IOWA — Dr. Craig Stevens talks about his daughter Brianna with affection, admiration, and pride. “She was competitive in sports and played the piano,” he says, “she had a degree from Drake in cellular biology and a Masters in bioscience from Iowa State.”
Stevens says Brianna started struggling with anxiety and depression as a teenager. The symptoms became increasingly disabling and she tried to kill herself multiple times. After ending up in the hospital last February, her psychiatrist recommended adding a new treatment to her current medications but it was denied. “She said this insurance company is going to kill me,” Stevens recalls, “she was just ready to give up.”
Eleven days after the denial, Brianna did give up. She died of an overdose on March 29th. “That Friday she’s sitting here talking and we were praying together,” her dad remembers, “then on Monday she’s gone. It just blew me away.”
Stevens isn’t just a grieving father, he’s also a retired doctor. “To me, it’s not surprising. I know when I practiced we would have these wrestling matches with the MCOs and go through multiple appeals.”
MCOs are managed care organizations – insurance companies that manage Iowa’s Medicaid program. “These people are supposed to be providing medical care for Iowans in need,” says Dr. Stevens, “but in her time of need they denied her.”
As her father, and executor of her estate, Dr. Stevens wrote to Amerigroup asking questions about Brianna’s case. In a letter dated November 1st Amerigroup’s plan president responded, explaining that the prior authorization was denied because the drug was not a covered benefit under the Iowa Medicaid program because it wasn’t on the state’s preferred drug list. it goes on to say that as an MCO, Amerigroup is contractually bound to follow coverage rules set by the Iowa Department of Human Services.
“They weren’t keeping up with community standards,” Dr. Stevens says, “other insurers were offering this treatment and it was widely available, but Amerigroup did not offer this treatment and had no official billing code. Amazingly, after Brianna died on March 29th they managed to have an official billing code in place and it works now.”
Dr. Stevens says all Iowans should be concerned about how MCOs are running Medicaid. “It’s their money that pays for this system and they should have an interest in where that money goes.” He says he’s sent about 20 letters to officials at every level about what happened to Brianna. He’s only received a handful of responses, but he isn’t the only one asking questions.
State Auditor Rob Sand recently released the findings of an investigation that he says shows a massive increase in illegal denials of care by MCOs. “In the last three years of publicly run Medicaid to the first three years of privately run, the number of times independent judges overturned denials of care – meaning, this was wrong, we’re going to give this care back – increased 891 percent.”
Iowa Medicaid director Elizbeth Matney calls the report “incorrect.” “The way the auditor structured this analysis is deeply flawed,” she says, “the comparison groups are simply not the same and the math just doesn’t add up.”
Sand acknowledges that the total number of appeals has gone down under the privatized system but says it’s the incredible increase in the number of denials that judges are overturning that most concerns him. “This program was brought in with the promise that it was going to improve access to care and quality of care,” he says, while Matney says it has. “What Auditor Sand did not acknowledge is that these samples are not comparable at all. There’s a first-level appeal process now through managed care in which a lot of those easier cases are cleared off the deck and things are resolved.”
There is no resolution for Dr. Stevens. The shock of his daughter’s death has worn off, but the devastating sense of loss has not. “There were many, many happy times with her and it wasn’t all depression,” he explains, “we just try to focus on the good times because nothing we can do will bring her back.”
Now he’s keeping her memory alive by sharing her story and hoping it makes a difference. “It’s pretty much been a wall of silence, but I’m not going away. If I can use this to help someone else not undergo this, I will.”
Dr. Stevens says he received responses from the offices of Senator Charles Grassley, Senator Joni Ernst, Congresswoman Cindy Axne, Attorney General Tom Miller and the State Ombudsman. He says he sent letters to, and has not received replies from; Governor Reynolds, The Iowa Department of Human Services, Iowa Medicaid, State Senator Jack Whitver, State Senator Amy Sinclair, State Representative Garrett Gobble, State Representative Joel Fry, and State Representative Mike Bousselot. Representatives Bousselot and Fry responded to our inquiry and reached out to Dr. Stevens. Gov. Reynolds’ office replied on her behalf to our inquiry.
You can read the responses Dr. Stevens received below:
A spokesperson for the Department of Human Services sent us a statement outlining the process for drugs to be added to the state’s preferred drug list.
Statement on Death of Medicaid Member
The Iowa Department of Human Services extends its deepest sympathies to the family of Brianna. While we cannot comment on specific cases due to confidentiality provisions in the law, we can share our process for approving new drugs under Iowa’s Medicaid program.
When a new drug receives FDA approval and is approved for Medicaid at the federal level (CMS), DHS works quickly to add the drug to the Preferred Drug List (PDL) or to the list of medical codes that can be billed. New drugs are reviewed by the Pharmaceutical & Therapeutics Committee or the Clinical Advisory Committee on a quarterly basis.
When a drug is prescribed that is not yet covered, it may initially be denied. Members or providers can appeal the denial or request an exception to policy.
Iowa’s Medicaid program is committed to reviewing our processes to make new drugs available on the PDL or through the medical benefit as quickly as possible.
–Clinical practice guidelines adopted: February 2019
–FDA approval for treatment resistant depression: March 2019
–FDA approval for acute suicidal ideation: August 3, 2020
–This was included in CMS’ 2021 code updates in Jan/Feb 2021.
–Spravato was reviewed and approved at the very next quarterly Clinical Advisory Committee Review on April 16, 2021 (January 1, 2021 effective date).Iowa Department of Human Services