D’ashon’s case was dismissed?
    • Nursing is requested for a specific time period, as the 3-month authorization period had already passed before the hearing the presiding officer determined the case should be dismissed
  • Minjarez – there was an initial date scheduled and the hearing was rescheduled, why?
    • Would need to go back, only reasons would be a conflict for the hearing officer or the member
  • Frank – Seems like if someone requests a fair hearing and it is delayed, then the end date should move out with it; might be an HHSC issue
  • Chair Raymond – Just to be clear, with 17 hour/day nursing, the parent is also present, child does not sit alone for the remaining 7 hours
  • Klick – If a child had been suctioned that often, would that not be well outside the norm?
    • Correct, 2-3 times per day is the norm, should cause a re-evaluation
    • Suction is traumatic for any child, treating pulmonologist should have been consulted
  • Klick discusses specific of suction procedure with Harmon
  • Harmon discusses the 2-to1 ratio as well, allegations that this violated state and federal law; Superior discussed issue with HHSC during the 82nd Session, which resulted in a cost containment rider allowing for up to 3 children & policies were developed at Superior and HHSC
  • D’ashon was receiving 1-to-1 nursing at the time of the incident reported
  • Keough – Regarding the ratio, DMN reported that the 1-to-1 ratio was a matter of life or death
    • We do not believe with the info we were provided that this was a matter of life and death
  • Keough – DMN alleged that you couldn’t care for the other child in the home at the same time D’ashon was receiving care
    • Do not have permission to speak about the other child, but we felt that this situation was safe
  • Keough discusses the specifics of the case, concerned about the ratios discussed & the assertion that there could be a 3-to1 ratio
    • Policy requires a back-up person present in the home able to intervene in case of emergency
  • Keough – And respite care personal can do this?
    • In respite care, he was receiving 1-to1 nursing
  • Minjarez – Asks after lack of pulmonologist review, notes exist regarding suction and airway; what was the breakdown in communication?
    • Did not have information related to info pulmonologist received
  • Frank – During the incident referenced in the DMN article, the nurse was not there, but the respite care nurse was?
    • Correct
  • Chair Raymond – Unsure why the splint wasn’t put on the child, seems like we could’ve avoided the incident
  • Harmon also refutes that Superior was sanctioned for this case, Superior was never sanctioned
  • Chair Raymond – Can you speak to the unauthorized access on the phone call regarding D’ashon’s care?
    • After the conference call, internal team convened a call to discuss this and other cases; invitation was sent out to everyone on previous call
    • Call was ended as soon as it was recognized, used a conference number that had been used previously
  • Chair Raymond – Asks after apparent confusion over nursing hours
    • Not trained on proper number of nursing hours, specifically looked to hire individual with experience to better educate Superior personnel on nursing hour requirements
  • Keough – Did you say that during the event that D’ashon was receiving 1-to-1 nursing?
    • He was authorized for 1-to-1 nursing, but D’ashon’s nurse was not there, only the back up
  • Keough – Article indicates D’ashon was left with someone who was not supposed to be there, D’ashon’s nurse seems to have been taking care of other child
    • Letters of authorization are reviewable
  • Keough – Not contesting that, just presenting what the article is saying
    • Confusing when I read it, seemed like the nurse referred to was not D’ashon’s nurse
  • Keough – Are you saying the DMN is lying, making a case against you?
    • Personal opinion is that they are misrepresenting the case to make us look bad
  • Rose and Sanders discussed issues with Care Pro, Superior notified Care Pro with notice of termination during the issues with this case, sued by Care Pro and Care Pro is still in network
  • Rose discusses Superiors current complaint process with Sanders, hear of complaints regularly; Sanders provided an overview of Superior’s complaints process
  • Regarding Heather Powell case
    • Client is required to receive annual assessment of need from Superior, similar for all clients
    • Client had a changed condition related to a healed wound, which resulted in a reduction of 98 hours to 67 hours per week
    • Client appealed and hours were held at 97 during the appeal, client made Superior aware of a new condition during appeal that led eventually to 78 hour/week determination
    • Subsequent new condition then led to final assessment back to 98 hours/week
    • Client is dual coverage, DME is covered under fee-for-service; DMN article mis-reported Superior as being responsible for DME provision
    • Superior did follow-up with Medicare DME providers related to services, found that service coordinator was not performing up to standards
    • Also had issues with requested modification, structural issues delayed to modification and it was moved to a different part of the dwelling
  • Frank – Were any of these issues brought to you by reporters?
    • Had very limited contact, tried to follow up on certain points, but did not have HIPAA waiver to discuss cases
  • Chair Raymond – How many members do you have?
    • 1 million members through Medicaid contracts
  • Chair Raymond – There will be members that need more attention, Superior should look at these members closer
  • Klick – Asks after cases with dual eligible members?
    • Sanders – Ms. Powell was dual eligible, around 50% in the STAR+PLUS members
  • Klick and Harmon discussed challenges with the dual eligible population, can involve large administrative burden in DME outreach
    • Harmon – For those members participating in the MMP pilot program, seem to be very satisfied
  • Klick – Asks after coverage process when fee-for-service providers deny
    • Would need to see denials from payers in the fee-for-service system, we are a payer of last resort & check to see coverage under Medicaid at the end
    • Cannot elect to cover without denials, in many cases it is difficult for us to override determinations from Medicare and Medicaid fee-for-service
  • Keough – Regarding the case of D’ashon again, article notes that 1-to-1 ratio with 17 hours/day is still a savings to Superior; article states that state concluded 2-to-1 ratio violated federal law, did the state conclude this, or did they review?
    • Will need to ask the state when they testify, they did ask us to put policy on hold while we reviewed it; it continues to be on hold
  • Keough – Concerned about cost containment rider allowing for charging for 3-to-1, is this just charging for this or authorizing 3-to-1?
    • Would need to look at data to see if we’ve done 3-to-1, would mean 1 nurse for 3 patients with 3 different payment methods

