Tom Fox/ Staff Photographer
Tammy Bolin’s 12-year-old foster child plays on the floor of Bolin’s home outside Kerrville. Bolin took in the girl, now 12, after the child had a medical crisis at Bolin’s sister’s home, where Superior HealthPlan had refused to provide some of the nursing recommended by a doctor.
‘Recipe for disaster’
Company’s refusal to cover medical care is hurting foster kids in Texas
By J. DAVID McSWANE and ANDREW CHAVEZ
Staff Writers

Last summer, child-welfare workers dropped a disabled girl, two pairs of pajamas and some diapers at Lorna Spears’ home in Kerrville, about 100 miles west of Austin. The 11-year-old could hardly see, couldn’t eat without choking and couldn’t survive without constant monitoring.

Spears knew that taking in a “medically complex” foster child would be tough, but she had watched her sister, a nurse who lived nearby, care for similar kids. Spears thought she could do it, too.

“I had raised my kids, and I just wanted to help,” says Spears, 52. “It’s just that motherly instinct.”

They had joyous moments, watching Disney’s Moana over and over, and laughing when Spears’ husband played Elvis songs on a guitar.

Often, though, Spears felt overwhelmed.

The state assures foster parents that everything the children need, including expensive home nursing, will be provided by a health care company that it pays hundreds of millions of dollars each year.

But Superior HealthPlan wouldn’t provide enough medical supplies to keep the girl clean and comfortable, Spears says. Nor would the company pay for all the home nursing her doctor recommended, covering only 16 hours a day and leaving Spears alone with the child for eight. Foster parents cannot give consent for their children to be publicly identified, so The Dallas Morning News is withholding the girl’s name.

Nurses noticed Spears’ stress: “Fatigue with high demands,” one wrote last August. “Risk for caregiver breakdown.”

Soon after that warning, when the nurse had left for the day, the child went into shock and stopped breathing.

“Her feet were black, and I was in total panic because I didn’t know what to do,” Spears says. “I was freaking out.”

Her sister, the nurse, raced over and stabilized the child.

But last fall, Spears finally asked caseworkers to find the girl, now 12, a new home.

“It broke my heart,” she says.

“I cried and cried.”

Pervasive problems with Superior’s health care management are worsening the state’s already troubled child-welfare system, a News investigation found. The company’s refusals to cover medical costs, from inexpensive diapers to costly treatments, have made some foster parents’ tough jobs nearly impossible.

Foster parents, doctors and child-welfare workers have filed hundreds of formal complaints about the company in recent years. Judges in Houston have stepped in to order medical care that Superior has denied to foster kids. And families who have taken in medically needy children are backing out, The News found, adding to the state’s drastic shortage of beds.

Despite those failures, Texas health officials are renewing Superior’s exclusive $350 million-a-year contract when it expires at the end of August — without giving other companies a chance to bid for the program known as STAR Health.

Superior says that it is committed to providing good care to the more than 30,000 foster kids it serves, and that it follows state rules to make sure the children “receive the right services in the right place at the right time.” The company declined to comment on specific cases, citing federal privacy laws.

Carrie Williams, a spokeswoman for the Texas Health and Human Services Commission, said that the state is doing acomprehensive review of Superior’s treatment of foster children but that any revamp to the program probably won’t happen until the company’s contract extension ends in 2021.

Williams defends sticking with Superior. Far fewer foster children are on psychotropic drugs than a decade ago, she says, and the company has received high marks for making sure kids receive routine checkups.

Those measures indicate managed care may be working well for healthy children. The company and the state save money if those kids receive preventive care that keeps them out of the hospital, for instance.

But half of foster kids have significant physical or mental health problems, and about 200 at any time are so sick or disabled that they need special care in “therapeutic foster homes,” according to the state.

Therapeutic Family Life, one of the largest groups that place medically complex children, says Superior’s tactics make it more difficult to find families to take in the kids, who otherwise can end up in expensive hospital facilities.

In just a few years, the agency has lost at least 23 beds for these children, says Janelle Holland, the group’s program coordinator. For foster parents, fighting for medical services becomes a full-time job, Holland says.

“The foster parents will give up on the children if they don’t have the services to meet their kids’ needs — because it’s not safe.”

