Tuesday, May 11, 2010
Tantalus shooting linked to DHS Medicaid program failure
by Larry Geller
The clues were in the news coverage, but it took an expert advocate to follow up:
Boegel said her son stopped taking the medicine in January because the insurance company, which she would not identify, would no longer pay the $90 monthly cost for the prescription drugs. [Honolulu Advertiser, Man shot on Tantalus may have had death wish, mom says, 5/11/2010]
If someone could not afford $90 a month for necessary prescription drugs, then almost certainly they would be participating in the Department of Human Services Medicaid program, QExA. The program has been under scrutiny in a number of legislative meetings and has faced several lawsuits. One issue has been the alleged unavailability of adequate coverage in the two plans, contracted to Mainland providers by DHS.
It took a dedicated advocate, Summer Harrison, who is an expert at connecting families to Medicaid services, to put together the systemic problems that nearly cost Martin Boegel his life. She writes the Disability Mom blog to document her struggle to get children services in Hawaii that are their civil rights. Harrison knew the people to call.
In her investigative report below, PCP means “primary care physician.” The “care coordinator” is a case management function that is required to be provided by the health plan to him. The February 1, 2009 date is significant because that falls within the time when DHS was cutting Medicaid clients over to the new system, amid accusations that the Mainland providers were not prepared and the dual-provider system was not properly designed to handle the transfer.
Client was unable to secure a PCP from Ohana and/or Psychiatrist, everyone he called (including his mother) would not take Ohana (Wellcare) Insurance. As a result when he went to pick up his prescriptions, it was denied for "prior authorization PCP". Martin had no PCP assigned and was unable to secure one, which was the responsibility of Ohana (Wellcare) Healthplan. He was never visited by his Care Coordinator as required by Contract for Ohana (Wellcare).
Although APS healthcare (Fee For Service Contractor for SMI) may be responsible for the payment of the psychotropic drugs as he is a Severally Mentally Ill (SMI) client (see attached Demograpics Highlighted), a PCP was still required to pick up meds and Martin could not secure one (Ohana failed to get him one assigned since Feb 1, 2009). He was never visited by his Care Coordinator, his card from Ohana reflects no PCP, the system was rigged to deny services for client.
Ohana receives $3,890 per month for this client and was responsible for coordinating his care. The medication only cost $80-90 per month. Martin just wanted to die and because of his religion suicide was not an option. This is another example of Wellcare's practice.
[Disability Mom, FBI told Honolulu shooting linked to Ohana Medicaid program, 5/11/2010]
It is unlikely that this is an isolated case. At informational briefings, when a problem is reported, either the plan concerned or DHS’s Medicaid Administrator Dr. Kenneth Fink move swiftly to resolve the issue. Unfortunately, it isn’t possible to know the depth and breadth of service cuts and failures if band aids are applied to each problem as it is discovered.
Hawaii has cut back on services to those with serious mental illnesses with deadly result. We reported two months ago, in Hawaii’s deadly cuts in mental health services demand state response (3/18/2010), on testimony taken under oath before a legislative committee reporting a 36% increase in deaths 2009 over 2008. There was no reaction to that testimony by legislators and apparently no followup.
The Boegel case would appear, subject to verification, to be directly attributable to a systemic failure to provide required care and case management—and the statistics indicate that he cannot be alone.
Had he encountered a less experienced police officer rather than a trained FBI agent, who probably shot to disable rather than to kill, Martin Boegel would possibly be dead today.
This case cries out for independent investigation of the QExA and adult mental health systems in this state. There is a plan to transfer Department of Health clients from the DOH Adult Mental Health Division into the QExA program. Prudence would suggest putting this transfer on hold.
News coverage of the Tantalus incident has painted Boegel as a criminal, but it may be more accurate to describe him as a victim of misguided state cost cutting.
Thank you Larry!! You're the best! How would we learn any of these kinds of things without "Disappeared News"?
This is just the beginning, there are many more that has been harmed by the cuts. Mahalo for your efforts in reporting "real news".