OUR OPINIONS: Doctor knows best

'Watershed' ruling keeps the state from limiting vital care sick children receive under Medicaid
By Maureen Downey
The Atlanta Journal-Constitution
Published on: 06/20/08

Because of strokes she suffered while in her mother's womb, 13-year-old Callie Moore of Danielsville has a host of complex medical problems. They include spastic quadriplegic cerebral palsy, refractory seizure disorder, mental retardation, gastroesophageal reflux disease, cortical blindness, dysphagia, bone cartilage disease, scoliosis, kyphosis and restrictive lung disease.

Callie's condition mandates round-the-clock care and treatment. Under federal and state Medicaid regulations and policies, she is entitled to screening, diagnostic and treatment services and, because she is medically fragile, skilled nursing care. Medicaid is a joint federal-state matching program that pays for medical assistance for low-income families and for people who would require institutional care if they were not receiving alternative services at home.

Callie's doctor prescribed 94 hours a week of nursing services, but state officials unilaterally reduced the hours to 84 in 2006. Her mother protested that the state had no right to disregard the doctor's order, and last week a court affirmed that under federal law, a Department of Community Health bureaucrat in an office tower cannot overrule a doctor in determining the level of medical care required by a sick child.

"The state must provide for the amount of skilled nursing care which the plaintiff's treating physician deems necessary to correct or ameliorate her condition," wrote U.S. District Court Judge Thomas W. Thrash.

The decision doesn't only help Callie. Georgia has a shameful record of minimizing the services it allows children under Medicaid, for example, by paring down a doctor's call for twice-weekly physical therapy to once a week. Historically, parents have had to fight for every hour of nursing services.

"The advocacy community is looking at this as watershed stuff," says Pat Nobbie, deputy director of the Governor's Council on Developmental Disabilities. "It puts the state on notice that it doesn't have the discretion it thought it had in deciding what services children eligible for Medicaid should have."

"Having a nurse in our home has kept Callie alive," says her mother, Pam Moore. Yet according to Moore, the state has tried to reduce her daughter's nursing hours about 10 times over the last decade.

"This is a very common story," says attorney Joshua Norris of the nonprofit Georgia Advocacy Office, which represented Callie. "In addition to having to go through the day-to-day grind of caring for a child with complex medical issues, there is the constant battle with a bureaucracy that is not focused on the needs of the child."

Despite laws mandating changes in how it treats children on Medicaid, the state has continued to create barriers to kids getting the amount of care they need. Nobbie hopes that this time, the clarity and vigor of Thrash's ruling will force the state to comply. Her advocacy organization is spreading the news of the decision across the state.

"We hope that prescribing physicians will get the word," she said, "and prescribe what they think kids need and stand up for what they prescribed if the kids are denied by the state."

So should the rest of us.

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