It’s wonderful to hear what substantial progress US Representative Gabrielle Giffords has made in recovering from the traumatic brain injury she sustained from being shot in the head in January. As the Associated Press reported this morning, Giffords has spent the past five months in a rehabilitation facility and has regained some of her speaking ability. Now she’ll move to the suburban Houston home of her husband, astronaut Mark Kelly, and continue daily intensive therapy on an outpatient basis. While at home, she’ll have round-the-clock help from a home care assistant.
On hearing about the 24-hour-assistance Giffords will receive, Celeste and I both had the same questions: Is her insurance paying for this? It turns out that Representative Giffords’ office has addressed this question – while noting that many other traumatic brain injury patients wouldn’t get the same extensive rehabilitative services.
In an April 7th news release, Giffords Legislative Assistant Lauren Alfred stated, “Congresswoman Giffords was injured while she was on the job and her rehabilitation is covered by workers’ compensation under the Federal Employees’ Compensation Act.”
The Department of Labor website explains that FECA is administered by DOL’s Office of Workers’ Compensation Programs. The “Injury Compensation for Federal Employees” publication (CA-810) describes the entitlement this way:
The FECA at 5 U.S.C. 8103 authorizes medical services for treatment of any condition which is causally related to factors of Federal employment. No limit is imposed on the amount of medical expenses or the length of time for which they are paid as long as the charges represent the reasonable and customary fees for the services involved and the need for the treatment can be shown.
Federal employees are entitled to all services, appliances, and supplies prescribed or recommended by qualified physicians that, in the opinion of OWCP, are likely to cure, give relief, reduce the degree or the period of disability or aid in lessening the amount of monthly compensation. Medical care includes examination, treatment and related services such as medications, hospitalization, as well as transportation needed to secure these services. Preventative care may not be authorized, however.
The ultimate generosity of compensation will depend on a judgment made by OWCP about the utility of treatment, but there’s certainly nothing in here to preclude a year or more of daily intensive therapy.
Varying Coverage of Rehabilitative Services
Back in April, the Houston Chronicle’s Zain Shauk addressed the question of how much Giffords’ rehabilitation might be costing and whether most people’s insurers would cover it:
Giffords currently benefits from broad coverage through federal workers compensation because she was shot in the head Jan. 8 while meeting with constituents in Tucson, Ariz. The type of acute rehabilitation she receives – involving speech, occupational and physical rehab – costs about $8,000 a day, according to the Brain Injury Association of America. Post-acute rehabilitation can range in cost from $600 to $2,500 daily. The expenses leave the treatment options well out of reach for most patients whose insurers won’t pay for the services.
While some insurers cover traumatic brain injury treatment, their limits on some rehab services often leave patients stagnant at times when they could be rapidly recovering, advocates say.
… About 80 percent of the recovery from a severe brain injury generally takes place within the first six months after the injury, and is more rapid early in the process, said Dr. Guy Clifton, a clinical professor of neurosurgery for the University of Texas Health Science Center in Houston and author of a book on health care costs.
Patients who have limited or no coverage are often forced to return home and end up recovering more slowly. Many wind up in nursing homes, said Jane Boutte, president of the Brain Injury Association of Texas.
The relevant insurance can differ if a person is injured on the job (as Giffords was) and covered by a workers’ compensation program as opposed to getting hurt while going about daily life and being covered by an insurance plan. Those who are uninsured could get emergency care, but probably not the kind of extensive rehabilitation Giffords has received. I was curious about what my health insurance would cover if I sustained a brain injury as traumatic as Giffords’, so I pulled up the summary plan description for my insurance, which is sponsored by my employer. My plan will cover:
- 90% of the cost of up to 100 days per calendar year of “inpatient rehabilitation facility services” at an in-network facility (or 70% of the cost at an out-of-network facility);
- 100% of the cost, minus a $35 per-session co-payment, of up to 60 visits per calendar year of outpatient physical, occupational, and speech therapy combined (or 70% of the costs for an out-of-network provider); and
- 100% of the costs of up to 100 home health care visits per calendar year – but this is *only* for services ordered by a physician, and the definition doesn’t include assistance with feeding, dressing, bathing, etc.
Even when rehabilitation services in general are covered, some specific types of therapy might not be. In a USA Today article, Steve Sternberg reports that cognitive therapy, “a collection of intensive exercises that improve cognitive function,” is considered experimental by some insurers and therefore not covered. A ProPublica/NPR investigation found that five of twelve major carriers (mine included) will cover cognitive rehabilitation therapy for head trauma.
The news release from Giffords’ office and the USA Today article mentioned above were both written about a letter that Representative Giffords’ staff sent to Health and Human Services Secretary Kathleen Sebelius. The new healthcare law includes a requirement (effective in 2014) that new insurance plans for individuals and small businesses cover “essential benefits,” which are broadly defined in the legislation and will be more specifically defined by the Secretary of HHS. Giffords’ staff wants that essential benefits package to include rehabilitation like the services Giffords has been receiving:
We believe it is imperative that all Americans with TBI have access to the same full continuum of medical treatment that Congresswoman Giffords has been so fortunate to receive. We urge you to ensure that all Americans have access to such care by defining it as part of the essential benefits package included in the Patient Protection and Affordable Care Act.
