Medicaid Fraud Investigation – TX Health Care Claims Study


cover2OFFICE OF THE COMPTROLLER TEXAS
Carole Keeton Strayhorn
(Former) Texas Comptroller of Public Accounts
FAX: 512/463-4965
P.O. BOX 13528
AUSTIN, TEXAS 78711-3528
512/463-4000

I am releasing this Texas Health Care Claims Study – Special Report on Foster Children.

Children are our most precious resource and the foster children of Texas need special attention because the state has taken either temporary or permanent guardianship of them in effect making the state and all of its citizens their parent.

This report reveals shocking evidence of the systems failure regarding the care provided to our foster children. In addition, it raises many red flags pointing to areas of potential fraud and abuse that I am referring to the Office of Inspector General at the Health and Human Services Commission to investigate.

In a separate report, Review and Analysis of The Medicaid and Public Assistance Fraud Oversight Task Force, I am recommending the Office of Inspector General report directly to the Governor and become an independent office.

I am making 48 recommendations to the Medicaid and Public Assistance Fraud Oversight Task Force in this report. For example, I am urging the Office of Inspector General to fully investigate potential fraud and abuse identified  in this report. The Department of Family and Protective Services should hire a physician to serve as a full-time medical director responsible for health care for Texas’ foster children.

In April 2004, I recommended DFPS create a “medical passport” for each foster child, which would follow each child as they move from one placement to another. I again call upon DFPS to immediately implement this long-overdue recommendation that would dramatically improve health care for our forgotten children—which could be done by using a simple paper copy system until an electronic version is available.

The medical director should be responsible for ensuring that a foster child’s medical passport be received by the foster child’s caregiver within 48 hours of being placed in a foster home or facility.

HHSC should require prior authorization for prescriptions to address the dispensing of non-FDA approved psychotropic medications for children. DFPS and the Department of State Health Services should seek lower-cost, less restrictive alternatives to psychiatric hospitalization and immediately develop rules for the psychiatric hospitalization of foster children.

The medical director and the Department of State Health Services should evaluate the case files of all medically fragile foster children and develop best practices for care. DFPS in coordination with HHSC and the Department of State Health Services should study complementary treatments to psychotropic medications—such as therapy, diet, exercise, therapeutic activities and mentor programs.

The Office of Inspector General at HHSC and the State Auditor should review the quality of the physical environments in which foster children live and make recommendations to improve standards for living conditions. My first investigation into the Texas foster care system in 2004—Forgotten Children— documented the tragic failure of the system. Part of the report focused on psychotropic medications and care prescribed to our foster children.

The findings caused me deep concern and led to my decision in November 2004, to look into this aspect of the system more closely. Out of concern for the foster children of the state of Texas and pursuant to my statutory obligation to review Medicaid claims for fraud under the Government Code Section §403.028, I reviewed the Medicaid claims of foster children in fi cal 2004 in depth. I am disappointed to report that the findings confirmed the conclusions of the Forgotten Children report.

Given the distressing findings contained in this report, I hope that the state will not delay in adopting recommendations, which have been crafted to help mend this broken system. My hope is that the state leadership and the health and human service agencies will work to make things better for our state’s most vulnerable children.

This report is available on the Texas Comptroller’s Web site at www.window.state.tx.us.

Texas is great, but we can do better. We have to—for the sake of our children.

Sincerely,

Carole Keeton Strayhorn

Texas Comptroller Chairman,
Medicaid and Public Assistance Fraud Oversight Task Force

According to the External Review by Dr. Julie Zito and Dr. Daniel Safer, Texas foster children had a 47.1 percent greater likelihood of being medicated with psychotropics than those residing in the Mid-Atlantic States.

Many foster children receive therapy, but Medicaid records reveal that this therapy often is inconsistent, with months passing between sessions, and some children in need of therapy never receive it. Diet and Exercise Diet and nutrition are important to a healthy lifestyle.

Forgotten Children revealed numerous incidents in which foster children received remarkably poor diets; Medicaid records indicate that there were more than 2,000 claims for the diagnosis of “child neglect nutrition” in 2004.

While some of these children were new to the system, others had been in the foster care system for years. Furthermore, special diets often are crucial to the more than 1,600 medically fragile children in foster care, and their diets should be monitored closely.

In August 2006, the Houston Chronicle reported how two brothers in foster care “were at risk of dying from the lack of proper food.”7

The young boys who were in foster care from 1999 to 2002, said they were forced to stay in a garage and ate dog food. The child who was 10 at the time weighed 56 pounds and the younger brother age 9 weighed 59 pounds.

In April 2005, the Dallas Morning News reported that a review of DFPS records showed an investigation of a foster mother who “withheld water on a hot day and withheld food as punishment.”8

According to the National Institutes of Health, People who get regular exercise, eat healthfully and avoid tobacco have a lower risk of chronic diseases that lead to premature death, such as heart disease, high blood pressure, diabetes and certain cancers. They also have reduced rates of disability, better mental health and cognitive function, and lower health costs.9

Dr. Andrew McCulloch, the chief executive of Britain’s Mental Health Foundation, has stated,There is a growing body of evidence, and a number of signifi cant voices are championing the role of diet in the care and treatment of people with mental health problems. The potential of dietary interventions in treating depression and Attention Deficit Hyperactivity Disorder, for example, are being increasingly recognized. We would be foolish to underestimate their importance…. Diet is a cornerstone of this integrated approach.10 The Mental Health Foundation report Feeding Minds states that depression can be linked to low intakes of fi sh, but diets rich in complex carbohydrates as well as certain foods also are thought to decrease the symptoms of depression.

