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

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Carole Keeton Strayhorn Texas Comptroller Chairman, Medicaid and Public Assistance Fraud Oversight Task Force HE COM T P F T R CaroleCarole KeetonKeeton StrayhornStrayhorn O O E L C TexasTexas ComptrollerComptroller ofof PublicPublic AccountsAccounts L I F E F R O T E X A S 512/463-4000512/463-4000 FAXAX: 512/463-4965512/463-4965 P.O.P.O. BOXOX 1352813528 AUSTINUSTIN, TEXASEXAS 78711-352878711-3528 December 14, 2006 Fellow Texans: Today, 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 system’s failure regarding the care provided to our foster children. In addition, it raises many red fl ags pointing to areas of potential fraud and abuse that I am referring to the Offi ce 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 Offi ce of Inspector General report directly to the Governor and become an independent offi ce. I am making 48 recommendations to the Medicaid and Public Assistance Fraud Oversight Task Force in this report. For example, I am urging the Offi ce of Inspector General to fully investigate potential fraud and abuse identifi ed in this report. The Department of Family and Protective Services should hire a physician to serve as a fulltime 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 fi les 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 Offi ce 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 fi rst 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 fi ndings 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 scal 2004 in depth. I am disappointed to report that the fi ndings confi rmed the conclusions of the Forgotten Children report. Given the distressing fi ndings 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 Table of Contents Executive Summary and Systemic Recommendations . .iii Reducing the Reliance on Psychotropic Prescriptions in Texas Foster Care . .xi Texas Foster Care Snapshot Demographics . xvii External Review: A Pharmacoepidemiologic Analysis of Texas Foster Care Background, Findings and Recommendations . ER-3 External Review . ER-7 Curriculum Vitae . ER-39 Chapter 1. The Cost of Medications for Texas Foster Children . 3 Chapter 2. Medical Concerns Foster Children with Psychiatric Hospitalizations . 13 Medically Fragile Foster Children . 27 Foster Children and Sexually Transmitted Diseases . 37 Foster Children with HIV and AIDS . 43 Pregnancies in the Foster Care System . 49 Contraceptives and Foster Children . 57 Injuries and Deaths of Foster Children . 61 Medicinal Poisoning of Foster Children . 63 Chapter 3. The Medications Psychotropic Drugs Prescribed to Texas Foster Children . 69 Antipsychotics and Antidyskinetics . .73 Stimulants and Other ADHD Medications . .81 Anticonvulsants (Mood Stabilizers) . .91 Antidepressants . .95 Anxiolytics (Antianxiety Medications) . 101 Hypnotic / Sedatives . 107 Foster Children: Texas Health Care Claims Study – Special Report — i Psychotropic Medications and Young Children . .111 Foster Children and Controlled Substances . .115 Compound Drugs Prescribed to Foster Children . .123 Chapter 4. In Her Own Words – The Story of a Texas Foster Child . .129 Acknowledgments . .137 Appendices I. The History of Examining Psychotropic Medications Prescribed to Texas Foster Children . .141 II. Statistical Comparison of the ACS – Heritage Study and Comptroller Study . .151 III. Foster Care Medication Data Comparison – Fiscal 2004 and Fiscal 2005 . .155 IV. Foster Children and Psychotropic Medications in Other States . .157 V. Foster Care Medical Managed Care Organization . .163 VI. Comparison of Psychotropic Drugs Included in the Comptroller Study and Other Studies . .165 VII. Psychotropic Drugs Included in the Comptroller Study . .169 VIII. Press Release from The Children’s Shelter of San Antonio . .173 IX. Psychiatric Inpatient Admissions for Texas Foster Children, Fiscal 2004 . .175 X. Top 50 Most Expensive Inpatient Diagnosis Claims for Texas Foster Children, by Total Amount Paid, Fiscal 2004 . .177 XI. DFPS Service Levels and Daily Reimbursement Rates for Foster Care . .179 XII. Drug Classes Used in the “External Review” Study and in the Comptroller Study of Foster Care Medicaid Drug Database, Fiscal 2004 . .183 XIII. Selected Diagnosis Codes for Medically Fragile Texas Foster Children . .187 XIV. Multnomah County Oregon Medical Foster Care Program Documents . .199 XV. Glossary . .211 XVI. Foster Care Medications Data Description . .225 ii — Foster Children: Texas Health Care Claims Study – Special Report Executive Summary and Systemic Recommendations Executive Summary and Systemic Recommendations “They’re everybody’s children, and nobody’s children. They are the forgotten children in the Texas foster care system. This report reveals shocking evidence of the system’s failure regarding the health care provided to our foster children. In addition, it raises many red fl ags pointing to areas of potential fraud and abuse that I am referring to the Offi ce of Inspector General at the Health and Human Services Commission to investigate. This report, as the Forgotten Children report did, gives these Î The complex children something they desperately need—a voice.” nature of the foster – Carole Keeton Strayhorn care system Texas Comptroller generates manyÎ Quote, quote, opportunities quote, quote, for finger- quote, quote, The Comptroller’s Health Care Claims Study must lie at the top, with the government agen- pointing, but – Special Report of Foster Children has re- cies that allowed this situation to develop. quote, quote, ultimately the vealed many failures and tragedies – by con- While not all foster care providers provide quote, quote, responsibility necting the dots between the state’s foster optimum care and treatment, HHSC and the quote, quote, must lie at the children and their Medicaid medical and pre- Department of Family and Protective Servic- quote, quote, top, with the scription drug claims. The picture is bleak, es (DFPS) must be held accountable. They quote, quote. and rooted in profound human suffering. It place the children and monitor them—or fail government.
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