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The House Appropriations Subcommittee on Article II and House Committee on General Investigating & Ethics met in a joint hearing on June 27 to hear invited and public testimony regarding oversight of the Health and Human Services Commission’s management of Medicaid managed care contracts. The committees also discussed recent news articles and certain managed care cases. The report below includes a spotlight on the extensive public testimony presented at the hearing.

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.

 

Opening Remarks

  • Davis – Referenced Dallas Morning News report; health care system needs strict oversight and administration

 

Combined Written Testimony

 

Patients & Impacted Individuals in Dallas Morning News Article

Linda Badawo, Self

  • Her son D’ashon began care in 2015 with many treatments
  • At 9 months old he was doing very well
  • At 1 year old he was very active
  • When he was transferred to the home he had 126 hours of nursing care
    • Was concerned after 5 months in the hospital and expected 24-hour care
  • Called superior help line – amount of care was not enough
    • Filed an appeal in April 2016
  • Davis – you filed an appeal to what?
    • 2 to 1 which is the system – one nurse to 2 children
  • Davis – so at one point a nurse was assigned for both children when each was supposed to have their own?
    • Correct that was a change made by Superior
    • Also a reduction in nursing hours
    • That is what was appealed
  • After the appeal it took roughly 2 months to get a date of review
    • Was told that her son would not receive 24-hour care before the hearing was completed
  • Davis – you have been involved in foster care and have been a nurse?
    • That is correct
  • Davis – have you been involved with children that have had splints like that?
    • No, not for a long period of time
    • Concerned that he would not continue to meet milestones if he could not have full movement of upper extremities
    • Problem is that he would pull out a trach and it needs to be put back in immediate and is a life and death situation when that happens
    • This is the reason that he needs a nurse available all the time
    • Told the doctor that the splint was not in the best interest of the child
  • Was told the splint would take about a month to get
  • Was told that the child should be placed in a different home
  • Refused to come do an assessment in the home
  • Seems like the managed care does not take doctors opinion for what it is
    • Causes a need to fight for everything with the MCO
  • MCO system does not work for her family
  • Davis – your primary frustration is with the fact that the MCO overruled or disagreed with the attending physician determined?
    • That is correct
  • Davis – do you have a managed care case worker within Superior?
    • Has a case worker
    • Does not know if they are supposed to come to the home but none has
    • Only have had one house visit after a major incident
  • Davis – was there any communication between foster care case worker and Superior?
    • Believes that the only communication was when the CPS case worker filed an appeal to Superior
  • Turner – the appeals centered on a requirement for 24-hour nursing care and at a 1 to 1 nursing ratio?
    • Correct
    • It was difficult to find nurses to stay on the case
    • Requires having to reorient nurses constantly
  • Turner – D’ashon’s sister also required a 24-hour nurse; which is why you appealed the nursing ratio?
    • Correct
  • Turner – it looks like the medical records showed that 1 to 1 nursing was required?
    • That is correct
  • Turner – also appears that there is a letter of medical necessity for 24-hour care. Do you know where that letter was sent?
    • It was sent to Superior
  • Turner – was it sent to anybody specific at Superior?
    • Unsure
    • It was included in the material from Superior when the appeal was made
  • Turner – when the appeal was denied, Superior sent somebody to the home?
    • After requesting that multiple times
  • Turner – did the Superior Doctor ever examine D’ashon?
    • No, and do not know what their decision was based on.
  • Roberts – how many children do you have in your home?
    • At the time there were 4 children and not there are 5
  • Roberts – do the other children have medical issues as well?
    • The other children do not require nursing care
  • Roberts – what other support is there within the home?
    • Her mother and husband and two biological children
  • Roberts – do you work outside the home?
    • Yes
    • When not at home, the husband is at the home
  • Roberts – regarding the fair hearing, what is you understanding of the basis for Superior to deny 24-hour care?
    • Believes that they were trying to save money
  • Roberts – did Superior give any medical reason for denying 1 to 1 24-hour care?
    • They stated that because he was not on vent or continuous feeding
  • Roberts – what was the initial order the primary physician write?
    • 24-hour care
  • Roberts – was there any additional appeals?
    • Believes that there are still options to continue to appeal
    • Appealed again immediately after first decision
  • Roberts – what was the decision of that appeal?
    • Did not get resolved due to medical issue that arose
    • So superior gave 24-hour nursing care after the medical event

 

Nancy Toll, Registered Nurse

  • Has performed home visit reviews in the past
  • Went into the home of Star Plus members to conduct reviews
  • Contract issues are the one thing that Managed Care waivers are implemented in Texas
    • The system encourages the system provider to do as little as possible
  • Identification of need should be separate from those providing the care
  • Waivers allow for adults to waive off institutional care
    • Waiver has many benefits
    • Each person in the waiver must have specialized and skilled nursing care in lieu of nursing facility care
  • The level of medical necessity leads to level of funding
  • Performed review of a sample of those in the waiver
  • Davis – how did you determine who you would go visit?
    • They were generated randomly
    • Did also go see patients with complaints
  • Many nursing tasks were given to family members to perform
    • Could include very specialized tasks
    • Sometimes family members are paid but must be trained by registered burse
    • Sometimes family members conducted those activities during non-paid times
  • Saw difficulties with respite care – family members were not often aware of this availability and was not even across care givers
  • Discussed potential issues that would go unknown or unseen by family members that are not trained to recognize the signs
  • No nursing care = no comprehensive assessment
  • Suggested hands on assessment and collaboration
    • Noted audible protest from MCOs
    • MCO nurses shared frustration with case load
  • Tried to address this issue by addressing the pay for service system
    • Nursing service plan created could be used as a checklist/worksheet for nurses
    • Protests from MCOs were heard
  • Saw a lack of recognition of the authority of HHSC oversight
  • When deficiencies were found previously there was a “referral” created which led to a report during the annual or regular reporting
    • Should have been several thousand dollars in fines
    • Was told that those fines would be detrimental to the MCO system
    • Recoupment was meant to recapture difference between state services and MCO services
    • Very small amounts were paid
    • “no extrapolation” was allowed to the rest of the population
  • Conducted private duty nursing review
    • Included the Badawo family
    • It was a very small group
    • Results led to minimum standard care flowsheet and process flow that has been implemented into the Star Kids Program – addressed 2 to 1 ratio
  • Believes that many in HHSC have desire to go into MCO afterwards which is a conflict of interest
  • Was not confident that determinations and options would be listened to or taken seriously
  • Need minimum standard of care
  • Need a financial floor for that minimum standard of care
  • MCOs pay bill and perform service coordination but do not provide care
  • Davis – would like copies of remarks if possible
  • Davis – have you reviewed reports given to legislature based on utilization reviews?
    • Believes they are very condensed and bulleted
  • Davis – what format was your initial data provided in?
    • First sample was 252 people across the state
    • Second was about 350 people
    • Data went into a self-created database which was submitted to HHSC on an excel spread sheet
    • It is difficult to see, and encounter data listed on service plan
    • Goal was to get it to be more readily available in real time through graphs, etc. to be able to better address it.
  • Davis – did you or your team make assessments on liquidated damages?
    • Would turn over the data which would be worked on with contract management to determine financial damages
    • There were usually arguments put in place to alleviate that
  • Davis – one article mentions that staff complained that MCOs were going to top state officials to get liquidated damages reduced, do you agree with that?
    • Does believe that happened
  • Davis – what officials were being asked to reduce liquidated damages?
    • Do not have specific names
    • Only heard that it would be at the legislature level where lobbyists would complain about damages or fees
  • Davis – do you still have any of the documents?
    • That should be available at HHSC
    • Only thing took was intellectual property which was already made public
    • Should look at the differences between a patient’s budget versus what was actually spent
  • Davis – do you have any perspective on network adequacy?
    • Cannot speak to numbers but believes that the network is inadequate from conversations and experiences
  • Davis – what are your thoughts on dual eligibility care coordination?
    • It is mentioned in the contract that it is supposed to be done
    • Believes that it was a very bad situation for the patients
  • Capriglione – discussing potential conflicts of interest at HHSC, do you believe that some MCOs have hired people that have been involved in the bid process?
    • There certainly have been people hired
    • They can get around the rules by putting them in another position for a period of time before putting them back into their area of specialty
  • Capriglione – do you have any specifics on where this might be a problem?
    • Some were laid out in the article
    • Do not have specifics
    • Many people in HHSC group discussed wanting to be hired by an MCO at some point
  • Turner – have mentioned physician regarding a patient case that had an argument with MCO about level of care?
    • HHSC was asking for further action and information regarding a patient, superior flat out said no that they would not do that
    • It was a disturbing trend in the system
  • Turner – what was the response from HHSC?
    • Only had local leadership in there, believes that it needs to be dealt with
    • HHSC has to be viewed as ultimate authority and as the experts
  • Turner – there was a finding through the utilization review that LVNs were doing the review instead of a registered nurse?
    • Do not believe there is an excuse for not having a person with the appropriate licensure conducting the review
    • Some can only read and implement not review or assess
  • Turner – can you speak to how your recommendations were watered down?
    • What we wrote was given to the director of utilization review, not sure what or how her feedback was received and what levels or people were involved in that
    • The bullets were a very high-level review and should have just been a top sheet on the review
  • Turner – did you ever hear of anyone having offers by MCOs while they were still at the agency?
    • Did not hear that happen
  • Turner – time of service was 2014 to 2017?
    • Yes
    • Served under 3 commissioners
  • Turner – were the problems identified existent over the course of your tenure or specifically under one set of leadership?
    • It was fairly similar the whole time
    • Part of the webinar was to help educate the MCOs
    • Have faith that utilization review is doing a good job, but want deficiencies identified to lead to more quick and strong implementations

 