Studies have shown that people with schizophrenia have lower levels of polyunsaturated fatty acids and lower levels of antioxidant enzymes. Children with attention deficit and hyperactivity disorder, interestingly, often have diets low in iron and fatty acids.11 ]

The U.S. Department of Agriculture’s Agricultural Research Service confirms that shortages of certain minerals in the diet may affect human behavior.12 Exercise is not only physically beneficial, but has been shown to improve mood and alleviate depressive symptoms dramatically.

There is a growing body of evidence, and a number of significant voices are championing the role of diet in the care and treatment of people with mental health problems.

Many case studies indicate numerous anti-depressive and anti-anxiety benefits.14

Exercising also provides an outlet for increased socialization, which helps the depressed patient further.15

Exercise can stimulate higher self-confidence and boost self-esteem. Exercise therapy, moreover, is low in cost and easily available, and improves physical health as well. In many cases, exercise combined with other therapy can be most effective.

Mentor-ship is a notable aspect of treatment.

The Comptroller’s Forgotten Children Report recommended that DFPS partner with volunteer and advocacy organizations to develop a Texas Foster Grandma and Grandpa Program.  Although this proposal was enacted in S.B. 6, DFPS has not implemented the program.

Foster children can benefit greatly from the presence of a person willing to act as an advocate, a role model and a friend. Involvement in the community, through local organizations or community projects, also is beneficial and therapeutic. Access to programs that focus on positive personal development through activities such as nature camps, sport clubs and dance can help normalize foster children’s lives.

A new program was started in September 2006 at a San Antonio residential treatment center for young foster children, to provide abused and neglected foster children with positive adult role models. The partnership with Big Brothers Big Sisters appears to be the first of its kind in Texas.

The vice president of the center said,

“this new program will provide the child with an established mentor throughout their time in foster care, and will also allow us to track the progress of the child throughout his or her childhood.

It’s a perfect marriage of two programs.”

Foster children can benefit greatly from the presence of a person willing to act as an advocate, a role model and a friend. (For additional information on this program see Appendix VIII.)

DFPS, in coordination with DSHS and HHSC, should study complementary treatments to psychotropic medication, such as therapy, diet, exercise, therapeutic activities and mentor programs. They then should develop best-practices guidelines for all foster care providers regarding these treatments.

DFPS, in coordination with DSHS, should study programs and providers that have successfully lowered the number of psychotropic medications given to foster children, and develop best-practices guidelines to help other providers emulate their success.

HHSC’s Office of the Inspector General, in coordination with the State Auditor’s Office and advocacy groups, should review the quality of the physical environments in which foster children live.

This should be accomplished by reviewing records related to abuse and neglect and poor health, and by site visits to foster homes around the state, including those in rural locations. The group should make recommendations to DFPS for standards to improve the living conditions of foster children.

DFPS, in coordination with HHSC’s Office of the Inspector General and advocacy groups, should develop a new format for the 2007 foster child survey.

It should be made more adolescent friendly and feature basic questions regarding the quality of housing, relations with foster parents or providers, diet and opportunities to exercise.

Endnotes
1 Interview with John Smith, assistant director of placement, Camp Comanche and Pegasus School, Lockhart, Texas, June 13, 2006.
2 The Mental Health Foundation, Feeding Minds, The Impact of Food on Mental Health (London, England, January 2006), p. 1.
3 Barbara Starfi eld, M.D., “Study Demonstrates a Powerful Association Between Decreasing Social Class and Poor Health and Behavior Problems in Children,” Ambulatory Pediatrics (July/August 2002), pp. 238-246.
4 The National Health Service, “Mental Health,” http://www.nhsdirect.nhs.uk/ articles/article.aspx?articleID=653. (Last visited August 26, 2006.)
5 American Academy of Child & Adolescent Psychiatry, Facts for Families No. 86 (January 2003), p. 1
.6 American Academy of Child & Adolescent Psychiatry, Facts for Families No.64, p. 1.
7 Eric Hanson, “Once-starving boys testify they ate garbage, dog food,” Houston Chronicle (August 26, 2006), front page.
8 Randy Lee Loftis and Pete Slover, “Abuses found at foster homes,” The Dallas Morning News (April 17, 2005), p 1A.
9 U.S. National Library of Medicine and the National Institutes of Health, “Diet and Exercise: The Real Fountains of Youth,” http:// www.nlm.nih.gov/medlineplus/news/fullstory_ 36687.html. (Last visited August 28, 2006.)
10 The Mental Health Foundation, Feeding Minds, The Impact of Food on Mental Health, p. 1.
11 The Mental Health Foundation, Feeding Minds, The Impact of Food on Mental Health, pp. 5 – 6.
12 U.S. Department of Agriculture, “Nutritional Defi ciencies Affect Behavior,” by Judy McBride, Washington, D.C., January 29, 1997, http://www.ars.usda.gov/is/pr/1997/970129. htm. (Last visited August 28, 2006.)
13 Western Washington University, The Root of Disease: Treatment (Bellingham: Western Washington University, 2006), pp. 3-4.
14 The Mental Health Foundation, Up and Running? Exercise Therapy and the Treatment of Mild or Moderate Depression in Primary Care (London, England, March 2005), p. 25.
15 Western Washington University, The Root of Disease: Treatment (Bellingham: Western Washington University, 2006), pp. 3-4

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