Monopoly over foster kids 

The state’s child-welfare system has been dysfunctional for years, so much so that a federal court recently found that neglected and abused children were often worse off when they left foster care than when they came in. Children are often shuffled from home to home, and thus doctor to doctor, making it hard to ensure consistent and adequate health care.

Texas wanted to improve that system when it created the STAR Health program and hired Superior to run it more than a decade ago. Health officials hoped giving just one company control over foster kids in all 254 counties would result in more consistent care.

Lawmakers were also trying to save money. As wards of the state, foster kids are enrolled in Medicaid, the government program that today provides health care for about 4 million Texans, including chronically sick kids, elderly and disabled adults and extremely poor people.

Under the old system, Texas used state and federal tax dollars to pay doctors directly for billed services. The state’s share of the costs was rising, and lawmakers were increasingly worried about fraudulent billing.

Superior, owned by Missouri-based Centene Corp., promised better health outcomes through “managed care,” which supporters said would reduce unnecessary costs and save taxpayer money while giving the company a small profit.

Other Medicaid managedcare programs, including those covering Texans with disabilities, give patients at least two companies to choose from. Because they have to compete for patients, the companies have incentives to provide better care, experts say.

But thanks to generous terms set in managed care’s early, experimental years, Superior has enjoyed a monopoly over foster children, whose identities and well-being are shrouded by multiple layers of confidentiality.

“The state is paying this managed-care organization a lot of money to take care of our vulnerable kids, but that care is never getting to our kids,” says Tara Grigg Garlinghouse, a Houston lawyer and director of the Foster Care Advocacy Center, which represents foster children.

“Our children should not be responsible for bolstering the bottom line of a company,” she says. “I have no idea how Superior has maintained this contract for so long.”

Profits, problems

Though foster children account for a tiny fraction of the 

Texas Medicaid population, in recent years they’ve been managed care’s most profitable line of business measured in dollars per patient. Superior makes twice as much profit on a foster child as it does on a patient in the traditional Medicaid plan for poor children and adults, state data shows.

Yet state health officials concede they’ve provided little meaningful oversight of STAR Health, and their own data raises questions about Superior’s performance.

Each year, more and more foster parents are filing appeals over Superior’s medical denials; those appeals have climbed 31 percent since 2014 — more than for any other Medicaid managed-care program in the state.

The News reviewed more than 4,000 complaints lodged against Superior in the last three years. At least 375 were about the care of foster children, and 50 came directly from the state’s own child-welfare workers.

The Texas Department of Family and Protective Services is supposed to advocate for foster children to get all the care they need, but it can’t force Superior to do anything.

“We may not always win, but our loyalty and service is always to the child,” says Patrick Crimmins, the department’s spokesman.

In June, the department began tracking when Superior denied care for foster children that was recommended by doctors or other medical providers.

It counted about 450 denials in just six weeks, withholding everything from physical therapy to expensive home nursing and medical supplies.

The department launched that effort after The News published a series that showed managed-care companies were bolstering their profits at the expense of vulnerable Texans.

One article focused on a foster baby named D’ashon Morris, who was denied round-the-clock home nursing as part of a statewide cost-savings strategy Superior deployed.

As the baby’s foster mother and doctors had warned he would if a nurse weren’t around, D’ashon pulled out his breathing tube, depriving his brain of oxygen. He is now in a persistent vegetative state. The foster mother, who adopted him last year, has since sued Superior over his treatment.

State records show that when D’ashon’s caseworker tried to argue for more home nursing, Superior’s medical director complained that she and several other caseworkers were meddling. Dr. William Brendle Glomb threatened to protest to the state health commission, his former employer, whose top officialsroutinely hid the magnitude of problems with managed care, The News found.

Foster children have been caught in the middle of such bureaucratic tugs-of-war for years, internal emails suggest.

Just weeks before D’ashon’s life-altering injury, one caseworker wrote, “Foster parents are leaving due to the issues with STAR Health decreasing services.” 

Extra hurdles 

Superior requires children to get approval before they can even see a specialist to be evaluated for physical, occupational or speech therapy.

In traditional Medicaid, in which the state pays doctors, that initial hurdle is explicitly prohibited. With other managed-care companies, a family doctor can refer patients to a specialist, who performs an evaluation and prescribes treatment.