 

Linda Badawo, Self

  • Shares experience of D’ashon Morris, D’ashon was progressing very well until the incident referenced in the DMN article
  • D’ashon began attempting to pull out his trach tube, medical practitioners recommended constant monitoring; made several expedited appeals requests trying to get proper care for D’ashon
  • Superior determined that appeals did not meet requirements to be expedited & that it could only be processed as 30-day appeal; presents letter noting that the health of D’ashon was in danger & recommended an in-home assessment, Superior has not assessed the home situation
  • Fair hearing was delayed 2 months as Superior doctor wanted to review all of the material related to D’ashon
  • Frank – So it was delayed because of the doctor at Superior, in conflict with what we were told
    • Agrees
  • D’ashon’s situation is very difficult, Superior does not seem to have a passion for health care; was expecting an apology from Superior, clear that they are not ready to solve or address issues
  • Frank – Are you D’ashon’s mom or foster mom?
    • I’ve adopted him, was D’ashon’s foster parent at time of incident
  • Klick – Were you present during the incident?
    • I was out of the country
  • Klick – How long have you been a foster parent?
    • Off and on since 2007
  • Klick – Do you have special training or medical training to allow you to care for medically fragile children?
    • Yes
  • Swanson – Why was the soft splint not being used during the time he was pulling the trach tube out?
    • Our physician would not sign authorization to allow use, soft splint is a restraint and a child needs to be 1-to1 to have a restraint used
    • Requested authorization from Superior, but they also did not want to give it
  • Swanson – So they refused?
    • Yes, asked for a Superior physician to grant authorization during fair hearing
  • Frank – Depends on who has the authorization to make the legal call
  • Klick – Don’t know that plans tend to send out plan physicians to assess and issue orders
    • Asked as Superior was not conducting any assessments or providing basis for denying

 

