Jackson Jambalaya

Your father suffers a massive stroke. He survives and is finally discharged from the hospital. However, many of his motor and cognitive skills are severely deficient. The doctor says extensive cognitive rehabilitative therapy can restore those skills or substantially limit the damage. No problem, you think, my father has insurance. Paid his premiums all of his life. You set up the appointment and the clerk tells you you have to get approval from the insurance company prior to enrollment. Well, that should be no problem as the doctor issued an order for the therapy. Fill out the forms, submit them to the insurance company, everything should be ok, right? Wrong. USA Today reported last year such therapy is usually not covered by insurance companies. (Yes, I know it was last year but I just discovered it while doing some research.) Your dad survived the stroke. Now he endures a living death of sorts as the therapy that could help him recover from the stroke if implemented almost immediately is denied. USA Today reports:

"Although Medicare, Medicaid and most insurers cover the brain surgery and intensive care necessary to save the lives of patients with such traumatic brain injuries, Manley says, most insurers scrimp on benefits for rehab programs, costly brain-injury "boot camps" that challenge patients to relearn skills and abilities destroyed by brain trauma. Such programs may cost anywhere from $600 to $8,000 a day, depending on the range of services they provide, says Susan Connors, president of the Brain Injury Association of America.

The lack of coverage means that thousands of patients are discharged each year from hospitals to nursing homes or to languish in their beds during the critical early months when their brains are most receptive to healing, according to data from the National Institute for Disability and Rehabilitation Research. At least two-thirds of patients discharged from rehabilitation hospitals after a typical stay of 16 days get no further treatment, the studies indicate.

Without intensive therapy, Manley says, brain-trauma patients may never regain full use of their limbs, their ability to use language, their emotional balance or their power to think clearly...

At least 3 million people in the USA live with disabilities because of traumatic brain injuries, the CDC says. Brain injuries take a huge financial toll: Americans spend roughly $60 billion a year — $10 billion for medical care and $50 billion for lost productivity — the agency says.

Yet many patients and their families don't realize rehabilitation services are available.

"Patients have no idea," says Brent Masel, director of the non-profit Transitional Learning Center in Galveston, Texas. "Insurance companies don't want people to know that there's another step after they leave the hospital."

The issue of how insurers cover brain-injury rehab made national headlines in December, when news reports disclosed that the Department of Defense 's insurance carrier, Tricare, refused to pay for cognitive therapy — a collection of intensive exercises that improve cognitive function — calling it experimental. The reports of injured troops being denied access to such therapy provoked a national outcry, a study by the Institute of Medicine and a series of angry letters from Congress.

"The fact is, a lot of people are not getting into rehab," says Rep. Bill Pascrell, D-N.J., co-chairman of the Congressional Brain Injury Task Force. Like Tricare, many insurance firms have based their refusals to provide coverage on an absence of evidence that the programs work. Even true believers concede that the case for cognitive rehabilitation rests on a shaky scientific foundation, in part because of the difficulty of studying the brain and a lack of funding for research.

"The evidence doesn't exist to definitively say that this has an impact. The studies are equivocal at best," says Allan Korn, chief medical officer of the Blue Cross and Blue Shield Association, which makes recommendations that member companies typically follow. "Blue Cross, Blue Shield doesn't run a science fair. We run a business that has to cover tragic cases like the congresswoman's."

"People who work in the field believe that rehab works," says Manley, who has been pushing for research. "We see the results. Where we have fallen short is by not studying this and providing objective evidence that rehabilitation changes the brain."..." Article

The irony is medical science has advanced to the point where more people survive such injuries, thus creating a new set of issues- how to treat those recovering from brain injuries and how to pay for the treatment.

NPR series on this issue.