Superior’s extra layer of approval limits its exposure to expensive claims while hurting the development of foster children, according to dozens of interviews with foster parents and disability lawyers. State health officials have known about the problem for years but have done nothing.

And when foster parents do cut through the red tape, Superior’s thin network of providers leaves them searching across the state to find appointments.

Late last year, Sharon Gerlach, a registered nurse and foster mom in Pearland, took in a 10-year-old girl who weighed 48 pounds and knew only nine words. She was in diapers and hadn’t been weaned from a bottle until she was 8, Gerlach says, so she couldn’t eat on her own. She often threw tantrums, screaming and kicking, her only way to communicate.

The child needed speech therapy, a treatment dozens of health care providers and parents say Superior routinely denies.

It helps children learn to socialize, but it’s also crucial in teaching children with developmental delays to chew and swallow food.

Between struggling to find providers and to get the layers of approvals Superior required, Gerlach says, it took seven months before the girl got therapy.

During that time, Gerlach says, she called paramedics twice because the girl was choking on food, once ending up in the emergency room.

“A normal family that isn’t medically trained would just give up,” she says. “It was frustrating for me. I did a lot of cussin’.”

‘Recipe for disaster’ 

Some judges have become so fed up with poor health coverage for foster kids that they’re ordering the state to pay directly for services and medical equipment. So the child-welfare department is shelling out thousands of dollars to respond to family-court orders, on top of the more than $920 a month that the state pays Superior for each child.

The state could provide no reliable data about how often it pays for court-ordered care. A spokesman said it isn’t often.

But in Harris County alone, three judges told The News they had signed dozens of orders for the state to pay out-of-pocket for speech therapy, household helpers, medical equipment and more.

“Even on a good day, the state is a lousy parent,” says Michael Schneider, the top judge in the Houston court that oversees thousands of cases involving foster children.

“When you compound that with a system that often denies coverage for these children,” he adds, “it’s a recipe for disaster.”

Earlier this year, Schneider issued a standing order requiring child-welfare workers to report each denial of care for every foster child who comes through his court.

In one order last September, a judge admonished Superior for creating barriers that were detrimental to a foster child who couldn’t get speech therapy.

In another case, Superior refused to provide a special “cranial helmet” that doctors prescribed for a child to prevent his misshapen head from becoming permanently deformed.

Superior argued that it was a cosmetic matter that it wouldn’t pay for, a lawyer who represented the boy told The News.

But without the helmet, the boy would be deformed for the rest of his life, the judge concluded after considering recommendations from several physicians.

“It is the responsibility of Star Health/Superior Health- Plan to pay for such a device,” the order reads.“It is not in the best interests of any child to experience stigma in the form of adeformity due to the unfortunate circumstance that he or she was in foster care …”

‘Break people down’ Outside of Kerrville, in a ranch house that foster parents call “Careville,” the air is filled with the beeps and gurgles of medical machines, cartoon melodies and Tammy Bolin’s exasperated phone calls.

Bolin is the sister of Lorna Spears, who tried and ultimately couldn’t care for the girl who went into shock one night last year. The child lives with Bolin now, along with as many as five other kids, depending on the week. Sometimes, children go home. Sometimes they die here.

Almost daily, Bolin says, she’s arguing with someone at Superior, or calling a doctor to resend a prescription that the company denied because of a misspelling, or fighting because Superior reduced a kid’s nursing.

Her latest battle: She doesn’t have enough of the syringes she uses to measure out children’s medicines. She and the nurses have been reusing them over and over, and she’s worried a child might get an incorrect dose.

“We have to wash them so much, there’s no numbers on them,” Bolin says.

Among Bolin’s kids is a girl who was beaten so badly that she’s lost almost all brain function.

At age 3, she’s had two strokes and a heart attack.

When Bolin leans down and speaks to the girl — “She’s sooo pretty,” Bolin says, pinching her cheek — the girl smiles faintly.

“That’s all she can do,” Bolin says.

In late 2016, Superior cut the child’s nursing; Bolin had to get a lawyer to fight the move, and even then succeeded only after state officials determined that the company’s nursing policy violated state and federal law.

“They try to break people down,” Bolin says of Superior.

“So if you’ve got 10 foster parents and two of them give up, well, you just saved that much money.”

dmcswane@dallasnews.com; achavez@dallasnews.com 

Twitter: @davidmcswane, @adchavez