Liz Kromrei, Department of Family and Protective Services

  • Frank – Who makes the call on medical decisions? Is it the foster parent, CPS?
    • DFPS has very clear policy regarding use of restraints, there is an allowance for a supportive restraint & a doctor would make this decision
  • Chair Raymond – So the attending physician said no, but the specialist said it was needed
    • Bawado – Problem here is that our physician was much more familiar with D’ashon’s situation, believes she met criteria to make the decision for the splint
    • Superior did not assess D’ashon directly
  • Klick – Has D’ashon been hospitalized during the time you’ve had him?
    • Yes
  • Klick – Did he try to remove his trach in the hospital? Did they use restraints?
    • No, no need as there was a caregiver with him in the hospital
  • Klick – We see restraints for the safety of the child often for the safety of the child
    • Kromrei, DFPS – Our policy at the time would have allowed the splint as described; allowed as a ‘supportive restraint’
    • DFPS is trying to piece together information, did not find a clear order or direction from a doctor
  • Frank – Asks after who is authorized make medical decisions
    • The child’s doctor
    • We need to go and find other funding sources if doctor ordered services are not eligible for whatever reason
  • Chair Raymond – If you’re made aware that whatever the treating doctor is recommending is not being done, you take this to court?
    • It is an option
  • Chair Raymond – How would you be made aware of it? Were you made aware of conflicting views
    • Accurate to say there were conflicting views, a lot of the discussion surrounded the opinion of the doctor at Superior
  • Chair Raymond – Maybe we need a law saying that the MCO does not have discretion in cases like this
    • Were not made aware of issues raised by child’s physician
  • Wu – When the split discussion was occurring, was D’ashon still in foster care or was he adopted?
    • Bawado – Foster care
  • Wu – Was there a court that could have ordered this, was there an attorney ad litem?
    • There was an attorney
  • Wu – Was there any request by CPS to go back to the court and ask them to order the service
    • Not aware
  • Wu – After adoption, there would be no authority for a court to order anything?
    • Kromrei, DFPS – Correct
  • It is DFPS’s role to advocate, doctors have the final say on if something will occur
  • Wu – So there was a request for supervision as D’ashon was pulling out his trach tube, Superior says no & suggests a restraint, then D’ashon’s doctor suggests supervision as it might impede D’ashon’s development
    • Bawado – This is my understanding
  • Chair Raymond – Confusing as to why the child’s doctor did not recommend the restraint at least during term of the appeal
    • Understands the concept, but we need a doctor’s order to place a restraint on the child
  • Chair Raymond – Just concerned on why the child’s doctor did not make this determination
    • Highlights Superior’s inconsistent nursing policies as more contributive to D’ashon’s negative experience, in time 24-hour 1-to-1 care would have benefited him
  • Rose – Do caseworkers advocate for you with Superior?
    • Caseworker filed the appeal with Superior, caseworker conducts monthly visits and provides this information to Superior; can provide documentation
    • Kromrei, DFPS – Caseworker’s role is to advocate, DFPS also has a consulting team to assist caseworkers in raising issues and participating in the appeals process
  • Rose – So did the caseworker receive documentation back from Superior?
    • Bawado – Yes
    • Kromeri, DFPS – Not sure what caseworker received, they were aware of denial and participated in fair hearing process
  • Rose – If we had a state agency advocating for this child, curious if Superior contacted the caseworker
    • If there is a denial, goes to person designated as the medical consenter, not sure if caseworker received formal notice, but they did participate
    • Received notice from Superior expressing annoyance with the caseworker
  • Rose – Asks for this notice to be provided to the committee
  • Bawado discusses how Care Pro dropped service due to issues with Superior, was problematic to obtain services afterward as other staffing agencies knew of issues with Care Pro
  • Chair Raymond – Do you know if it happened after Care Pro was on a call they were not supposed to be on & when they were listening to patient info they were not entitled to
  • Minjarez – Superior complained about the caseworker?
    • Kromrei, DFPS – Superior’s doctor did
  • Bawado contests Superior’s assertion that pulmonary doctor was involved in D’ashon’s hours authorization, always only the child’s doctor
  • Wu – I feel like I’ve been in this hearing before, reminds me of the special education cap TEA had; legislature seems to underfund programs & effectively create incentives for bad things to happen

 