Caroline Cheevers, Self

  • Mother of 4 medically challenged children
  • August of 2017- She needed antibiotic to help with digestive failure, but ran into roadblocks
  • 4 days after antibiotic order, denied twice, even after 2 authorizations and peer to peer
  • Approved on August 25th, but since Hurricane Harvey didn’t get the medication until September 6th
  • Difficult to find a pharmacy that could do all of the required prescriptions
    • Had to use two pharmacies
    • Could not be discharged until all of that was sorted
  • United Health Care had issue with getting medications approved
  • There was a lot of back and forth (up to three weeks) and filing the fair hearing to get some issue approved by MCO
  • Lost three specialists when switched to MCO
  • Has personal contacts at HHSC but most people do not have those resources
  • Have had 2 appeals on traditional Medicaid in three years; with MCO filed 31 complaints or appeals
    • Noted one instance with a wheelchair approved but not the wheels as an example of difficulties with MCO
  • Without Medicaid status many potential parents would not adopt special needs children
  • Davis – the biggest source of frustration is a constant denial of services?
    • That is correct
  • Turner – how often does your child need trach clearing?
    • On a good day: 10 times per hour

 

Managed Care Organizations

Mark Sanders, Chief Executive Officer, Superior HealthPlan

  • Discussed dual eligible member plans in MMP program
  • Having to separate plans covering services introduces complexities for all entities involved
  • Davis – is care coordination not something that is part of the MCO role?
    • The point was that if the member is under the MCO for the Medicare portion would allow for better streamlining of services and status updates
    • In many cases DME providers have unique requirements
    • The MMP program is set to end in 2019 and would like to recommend that that program be extended and expanded
    • Surveys show that MMP programs members have a much higher level of satisfaction
  • Davis – assuming the legislature lets this program end, what are your plans if that happens?
    • Majority of members are dual eligible and not in MMP program
    • Have conducted reviews of needed staffing requirements to provide the level of service
    • Have met those staffing requirements

 

David Harmon, Chief Medical Officer, Superior HealthPlan

  • Discussed fair hearings
    • Federal requirements do not look at medical necessity, only if the process followed requirements
  • Roberts – fair hearing does not look at medical necessity?
    • The hearing members on the state side are lay people not medical professionals
  • Roberts – who is involved?
    • The state hearing office, MCO, member
  • Roberts – that would seem to be the first problem that they are lay people, what is the basis of the approval or denial if it is not medical determination?
    • Based on contract requirements
    • Looks at if the process is followed correctly
  • Roberts – how can they determine if the decision is made correctly?
    • That is the requirement of the federal rule
    • There are many improvements to be made in the process
    • Some states have implemented 3rd party assessment
  • Roberts – there is not a third-party arbitrator in Texas Medicaid program?
    • Not at this time
  • Roberts – if it is a medical necessity decision does the MCOP approve or deny based on the contract?
    • There are clinical policies and procedures that are followed as well as through conversations with medical experts
    • Purely clinically based decisions
  • Roberts – so ultimately the decision is all within the MCO, and none of the appeals are with a medical professional
    • That is correct
  • Bonnen – you said fair hearing looks at policies and not medical assessment, and then said there is a review of medical necessity
    • Only a physician can make that decision
  • Bonnen – that physician in employed by the MCO?
    • That is correct
  • Bonnen – seems that decision could have an impact on the patient, what type of responsibility exist for the person making that decision?
    • All of the same responsibilities still apply
    • Texas Board of medicine has stated that review is not patient care
  • Bonnen – could it happen that your medical professional making a decision contrary to the primary without meeting with the patient?
    • It could
    • There are ongoing reviews and tests to ensure consistency and quality of the decision making
    • Civil litigation would be the recourse for the member
  • Bonnen – none of this is practical for a patient trying to get treatment in a timely or effective manner
  • State should consider looking at best practices in other states like Florida in determining foster care for medically fragile children
  • Supports DFPS appointing a pediatrician as medical director
  • Recommends monitoring the quality of home health and beefing up the monitoring and creating a preventable events program with incentives and disincentives
  • Davis – do you believe that the previous testimony and the DMN articles were not rare instances but more systemic issues?
    • Do not believe that it represents that
    • Believes that the MCO folks are passionate
  • Davis – discussed ratio of nurses to members that does not sound adequate (1,000 nurses to 72,000 members)
    • Doi believe are fully staffed to meet staffing requirements
  • Roberts – discussed Florida as best practice model, is there a limit to number of medically fragile children to each foster home?
    • Maximum 5 including biological children
    • Up to three children with the lowest level of needed care
  • Roberts – does DFPS have similar requirements?
    • Will defer to DFPS to answer that
    • Have seen up to 10 medically fragile children in one home
  • Roberts – what is DFPS role in the delivery of care in this program and in the appeal process?
    • Try to make it a collaborative role
    • Have ongoing meetings related to medically fragile children
  • Roberts – in the meetings, is the MCO the only one with medical professionals or does HHSC or DFPS have medical professionals?
    • Often the treating physician may be invited
    • There can be but are not always in attendance
    • Believes that these meeting are coordinated at the local level
  • Roberts – do you believe that a capitation program is preferred or least preferred in insuring adequacy of care?
    • Sanders – Superior took this issue very seriously. Disagree with some of the implied incentive for MCOs to deny services, ensuring members receive services causes less cost down the road
    • A lot of thought and diligence from leaders have created a model that does work
  • Capriglione – have looked through the RFP and the discussion of analytics, do you measure how many people are being denied and how is that measured? And is that rate compared to others in the industry and is that provided to HHSC for review?
    • There is a requirement to report UM statistics in summary data to the state on denials to be compared to other MCOs
    • Compared to other states plans
    • Monitor medical directors for variability within the industry
  • Capriglione – what is the rough percentage?
    • Roughly of 9%, 92% are approved
  • Capriglione – regarding recruitment efforts, (listed statute related to recruitment of those involved in the RFP or subject matter experts on the contract) do you use consulting companies that employ those who have served in HHSC before and how to you check?
    • Follow the statute
    • Notify HHSC for full disclosure
  • Capriglione – how many employees?
    • About 3800 employees
    • Do not know how many have worked for HHSC in the past
  • Davis – would like further information provided regarding that issue. How many former HHSC employee are you employing.
  • Turner – wen changes are made to a member’s plan, who is involved in the process?
    • Receive a request from the agency that is providing the service
    • Provide a new proposed treatment plan with justification
    • Processed by MCO
    • Goes through the medical professionals for review
    • Only medical director can make final determination
    • May require additional information from requesting physician
  • Turner – what is the process to initiate a change that results in reduction of services?
    • Would get a continuation request at a different level
    • Would go through the same level of review
  • Turner – heard Superior was using LVNs when a registered nurse was required and what is Superior doing to ensure that going forward?
    • That initial recommendation has been utilized to only use RNs although contract allows LVNs
    • Have been working to change all LVNs to RN
    • Have approximately 50 LVNs but are working toward exclusively using RNs
  • Turner – at what point does state or federal law dictate what services a member receives and when the MCO has discretion, can you speak to that?
    • Federal law trumps everything
    • As long as the state is not more restrictive that federal law that can impose additional restrictions
    • Sanders – one other layer is the MCOs contract with the state
    • Sanders – dual eligible members – contract outlines that the MCO is the payer of last result
    • Sanders – have requested additional clarification in the contract for who is to pay for certain items
  • Turner – related to the Morris case, what is the role of the medical director?
    • Medical directors are not treatment providers
    • Thy review pediatric cases
    • Determination is based off of recommendation from nursing agency
  • Turner – but he was advocating for a splint
    • He was offering an alternative although he could not prescribe that himself
  • Turner – how do medical directors deal with the inevitable situation of overruling the treating physician, and how is that reconciled?
    • It is not a position that is ideal, but at the same time it is requires through TDI and the contract to only provide what is deemed as medically necessary treatment
    • Have invited the OIG to investigate any allegations and Superior’s responses
  • Turner – related to the letter described, Ms. Morris said she got the letter from Superior?
    • Does not believe that it was in that packet.
  • And does that pertain to D’ashon or to his sister?
    • Pertains just to D’ashon
  • Turner – It was determined a medical necessity because of the two feedings and trach issues, @ 17 hours/day, was this because of him pulling out the trach?
    • Not because he was pulling it out, but at that time he was beginning to play with it
  • Turner – So the potential was there
  • Turner – And the suctioning, he also needed a nurse present for that?
    • Yes, he was being suctioned 2-9/hour
  • Turner – So the 17 hours was approved based on that, why is this given that suctioning and trach issues could happen at other times?
    • This is why the soft splint came into play, could be a solution
  • Turner – if it was known the D’ashon was playing with is trach, what was the reasoning for only determining that he needed 17 hours of nursing per day?
    • It gets into an issue of what is needed versus what may happen
  • Turner – did the treating pulmonologist ever prescribe the splint?
    • No
  • Turner – do you know the timing of those conversations?
    • Believe the fair hearing was scheduled for 8/2 and Superior’s Doctor spoke with them ion the 8/4
  • Turner – it sounds like the DFPS was trying to look out for the child, Superior’s doctor commented that he would be filing a complaint, what would prompt that?
    • He was concerned that the case worker was describing the splint as a restraint
  • Turner – does that constitute medical advice?
    • Could be considered as preventing him from getting the necessary medical treatment
  • Turner – described a statement related to using nursing as foster care
    • There is a requirement that there is someone else in the home
  • Turner – is it the role of the medical director to make judgements on the suitability of foster parents?
    • When we have concerns, it is our duty to relate those concerns
    • It appears that Superior’s doctor was trying to relay those concerns
  • Turner – Superior’s doctor is medical director, does he report to you?
    • That is correct
  • Turner – understand that Superior’s doctor used to work for HHSC, were you involved in hiring and how long has he been with Superior?
    • He did, and was a part of that hiring process and has been with superior for 4 years
    • Described the hiring process of Superior’s doctor
  • Davis – he Has been with you since 2014?
    • correct
  • Davis – do you know how long he was with the agency before going to Superior?
    • Believes roughly 5 years
  • Davis – related to the soft splint issue, Dr. Roman agreed?
    • Believes that is correct
  • Davis – then why did this not happen?
    • There was a lot of confusion with DFPS believing that it was a restraint
  • Davis – Superior’s doctor described the relationship with DFPS as adversarial, were you aware of this issue?
    • Had not seen the letter until the last hearing
  • Davis – noted that could not find another physician that agreed with the soft splint. It seems as though the medical director believed that he knew better that the treating physician, and due to that we have a child that is braindead. All we have gotten from Superior is that they haven’t done anything wrong.
  • Turner – there was testimony related to the appeal before the denial of additional hours and a request for a home assessment that was not followed through with, why did that not happen?
    • Do not know in that particular case, will follow up with that
    • Have guidelines that should have had a home visit
    • Not aware of anything that would have prevented a home visit
  • Munoz – what percentage of denials are overturned?
    • About 25% of the time
  • Munoz – that would be how many requests?
    • Does not have a total volume number but will provide that number
  • Munoz – how many medical directors do you have?
    • 3 senior medical directors and 12 full time medical directs plus a few that fill in
    • Roughly 16 medical directors
  • Munoz – in determining payer of last resort, does the state give you the money for the item and you sit on that money until other payment options are exhausted?
    • Referenced items that were not intended to be paid for by MCO
    • That is why we have asked for further clarification in the contract
  • Munoz – have you been penalized in any way for the D’ashon Morris Case?
    • No
  • Munoz – have you made a formal request to OIG to investigate?
    • That is correct, we have
  • Munoz – have you paid damages to HHSC?
    • We have, and can provide that information
    • Most state fiscal years have been less that $1 million
  • Munoz – you will be able to provide the reason for the penalty correct?
    • Correct and will provide that information
  • Munoz – discussed liquidated damages
    • Have a very involved process of determination with HHSC regarding Liquidated damages
  • Munoz – described a situation with the medical director conflicting with treating physician, you would agree that it happens more often than not?
    • Do not agree with that
  • Munoz – what about the other 8%?
    • That was over a 1-year period?
  • Munoz – do you employee any lobby efforts?
    • We do engage with lobbyists and consultants

