Everyone I know is cheering for Rep. Gabrielle Giffords. After a life threatening gunshot wound to the head she was transferred from Arizona to a first class rehabilitation hospital in Houston where she could undergo her rehabilitation and at the same time be close to her astronaut husband’s workplace. We continue to get encouraging reports of her steady progress and have been told that she may even attend the launch of her husband’s mission into space. Gabby Giffords is getting the best care possible and is a perfect example of our ability to save lives and return people to their highest level of function. It is the care that she needs and we are all delighted that she is receiving the best that medicine has to offer. The question is, would you or your family be able to obtain the same level of care?
The Real World
The rehabilitation of a person following a stroke or brain injury is an intensive process that can take years and involves numerous people, but the reality is that many people do not get the intensity of care they need. There has been extensive reporting on the fact that cognitive rehabilitation after a brain injury or stroke is not covered by many insurance companies. When the chief medical officer of one of our countries major health insurance companies was asked why they did not cover cognitive rehabilitation, he replied that his company “doesn’t run a science fair. We run a business that has to cover tragic cases like the congresswoman’s.” The excuse has been that evidence based medicine does not support such services. This can no longer be their excuse, as a recent study published this month reviewed 112 studies and concluded that there was “substantial evidence to support interventions for attention, memory, social communication skills, executive function and for comprehensive holistic neuropsychologic rehabilitation after TBI (Traumatic Brain Injury.)”
Rep. Giffords has been in an inpatient rehabilitation hospital for over three months and I suspect she will stay for as long as her doctors feel it is necessary. Unfortunately, this may not be the case for the average patient who is assigned a case manager by the insurance company very early following an illness, injury or stroke. In fairness to the insurance companies, they probably believe they are making sure that their dollars are being spent wisely and that the person moves to the “appropriate” level of care at the right time. However, many patients never see the inside of a rehabilitation hospital and are sent to skilled nursing facilities (nursing homes) for less intensive care. They are never given the opportunity to thrive in the more intense setting of a rehabilitation hospital. Was this done just to save money or because the person unwittingly chose an insurance policy that did not cover this type of care?
If they are fortunate enough to get to a rehabilitation hospital, there will be constant monitoring and pressure to move them to a cheaper and therefore less intensive setting. Do you think there is a person anywhere who would raise that issue with Gabby Giffords or her husband?
I love the idea of Gabby Giffords going on a “therapeutic pass” to watch her husband’s lift off into space. This is precisely what rehabilitation is all about; allowing the person to slowly try out their new skills in real life settings. Twenty years ago this was standard practice but, now if the physician wants a patient to go out over night to see how they will function in their home and community setting, we are told by the insurance company that if they go out of the hospital overnight, their stay will not be covered. Again, do you think there is an insurance case manager who will tell the Giffords and the national media that she cannot go watch her husband’s flight into space?
It is not just rehabilitation services that are affected by such a “Catch-22” situation, for there are many restrictions affecting the very definition of “disabled.” A few weeks ago I was told about a person who had a stroke and was paralyzed on one side of his body. He could neither walk nor use his arm for dressing and feeding. He did have some minimal movement in his hip and shoulder, but it was not enough for him to stand or even move his hand. We call this type of paralysis, hemiparesis. He applied for disability and was turned down because his policy only paid if he had hemiplegia, the total loss of all movement on one side of the body, a much less common situation. Do you think the policy was intentionally written this way and that a layman or even a physician buying the policy would notice this seemingly subtle difference that allowed the carrier to deny the claim for disability benefits?
Five Things You Need to Do?
Most people worry that they may get cancer or heart disease but don’t realize that they are more likely to be disabled by a stroke, the most common cause of adult disability. The fact is, you will likely need rehabilitation some time in your life and don’t even know it. Here are five things you need to know.
1. Check your insurance policy to see if you can insist on going to an inpatient rehabilitation hospital (IRF) as opposed to being forced to undergo rehabilitation in a skilled nursing facility (SNF), also called nursing homes. After a stroke you are three times more likely to return home to your family and loved ones if you go to an inpatient rehabilitation hospital instead of a nursing home for rehabilitation. Consumers take note- nursing homes often include the words “rehabilitation center” in their names, but that doesn’t make them a hospital.
2. Read your insurance policy and see if you have a rehabilitation benefit. Does it dictate how many days or visits it will pay for? Many policies restrict the number of therapy visits and as noted above, many will not pay for cognitive or psychological services. Thirty visits may sound like a lot until you need months of rehabilitation following a catastrophic injury.
3. Recruit your physician as your advocate to push for everything you and your family need.
4. If you are unhappy with a decision, insist on an appeal process before you are sent somewhere you do not want to go.
5. Educate yourself and ask questions. What is considered “state of the art” therapy and where is the best place to receive this treatment? The Internet is a phenomenal resource. Use it.
We all wish Gabby Giffords the best and I know she will get every ounce of therapy that is available. But, it shouldn’t be just because she is a “special” person. Insurance policies should meet the needs of all people. Know your rights and read the fine print for the devil is in the details.