Well timing is everything! There is a wonderful article in USA Today’s cover page about Traumatic Brain Injury and how the victims of this injury fall into the “treatment gap” in the healthcare world. Please do an internet search to read it. It’s time to share what we’ve been dealing with…
The accident occurs, the helicopter deploys the victim to a trauma center, the ICU saves the victim’s life, the family chooses the best facility that will provide intensive rehabilitation to help their loved one regain what is lost and then the insurance companies get to decide the timing of the patient’s recovery as well as limits for coverage and payment for those desired services. The time frame is based on a national average which includes the spectrum of injury levels from severe to mild. The coverage is often masked in the fine print of a medical plan that most subscribers do not read because who ever thinks they’ll need coverage for a traumatic injury?
In our case, we have no lifetime cap for acute care. Yes, Corey is in an acute facility. That is precisely why the insurance company wants her discharged. She’s going to cost them too much money. They are making a business decision. Once she is discharged, the sub acute coverage is limited to 120 days per calendar year. Once the personal insurance is exhausted, Medicaid then picks up the bills. However, not all services and medical devices needed for her care are covered; they have limits as well.
Insurance bases the TBI recovery on the FIM scale. (Functional Improvement Measurement) The criteria for this scale is ridiculous for the severely injured to be gauged on. It would be similar to comparing an amputee to an athlete! We have fought to have Corey evaluated on the CRS scale. (Coma/Cognitive Recovery Scale). So far the combination of this tool along with the recent physical strides/responses she’s been making has been the key to our extensions.
As we wait for the denial week to week, we have to prepare for the next move. Our choice is a 65+ sub acute nursing home or going home. There are NO sub acute facilities in the tri-state area geared for 18-50 year olds that have an expertise in TBI, spinal cord or other neurological injuries nor rehabilitation that is required to fit their needs. This is not a local issue. This is a national issue and, might I add, a tragedy for this demographic of victims!
The article in USA Today is outstanding! It highlights that ‘without intensive therapy, 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’. ‘Insurance bases their refusals to provide coverage on an absence of evidence that the programs work’. Many insurance companies believe that cognitive recovery is still experimental! We were told that we needed to gather documentation for our appeal to support our claim that intensive rehabilitation is driving Corey’s recovery strides. USA Today reports, ‘The lack of evidence is due to the difficulty in studying the brain and lack of funding for research. The article stated that ‘research dollars for each TBI patient averages $57 per patient. Compare that to $5,000 per breast cancer patient’.
Where do we currently stand? Corey has been denied by 20 local sub acute nursing homes. That leaves us the choice to look outside the state or what is needed to bring her home. In the last 10 days I have been working to that end researching what home renovations need to be made, 24 hour home care coverage and the availability of coverage for in home therapy. To my surprise and frustration, Blue Cross will deny coverage for in-home nursing care because Corey “does not meet the medical necessity criteria to warrant home care”. Basically, her body is too healthy…they are not looking at her brain injury as part of their criteria. This led me to multiple organizations researching state, federal and foundation funding through waivers that are either capped or unavailable due to budget cuts or wait lists.
Our bottom line…WE WILL CONTINUE TO FIGHT to stay at Bryn Mawr while we continue to look at other alternatives! The article poignantly states; “Traumatic Brain Injury isn’t an event that you recover from. It’s an event that you live with for the rest of your life”. “Rehabilitation is important, because it can retrain the brain”. The progress Corey has made in just the last month is evidence that intensive therapy is crucial to her recovery process.
Most importantly, Health Systems across the country have to provide a facility that offers the quality and quantity of services this forgotten demographic of 18-50 year olds deserve! If each major city had just “1” sub acute skilled nursing facility for these ages, think of the quality of life the patients would regain. Why should this group of individuals and their families accept the standard answer, “We don’t have age appropriate facilities with the same level of rehabilitation that you’d find in an acute facility, that’s just the way it is”? If this answer of accepting the status quo for our lives is sufficient, then why are you reading this post on a computer via the internet? We will not make the change as a single voice, but collectively we will be heard!