 

LeAnn Behrens, Amerigroup

  • Reading the DMN, it does not reflect Amerigroup
  • DMN is useful as a “watchdog” entity, good that they focused on vulnerable populations in STAR Kids and STAR+PLUS
  • Did a good job on assigning corporate responsibility
  • Network adequacy is something all involved entities are concerned about, will have recommendations
  • DMN spoke to data issues at Amerigroup, there have been encounter data issues resulting in ~$20 million in LDs; the system worked, HHSC worked with us, Amerigroup corrected the problem & paid penalties
  • Had other data issues uncovered in operational audit in 2017, those have been corrected as well
  • Davis – What other data issues?
    • Involved reporting issues in Houston
    • In 1998, the region was built around Harris County, region expanded and Amerigroup
  • Capriglione – You said there was around $20 million in LD, and this is what you paid?
    • Yes
  • Capriglione – And this reflects the total bill due?
    • We have had very few LD reductions, we’ve sent correction before to LDs & sometimes that has cost us more
  • Capriglione – What happens after you point out issues?
    • There is a phone call or meeting between Contract Compliance and the MCO, go through by line item to check disagreements
    • Can provide original letter so you can see the differences, relatively small for our company
  • Capriglione – And Contract Compliance are the arbiters on the final amount?
    • Yes, not sure of HHSC’s internal procedure
  • Davis – So you get a notice & you then negotiate with someone at HHSC; does anyone who is employed by you or who represents you interact with anyone other than HHSC over LDs?
    • No, have not had employees and lobbyists discuss LDs
  • Davis – Heard this morning that there have been conversations with legislators or executive branch individuals regarding LDs
    • This has not happened for Amerigroup
  • Regarding the UMR audit, audit process is effective for Amerigroup to improve its processes as well as for HHSC to identify areas for improvement
  • MCOs do make mistakes, Amerigroup works hard to correct these and to work with agency & maintain expectations
  • Davis – What are the expectations of the agency & are those expectations high enough?
    • Amerigroup tries very hard to align to the contract & our assumption is this is the expectation of HHSC
    • Contract has not substantially changed in 20 years, there are areas that could be reviewed
  • There were some inaccuracies in the DMN article, some surrounding Amerigroup member “Mr. Berry”
  • Amerigroup did not respond to questions for DMN, largely due to quick turnaround, but have since gotten release from Mr. Berry
  • Berry has made it clear to Amerigroup that he did not want to be in the newspaper & he has said DMN information is inaccurate
  • Amerigroup has not denied services to Mr. Berry; DMN reporter released audit paperwork with Mr. Berry’s info, but services identified for follow up in the audit were declined by Mr. Berry as his neighbor was providing them, DMN article does not make this clear
  • Davis – So he was identified in the UMR audit and they found he was not receiving services he was eligible for, and you followed up and he denied services?
    • We did an annual review for him & was flagged for nursing services,
  • Davis – Is there any reason he wouldn’t have been flagged by you?
    • We identified his eligible services and he declined
  • Davis – And you realize that it has been reported to us that he is afraid of losing those services?
    • We realize DMN has reported this, we have been in contact with Mr. Berry who has said he has started refusing calls from DMN
    • Berry is moving, and Amerigroup is ensuring he will get services that will no longer be provided by his neighbor
  • Amerigroup meets all network adequacy standards via both TDI and HHSC
  • DMN reported on Amerigroup’s relationship with Texas Children’s, Amerigroup terminated its contract in 2013 as Texas Children’s was receiving far higher rates than others for delivery services, though has continued to speak with Texas Children’s at certain times
  • Reviews top quality children’s hospitals across the state; Dallas Children’s, MD Anderson, etc.
  • Davis – And how many of those are in network with Amerigroup?
    • MD Anderson does not contract in network, Memorial Hermann is
  • Amerigroup has tried to ensure it is paying consistent prices for consistent services in this area, tracked 3 common children’s issues and found them to be much higher at Texas Children’s
  • Roberts – And this is network versus out of network?
    • No, these are Medicaid rates
  • Amerigroup decided that it could provide high quality care at Memorial Hermann
  • Davis – However, Texas Children’s would likely state that they take a large number of your patients as out-of-network patients & that many of these are medically complex; what would you say to this & how can you say you have an adequate?
    • Difficult to look at 2018 data, in 2017 we saw 481 cases, 383 were ER, 46 were urgent; 2016 was similar
    • We are working on redirecting emergency care, but difficult to prevent people from walking into the ER
  • Davis – What is the proximity between the two ERs?
    • Unsure, I know their hospitals are relatively close
  • We offered contract rates to Texas Children’s equivalent to what is paid to Memorial Hermann; open to conversations about specialties & providing specific case rates for those things
  • Struggle with contracting for higher rates when we can get similar services for less in close proximity; focused on efficiency of state Medicaid dollars
  • All hospitals in Texas that serve children have high rates compared to national average rates, could warrant broader review; cites rate comparisons between Texas facilities and other states
  • Recommendations
    • Would be interested in a process with larger sample sizes and closer timelines than the current UMR process; suggests looking at NCQA for their audit process
    • Adequate networks are determined on distance and time currently, should look at provider to member ratio as well, especially regarding specialties
    • Should also look at how we account for telemedicine
    • Contract and processes could be reviewed and improved, could look at quality metrics to drive individuals who have not chosen a plan towards one
    • Sometimes HHSC does not understand MCOs & MCOs do not understand HHSC’s process, could lead to better oversight to review this
    • Should also look at dental services as added benefit
  • Capriglione – So you get paid fees & forecast cost based on the RFP, etc., but sometimes costs exceed expectations; what do you do in those circumstances? Do you swallow the cost & wait until review, do you contact HHSC?
    • It is a risky business, and state spend is stable regardless of events like heavy flu season, etc.
  • Capriglione – It is a good system as long as its priced right & we do not endanger services
    • Texas has a profit share margin, there are years we spend more than our premiums cover; this flu season was an example
  • Capriglione – So what do you do, do you make changes to services, etc.? What?
    • We can’t change benefits provided, data like that drawn from the heavy flu season gets factored into the rate setting cycle
  • Capriglione – So the short answer is you never try to change definition of benefits or scope?
    • You cannot do this, you sign the contract as is
  • Capriglione – But there are interpretations of benefits needed
    • We would have a moral crisis if we did not provide the benefits
  • Capriglione – What is your profit margin?
    • Amerigroup runs around 5%, generally 1 or 2 points above other MCOs
    • For profit hospitals are typically 7-10%, nonprofit are roughly 2%, Amerigroup is roughly in the middle
    • We generally wait for rates to catch up whatever the experience, though there are some exceptions like high-cost specialty drugs, there were conversations between many MCOs and HHSC over the massive cost
  • Capriglione – You have to provide the service unless you deny, you have to provide unless you say you don’t necessarily
    • Some services are medically necessary
  • Capriglione – So it was 5% last year, what was it before that?
    • Has been very close to this for the last 5 years, between 4-6%
  • Shine – Data shows that you had a computer glitch leading to double payments of $18 million, is this a state issue?
    • Spoke about this at last weeks’ Human Services hearing, DMN reported this as Amerigroup making an additional $18 million, this is absolutely incorrect
    • Amerigroup’s claims system was struggling with paying $18 million when nursing facilities were carved in, actually made $18 million in overpayments during the carve-in
    • Amerigroup did recoup the money; this situation was what messed up our encounters data
    • Vast majority of LDs were due to this
  • Shine – Spokesperson from Amerigroup said it was a computer glitch and that it was overbilling
    • It was our system & it was overpayments that were made
  • Shine – I see 8% out of every dollar as profit margin for Amerigroup, how does this reconcile with 5% margin
    • 8 cents out of every dollar is what goes back to the state, share for state increases based on margin

 

Daniel Chambers, Cigna-HealthSpring

  • Cigna only serves STAR+PLUS in Hidalgo, Northeast, and Tarrant service areas
  • Service coordination is the backbone of the system, home visit nurses are a big part of this
  • Davis – How many nurses do you employ?
    • We have 100 RNs specific to visiting homes, we have more LVNs that take calls
  • There are many forms involved in home assessments, often visits revolve around filling in large amounts of forms, should evaluate for efficiency
  • Should make sure assessments are less about forms and more about members
  • Davis – What is required for in-home assessments? Who is eligible? Does it vary?
    • Can speak to STAR+PLUS, it is a requirement contained in contract
  • Davis – So no HHSC rule requiring assessment, only in contract?
    • Face-to-face assessments are required as part of the program, Cigna also visits after this based on assessment of need
  • Davis – And the MCO determines level of need and case management?
    • Goes back to needs assessment, these ultimately drive level of service
  • A lot of opportunity to ensure accurate and consistent data is reported across MCOs, could do more to ensure data is consistent; HHSC is underway and would commit to partner with HHSC to continue
  • Important to ensure continuity of care and services, should have a way to encourage members to remain with providers and MCOs for long periods of time
  • g. members may often change service providers when attendants change agencies, can be difficult for MCOs to retain these members; HEDAS measures and other metrics have shown managed care works better than fee-for-service
  • Davis – I do believe managed care can deliver better health outcomes, but concerned on if this is true for medically fragile individuals
    • Cigna has spun up programs specifically targeting services within the home, does not require authorization for visits & have seen good outcomes
    • Also running a drug information program, good results show us that MCOs are incentivized to run programs like this as it decreases ER utilization, etc., while increasing outcomes
  • Opioid epidemic is a huge initiative within the MCOs, we don’t control the formulary so can’t control this way, but we do send info to providers and members regarding reduction of opioid use
  • Davis – I appreciate this, wasn’t aware it was an issue for those in STAR+PLUS
    • It absolutely is, members experiencing severe trauma can often become addicted & will seek medications within ERs, etc.

