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Copyright © 2015 Albuquerque Journal
It’s tough finding a place for Daniel.
Ten-year-old Daniel Rowe-Sherman from House, N.M., has threatened to kill others and harm himself. He gets into fights, has thrown chairs at schoolmates, has bitten himself until he bleeds, defecated on a school bathroom floor and has sat for hours in his own soiled pants. He gets frustrated, angry and overwhelmed by loud noises and crowds.
His mother, Lisa Rowe, a former school psychologist for prekindergarten children, said Daniel has been treated for depression, oppositional defiant disorder, Asperger’s syndrome and neurosensory issues that make him hyper-sensitive to sounds, crowds and touch. He has to be watched 24 hours a day and needs an in-school aide while attending classes.
With a measured I.Q. of 130, Daniel “is very intelligent, but emotionally he is unable to regulate what’s going on inside his head and body,” Rowe said.
The state Human Services Department administers state and federal Medicaid funds and contracts with four managed care organizations: United Healthcare, Molina Healthcare, Presbyterian Healthcare and Blue Cross/Blue Shield.
The MCOs, as they are called, oversee the provision of funds and services, and contracts with the residential treatment centers and other providers, said department spokesman Matt Kennicott.
MCOs that oversee Medicaid cannot pay residential treatment centers below the “base rate” of $270 a day but can negotiate a higher daily rate when it is warranted, he said.
But House, a community of roughly 60 located in Quay County in eastern New Mexico, is so remote that Daniel’s medical, psychological and special educational needs cannot be met there. That situation led his mother on a journey to treatment facilities throughout the state and beyond to get her son, who is on Medicaid, the help he needs.
It also got her into a protracted battle with United Healthcare, which through its Centennial Care plan is the managed care organization, or MCO, that controls payment for Daniel’s Medicaid-funded medical and mental health services.
Rowe said she has been told by one of Daniel’s doctors that her son is among the 20 percent of kids who require placement in a residential treatment program but because of their conditions don’t fit neatly into any one of them.
During the last fiscal year, according to state Human Services Department spokesman Matt Kennicott, the four MCOs that serve kids who are on Medicaid placed 777 children in various residential treatment centers that are licensed and accredited by the state Children, Youth and Families Department. Kids in CYFD custody who need residential treatment programs can only be placed in agency-accredited facilities. Another 330 Medicaid children went to other facilities.
‘Outside the bell’ curve
Daniel was in the children’s psychiatric unit at the University of New Mexico Hospital for three months last year before winding up at Presbyterian Kaseman Hospital, where he has been a patient since January. Both are acute care facilities and not intended for long-term treatment.
The route that took him there and briefly to a treatment center in Texas, is largely why Rowe finds herself at odds with United Healthcare. Finding a Medicaid-approved, in-state residential treatment center that is equipped to handle children under age 12 with Daniel’s myriad problems, she said, and which has a contract for services with United Healthcare, is extremely difficult.
Rowe has been trying to get Daniel admitted to Villa Santa Maria, a residential treatment center in Cedar Crest that she believes is equipped to handle Daniel’s problems. United Healthcare, she says, is refusing to send him there because the facility requires a higher daily rate, and is now pushing to send Daniel to a treatment center in either Provo, Utah, or Canyon City, Colo.
Villa Santa Maria in Cedar Crest quoted a $500 per day cost for providing the services necessary to treat Daniel, but United Healthcare was willing to pay $243 a day, “which they said was $5 over the state-mandated rate, something I’d never heard of before,” said executive director Joe McGuill.
In fact, according to HSD, there is a minimum “base rate” of $270 a day that MCOs overseeing Medicaid must pay to residential treatment centers. Residential treatment centers generally charge between $400 and $600 a day, depending on the services and programs required, McGuill said.
Rowe gave permission for both United Healthcare and Kaseman to speak to the Journal about Daniel’s situation and related treatment issues, but both declined. United, which was emailed a list of questions , said only that “we work closely with providers and our state partner to ensure Medicaid beneficiaries receive access to the best quality and affordable health care available for their condition.”
McGuill, however, was not so constrained.
