Pain & Profit: Hope Remains for Fixes to Texas' Broken Medicaid System, But Biggest Tweaks Are Likely Dead

AUSTIN – Lawmakers in the House ran out the clock on a sweeping bill to add protections for extremely poor and disabled patients who rely on Medicaid. That bill, which among other things promised a crack down on health care companies that denied vulnerable Texans of needed care in order to boost their profits, died a procedural death last week.But several less expansive bills, most originating in the Senate and now churning through the House, offer some hope for advocates and lawmakers who want to see more transparency and fewer delays or denials of drugs and treatments in the program known as Medicaid managed care."The legislature has an opportunity in the remaining days of the 86th session to do the right thing," said Hannah Mehta, who leads Protect TX Fragile Kids, a group of parents of sick and disabled kids who have pushed back against the state's privatized Medicaid system. "Failure to properly address this issue literally means life-and-death repercussions for thousands of little Texans with complex medical needs," she said.Texas and the federal government pay about $22 billion a year to companies and a few nonprofits that act as middlemen, deciding which doctor bills to pay and which services to approve. The state pays up front, and companies make billions in profit from what they don't spend on patients.In exchange, those companies promise to provide better and cheaper care by cutting costs for unnecessary services and connecting patients with doctors and specialists.But a Dallas Morning News investigation found years of inept state oversight allowed those companies to refuse or take away medically necessary services and force patients and families of sick and disabled children through a maze of endless appeals -- sometimes with dire consequences. Those managed-care companies vastly overstated how many doctors and specialists were available to their patients, The News found, and they routinely failed to meet the terms of their contracts.That investigation spurred more than two dozen pieces of legislation, including the so-called "Managed Care Accountability Bill," authored by Rep. Sarah Davis, a Houston Republican who launched a House investigation into problems with managed care last year. Among many other things, her bill would have forced the state health commission to better track medical denials and other data to identify trends and find companies that might be denying needed services to boost their bottom lines. It also sought to expand a program that sends state nurses to check on severely disabled patients in their homes, to make sure companies are providing the services taxpayers paid for.That 60-page bill made it out of the House Human Services Committee, despite significant pushback from lobbyists working on behalf of managed care organizations, commonly referred to as MCOs. But the chairman of the committee, Republican Rep. James Frank, let nearly a week pass before forwarding the bill to its next stop, the Calendars Committee.As many bills are pre-ordained to do, Davis' bill languished in Calendars, never making it the floor before the deadline to pass House bills lapsed."I was disappointed that HB 2453 died, but not all that surprised," Davis told The News. "We always knew making major reforms was an uphill battle. The MCOs were fighting us every step of the way."A few other bills offer smaller fixes live on and are not facing as much opposition as Davis' bill. A bill by Sen. Charles Perry, a Lubbock Republican, is focused on a small population of sick and disabled kids and aims to prevent lapses in treatments and drugs that parents like Mehta experienced as the state forced families into managed care.Another bill by Sen. Lois Kolkhorst, a Brenham Republican, is also narrowly tailored to address the concerns of Mehta's vocal group of parents, but it goes further to require the state to do a better job of tracking and addressing complaints from families and patients when they are denied services.Kolkhorst, chairwoman of the powerful Senate Health and Human Services Committee, acknowledged earlier this legislative session that those bills do little to address pervasive problems seen in the health insurance program for more than 30,000 foster children or the program for disabled and elderly adults.Sen. Kirk Watson, the Austin Democrat who carried some of Davis' broader measures in the upper chamber, said he's hopeful that the House will pass through one of his bills to create an external medical review organization.That would give patients and parents who are denied treatments or equipment an extra chance to appeal to a group of clinicians who are not affiliated with either the health care companies, which seldom reverse their denials, or the state health commission, which almost always sides with companies.It was "disheartening," he said, to see lawmakers slow-play and ultimately kill bills that would have offered broader, systemic patient protections. "Coming into this session I was very optimistic that we would be able to pass significant reforms," he said. "Sadly, despite the hard work by myself and others, I am afraid we are going to conclude this session with little progress on updating our MCO system."  Continue reading...