Over the last year, dozens of families have lost state subsidized nursing support to care for their sick children.
Some parents say the reductions have made it hard to juggle work and keep their kids healthy.
New Hampshire hired a private company, Schaller Anderson to manage these cases.
Frustrated parents accuse the company of making decisions based on money, not the health of their children.
There are about 150 families in the state of New Hampshire with children so ill most of them need medical care every day.
Many of them can’t walk or talk; some are fed through tubes, some have debilitating seizures.
Historically this state has provided nurses to help these families care for their kids.
In 2010, New Hampshire spent almost $10 million dollars sending nurses to children’s’ homes.
By 2011, it had been years since the Department of Health and Human Services had taken a hard look at the program to make sure they were spending their money well.
HHS’s Lisa Britt Solsky says she was hearing stories.
“We would have the most highly credentialed nurse in a home, overnight, where the patient was at all times stable sleeping through the night.”
Should your most qualified, most expensive nurses be on the clock when their patient is sound asleep?
What are the consequences of taking that highly skilled nurse away when minutes could be the difference between life and death?
Legitimate policy questions....particularly at a time when other programs are being gutted due to the budget crunch.
But tricky, too.
These are some of the state’s most fragile and expensive Medicaid patients.
The state asked its Medicaid contractor Schaller Anderson - a company with a 20 year track record that manages more than 1 million Medicaid patients across 11 states – to tackle this delicate project.
“They were hired to bring a level of professionalism and resources...this is what they do.”
Solsky explains Schaller’s job was to basically check up on the 150 patients every 12 weeks to make sure skilled nurses did medical things, and the nurses with less training did things like...watch patients while they slept.
Solsky says if a family didn’t like a cut made by Schaller, that family had options.
“Somebody who disagrees has the right to appeal.”
Schaller Anderson has reviewed 800 cases.
In that time, they changed nursing service for about a third of the families.
And families appealed just 5% of the decisions.
But the appeals...man, are there some upset people.
“It’s convoluted. It doesn’t make sense whatsoever.”
That’s Elizabeth Fouts.
NHPR has heard from half a dozen families who expressed everything from bewilderment to outrage with Schaller and the state.
Fouts’ odyssey began last May when Schaller reduced her son’s nursing care from.40 hours a week, to 32.
“We had very few hours cut....But 32 hours is huge when it’s the difference between being able to get to work on time and function.
From the get-go, Fouts questioned Schaller’s methods.
No one ever stopped by to meet her 17-year old son Adrian who has heart problems, micro feet, is deaf, legally blind, can’t walk on his own, adores Fig Newtons and loves to cuddle.
Instead, Schaller relied on their assessment of Adrian’s medical records to determine how much nursing he needed.
But Fouts says if anything, Adrian’s needs kept growing...he sometimes suffered from 8-10 minute seizures.
“If he has a seizure, he quits breathing...he is oxygen deprived, if we do not have the ability to give him medicine rectally that will stop the seizure, we call 9-1-1 b/c there is absolutely nothing we can do.”
As ridiculous as the cut seemed to her, Fouts knew she had to try and get those 8 hours back.
Easier said than done.
“There really isn’t a state office that can inform you who SA is, what they are doing. And frankly the person who called me the contact person...she’s not forthcoming about what the decision was based on. What the criteria are for hours, all of that, all of the questions I asked went unanswered.”
HHS didn’t make Schaller available for this story, nor did company officials return calls for comment.
Even though Fouts appealed, she had to wait 6 months to get her hearing with Schaller.
When the date finally arrived, Fouts was sure to bring Adrian, wanting Schaller to actually meet her boy.
She wanted to overwhelm Schaller with evidence that they had screwed up.
When given the chance, she grilled the company’s doctor.
“I said to Dr. Robinson...do you feel now that you’ve met Adrian, you’ve seen the medical reports, that he’s represented .?....and he said, no. ‘Clearly, a mistake has been made. And I am prepared to reverse this decision right now.”
Good news for Fouts and her son.
“We sort of went home feeling, the pediatrician, the nursing agency, good sense prevailed...and 10 weeks to the day, I got a phone call saying your hours have been cut.”
Cut back down to 32 hours, for a second time.
It was as if the first appeal hadn’t even happened.
“If I could go back to Dr. Robinson and say we went through this. We wasted your time. you wasted our time. but we came to a decision. Why would we do that again?”
But Fouts neither Schaller nor the state ever made Dr. Robinson available....so she appealed....again.
Families and nursing agencies also say Schaller Anderson staff has made heartless comments.
Dawn Mrotek runs Silver Touch Home Healthcare, one of the nursing agencies that has lost money from the Schaller cuts.
“The parents need to get a grip, their children are going to die....I have had that said to me.”
The comments and Kafkaesque process has convinced people like Disabilities Rights Center attorney Rebecca Whitley that Schaller is motivated by money.
“How is it efficient, both time and money, to do these 12 week reviews, continue to do appeal after appeal? How is that efficient? For these children whose conditions do not change. It doesn’t make sense.”
If the state is really interested in savings, Whitley suggests HHS invest in a better way to review cases...one that doesn’t involve repeated nursing cuts for people who have successfully appealed.
That’s where critics believe the state has really fallen short, there’s no oversight.
Nobody at the Department is willing to override Schaller, exercise some discretion, or say ‘I’m sorry.’
HHS’s Lisa Britt Solsky says in no uncertain terms Schaller doesn’t profit from making more cuts than necessary.
But she admits in some moments the state should have done better by their clients.
She says concerned families should call the Office of Medicaid Business and Policy.
“If we had the opportunity to work directly with the families, we could iron out some of the anomalies. Some of these situations that don’t seem to make a lot of sense, and don’t seem consistent with what our goal was when we undertook this review a little over a year ago.”
That said, Solsky believes the project has been worthwhile.
She believes this project helps the state as the Department inches towards outsourcing their entire Medicaid program this summer.
The bulk of Medicaid patients – kids and mothers – are relatively healthy and not terribly expensive.
The opportunity for savings in Medicaid, says Solsky, is in controlling the costs of the elderly and disabled.
Reviewing all 150 severely disabled kids helps the state hit the ground running.
“Now that we know more about their day to day needs, we are in a much better position to make those assessments. And we are in a better position to make the transition as we move into managed care.”
The Department is currently negotiating contracts with three managed care companies.
HHS will make the names public in about two weeks.
In a little more than 3 months, HHS will be enrolling most of its 120,000 Medicaid patients into one of several private managed programs.
That’s about 10% of the state’s population.
Some advocates predict this trouble with Schaller is just a preview of how the state will handle managed care writ large – where, they say savings trumps care.
Steve Norton with the New Hampshire Center for Public Policy Studies says managing Medicaid means being more aggressive, cutting services.
“You create cliffs, and those cliffs create pain for a small group of people who fall over that cliff into a place where they no longer receive the same services.”
But Norton says there’s nothing about managed care that requires HHS to abandon its duty to its patients.
There’s nothing that prevents the state from building some safety valves to help people when they hit brick walls with the private Medicaid companies.
That, he says, is well within HHS’s power.