 

Anne Rote, Molina Healthcare

  • Molina is mentioned briefly in the 4th segment of the DMN article around Rio Grande Valley issues in 2012
  • HHSC set capitation rates for the area based on historical rates and assumed savings, Molina did not realize those savings when it entered the area
  • Had conversations with HHSC about what needed to be done, reduced home & community-based providers rates by 10% and many terminated contracts
  • HHSC assessed $1.8 million in LDs and froze enrollment for 12 months, Molina learned from its mistakes, worked more closely with HHSC, restored rates, etc.
  • Launch of nursing facility program in 2015 is a good contrast, Molina began the process much earlier and reaching out to providers, hired staff with expertise, contracted with many homes, ensured they were administratively capable, etc.
  • Molina also runs a quality incentive program paying providers based on 7 metrics: flu vaccinations, staffing ratios, etc.
  • Capriglione – Regarding data and analytics on denial of care, is this information public? Does HHSC have it?
    • Unsure if this is a category reported
  • Capriglione – Do you think there are differences between quality and access? Is this something we should be deciding on when HHSC awards a bid?
    • Yes, quality should be a factor
  • Capriglione – What can we ask? What metrics can we use to determine this?
    • It is very difficult, there are other actions in other states
    • Many want as broad a network as possible, might look the same between MCOs so it is not enough of a measure
  • Munoz – If you’re able to sustain a 10% loss per year and still operate, is it because HHSC makes up the difference in the following year? I know MCOs are given supplemental payments
    • HHSC sets our rates annually, sometimes there is a mid-year adjustment
    • Nothing says we will be made whole for losses, TDI regulates that we have reserves to cover bad years
  • Munoz – How could the rates have been off by so much in the Rio Grande Valley, begs the question of whether we set rates to get the business and adjust later
    • Not in Texas, HHSC sets the rates & will only pay a certain number
    • Cannot speak to 2012 and HHSC actuarial process
  • Munoz – If you sustain a loss and discuss this with HHSC, HHSC has discretion to infuse funds?
    • Not aware of that
  • Munoz – So you wait the entire year to set new rates?
    • Yes, in the 2012 instance rates must have gone up
    • Things have normalized a bit, there are some feelings that cost savings will be realized
  • Munoz – But you can get money on the backend that will fill in losses?
    • No, we get paid rates prospectively
  • Munoz – In setting rates for the upcoming year, can you recoup losses from the previous; In Appropriations it sometimes notes that supplemental payments offset losses in managed care
    • It could make up for previous losses
  • Munoz – How many medical directors do you have? Population?
    • Around 12, around 230k members
  • Munoz – And the medical directors are in Texas?
    • Yes, 10-12, there are other we can call on for expertise
  • Munoz – And these are all in Texas?
    • Main Texas office is in Irving, main HQ is Long Beach
  • Munoz – If we had a request to review medical necessity, there is a possibility that a medical director outside of Texas would make the determination
    • No, only Texas licensed medical directors can make the decision, out of state individuals are only for consultation
  • Munoz – So you might consult with an out of state director for a patient in Texas?
    • Yes

 

Don Langer, United Healthcare Community Plan of Texas

  • Regarding coordination of benefits process, a team coordinates benefits and helps manage process of what services are covered and not under multiple coverage
  • Network specialists determine special needs under STAR Kids program
  • United ran a survey of 144 children with most complex needs, responses saw greatly increased outcomes and savings and then money was reinvested back into the program
  • Have spoken with families over frustrations, have learned that we need to do a better job of educating providers on benefits coverage
  • Also found letters were confusing to members, need to work on fixing letters
  • There are some policies brought over from standard STAR,
  • Davis – Did you speak with Ms. Cheevers this morning?
    • My team did, received text updates; do not have a waiver and cannot speak in depth
  • Davis – Very familiar with this line
    • My team did resolve the issues involved, working through frustrations with the process
  • Davis – I think she was frustrated with the repeated denials and process
    • Happy to follow up when I obtain the waiver
  • Roberts – Formulary is a close drug formulary & United owns its own PBM, can you tell me about the prior authorization process and how a physician could write an RX, the member take the RX to the pharmacy, and the pharmacy say the member needs to consult PBM for a PA
    • The concern in this case wasn’t what she was getting, but rather which pharmacy she was getting the prescription from
  • Roberts – Could you follow up with specifics on this process, I want to know the path from the time it was submitted to the PBM
    • Will follow up with the committee
  • Turner – regarding liquidated damages: when they are proposed for the MCO who is contacted outside of the agency
    • All panel members – All contact is with the agency and not outside
  • Turner – one of the ways to make a complaint is through the state representative, have received complaints that members have been scolded for filing complaint through the legislature. What is your policy related to making a complaint to the legislature?
    • All panel members – staff should not be discouraging complaints in any way. Welcome any complaints indeterminate of the source
  • Davis – some of the discussions today have revolved around data, and testimony today is not represented in the articles written. Have to wonder about the form of the data given to the agency, and if they can analyze the data

 

Ken Janda, Community Health Choice

  • Described Community Health Choice
  • Created by Harris County Hospital District
  • One advantage of not for profit health plan is savings in excise taxes to the state
  • Have had much discussion of where there is fault in the system and what opportunities there are to fix it
  • 4 million people depend on Medicaid in Texas
    • Several million that should be in the plan as well which are served by cobbled together plans at present
  • 2 million people are relatively healthy
  • 750,000 are very frail
  • Need to think about how to move forward with Medicaid knowing that there are different populations that are being served
  • Medicare has improved over the years in quality
  • Have had virtually no medical inflation in last 12 years in Texas
  • Legislature needs to set very clear goals and should include
    • Access to care for Medicaid beneficiaries
    • Improve health of that population
    • Need to control costs adjusted to population growth
  • Current contract is 500 pages and 2,000 pages of manual
    • Need to determine the goals and how to measure it
    • HHSC is given tons of data
    • Not sure what HHSC does with all of the data
    • Need to determine which are the most important to keep and get rid of the ones we don’t and build the ones we need
  • Need to figure out how to have good access across the state
  • Davis – regarding geographic accessing written testimony, are those categories available in the commercial market?
    • No, need to determine why that it and better align with concerns of today as compared to what the needs were 20 years ago
  • Davis – network adequacy is self-reported correct?
    • It is, but the industry needs to own data accuracy
  • Davis – it seems like the private sector still does a better job in that
    • That is something that the provider organizations need to work on
  • Noted HHSC has report cards on their website available to everybody
  • The fair hearing process doesn’t work the way it is supposed to
  • Should consider streamlining the appeals process by making them more similar between programs
  • Need to better coordinate care with people who have multiple coverages
  • Davis – before session we receive reports, one focused on lack of managed care in managed care, believes there is a need for better coordination of care within the entire system, do you agree?
    • It is a great thing that we do right now but would like to get better
  • In terms of controlling costs, current model is better than fee for service model
  • Worried that we will have more burdensome oversight as opposed to smarter oversight
  • Do have 2 employees that used to work for HHSC that were not in high level management positions, and deny about 25% of care
  • Bonnen – in terms of denials a notation is preauthorization and claims denials, do you know the number for claims denials?
    • Roughly 2%
    • Have provided detailed stats and data in written testimony
    • Set up to lose about 4% this year

 

