Lawmakers Question Oversight Of Privatized Care For Poor Texans

“There’s particular concern that these companies really have wide latitude to decide what care is medically necessary.”

By Rhonda Fanning & Michael MarksJuly 2, 2018 7:22 am,

Some healthcare companies are using taxpayer dollars to line their own pockets instead of administering necessary care to vulnerable Texans – that’s just one of the findings from the Dallas Morning News investigative series “Pain and Profit,” which has grabbed the attention of elected officials in Texas.

Last week, the Texas House General Investigating and Ethics Committee held a hearing with insurance executives, Medicare recipients and state agency representatives quoted in the report. David McSwane, one of the journalists behind the series, says state officials were concerned that the companies aren’t providing all of the care state guidelines require.

“There’s particular concern that these companies really have wide latitude to decide what care is medically necessary,” McSwane says. “They’re supposed to follow some broad state guidelines, but as we showed, they’ve they’ve developed some processes by which they were able to deny some some pretty scary things like home nursing for really sick kids.”

For those outraged by inadequate coverage by managed care providers, the question emerges: how and why did regulators allow this? McSwane points out that the Texas Health and Human Services Commision has admitted that it did a poor job of enforcing existing rules.

“Some of the most explosive testimony last week came from a nurse [named] Nancy Toll,” McSwane says. “She said one of the reasons [for poor enforcement] was that a lot of folks at the commision aspire to work for these companies because they pay more…they don’t want to rock the boat too much.”

One possible solution being floated by lawmakers involves shutting the revolving door between regulatory agencies and the industries they’re supposed to be overseeing. More regulators are also being hired.

“So far the commission’s gotten clearance to hire about 100 new regulators, which is a pretty big deal,” McSwane says. “Forty-seven of those jobs are to check directly on patients, which is really….the best lens into seeing what these companies are doing.”

Written by Josue Moreno.