IQ expert Jason Beans: Health insurance lessons from Gabby Giffords’ recovery

Jason Beans

Q: I heard Congresswoman Gabby Giffords interviewed and am heartened by her comeback, assisted by hours of speech and physical therapy each day and around-the-clock care. I’m one of the 44 million uninsured people in the United States. If something that awful were to happen to me, how would my care differ from hers?

A: Rehabilitation for a traumatic brain injury (TBI) is a long, tough, expensive process.

The federal Centers for Disease Control and Prevention reports that TBI costs the United States an estimated $76.5 billion each year (direct medical costs and indirect costs, such as lost productivity). So even if you have insurance, you would have to have the right insurance that covers TBI. Over a lifetime, the estimated recovery costs for someone with TBI range from $85,000 for a mild injury to $3 million for a severe injury.

Mark Kelly has been by wife Gabby Giffords’ side throughout her recovery from a traumatic brain injury.

If you do not have the insurance or resources to pay for those sky-high expenses, state or county government programs for indigent care might reimburse health care providers for part of the costs. In other cases, health care providers may just write off the expenses. Keep in mind that until the debt is forgiven, dismissed or settled, health care providers can continue to seek payment.

Fortunately, Gabby Giffords’ congressional health insurance plan allowed her to get the best treatment possible. Our military personnel and Medicaid recipients do not get that same coverage, even though the need for TBI coverage is apparent.

One in five combat veterans of Iraq and Afghanistan has suffered some form of TBI. Despite that figure, TriCare, the health insurer for the military, continues to balk at covering cognitive rehabilitation therapy (CRT) as a stand-alone therapy. The reason? TriCare says scientific evidence doesn’t exist to support the effectiveness of CRT.

Look at the cost of one-on-one therapy for TBI, and you can see why an organization might question its effectiveness. For a patient to re-learn basic life skills (language, math and memory), one-on-one therapy costs roughly $50,000 for four months.

Fortunately, Congresswoman Giffords of Arizona, ABC reporter Bob Woodruff and U.S. Sen. Tim Johnson of South Dakota — all TBI survivors — have been able to get CRT. Help may be on the way for military veterans who are recovering from TBI; a bill pending in Congress would improve rehabilitation services for them.

With millions of Americans lacking health insurance or having inadequate coverage, it’s very unlikely that the Cadillac level of care received by Giffords would be available to most people. This isn’t just a matter of the haves and the have-nots. Many folks who do have insurance still face an uphill battle to get their expensive, lengthy rehabilitation covered.

If you’ve got health insurance, here are five things you should do to make sure you’d be cared for properly if you were disabled and needed rehab:

1. Call your health insurance company to see whether your policy would let you to go to an inpatient rehabilitation hospital rather than a nursing home. According to a study in the Journal of the American Medical Association, stroke victims are three times more likely to go home from an inpatient rehabilitation hospital than from a nursing home. Nursing homes often use words like “rehabilitation center” in their names, but that doesn’t mean they’re hospitals.

2. Read your health insurance policy to see whether you have a rehabilitation benefit. If so, how many days or visits will it pay for? Many policies restrict the number of therapy visits and may not cover cognitive or psychological services. While 30 visits may sound like a lot, it’s not if you require months of rehab after a catastrophic injury.

3. Enlist your physician as your advocate.

4. Appeal any decisions by your health insurance company that you think are unwarranted.

5. Do your research. Find out who provides the best treatment for TBI (or whatever disability you may have).

Beyond financial considerations, emotional support comes into play. Facing TBI is not a battle you should fight on your own. It takes caring, patient relatives and friends to push the medical community and insurance companies. The support, love and optimism that Giffords’ husband has demonstrated throughout his wife’s recovery accounts for a great deal of her progress.

Jason Beans is CEO of Chicago-based Rising Medical Solutions, a medical cost containment/care management company serving the workers’ compensation, group health, auto and liability markets. Beans founded Rising in 1999. Since then, Beans has received a number of honors, including Business Council Advisory Man of the Year and Midwest finalist for Ernst & Young Entrepreneur of the Year. Rising has appeared several times on the Private Company Index’s Top 10 Growth list and Inc. magazine’s Inc. 5000 list.

Beans earned a master’s degree from MIT’s Entrepreneurial Masters Program and a bachelor’s degree in finance from Boston College.

For more information, visit www.risingms.com.

If you have a health insurance question for Jason Beans, please send it to john.egan@insurancequotes.com.