LeAnn Behrens, Amerigroup

  • Has been involved in Texas Medicaid and nonprofit health care work for many years, difficult work that definitely makes a difference in patient’s lives; DMN article did not represent this correctly
  • Appreciates ‘watchdog’ role of DMN in this case, but some issues were not properly reported & were missed
  • DMN also gave a voice to some vulnerable citizens, which we should be pleased about
  • DMN was right to focus on corporate responsibility, Amerigroup agrees, but notes that there would likely be similar issues in nonprofit managed care entities & DMN only singled out for-profit entities
  • References data showcasing that MCOs who make more profit have less complaints, has been characterized as a bad sign, but MCOs providing proper care with good business practices are also likely to have less complaints
  • Agrees that there are network adequacy issues, Amerigroup provides transportation to providers and attempts to help clients locate services
  • Klick – Do you have members in rural areas?
    • Yes
  • Klick – Are the counties without providers an issue?
    • Definitely, trying to work with providers of telehealth to put kiosks for behavioral health access in facilities
  • Addresses encounter data, Amerigroup has spoken to legislature about failures with encounter data; had another issue DMN reported on, DMN represented it as Amerigroup gaining $18 million, but this was actually recoupment of $18 million in mispayments
  • Amerigroup has also been fined in the past, did not fight these fines previously and have accepted responsibility; process has led Amerigroup to develop a robust encounters system
  • Keough – Refers to material from Amerigroup noting that they were not prepared for the new payment systems; how did we have a system where this can happen?
    • We thought we were prepared to handle the payment systems for nursing facilities
    • For example, Amerigroup did not properly capture the daily changes delivered by the state
    • System is very complicated, all managed care companies had to adjust systems; Amerigroup failed to adjust quickly and was fined for it
  • Regarding utilization management, HHSC does conduct utilization management audits
  • Amerigroup has put policies in place to ensure it respond quicker, ensures that services follow up for fragile STAR+PLUS members if an authorization exists
  • Highlights letter in response to DMN article sent to Gov. Abbott, letter sent to Chair Raymond regarding encounters situation, & spreadsheet responding to DMN allegations
  • DMN article started on first Sunday in June, Amerigroup was contacted Wednesday or Thursday the week prior with a list of questions from the reporter; was difficult to respond to questions as they were too general
  • Responses were asked for by Friday afternoon, not possible to get a release to talk about case highlighted in DMN
  • Regarding case of George Berry
    • STAR+PLUS individual who was dual eligible, flagged for audit and Amerigroup discussed with HHSC; DMN presented case as if it was lost, but Amerigroup followed up with audit
    • Protocol determined a nurse was needed to assist with insulin, to fill pill bottles, and an attendant
    • Amerigroup provided an attendant, but the member declined additional nursing services; member reports being very satisfied with Amerigroup services
    • Member also felt like he was being harassed by the DMN reporter, reporter did not disclose how he obtained the member’s info; Amerigroup has reported this to HHSC and OIG as they believe personal health info was improperly used
  • Amerigroup was also criticized on profits; Texas has a system that restricts profits MCOs can make, above 3% profit triggers clawback to state
  • $.85 of every dollar is spent on health care, $.05 on administrative costs, $.02 built in to return to state, ~$.06 on profit; average of roughly 5%-6% profit
  • Amerigroup does seem to have higher profit than other MCOs in Texas, but cannot speak to other MCO business practices
  • Highlights profits made by other health care industry participants; for-profit hospitals make 8%-10%, nonprofit make 2%-3% margin
  • DMN also speaks to two audits that found $600k & $500k not related to Texas Medicaid; Amerigroup’s finances are audited every year, some items are misclassified & Amerigroup properly corrects issues presented by audits
  • Every instance identified as “parties” attended by Amerigroup were events for nonprofit group donations
  • Keough – When you pay fines, were does this come from? Administration expense?
    • Cannot be counted as administrative, has to come from corporate body
  • Keough – What percentage of profit is paid in fines?
    • Unsure, likely has been higher than normal recently due to nursing facility struggles; have had relatively few in the past and recent issues were an anomaly
  • Keough – If you make 6% profit & anything over 3% is subject to clawback, how much of this is already resources originally given by the state of Texas
    • Texas builds in a 2% margin for rates
  • Keough – But your documents say 3%?
    • Texas builds 2% into the rates roughly, 3% clawback limit is a safety valve
  • When we make profit, it allows us to reinvest in programs that promote health outcomes
  • Keough – According to materials, quality improvement comes before profit, not after
    • Quality improvement refers to things like immunization rates, not these types program I’m referring to

 