Sebelius and her staff face a tough job in defining these benefits. Dozens of stakeholders are pushing for a range of specific treatments to be included, but the more requirements insurers face, the higher premiums will be.
Many workers who are injured on the job, as Giffords was, are eligible for workers’ compensation. This isn’t true for all workers, though. In Texas, employers aren’t even required to carry workers’ compensation insurance; in Kentucky, employers in the agriculture sector are exempt from the requirement. And employees who are technically classified as independent contractors, or who are paid off the books, often don’t have access to workers’ compensation or other types of insurance available for regular employees.
Like health insurance benefits, workers’ compensation benefits vary widely. (I’m focusing on medical and rehabilitation benefits here, but disability benefits are also extremely important to injured workers and their families.)
When I think about jobs in which workers are at high risk of traumatic brain injuries, troops serving in Iraq and Afghanistan are the first to come to mind. Earlier this year, T. Christian Miller of ProPublica and Daniel Zwerdling of NPR published an in-depth report on the refusal of Tricare, the health plan for troops and many veterans, to cover cognitive rehabilitation therapy:
Tricare, an insurance-style program covering nearly 4 million active-duty military and retirees, says the scientific evidence does not justify providing comprehensive cognitive rehabilitation. Tricare officials say an assessment of the available research that they commissioned last year shows that the therapy is not well proven.
But an investigation by NPR and ProPublica found that internal and external reviewers of the Tricare-funded assessment criticized it as fundamentally misguided. Confidential documents obtained by NPR and ProPublica show that reviewers called the Tricare study “deeply flawed,” “unacceptable” and “dismaying.” One top scientist called the assessment a “misuse” of science designed to deny treatment for service members.
Tricare’s stance is also at odds with some medical groups, years of research and even other branches of the Pentagon. Last year, a panel of 50 civilian and military brain specialists convened by the Pentagon unanimously concluded that cognitive therapy was an effective treatment that would help many brain-damaged troops. More than a decade ago, a similar panel convened by the National Institutes of Health reached a similar consensus. Several peer-reviewed studies in the past few years have also endorsed cognitive therapy as a treatment for brain injury.
Miller and Zwerdling note that a few military and veteran facilities provide cognitive rehabilitation therapy, but most lack the capacity to provide full programs.
Giffords’ staff has also pressed for improving coverage of rehabilitation for members of the military suffering from traumatic brain injuries. A May 13th news release explains:
Several initiatives proposed by the office of U.S. Rep. Gabrielle Giffords were included yesterday when the House Armed Services Committee approved an authorization bill for the Department of Defense.
Among the initiatives in the FY 2012 National Defense Authorization Act proposed by Giffords’ staff is one that would require the Defense Department to develop guidelines for the post-acute rehabilitation of traumatic brain injuries.
… “Congresswoman Giffords is receiving excellent medical treatment,” said Pia Carusone, chief of staff to Giffords. “She was injured while she was on the job and her rehabilitation is covered by workers’ compensation under the Federal Employees’ Compensation Act. The members of the military who step forward to serve our nation deserve no less if they suffer a traumatic brain injury.”
… Under current law, the Defense Department must establish guidelines for TBI treatment before it can cover comprehensive TBI rehabilitation under Tricare. The initiative proposed by Congresswoman Giffords’ staff would start that process of establishing guidelines.
Intensive therapy in the months following a severe injury can make the difference between returning to work and a lifetime of disability — and between living independently and needing constant caregiving. The federal Office of Workers Compensation might feel inclined to cover such therapy generously in the hopes that a big investment now will reduce the payments they might have to make over the rest of an injured federal worker’s life if he or she doesn’t recover substantially. Health insurance companies don’t face the same incentives; if I fall off a bike and sustain a brain injury so severe that I can’t work any more, my insurer is on the hook for my medical bills (including the number of days of therapy allowed under my plan) but not for any disability payments I might be entitled to.
What I don’t understand is why the Department of Defense wouldn’t invest in more-extensive rehabilitation for brain-injured soldiers in order to reduce the disability payments it’ll have to make in future years. Is it because the federal budget process focuses more on the short-term numbers, and people figure they’ll just deal with massive disability expenditures later (when there might be fewer troops deployed and higher tax revenues)? Is it because the system just isn’t equipped to deal with an enormous influx of wounded veterans needing extensive rehabilitation? Does the Pentagon just have a million problems to address, and this one hasn’t made it to the top of the necessary priority list?
When I do the mental math – including the costs that are hard to quantify – it makes sense to invest in rehabilitation for patients with traumatic brain injuries. But the answer will vary depending who’s doing the calculations and who’s paying the bills.