The MCOs, he said, are “more interested in admitting a child into a residential treatment center for 30 to 90 days for rapid, acute treatment for purposes of stabilization, and then shift into a ‘step-down’ program that can involve placing a child in treatment foster care, a group home or returning the child to the family along with wraparound services.”
Unfortunately, not every child fits into that model, McGuill said. Some, like Daniel, are extremely complex and need a “long-term process of treatment” that can range from 18 to 24 months or longer.
Further, he said, keeping a child like Daniel in “this revolving door of acute care” at places like UNMH or Kaseman at a cost of $1,000 a day or more is not going to save money for the MCOs.
“What they do save is their system of care, which is based on managing the risk pool, or the group,” he said. “Daniel is what’s called an outlier. If you look at the bell curve for mental health, Daniel is outside the bell.”
From a young age
Family members began noticing that Daniel was something of an outsider when he was as young as 3, Rowe said.
“He wouldn’t play with other kids and they would call him names like ‘baby’ because he couldn’t run and walk very well. Then he’d lash out at them and bite them.”
As he got older, Daniel received special education in his Florida elementary school for his “social, emotional and adaptive delays,” Rowe said. Her son was put on medications to treat Asperger’s, obsessive-compulsive disorder and severe anxiety.
“They really couldn’t put their finger on it,” she said. “Every time he went to somebody new, they would tell you something different and put him on different medications.”
After moving to New Mexico two years ago, Daniel briefly seemed to become more social and got involved in agriculture and animal projects through 4-H. He also enjoyed archery and rifle target shooting. Those were soon taken away from him after outbursts at school in which he would threaten to kill people. The family was also forced to hide all knives and medications, including over-the-counter drugs.
In House, the elementary, middle and high schools are located in one building. Conveniently, Daniel and his family live across the street.
“When Daniel would say things in school, like ‘I’m going to kill you,’ the principal would just walk him home and say, ‘We can’t keep Daniel here today.’ ”
Daniel began threatening to kill himself in August and was taken to emergency rooms in Tucumcari, 46 miles to the north, and Clovis, 55 miles southeast, and eventually wound up in the children’s psychiatric unit at University of New Mexico Hospital in Albuquerque for three months. Rowe’s husband, Avon Sherman, and their daughter, Emy, 18, drove 195 miles each way for weekend visits.
Rowe researched residential treatment centers and learned about Villa Santa Maria in Cedar Crest. The facility, which also provides grade-appropriate schooling, agreed to accept Daniel.
United Healthcare, however, “wanted an actual Medicaid-contracted facility,” rather than having to negotiate a one-off contract for a single kid, Rowe said.
United suggested three treatment centers in Albuquerque – Desert Hills, Bernalillo Academy and Children’s Treatment Center – all of which accept United’s Medicaid contracts but rejected the placement, she said, because they didn’t have the resources to deal with Daniel’s multitude of issues.
“I appealed the United Healthcare decision to get him to Cedar Crest, and instead United said they’d approve him going to San Marcos Treatment Center,” a Medicaid-contracted facility located 30 miles south of Austin but also 550 miles from House and more than 700 miles from Albuquerque. On Dec. 28, Rowe took her son to San Marcos, where she was told that 150 kids from New Mexico, most of them on Medicaid, are sent to the facility each year.
Rowe returned to House. But less than three weeks later, she retrieved Daniel after the Texas Department of Family and Protective Services called to say he had been repeatedly beaten up by other kids “due to a lack of adult supervision.” Department spokeswoman Julie Moody confirmed that an investigation is ongoing.
Rowe asked United Healthcare to try once again to make an accommodation with Villa Santa Maria in Cedar Crest. Still no agreement could be reached. Meanwhile, Daniel’s condition continued to deteriorate, and after he swallowed a handful of Tylenol pills and tried to jump from a moving car, it was back to the ER in Clovis and then another ambulance trip, this time to Presbyterian Kaseman, where he remains.
Rowe said she is appealing United Healthcare’s denial to send Daniel to Villa Santa Maria to the Medical Assistance Division of the Human Services Department. A hearing has been set for April 9.