Chair Raymond calls Superior back to testify in response

Mark Sanders, CEO Superior HealthPlan

  • We do have orders from the treating pulmonologist for nursing after D’ashon was discharged, we have documentation that the pulmonologist was the ordering physician
  • Superior never received a letter of medical necessity from the child’s physician for the nursing hours
  • Have material suggesting child’s physician did not think of soft splints until Superior’s doctor suggested this
  • Have claims payment and documentation that Superior was paying for a 1-to-1 ratio, Superior was also never notified he was put into respite care
  • State fair hearing was not rescheduled, only scheduled very far out; if MCO was not prepared it would have been settled in favor of appellant
  • Was made aware of certain factors of D’ashon’s care, conflicts with requests for constant feeding and testimony that D’ashon was being suctioned constantly
  • Care Pro never stopped billing us, we did terminate Care Pro for violation we believe happened on the internal call
  • Superior’s doctor was advocating for this child
  • Chair Raymond – Would recommend you type this up in a letter to distribute this to us, the General Investigating & Ethics committee, and the Appropriations S/C Art II committee
  • Swanson – So at no point did a doctor tell you that the soft splint was a restraint
    • Spoke with the pulmonologist and our physician who recommended its use
  • Rose – Asks after letter stating Superior was annoyed with the caseworker
    • Have not seen the letter; Caseworker was stating soft splint could not be used, Superior’s doctor was advocating that it could be
  • Chair Raymond – Who was it that informed the child’s doctor about this? What was her response?
    • Our doctor, child’s doctor was not aware
  • Chair Raymond – And yet she didn’t sign off on it?
    • Unsure, we don’t have documentation
  • Rose – Seems like your diminishing the importance of the letter
    • It was a dispute about the soft splint
  • Rose – Appears that it was more the Superior doctor insisting on a certain course of action

 

Enrique Marquez, Health and Human Services Commission

  • Legislature and Governor approved transfers to do utilization reviews, also given additional authority to hire contract oversight staff
  • HHSC Interim Commission Cecil Young asked OIG to weigh in on DMN case, will be sharing results in the future

 

Stephanie Muth, Health and Human Services Commission

  • Link to HHSC presentation on Contract oversight
  • HHSC has built a solid foundation, results of contract oversight have improved
  • Highlights difference between fines and liquidated damages, LDs are a result of actual damage to the state and not issued as part of the contract
  • Had a 400% increase in issuance of LDs in 1st quarter 2017 as compared to all of 2016
  • Transfers will assist in oversight of STAR+PLUS and MDCP
  • Providers make decisions to participate in the program based on provider density, provider capacity, program administrative complexity, and payment rates
  • Highlights points from pg 3, Oversight Approach to Network Adequacy
  • HHSC has been working on streamlining provider enrollment process, able to reduce timeframe by 34% in 2017
  • Legislature established time and distance standards in 2015, incorporated now in contract monitoring
  • Currently there are a number of things being done on network adequacy, but it has not yet come together as a systemic approach, so work can be done
  • Highlights network adequacy distance & time standards on pg 4, Texas has more stringent standards than the Medicaid program does
  • HHSC’s External Quality Review Organization looks at network adequacy through “secret shoppers” who call enrolled providers to check availability
  • EQRO removes providers who do not accept Medicaid from the study, but Muth notes that HHSC is trying to look closer at this data & that large numbers of providers not accepting Medicaid could be indicative of a problem
  • Pg 5 has various statistics on timeline to access to care
  • HHSC monitors time & distance quarterly, we do use MCO self-reported data; provider networks change daily and this complicates oversight