State Agencies

Mike Diehl, Legislative Budget Board

  • Gave brief overview of managed care in Texas
  • Discussed caseload growth from 2003-2019
  • Described population and history of current managed care programs
  • Reviewed Medicaid funding by method of finance
    • Important to note that “savings“ are in relation to cost of the program with a fee for service model
  • Not all cost reductions can be attributed to cost reduction methods by MCOs
  • Discussed calculations of capitation rates for MCOs
    • An amount for health care services performed (including adjustments for service specific rate changes or the addition of new benefits)
    • An amount for administration (including both fixed and variable administrative components)
    • An amount for the risk margin (reflecting the level of uncertainty regarding the costs of providing coverage)
  • Reviewed experience rebate rates
  • Administrative caps may be deducted from revenue for determination of experience rebates
  • Davis – discussed if there are some unallowable administrative expenses, the state would not know for roughly 2 years
  • Discussed internal and external oversight of MCO contracts
  • Davis – related to federal oversight, are you aware of any involvement after allegation of denial of care?
    • Not aware of anything at this time, that has come up in the past though
  • Briefly reviewed 2018-2019 General Appropriation for the Medicaid and CHIP programs
  • Davis – that seems like a lot of money in FTEs and revenue, does this seem like an adequate amount of funding?
    • Not all of that money is specifically available for paying FTE and contract oversight
  • Bonnen – is there any thing in the budget that would be comparable
    • Sarah Keeton, LBB – do not have that analysis but will provide that information to the committee
  • Bonnen – noted 225% increase in costs and about 125% increase in case load, why would that be?
    • Nothing specific at this time, could be related to new programs but likely is just cost accelerating faster than case loads
  • HHSC has broad authority to allocate funding and FTEs that are not otherwise restricted by a rider in the 2018-19 GAA between functions and activities within the Medicaid and CHIP Contracts and Administration strategies.
  • HHSC requested and received approval from the LBB on June 1, 2018 to transfer an additional $4.5 million and 98.0 FTEs for the biennium from Strategy I.1.1, Integrated Eligibility and Enrollment, to Strategy B.1.1, to increase contract oversight and utilization review of the Medicaid program.
  • Davis – these would be 98 new people into the agency, do you have a sense if these are nurses or…?
    • Reviewed allocation of FTEs does not have a breakdown by position, but the agency should have that information
  • HHSC’s LAR for the 2018-19 biennium included a request for $13.7 million in All Funds
  • Discussed HHSC MCOP procurement process
    • Reviewed the planning, solicitation, evaluation and negotiation, contract award, and contract management and oversight phases
  • MCO procurement concerns
  • Staffing shortages
    • Procurement and Contracting Services (PCS) had 109 vacancies out of 256 total FTEs as of May 2018
  • Evaluation Tools and Process
    • Lack of quality control in vendor scoring and evaluation
  • Corrective Actions
    • Audits and management review of procurement processes
    • Procurement consultant RFP released in May 2018
    • In June, HHSC received approval to transfer $0.6 million in All Funds ($0.5 million in General Revenue) and 4.0 FTEs for the biennium into Strategy L.1.1, HHS System Supports, to increase salaries and provide for a quality control team in PCS
  • Roberts – interpret admin cap as the state paying the MCOs for staffing overhead, is that accurate?
    • That is essentially correct
  • Roberts – why outside of paying for the healthcare claims, would the state pay for the cost of doing business? Admin is outside claims costs?
    • that is correct
  • Roberts – is it possible to take a year of history and if we shared savings 50%-50% what would that look like compared to the current contract?
    • Leora Rodell, LBB – It is possible but do not currently have the information available
  • Roberts – in terms of internal contract oversight, that is monitoring compliance correct?
    • Correct
  • Roberts – is there a defined scope between the various oversight entities?
    • There is
  • Roberts – is each work product turned into a report?
    • HHSC may be better able to address that?
    • Ben Mcculloch, LBB – discussed report creation for use by Legislature
  • Roberts – what is the external audit process?
    • Ben Mcculloch, LBB – look for high risk items to the state
  • Roberts – who is on the contract advisory team?
    • Jake Pew, LBB – contract advisory team is run through the comptroller’s office comprised of many agencies to review during the solicitation phase
  • Roberts – is there somebody who knows managed care contracts that is on that team?
    • Do not have that specific information
  • Roberts – is the procurement consultant part of that team?
    • No, may be an aid for HHSC but not to the advisory board
  • Capriglione – does HHSC have to respond to CAT recommendations?
    • There is not anything that exempts HHSC from that process
  • Bonnen – understanding the increase in costs would be very helpful
  • Discussed all of the members of the Contract Advisory Team
  • Davis – is that in statute?
    • That is correct
  • Turner – how many different capitation rates are there in the MCO system?
    • There are many various types, well over 100
  • Davis – discussing reports that deal with care coordination within Medicaid, can you refresh the committee?
    • Kyle McKay, LBB – reviewed the report:
    • managed care was intended to aid in care coordination at reduced cost
    • Establish financial incentive through capitation
    • Report identified concerns with access to care coordination
    • One key concern is service coordinator is also responsible for conducting service assessment
    • Survey showed 30% of members were not receiving skilled nursing services
    • HHSC did not recover funds from these violations
    • Many denials led to utilization reviews
    • 7 million children enrolled in STAR program in 2018, while less than 10,000 had a service plan

 

John Young, State Auditor’s Office

  • Released three reports in the last year and a half
    • Medicare managed contracts
    • Managed care organizations
    • HHSC management of MCO Contracts with Superior Heath Care
  • Discussed government code requirements that led to the reports
  • HHSC has addressed the recommendations, the other two reports have not had responses yet due to recent timing of the reports

 

Willie Hicks, State Auditor’s Office

  • Commission had lack of an overall strategy has resulted in gaps in audit coverage of MCOs, lack of consistent follow-up on audit findings, inconsistent application of procedures, and duplication of effort.
  • Reviewed audit findings of An Audit Report on Medicaid Managed Care Contract Processes at the Health and Human Services Commission
  • Davis – some of the dates show dates in the past, is that correct?
    • These are all self-reported and this is the latest information available

 

Arby Gonzalez, State Auditor’s Office

  • Discussed an Audit Report on HealthSpring Life and Health Insurance Company, Inc., a Medicaid STAR+PLUS Managed Care Organization
  • The overall conclusion for both the Healthspring and Superior audits was that each MCO accurately reported expenditures for medical and prescription drug claims to the Commission.
  • Reviewed audit findings
  • Davis – related to unallowable expenses, the articles talk about MCOs spending money on parties, do you have a recollection of what parties mean or any of the details of any of the expenditures?
    • Found a number of questionable items
    • Do not have specifics of certain instances
  • Capriglione – is the FSR a different sort of financial statement, used to determine the rebate?
    • Correct
    • Also used for what can be allowed for administration
  • Capriglione – if you include a bonus in the wrong place, you are using that twice?
    • Found that bonuses were unallowable no matter where they were placed
  • Capriglione – most of the unallowable expenses were in bonuses?
    • That is correct
  • Roberts – does HHSC claw back those unallowable expenses?
    • HHS can better describe that
    • John Young – depending on the amount there would or would not be recoupment
  • Roberts – at the end of the day they had to eat that cost?
    • That is correct
  • Turner – how do you determine that funds were appropriately separated for items like lobbying?
    • It is unallowable for an MCO to include that as line items in the report
    • It should not have been included at all
  • Recommended that the commission align business practices to contract
  • Roberts – requested clarification of intentional reporting of bonuses to the Medicaid program
    • Cannot speak to intent of that reporting
    • Found evidence that it was an agreed upon business practice by HHSC
  • Roberts – what would have happened if you had not caught that?
    • Cannot speak to that
    • It would have been part of the calculation
  • Davis – HHSC has not amended the contract to allow this as an expenditure at this point, and you were only auditing based on the specific time and situation?
    • That is correct
  • Davis – we haven’t done that analysis, so we do not know if there was a significant impact statistically
    • Our issue was that the business practice did not line up with the contract
    • If they wanted to amend the contract to allow that practice and if they do to separate bonuses out from other expenses
  • Capriglione – the commission modified the language related to executive compensation, what was the change?
    • Result was to make the executive compensation cap effective

 

Olga Rodriguez, Chief Strategy Officer, Office of the Inspector General

  • In January of each year the OIG does a 2-year audit plan – anticipated audit of STAR Health and STAR Kids
  • HHSC requested audit of those two programs in March
  • Scope was to determine if MCOs were delivering needed services
  • Focused on the most vulnerable factions
  • Audit is in the planning stage
  • Will be selecting MCO to begin with
  • Will begin in July after selection of MCO
    • Will look at processes that lead to service delivery
    • Development of individual service plans
    • Medical records and interviews
  • Expect the audit to take 9 months
  • Expecting to meet with HHSC on regular basis throughout the process
  • Davis – there has been a lot of discussion of sending things to investigate by OIG, how many open investigations of MCOs are being conducted?
    • Have done many types of audits and reviews
    • Can speak to audits, will need to speak off line related to investigations
  • Turner – do you respond to 3rd party requests?
    • Administratively attached to HHSC, and will report directly to the governor
    • As far as implementing an investigation, it is based on allegations inside or outside of the agency
  • Turner – is there any limitation on what you cannot investigate fully?
    • No
  • Turner – is there any statutory changes needed in that regard?
    • Looking into that right now
  • Munoz – if you found something what is the worst-case scenario?
    • We refer criminal cases to OAG
  • Munoz – we hear a lot of talk about investigations, and it doesn’t seem like anything come from it

 

Hank Whitman, Commissioner, Department of Family & Protective Services

  • Was disturbed by the reports in the Dallas Morning News
  • About 30,000 children in DPFS at any given day and over half of them are in STAR Health
  • Working to implement new protocols to educate case workers and providers
  • Described continuing struggles including:
    • Access to home-based services
    • Insufficient provider network
  • Spoke relating to D’ashon
    • The system failed this child
    • Children shouldn’t have to hope for a persistent advocate to get the help they need
  • Davis – do not have criticisms of DFPS, case workers were fighting for D’ashon and it could never be more important to maintain funding for your agency.
  • Davis – does being the legal parent mean that you can make medical decision like if something is or isn’t a restraint?
    • Want it to be made clear that no DFPS case worker that can tell a doctor the validity of medical treatments

 

Liz Kromrei, Director of Medical Services & Accountability Division, Department of Family & Protective Services

  • Davis – who makes the final medical decisions for foster youth? Given allegations of Superior medical directors overruling the primary physician, where do you come in?
    • The doctor makes the decision on what is medically needed
    • Case workers advocate for the medically needed items
    • We are not the doctor and cannot take the role of ordering a medical need
    • Have staff that is available throughout the state that are nurses and program specialists that act as specialist to help caseworkers who need help understanding the details of difficult cases
  • Davis – so there is still tension being developed or was this a unique situation? Discussed letter from medical director stating that the case worker interfered in the medical decisions of the case.
    • Have not received other email of this nature, so this was a unique circumstance
    • Believes the case worker was advocating within her role
    • Meet regularly with Superior to address issues that come up with cases, certainly use complaints with HHSC when necessary as an avenue of advocacy
  • Turner – the case worker who was advocating for the private duty nursing, was she doing her job?
    • Yes sir
  • Turner – she was working within her responsibilities as a caseworker and advocate?
    • She was
    • She was also communicating regularly with the doctors and the foster parent
  • Turner – you would not consider that interfering with doctors or practicing medicine without a license would you?
    • Whitman – No, we are proud of this case worker and did the right thing
  • Turner – Superior’s doctor said he would be reporting this interference with HHSC, have you received any feedback from HHSC?
    • Have not personally received anything from HHSC related to that
    • Met with HHSC contact person for recommendation on how to handle this situation
    • Not sure that5 an official complaint was actually filed
  • Turner – referenced Superior’s doctor’s assertion that the foster parent was using private duty nursing as child care, wouldn’t that be up to DFPS and not the MCO to make that decision?
    • Determination of the appropriateness of the home is a very individualized situation
  • Turner – there is nothing that says that a foster parent cannot work?
    • That is correct
  • Turner – the foster parent, by all indications, seems to be a good one, is that the indication from your agency?
    • Not aware of anything differently
    • Was not aware of her specifically before this incident
    • She provided placement stability and care and ultimately adopted the children

