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Brain injuries: Insurance won't always pay for long-term rehab

Many of the 1.7 million people in the U.S. who experience traumatic brain injuries each year don’t have enough health insurance coverage to pay for the rehabilitative care they need to reach their full potential for recovery.

“Every year we get thousands of people who call to complain that their recovery has been delayed or denied because the payer won’t pay for treatment needed after hospitalization,” says Susan Connors, president and CEO of the nonprofit Brain Injury Association of America. “You are discharged from the hospital and you’re done.”

Each March, the association publicizes such issues during National Brain Injury Awareness Month. While most insurance companies, along with Medicare and Medicaid, cover the intensive care that’s necessary to save lives following a brain injury, there’s much less support for costly long-term rehabilitation, Connors says. The care may involve speech therapy or relearning impaired motor skills, such as walking.

The cost of hospitalization following a brain injury can add up to $6,000 a day or more, depending on the severity of brain-injurytrauma, she says. After the initial hospital stay, ongoing therapy can range from $250 to $2,500 a day. Connors estimates that less than one-fourth of the patients who could benefit from long-term rehab actually receive it.

Finding the help you need

Most people with private or public health insurance wrongly assume they’re fully covered for traumatic brain injuries, says Dr. Mark Ashley, co-founder and president of the Centre for Neuro Skills, which has locations in Texas and California.

Of an estimated 275,000 people who are hospitalized for brain injuries each year in the U.S., about two-thirds return home without getting additional medical treatment, he says. The national average for inpatient rehab is nearly 17 days.

“When a person has cancer, we treat the condition until the condition is stable, until the patient dies or until the patient is cured,” Ashley says. “When we injure the brain, we are not doing that.”

Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade association for the health insurance industry, says that rather than limiting care, insurers are making sure brain injury patients receive the appropriate care in appropriate settings.

Doctors employ procedures to transition patients out of rehab therapy when they have made sufficient progress, Pisano says. Most people have health insurance that covers an inpatient stay for acute care. Subsequent therapies, she says, depend on the physician’s treatment plan and recovery goals.

Ashley worries that because of their disabilities, brain-injured patients often are unable to protest if they think they’re not getting adequate care. They aren’t capable of effectively negotiating with health insurance companies, he says.

“A brain injury makes you immediately vulnerable,” Ashley says. “You can’t advocate for yourself. You can’t participate in an appeals process.”

Some people have long-term care insurance policies that help with the day-to-day activities that are necessary to live independently, such as dressing, bathing and using the bathroom. Rather than offering unlimited care, most long-term care policies provide only a few years of support.

If you have such a policy at the time of a brain injury, it could provide for your day-to-day needs, but typically it wouldn’t pay for rehab, says Jesse Slome, director of the American Association for Long-Term Care Insurance, a trade group.

How do brain injuries happen?

According to the federal Centers for Disease Control and Prevention (CDC), the leading causes of traumatic brain injuries are falls (35 percent), followed by car and motorcycle accidents (17 percent), injuries related to being struck by moving or stationary objects (16.5 percent) and assaults (10 percent).

Whatever the cause, the likelihood of receiving adequate care for such injuries improves dramatically if you’re hurt on the job and you’re covered by workers’ compensation insurance, Connors says.

Because workers’ compensation programs tend to have lifetime commitments to patients, administrators have a financial incentive to give patients all the care they need so they can return to the workplace. The goal is to save money by shortening the length of care.

Former U.S. Rep. Gabrielle Giffords, who was critically injured by a gunshot wound to the head in 2011, has received excellent rehabilitative care for her brain injury, under a federal workers’ compensation program, according to Connors. Brain-injured patients who undergo such care are more likely to resume the activities they enjoyed before they were hurt, she says.

Unfortunately, Ashley says, efforts to control health care costs are preventing most patients from getting anything close to the level of treatment that Giffords has received.

“The expectation is that folks will recover from their brain injury quickly,” he says. “The reality is those with moderate to severe injuries don’t recover quickly.”

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