  • HHSC has various initiatives for improvement of access; improvement of time and distance standards, analysis of access to specialty services, identify opportunities for alternative delivery models, promote pay-for-quality/performance measures, etc.
  • HHSC is exploring trends arounds complaints and aggregating information
  • Klick – In complaint aggregation process, do you have personnel with medical background as part of that team?
    • Have not had medical staff involved in developing criteria used to collect information, we do involve medical staff in access to care issues identified as needing escalation
    • Will explore incorporating more medical personnel into the process
  • Developing portal to help coordinate complaints data and analysis
  • Highlights process for operational reviews, detailed on pg 10
  • Also conduct long-term services and supports utilization review, detailed on pg 11, important tool to ensuring appropriate service are provided
  • Frank – Is medically necessary defined by you or each MCO? How much consistency is there between MCOs?
    • HHSC has the Texas Medicaid Provider Procedures manual, medical necessity is defined via appropriate amount, duration, and scope
    • Can vary between situations
  • Frank – But does it vary between MCOs?
    • It is the same, based on state guidelines
  • HHSC can use utilization review nurses to examine individual cases, this happened in the Heather Powell case reported by DMN; this led to HHSC assessing LDs against Superior totaling $3 million
  • DMN also spoke to HHSC reducing >$100 million in LDs to ~$11 million, misrepresentation as original number was based on contractual maximums as identified by utilization review nurses
  • Was not an arbitrary decision to assess $11 million, HHSC has built a framework for determining actual damages to the state
  • Keough – What are the four tiers of risk for LDs?
    • Listed on pg 23 of presentation, based on HHSC regulatory framework
  • Rider 61(b) directed HHSC to have an independent review, Deloitte has been producing a report; expecting completion of portions by mid to late July covering audits, data necessary for evaluations, and need for training or additional resources
  • Chair Raymond – If you want to get into more specifics for the Heather Powell case? We obtained the waiver
    • Will respond to any questions concerning the case
  • Chair Raymond – Do you want to speak to the $3 million in LDs?
    • Do not disagree with anything Superior said, case was complicated, but nothing specific to add
  • Minjarez – Is HHSC made aware of outside lawsuits settled by MCOs and providers?
    • Unsure, will get back to you
  • Rose – Do you count complaints you receive regarding MCOs?
    • 3 sources for complaints currently; MCOs, ombudsman, and HHSC staff receives complaints
    • Everything is reported, there are duplicates so no single number to provide
    • Will have information to share with committee soon, ultimate goal is to pool all complaints for trend analysis and development of the portal
  • Rose – Is there any part of the appeal system where a neutral party looks at medical information?
    • First part of the process is a direct appeal to MCO, can request fair hearing after this and this is run by HHSC legal
  • Rose – Does any other state have an outside appeal management vendor?
    • Can research this
  • Minjarez – Bawado testified that D’ashon’s fair hearing was delayed due to Superior being unready, Superior testified that this would have resulted in a dismissal in favor of the appellant, can you speak to this?
    • Karen Ray, HHSC – If MCO personnel are not ready it does not automatically result in a dismissal in favor of the appellant
    • In this case, it wasn’t so much a postponement of the hearing, rather a continuation of discussion between parties that exceeded the authorization period
  • Minjarez – Are these hearings recorded?
    • Yes
  • Chair Raymond – Asks Marquez if he can speak to statements in the DMN article?
    • Marquez, HHSC – Relied on information given to me, words I chose were impersonal and should have chosen wording better
  • Chair Raymond – Asks after outside organization obtaining information on these cases
  • Frank – Open Records Requests doesn’t allow you to see names, correct?
    • This information would have been redacted