 

Enrique Marquez, Deputy Executive Commissioner for Medical & Social Services, Health & Human Services Commission

  • Thanked legislature for approval of 47 employees for utilization review
  • In first 3 quarters of 2017 HHSC has assessed 400% more liquidated damages against MCOs than in 2016 combined
  • Additional staff with further oversight of the MCOs
  • A greater emphasis on accountability with MCOs
  • Looks forward to continuing to work with the legislature on management of managed care organizations

 

Stephanie Muth, State Medicaid Director, Health & Human Services Commission

  • Are aware that Medicaid serves are a vital lifeline for many residents
  • Briefly discussed network adequacy
    • Influenced by several factors (provider density, provider capacity, payment rates, etc.)
    • Working on streamlining provider credentialing and simplifying provider enrollment to improve network adequacy
    • Described contract monitoring and oversight – MCOs report providers to HHSC which then used to plot time and distance standards
  • Davis – the MCOs report the providers are and then you plot them to make sure that time and distance requirements are met?
    • That is correct
  • Davis – you are relying solely on the MCOs to provide that information, and is that the best way to adequately monitor networks that way?
    • Does not believe that model accurately reflects the providers that are currently accepting new Medicaid patients
    • Need to look at a number of factors together to determine network adequacy
    • have an independent analysis being conducted on contract oversight which will make comments based on other states best practices on areas that can be improved
  • Davis – if you are relying on MCO data there must be more oversight that the MCO has updates information, and couldn’t that be a part of case management?
    • Yes, do require provider directories to be updated on a weekly basis
  • Davis – discussed calculation of appointment availability and accuracy of that in context of network availability
  • Bonnen – with respect to the network, data is reported by the MCOs, there is no method to verify the reported data?
    • There is a very small sample size (250 providers per quarter) that is tested for verification
  • Bonnen – how many providers are there in all of the MCO panels?
    • That 250 represents a fraction of a percent
    • Not intended to represent that that is an adequate review
    • Discussed limitations of available reviews
  • Bonnen – moving forward there needs to be a much better effort to review and validate the reported information from the MCOs
  • Davis – heard reports of 16 MCOs with inadequate networks?
    • Yes, based on time and distance standards
    • There are 16 that are on corrective actions plans
  • Davis – what does the corrective action plan look like, and what is the timeframe on this?
    • It depends on the actions described in the plan
    • They will propose actions and a date, HHSC will either approve or deny that corrective action plan and monitor for compliance
  • Davis – are you able to give an update on that?
    • Will confirm, but believe that there are 16 that have corrective actions in place
  • Davis – how long do you monitor?
    • Until each of the items on the action plan are addressed
  • Davis – does the agency confirm that or rely on self-reporting from MCOs?
    • Some of the items are self-reported and some are confirmed
    • There are yearly programmatic audits to verify the information that is reported by the MCOs
  • Capriglione – is HHSC keeping track by program the denial of service numbers?
    • There are a number of types of denials
    • With additional resources we are able to pull samples and do validation of that information
  • Capriglione – do you categorize these denials and getting the data from MCOs?
    • Do receive information from MCOs
    • Do not have prior authorization reviews at present
  • Capriglione – is that kind of information subject to public information requests?
    • Not sure, but have had conversations related to public information as a method of verification
  • Capriglione – you could add that into the contract?
    • That is correct
  • Capriglione – is HHSC represented on CAT?
    • The agency does but the Medicaid division does not but will have to confirm that
  • Capriglione – do you have a policy at HHSC about employees related to disclosure and employment at MCOs?
    • Marquez – we do but will defer to another representative
    • Karen Ray, HHSC – that is covered through the agency ethics policy which covers revolving door policies as well as is covered through training and have an ethics office as a resource to all employees
    • Ray – there is a specific prohibition on recruitment of HHSC personnel
  • Capriglione – there is language in the MCO contracts, which CAT recommended stronger language; would like to see that stronger language utilized in the future for all vendors
    • Ray – attempting to track down the recommendation from CAT right now
  • Capriglione – why are we verifying that providers are on the plan as opposed to requiring the providers to log in frequently to verify that they are still providers
    • There are a few issues: are they registered with the state and do they have contracts with MCOs
    • The provider may also be actively billing Medicaid patients but not accepting new patients
  • Related to complaints HHSC is collecting reports, providers and consumers are also able to make complaints
    • Definitions are not consistent there are opportunities to streamline and better account on the complaints
  • Discussed verification and assessment of prior authorizations via site visits to MCOs
  • Davis – can you explain the 90 new employees that are being transferred?
    • It is 98 additional positions
    • 47 will be dedicated to utilization review team – due to addition of utilization reviews for STAR Kids and STAR Health
  • Davis – have gone back and looked at utilization reports from ‘14, ‘15, and ’17 and they do not seem to be representative of what the nurse’s notes are saying. Is this something you can do better?
    • There are already a number of improvements made to the utilization reviews
    • Several changes will be made for the next utilization review reports
  • Davis – what is the appropriate sample?
    • It will still be taken yearly
    • Goal is to get a statistically significant sample size
  • Discussed the utilization review liquidated damages
  • Davis – which nurses assess liquidated damages?
    • Nurses do not assess liquidated damages, they assess risk of harm each individual case was in
    • A physician reviews each categorization to confirm
  • Do not have a breakdown of utilization reviews but will provide that information to the committee
  • Have contracted with Deloitte to conduct the Rider 61 study – the comprehensive study of Managed Care Contracts
    • 61B speaks to independent review of the states oversight of managed care
    • Requested that portion be prioritized – should be available to the legislature in mid to late July
  • Related to Superior’s audit and the bonuses – the question revolves around the definition of an affiliate
    • We prohibit payments of bonuses to affiliates as unrelated business entity
    • SAOs interpretation of affiliate included parent corporation even those who are working directly on managed care
    • Working with state auditor’s office to clarify that language
  • Roberts – bonus as in standard additional compensation?
    • We do not dictate the compensation structure with the exception of executive compensation
  • Roberts – bonuses to staff is an allowable expense to the Medicaid program?
    • It is an allowable expense as administrative expense
  • Roberts – that is the way the contract was negotiated?
    • That is correct
  • Shine – can you clarify in the audit report what are allowable costs?
    • Will provide that clarification to the committee
  • Turner – speaking to recommended liquidated damages, is there new information since the report?
    • No new information at this time
  • Turner – regarding the DFPS case worker and the Superior Medical Director speaking of filing a complaint, do you have a record of that?
    • Do not know where the complaint may have been filed, and does not have record of that complaint that is aware of
  • Turner – does the commission have a policy related to disputes between MCOs and case workers?
    • Will provide additional information to the committee
    • The fair hearings process is the method for resolving those type of disputes
  • Turner – how is an MCO supposed to determine medical necessity? And what type of oversight does HHSC have over that?
    • That is a clinical assessment, the Medicaid providers procedure manual is available to help determine medical necessity
    • There are some checks and balances involving the fair hearing process and the utilization reviews
    • Have had discussions with medical director’s office related to additional clinical oversight piece
  • Turner – so it could be that an MCOs medical director that does not have direct contact with the patient could make medical decisions?
    • That is accurate
  • Turner – related to the Morris case, is there ratios of patient to full time nurses in statute?
    • Believes that it is in a rider, but in addition the provider manual speaks to 2 to 1 ratio
  • Turner – does the commission believe that this situation met the requirements for a 2 to 1 ratio?
    • OIGs office looked into this issue, HHSC had trouble recreating the exact situation after the fact and is unclear if it was inappropriate to have a 2 to 1 ratio
  • Roberts – do you believe medical necessity should be determined by medical professionals?
    • Yes
  • Roberts – but the hearing officers are laypeople?
    • Ray – the members of the fair hears hear other hearings as well and are laypeople
    • Ray – often a decision boils down to if the thing is a medical necessity or not
  • Roberts – why would we not want a medical professional determining medical necessity in that fair hearing?
    • If we want a fair and impartial person taking in information and making a fair determination, then it is not necessary to have a medical professional in that membership
    • Described the fair hearing process
  • Bonnen – who makes the decision at the fair hearing?
    • The medical officer, with HHSC
  • Bonnen – the piece that is missing is the patient’s physician
  • Roberts – again, why would we not want a medical professional making the final determination at the fair hearing
    • Further clarified the fair hearing process
    • Will provide to the committee statistics related to the treating physician and other people providing evidence in the hearing
  • Davis – it sounds like a balance of power issue at these fair hearing
  • Davis – regarding liquidated damages, the article stated an initial liquidated damages assessment of around $100 million but the actual amount assessed has been 11 million?
    • That is what has been assessed as of yet, investigation is still ongoing
    • Noted that the reconsideration process is not a negotiation
  • Davis – why was there a more nuanced methodology initiated?
    • The utilization nurses are not the contract experts and need to work with contract management to determine the numbers
  • Davis – did the utilization nurses enter these numbers then?
    • They calculated that based on maximum allowable assessment
    • Liquidated damages must reflect actual damages so that initial number must be amended
  • Discussion of history of liquidated damages assessments at HHSC
  • Davis – do you think the tiering of the liquidated damages looks punitive even though it cannot be according to the contract
    • Ray – what the contract says is that the administrative damages should be determined on a case by case way, the tiering allows for individualization of assessment of damages
  • Davis – discussed the specifics of the tiered damages. Having trouble rectifying assessment numbers listed in article versus the provided material. At some point a notice had to be sent to the MCO if the number could get down to $11 million
    • No notice was sent to the MCO
    • Did provide them with case details, but not contractual remedy
  • Davis – where does the $40 million mentioned in the article come from?
    • Based on the determination and extent od damages to the family, it was a programmatic decision
  • Davis – it had been 10% for first violation and now it’s tiered?
    • Evolved to the approach utilized to avoid being punitive
    • Written notice was provided as the start of the formal process to notify the MCO of the damages
  • Davis – the tiering system is how you will be assessing liquidated damages based on utilization reviews, not for other types of damages just on utilization reviews?
    • That is correct
  • Turner – assessed over 3 million in liquidated damages in the Powell case based on services not being provided?
    • There were additional issues identified in the process that led to that determination
  • Turner – how does the commission handle or give guidance on the MCO being the last to pay out?
    • That is a particular challenge and the MCOs have requested additional clarification
    • The often can avoid liquidated damages if an attempt was made to coordinate with CMS
    • Need to work to streamline that process and work with the FEDs
  • Turner – written testimony shows slide on stage 4 – suspension of default enrollment, have any MCOs reached stage 4?
    • No, it has been used in the past but is not currently being used as a remedy

