• https://interactives.dallasnews.com/2018/pain-and-profit/part1.html
• https://interactives.dallasnews.com/2018/pain-and-profit/part2.html
• https://interactives.dallasnews.com/2018/pain-and-profit/part3.html
• https://interactives.dallasnews.com/2018/pain-and-profit/part4.html

Provide names of other journalists involved.

Reporters: J. David McSwane and Andrew Chavez

Editor: Leslie Eaton

List date(s) this work was published or aired.

June 3: “The Preventable Tragedy of D’ashon Morris” June 3: “As patients suffer, companies profit” June 4: “Texas pays companies billions for ‘sham’ networks of doctors” June 5: “Glossover of the horror” Oct. 25: “Stacked against them”

Provide a brief synopsis of the story or stories, including any significant findings.

When Texas turned over the care of sick and disabled people to giant health care companies, they made billions of dollars as they systematically denied life-sustaining drugs and treatments – often with dire consequences for patients. The Dallas Morning News exposed systemic problems with the way Texas provides health care for its most vulnerable citizens through Medicaid managed care. The series showed how years of inept state regulation allowed corporations to profit even as they skimped on treatment for thousands of sick kids and disabled adults, with life-threatening results. And how Texas health officials hid the full extent of the problems from the public.

We led with the story of D’ashon Morris, a foster baby, who suffered a catastrophic brain injury because his managed care companies refused to provide the overnight nursing he needed. It’s a narrative built through public records requests, confidential sources, emails, leaked confidential memos and dozens of interviews. D’ashon’s nurses, doctors and foster mother had all warned the insurance company that he needed 24/7 nursing care because he constantly pulled out his trach tube, records show. The company refused to pay for medical supervision, saving hundreds of dollars a day and costing D’ashon everything.

His story was just one example of how the system allowed companies to place profits over their patients. Other significant findings: Using social-science techniques to analyze data collected by health-commission nurses, we found that at least 8,000 disabled and elderly Texans in just one of the state’s many managed-care programs weren’t getting the care they needed.

The News obtained confidential records and data that enabled reporters to find victims like Heather Powell, a quadriplegic woman who was denied the medical bed she needed to avoid life-threatening bed sores, among other cruel denials of care. Some companies inflated the number of doctors and specialists that were in their networks and available to million of vulnerable Texans. When companies refuse to provide treatments or services, patients are supposed to be able to fight back through a so-called “fair hearing.” But that system is stacked against patients. Our analysis showed how personal bias and secret policies enabled companies to win more than two-thirds of the time. The state knew thousands were suffering, but it covered up problems and ignored its own data while companies avoided hundreds of millions of dollars in fines. Key lawmakers knew about these failures, yet they gave these companies billions of dollars more anyway.

Explain types of documents, data or Internet resources used. Were FOI or public records act requests required? How did this affect the work?

We made more than 170 public-records requests while reporting this project, many of which were for data and other electronic information held by the state of Texas. Our efforts to use the state’s records law were frequently thwarted by a recent court ruling - Boeing v. Paxton - that substantially limited access to material involving companies and corporations. The state health commission fought many of our requests, citing a wide range of often-questionable exceptions, and petitioned Texas’s attorney general to rule against our requests dozens of times.

The News spent about $24,000 in legal fees to fight for public records. Often, companies and state bureaucrats hid behind HIPAA. We lost some of those fights but won enough to expose systemic failures in privatized Medicaid, the state’s largest single expense. We were able to get access to some of that information by making requests to 16 other states. Some key records were ultimately provided by whistleblowers.

Altogether we collected more than 70,000 pages of documents. We scraped provider directories from company websites and used data collected by the state to show that the companies frequently exaggerated the size of their networks. (For example, we called all 377 psychiatrists in one company’s directory for foster children and found only 34 could see a new patient.)

In response to our work, the state health commission pledged to abandon its flawed methodology for evaluating provider networks. To connect the human suffering we saw to financial decisions made in far-flung corporate offices, we joined thousands of spreadsheets, logged hundreds of phone calls, and knocked on doors from Lubbock to Houston.

Explain types of human sources used.

We spoke to more than a hundred patients, doctors and advocates who deal with managed care on a daily basis. Our reporting was greatly helped by multiple whistleblowers, who provided documents and insights that were essential to our findings. Confidential sources provided records the agency would not release as well as patient-specific material that proved some companies caused significant harm to their patients. We also relied heavily on experts and former regulators to help us understand the mounds of documents and data we had gathered.

Results:

Our investigation spurred positive change long before it published. In 2017, as McSwane and Chavez requested records that reflected shoddy oversight of $22 billion a year in Medicaid spending, top health officials changed internal policies, began tracking problems and overhauled the agency.

The reporters asked their first wave of questions in late 2017, and soon after, Gov. Greg Abbott wrote to his health commissioner, demanding a crackdown on companies that had skimped on care of elderly and disabled people. In early 2018, a Houston family court judge was outraged by our findings and issued a standing order that caseworkers report every denial of medical care sent to foster kids in Harris County.

State lawmakers launched official inquiries, and Texas health officials publicly acknowledged that the program is flawed and needs to be fixed. The Texas legislature only meets every other year, but top lawmakers reached a rare out-of-session agreement to spend $7 million more a year to hire nearly 100 new regulators, including nurses to check on patients in their homes.

The state’s child welfare agency began tracking when 30,000 foster children are denied medical treatment, and health officials are overhauling a broken medical appeals system. Senior lawmakers have pledged to file reform bills when the legislature goes into session in January.

Follow-up (if any). Have you run a correction or clarification on the report or has anyone come forward to challenge its accuracy? If so, please explain.

Though they do not like our stories, the private companies providing care in Texas have not been able to point to any substantive errors or omissions. We failed to note one chief executive had been promoted to vice president of his company’s parent corporation, and for clarity changed two words in one piece, to “racked up” from “raked in.”

Advice to other journalists planning a similar story or project.

There’s no shortage of reporting on Medicaid spending and political squabbles, some sprinkled with horror stories of people who couldn’t get the care they needed. We focused on who did the hurting and why, and on the perverse financial incentives in the managed-care system in Texas. We sought to explain the specific decisions, policies, justifications and actions that can lead to someone’s life being destroyed so a company could save money. For each major finding, we found people whose journey could guide readers through a messy system, exposing its failure points.

When audits and legislative reports identified vague programs, we tracked down the hurting people hidden between the lines. Lots of data purport to track how patients are faring, such as the Healthcare Effectiveness Data and Information Set, or HEDIS. But experts warned us these measures – which track vaccination rates among millions of mostly healthy kids, for instance – missed the problems we were hearing involving hundreds of thousands of homebound adults and disabled children. To figure out what data exists in your state, get hold of every contract and pick through the “deliverables,” a table detailing everything companies must report to regulators. We requested nearly everything, and the themes began to emerge.