 

Additional Testimony on Detention Centers

Opening Comments

  • Chair Raymond – This was not posted for, but invited individuals to speak; my understanding is that President Trump signed an order regarding this so it may be moot
  • Chair Raymond – Would like witnesses to speak to 2 points, role of HHSC and any harm

 

Victoria Ford, Health and Human Services Commission

  • HHSC has responsibility for licensing these types of facilities, licenses are granted on minimum standards
  • HHSC inspects on a regular basis, licensed as residential
  • Chair Raymond – Are permits issued to private companies that then contract out?
    • Often nonprofits, these are private companies, they contract for the placement of children
  • Chair Raymond – Not necessarily just children of immigrants, could be others
    • Correct, populations not usually mixed within the facility, but both are held to the same standard
  • Chair Raymond – Do you know how many

 

Jean Shaw, Health and Human Services Commission

  • ~5,200 Licenses
  • Chair Raymond – Does this mean we have 5,000 children?
    • Close
  • Chair Raymond – asks after locations
    • Several in Houston, several in the Rio Grande Valley, San Antonio, Los Fresnos, other areas
    • No specifics currently

 

Hank Whitman, Department of Family and Protective Services

  • 37 facilities licensed at this time
  • We treat these facilities and children there as any other child within the system
  • To date have had 32 investigations, 23 have been ruled out and 9 still active; do not have jurisdiction over actions in other countries, but will inform consulates and will investigate
  • Chair Raymond – What happens to the children without an order from the President? Do they funnel into our system as foster children?
    • Could be, could stress our systems
  • Klick – Very concerned that this could overburden our foster system, isn’t there a federal foster system?
    • There is, we will be competing with them; they pay higher rates
    • Concerned about how this will impact the 30,000 children in our system
  • Minjarez – Are caseworkers going into these shelters?
    • Licensing does this, DFPS goes in along with them to investigate allegations of abuse
  • Minjarez – Have there been allegations of abuse in the shelters themselves?
    • Unsure, can get this to you
  • Minjarez – How often are inspections done?
    • Shaw, HHSC – At least once a year, but often in there more frequently, e.g. in the case of deficiencies
  • Minjarez – Are these children receiving medical care in these facilities?
    • They must get medical assessments covering general health and emergency needs
    • Also required to provide education for the children
  • Minjarez – Are you responsible for finding resident families who can take custody?
    • This is done through office of refugee resettlement
  • Chair Raymond – Asks after requests to increase numbers of children at facilities?
    • Ford, HHSC – There is a variance request process, but there are additional standards they must meet to have this granted
  • Chair Raymond – Have there been instances where variances have been asked for square footage difference per child?
    • Shaw, HHSC – Yes, some have asked for this and some have been granted, we monitor closely to ensure it does not get uncomfortable for children
    • Also monitor recreational activities
  • Chair Raymond – Asks for a response to news reports, have heard some do not let children outside more than 2 hours/day?
    • No requirements for hours/day, differs at each facility
  • Frank – Do you know the average stay per child?
    • Do not have this information, tracked through ORR
    • Whitman, DFPS – They must go through judicial process, cannot say how long this is
    • If they move to a military facility, we lose jurisdiction over them
    • We also cannot remove children, must go to federal authorities
  • Frank – How long has this been going on?
    • Ford, HHSC – Current situation has been going on for a few months, but have had facilities for many years
  • Chair Raymond – Unaccompanied minors is one issue, but bulk now is family separations
    • Whitman, DFPS – There are families coming over with their children, but border patrol has difficulty figuring out as they have no papers
  • Rose – I think the difference now is that adults are being charged, is it a misdemeanor?
    • Not sure what the charge is
  • Rose – This is the difference, people seeking asylum are being charged
  • rose – I thought the ORR was eliminated in Texas?
    • Ford, HHSC – Referencing federal office
  • Wu – State’s current capacity is 5,000 children, based on existing capacity; were any facilities licensed within the last few months?
    • Shaw, HHSC – No new licenses, one current applications
  • Chair Raymond – What about variances?
    • Have been doing variances since about late March
  • Wu – Are these licenses similar to charters? Or is it one license per facility?
    • One license per location
  • Wu – New facility opening in Houston, San Antonio, etc., are these facilities required to be licensed?
    • Yes
  • Wu – So you’re only aware of facility in Houston requesting a license?
    • Yes
  • Wu – When was the last time someone requested a license on top of capacity?
    • Most recent is Houston, would need to check on before that; has been months or years
  • Wu – How many variances have been requested since February or March?
    • Will need to look this up
  • Wu – Can you look about requests for variances because of this program?
    • Ford, HHSC – Can look up variance requests due to ORR, but not because of specific policy
  • Wu – I think some members have requested a list of all facilities in Texas delineated by age and gender, has this been made available?
    • Shaw, HHSC – Not aware of request
  • Wu – Can I make this request?
    • Will report back to the committee
  • Wu – When these variances were being requested, was state leadership notified?
    • Not specifically, grant variances according to rules and procedure, but no requirement exists to notify government
  • Wu – But you didn’t notify the Governor?
    • Discuss regulatory issues, but not specifically; variances are a normal occurrence
  • Wu – What is the maximum size?
    • Ford, HHSC – Differs based on specifications of the facility
  • Wu – Current state law regarding abuse and neglect apply for these facilities, correct?
    • Whitman, DFPS – Federal facilities, but state law applies
  • Wu – So reporting requirements surrounding abuse apply? If an employee finds out about abuse from a child, they are required to report under law?
    • Correct
  • Wu – And incidents would fall under abuse or neglect, correct?
    • Or supervision issues, sexual abuse, exploitation, etc.
  • Wu – Under a normal CPS case, if children are left to cry without intervention, is this cause for an investigation?
    • Certainly for a review, personnel exist to make determination if investigation is needed
  • Wu – Is it your understanding that leaving children without attention or comfort for long periods of time has potential for sever harm?
    • Yes
  • Wu – If there is a sudden increase in number of children held at a facility, would your office conduct additional inspections?
    • Ford, HHSC – Wouldn’t necessarily be required, would conduct normal investigations
  • Wu – When you do inspections of facilities, do you talk to the children? Look at medical records
    • Yes, will look at records, admission assessments, needs, etc.
  • Wu – Is psychological care or counseling provided at facilities?
    • Required to implement recommendations if from a medical professional
  • Wu – Is there any requirement surrounding psychological care?
    • Requirements for general medical assessments
    • Whitman, DFPS – We did have an episode where a child had a psychological episode and was transported to a hospital for treatment
  • Chair Raymond – Can you tell the committee about the new organizational chart?
    • Ford, HHSC – Former Exec Comm Smith asked me to look at COO position and if it was too big for one person
    • When Exec Comm Smith resigned, became apparent that we did not have a good chain of command structure
    • Also made aware that organizational chart didn’t prioritize services
    • New organizational chart is designed to correct those concerns
    • Highlights changes to give clear guidance on chain of command and programmatic changes
    • Org chart finalization has allowed us to post for COO position