 

Interested Parties and Stakeholders

Kabby Thomas, Director of Managed Care, Texas Children’s Hospital

  • Gave presentation
  • Described Texas Children’s Hospital and the hospital’s ranking
  • Nature of the facility attracts medically complex patients to the facilities
  • Have contracts with multiple managed care contracts
  • Amerigroup offered TCH 45% of the Medicaid dollar
    • As an out of network provider they would be required to pay 95% of Medicaid
    • Texas Children’s did not accept it
    • Texas Children’s and Amerigroup split and now we are taking care of their patients through the STAR kids program
  • Bonnen- Are you contracted with the other MCOs? Are you out of network with all network MCOs?
    • No, we are out of group with Molina and Amerigroup
    • We are contacted with Texas Children’s Health Plan, United, Community Health Choice and Superior
  • Slide 7 mentions network adequacy
    • Out of network utilization is a pattern that defines the gaps in care
    • Need to figure out how to transition patients to the plans that have the providers they need
  • Bonnen- What about elective referrals or if they come into the ER and are discharged do they follow up?
    • In most cases they do
  • STAR Kids was intended to help kids with medically complex needs
    • Data showed TCH was the provider for 70% of that population
  • Bonnen – if they come into the ER, do they typically do a follow up as outpatients?
    • Many do, we have a large amount of reporting and follow up work
  • Bonnen – if it is someone who has not been seen before and it would be out of network are you scheduling those appointments?
    • We do and contact Amerigroup for out of network authorizations
  • Bonnen – would there be additional financial responsibilities for the patient?
    • No
  • Network adequacy for STAR Kids did not reflect the situation
  • Discussed the FRP for network population needs
  • Bonnen – if we are to assess who is performing at a better rate, do you have a specific recommendation to assess the adequacy of the networks?
    • Cannot assume that the criteria for a medically complex population is the same as a fairly healthy population
  • Bonnen – are you out of network with all MCOs?
    • Are not, are contracted with Texas Children’s Health Plan, Community Health Choice, Superior and others
  • Bonnen – you have been able to successfully negotiate managed care contracts with other MCOs
    • That is correct
  • Noted patient advocacy – health plans with out of network utilization submit report with exceptions and those exceptions just continue and there is no closure
    • What are we actually measuring self-reported data against?
  • A big determining factor in the gaps in care is out of network utilization providers
  • Oversight should also look at how to transition patients that have access to the providers they need
  • Patient advocates should be helping to get patients to the access they need, and that will slow out of network utilizations and exceptions
  • Believes that managed Medicaid works and works best when it is delivered in a system that works closely with local and community providers

 

Ray Tsai, Senior Vice President, Children’s Medical Center of Dallas

  • First center dedicated to treating children in foster care
  • Reece Jones Center outlined several ways to improve medical care for children in foster care in a white paper
  • Glad to see legislature take steps to improve health care for Texas’ medically fragile children
  • Recommendations:
    • Need to enhance communication between medical home and child welfare system
    • Expand the responsibility and resources of DFPS
  • SB 11 provisions will enhance communications
  • Believes office of medical director should be strengthened to include being an ombudsman for process improvement in Texas foster system, provide adequate medical expertise for case workers, lead the review of denials of in home supports
  • Davis – are you able to comment on the assertion of the MCO’s doctors believe in using the splint?
    • Understand that the attending physician made an order for private duty nursing at a 1 to 1 ration
    • Unaware of any order to use a soft splint in this case
    • The attending physician is the best person to determine the care plan for the child

 

Ruchi Kaushik, Medical Director, Comprehensive Peds for Complex Needs, The Children’s Hospital of San Antonio

  • Transition from inpatient to outpatient services can be very difficult for children
  • Has become more difficult to order outpatient services prior to discharge
  • Discussed “money follows the patient” program and the challenges with getting medically necessary equipment and training into the home after discharge
  • Bonnen – when did you begin to encounter this type of challenge?
    • Roughly for 2 years
  • Bonnen – with the DME is it more a matter of timing or getting it approved period?
    • Getting the DME approved
  • Bonnen – you are saying there are instances where the specialist is required to be the prescribing physician and in other circumstances it required to be somebody else
    • Yes, do not feel there is a standard for that
  • There is an influx of forms that have to be completed which then get submitted, but the forms that follow the title 19 forms can be redundant and an administrative burden
  • Bonnen – in your office you have staff that will fill out the forms?
    • For the first 3 years she did it all
    • Now has a case manager to help with that
  • Bonnen – who pays the case manager and what do they make?
    • Children’s hospital pays for then, unknown salary
  • Bonnen – notes the significant cost of additional staff
  • Once the requests are submitted, there is either an approval or denial
    • The opportunity to speak with somebody before it is denied gives 4 business hours to speak with somebody before it is denied
    • These are peer to peer reviews
  • Bonnen – what happens if you are not available?
    • You get a denial
  • Discussed difficulties with this process
  • Bonnen – have you had any success with prescheduling peer to peer reviews in a bulk setting
    • Have not tried that
  • Was not aware of ability to attend fair hearing in past
    • There is also a lot of legal language that is not understood by physicians at these hearing
  • Bonnen – do you feel you understand criteria that would be required to meet medical necessity
    • Yes
  • Discussion of frustrations with process of getting approval of DMEs and necessity of testing

 

Hannah Mehta, Protect TX Fragile Kids

  • Thousands of Texans depend on critical life-saving programs and want to see changes as a result of this investigation
  • The transition to Medicaid Manage Care (SB 7) causes delays, and makes it harder to attain appropriate treatment for fragile kids
  • The transition to Manage Care ignored the advice of advocates of the Fragile children of Texas
  • Medicaid in Texas is being delivered in such a way that consumers have become the oversight, not the government
  • There is a problem with trying to apply Manage Care to such a diverse population, it was not designed for children with life-threatening diseases
  • We must prioritize families and cut out the red tape to ensure the care of the fragile children around Texas
  • Allow children to receive the doctors that they’re family has chosen, and the correct medication prescribed without having to go through
  • Asked to consider geographic boundaries when considering care center locations
  • We believe there should be no restrictions to specialty care
  • Implement a pilot program to determine the best way to treat the diverse population
  • We believe transparency and cooperation between MCOs will greatly help this process
  • There should be a member-only online portal when checking notifications on referrals, acceptances, and denials to decrease confusion
  • We believe the determination of necessity and need should always default to the treating physician
  • MDCP eligibility needs to be addressed, 14% increase in denials in the past year compared to 2-3% increase in past years
  • The conflict of interest of the case worker working for the MCOs determine the children’s wellness and need for care
  • We need outside panels made of parents and qualified professionals with the ability to weigh in on denials
  • Make a provision for those who have private insurance to use, which would save the State money
  • We believe there needs to be a protected complaints program, because there has been repercussions for some families that have spoken out/complained
  • When speaking with treatment physicians or surgeons, parents are often told that they do not have the funding to even complete the necessary paperwork and get around the government red tape. They are told to go to the Emergency Room instead
  • Our priorities must reflect our political rhetoric to “value all life” by cutting our meaningless bureaucratic steps
  • Roberts- These are very good and thoughtful recommendations, but does private insurance have any benefit in this program?
    • There are constant conflicts with the overlap of insurance providers with when you receive medication, cost, etc.
  • Roberts- If an employer covers you, and is your primary provider, once you max out that coverage then Medicaid covers the extra?
    • It depends on the plan, but we should make it so if you have private primary insurance you should not be placed in Managed Care to avoid unnecessary issues and wasted time

 

Pamela McPeters, Vice President of Public Affairs, TexProtects

  • Testifying on recommendations made to improve foster care system regarding the STAR Health
  • Challenges include fragmented care, lack of coordination, overmedication
  • Made improvements in electronic equipment, misuse of medication
  • Strengthen and expand the Department of Family and Protective Services director’s office
  • Include additional medical professionals to provide
  • Add accountability and process measurements to check complaints
  • Ensure children have access to the care they need by determining foster cares of excellence, and having others follow that lead
  • Partner with stakeholders to determine a system with barriers, that better supports the needs of these foster children
  • Provisions like a medical home, and advocacy system we can improve care
  • Foster children on wholly dependent on this system, so it needs to be run efficiently and with care

 

Bob Kafka, Organizer for Adapting Texas

  • STAR Plus is the integration of long-term services and support
  • Medical care is intended on providing disabled/diseased people the opportunity to do what they want
  • The system should be based on needs of individuals, it should not matter what their medical label is
  • The hands-on community attendant needs to be addressed, as that is the person that disabled people see the most
  • STAR Plus does not have a good delivery system that needs to be addressed
  • There needs to be consumer advisory groups on the regional basis to take into account the vast array of problems around Texas

 

Dennis Borel, Coalition of Texans with Disabilities

  • Medicaid is a hugely positive program for our well-being both economically and physically, but we need to make improvements
  • We should study the capacity of HHSC to see if they have enough people to get their job done
  • We are lacking a flagging system to expedite cases that are close to authorization expiration
  • D’ashon was going through the appeals process with his previous care of 12 hours, despite being recommended for 24-hour care
  • We should stick with the recommended care during the appeals process, and have a system where cases can be expedited
  • We need an objective system for fines and liquidated damages, but there is concern about where those fines are going to
  • This money should go to under-funded parts of this system
  • Medicaid is chronically under-funded, which puts Texas at or near the bottom on the number of people not able to receive care
  • We need to rethink what we fund in Medicaid, such as dental benefits for adults
  • Rather than pay for dental care and preventing future problems, we pay for the emergency room visits when dental pain gets too much. The patient is then often given an opioid medication which creates the chance of addiction
  • The level of need for SSLCs is no higher than it was 10 years ago, despite lower populations in these centers
  • We should drop the numbers of SSLCs from 12 to 6, which would save a significant amount of money

 

Terry Anstee, Staff Attorney, Disabilities Rights Texas

  • Davis- How typical is it that someone would have a lawyer at the fair hearings?
    • It’s not typical for a medicaid recipient, but we do provide that service and it is more common to win these types cases with an attorney present
  • Davis- If it’s about medical necessity, why do we need lawyers present at these hearings?
    • The system is mandated to look at evidence and determined whether the MCOs used the correct policies, which they are not
  • HHSC has sent notice to the MCOs saying that they cannot pass rules that contradict the state plan
  • NBCP used a new assessment form (SKSAI) to figure out what care is need, patient information, access need for NBCP
  • Parents have seen errors/omissions in SKSAI forms, so we should see these forms before they are sent for medical evaluation
  • These forms are not filled out in front of the parents, making information grossly inaccurate
  • HHSC should make it mandatory for these assessments to be done with parents and be seen by parents before being sent off for medical evaluation
  • Many cases in which TMHP denies those who should not be denied when diseases have not changed from when they were previously accepted
  • Payment delays/issues are far too common in the current system
  • When STAR started, the networks that had been previously built were taken away because you can only choose a doctor in your specific network
  • Parents and families should be able to have more control over their care, doctor visits
  • HHSC can built another “DADS-like” agency to determine medical need rather than the SKSAI assessment
  • There are fundamental due process issues with the MCOs
  • With denial letters, they must provide a reason and specific regulations that support that reason
  • If someone does not understand why they are being denied, there would be no foundation for a fair hearing
  • The denial letters need to be clarified and simplified
  • There is only one Manage Care organization for foster children, need more added to improve services
  • The attorneys fighting for foster children need to be able to attain all information on their client

 

Rachel Hammon, Executive Director, Texas Association for Homecare and Hospice

  • Inconsistent application of medical necessity, burdensome prior authorization processes, unsustainable rate reductions, poor communication by MCO’s are all issues that we are concerned with
  • Encourages collaboration between the committee and MCO’s in order to reach a solution
  • Variability occurs with the application of the definition of ‘medical necessity’
    • MCO’s have set thresholds that are too restrictive, causing kids to not receive the therapy they need that might be provided to them through HHSC policy
    • This conflict between internal policy and HHSC policy is impacting the care these children receive
  • The legislation was only meant to establish a group billing code, not develop a policy to be driven by cost savings
  • No way a payer source can determine compatibility between patients before even placing the patient in the home, this is a decision the nurse needs to make
  • The 1:1 ratio was developed to insure the safety of the patients in these homes, not to increase the profits of the MCOs
  • Only meant to allow “group billing”
  • Davis: What are your solutions?
    • HHSC must be the one to establish standards across the boards for MCOs, and not allow them to take advantage of these children
    • The solution to prior authorization delays is to enhance the Uniformed Managed Care contract to enforce timelines
    • Unless MCO’s can decrease the prior authorization timeline, we will need legislation to bring that timeline now

 

Julie Ross, The Arc of Texas

  • We promote, protect and advocate for children with IDDs
  • HHSC must consult with those in direct care of the MCOs and evaluate their experience
  • Targeted recommendations
  • Give Texas more time to evaluate and react to future carve ins
  • Direct HHSC to go through another RFP process to determine if MCOs can provide this
  • Require HHSC to develop verifiable utilization data for every service delivered in managed care for Texans with IDD
  • Direct HHSC to implement prior-authorization portals where patients and HHSC can see data
  • Direct the managed care utilization review department to specifically monitor requests for financial help
  • Recommend streamlined and easy to use complaint system against MCOs that is publicly available
  • The ARC cannot support any IDD/LTS carve in that does not have a protective provision, as previously negotiated in SB 7
  • Significant majority of states do not carve in IDD/LTS, asks board why Texas then?

 

Andy Keller, Meadows Mental Health Policy Institute

  • Warns board that data we are working with currently was collected in 2012, so during that over 6 years improvements have been made
  • A lot of data is being collected currently, but actual analysis of the data is not available currently
  • The more important lens to look at this issue through is how the population is benefitted as a whole, we can’t look at specific examples as frequently
  • Many of the needs we want to track in adults with serious mental illness are physical needs
  • ROI is currently being performed, the report is due in December to ensure that MCO’s are providing the best care that they can
  • Speaks to the importance of value-based contracts and purchasing to achieve the benefits of MCOs
  • Would recommend that HHSC designate a percentage of the VBP to focus on providers who care for the seriously mentally ill population
  • There needs to be accountability for the MCOs, far too many counties do not have psychiatrists available for children
  • Many effects of fee for service linger currently and impact the level of care that MCOs can offer
  • By forcing the MCOs to use outdated requirements from the fee for service model has caused them to have their hands tied behind their back
  • The last recommendation that we have is a child psychology access program, for $2 a year we can educate these pediatricians to handle basic cases as opposed to always referring to a specialist
    • 30 other states are already doing this

 

Jill Bradshaw, Self

  • Medicaid has been helpful along the way, however the last year and a half it has been incredibly difficult for us
  • We are forced to go out of state quite often to get care for her
  • A year ago, we were forced to spend 3 months fighting for her right to get speech therapy, all I want is for her to be able to contribute to society
  • We had no problems on traditional Medicaid, however when we switched to an MCO our experience became significantly worse

 

Ann Dunkelberg, Center for Public Policy Priorities  

  • There is a culture that no one wants to hear bad news, and the reason that articles like what the Dallas Morning News published happened, is that fear of sharing bad news with you all
  • Speaks to the value of transparency in this industry
  • Transparency and improvements need to be first, while embarrassment of the MCO or the legislature must be second
  • The current system that creates too many avenues for profit in the Medicaid industry is not helping us at all

 

Spotlight on Public Testimony

Tammy Pepper, Protect TX Fragile Kids Group

  • Shares story with committee about malpractice that occurred to her granddaughter and how it has left her intellectually disabled
  • Our primary concern is our lack of access to therapy- we are not denied we are just not offered the service
  • While under traditional Medicaid we had in home therapy, that is no longer the case
  • After a year and a half with no therapy, she has significantly digressed
  • All our doctors are surprised that she does not have a trach, however because of the hard work in therapy we were able to keep her head up, this is no longer the case
  • Because we do not have therapy, we are being forced to consider having the operation. This could all be alleviated with appropriate access to therapy
  • She finally was able to pass a swallow study after 5 years of speech therapy, she was able to eat 15-20 bites per meal during therapy, this is no longer the case. We struggle to get even one bite down.
  • We do not have anyone close enough to our house to come and provide therapy, there is something wrong here
  • The occupational therapist reimbursement rate has been cut so substantially that they cannot afford to provide the care that our child needs

 

Dr. Joyce Mauk, Texas Pediatric Society

  • Doctors cannot make a living seeing children with Medicaid and much less provide the care that they need
  • Seeing these children takes longer and the reimbursement is significantly less
  • Most psychiatrists do not accept Medicaid or commercial plans
  • Roberts – In your professional opinion, are children with complex needs receiving better treatment under managed care or was it better under the fee for service model?
    • Not enough information available yet about the managed care environment and all the plans are different. You’re comparing a myriad of factors, this isn’t apples to oranges.
    • Fee for service is much easier for the physicians, however whether or not the care is better is hard to asses due to the difference in plans
  • If 95% of prior authorizations are approved, why do we need this in the first place? We have two people dedicated to achieving prior authorization, this is an unnecessary burden.
  • Davis – There seems to be a need for uniformity among MCOs in obtaining prior authorization, each MCO has their own unique requirements.
  • The managed care organizers are incredibly difficult to get ahold of, often times we are told that we aren’t even allowed to talk to them

 

Victoria Petersen, Texas Medical Equipment Providers Organization

  • MCOs take advantage of different guidelines by following the protocol that is most advantageous to the MCO
  • Concerned that HHS and the legislature do not practically monitor sole-sourcing contract agreements
  • Understanding how MCO’s go about obtaining profit is paramount
  • The only way for a provider to deal with these rate cuts is to provide items of lesser quality to the patient

 

Mark Gallen, Angel Medical Supply

  • Network inadequacy can be attributed to the fact that MCO’s can pick and choose who they want in their network
  • MCOs are not updating their providers on a regular basis
  • No MCO is accepting applications for new providers
  • TMHP accepted all providers
  • Turner – Are there things that the state should be getting from the Feds to improve this?
    • Medicare is the answer
  • Roberts – Were you willing to accept their reimbursement rate? In reference to United Healthcare
    • Yes sir
  • Any STAR program is closed to all new applications at this time

 

Steve Abshire, Outreach Home Care

  • Tough to support managed care from a provider’s standpoint
  • Need to implement real and severe penalties for MCO problems

 

Sean Montgomery, Countryside Therapy Group

  • Has seen system errors in the MCO system
  • Does not believe MCOs are spending all of the money they are given appropriately

 

Laura Montgomery, Countryside Therapy Group

  • The MCOs have made it difficult for providers to continue providing services due to low rates