 

MCO Response to DMN Article

Anne Rote, Molina Healthcare

  • Molina was mentioned briefly in the DMN article related to rollo9ut of managed care in Rio Grande Valley in 2012
  • When rates were set by HHSC during this time, used historical rates and assumed savings, which were expected quickly
  • Molina found this not to be the case, were losing ~$8 million/month, loses caused by lack of realized savings
  • Cut personal attendant care services by 10%, DMN represented this as cut to provider, but it was for a specific type and for 10%
  • Lost membership and many providers cut contracts, Molina was fined $1.8 million and membership was frozen
  • HHSC responded appropriately, Molina learned a lot from the experience & has become more open and responsive in working with HHSC
  • Operation in Rio Grande Valley are going very well; highlights quick response to flooding in the area this morning

 

Don Langer, UnitedHealthCare

  • Spoke with all members who had issues from the last hearing (surrounding MDCP)
  • Implemented new policies surrounding coordination of benefits, need to continue working on this, need to work on language in notice letters, & need to work on policies broadly
  • Also working on new supports for providers, including a new warning system that alerts providers that claims are likely to be denied, new tool for informing providers what is needed for priori authorizations, new tool to inform doctors prescribing about priori authorizations, pilot to give multiple-event conditions one prior authorization
  • Chair Raymond – Talk about that cancer treatment process again?
    • Focused on treatments that are common among cancer patients
  • Chair Raymond – Why would this be hard?
    • Klick – Variations among patients
    • Not piloting in Texas currently, but can speak to United personnel
  • Regarding DMN article and network adequacy, network adequacy issues are directories being outdated as soon as published, and providers/doctors changing Medicaid acceptance month-to-month
  • Chair Raymond – And other states have this problem, have any solved this?
    • No, United is checking with doctors every 6 months to re-confirm if they have taken no Medicaid patients
  • Regarding DMN & service coordination, United has a great service coordination program, important for United not to vendor-out this program
  • Chair Raymond – Might be something for HHSC to consider; If we see 1 or 2 MCOs doing something that works well, then we need to look at this from a statewide perspective
  • Frank – Need to look at performance across the industry,
    • Rote, Molina – This is something we are looking at & trying to figure out, through HEDAS measures in other areas
  • Frank – Best practices should be looked at, but what works in one service area might not work in others; hard to measures outcomes given mix of patients
    • We do measure, but hard to boil down to who is the best

 

Daniel Chambers, Cigna-HealthSpring

  • Cigna only participates in STAR+PLUS, so only the elderly and adult populations
  • Cigna was only briefly mentioned in the DMN in regard to an SAO audit in 2015
  • Accountability is largely done through administrative caps and quality measures putting some of the rates at risk
  • DMN stated that MCOs were incentivized to deny services in favor of profit, but this is a misrepresentation; MCOs are often able to direct more resources at patient care
  • HEDAS and EQRO data has shown managed care has reduced hospital and ER visits, but increased access to community health care; other specific condition outcomes show similar positive results
  • DMN pointed out $34 million in charges questioned by audit, but Cigna demonstrated to HHSC that these were allowable and supportive of health care
  • Also fixed issue leading to unallowable expenses identified in the audit
  • MCOs are incentivized to develop specialized programs to improve health outcomes, Cigna has developed a disease management program targeting sickest members, also running diabetes program focused on diet education through nurses
  • Also focusing on opioid crisis, Cigna has done significant outreach to provider groups, etc., also reducing utilization by 25%
  • Managed care has been successful in Texas