Tuesday, January 23, 2007

Insurers Often Cap Coverage for the Latest Spinal Cord Injury Treatments

New technologies and more aggressive approaches to treating spinal cord injuries pioneered in Detroit are giving patients new independence and improved mobility.

But the innovations come at a big price at the very time insurers are trying to hold down rising health costs. While some advocates see progress in getting insurance to cover the treatment, patients are finding that insurers are willing to pay only so much for only so long.

Bob Smith of Harrison Township, injured in a diving accident on July 4, 1999, learned in December that Health Alliance Plan no longer would pay for his therapy at the Rehabilitation Institute of Michigan in Detroit, as it had for 2 1/2 years.

In 2003, Smith became the first American to go to China for experimental surgery to repair his spinal cord. The health plan told Smith that his gains had plateaued, and it no longer would pay for his rehabilitation.

"I'm worried I won't be able to maintain the strength and health I have," said Smith, a former Chevy salesman. Though he can't walk unassisted, he has gained considerable strength, has improved bladder function and hand movement and even has begun to feel sensation in his toes, he said in early January.

Insurers say that physical therapy is an extra health benefit that companies and individuals must purchase. Once people exceed the lifetime cap on those benefits, the expense far exceeds the cost of the policy.

"We try to do the right thing," said Dr. Mumtaz Ibrahim, senior associate medical director at HAP, noting that he could not talk specifically about Smith's case without Smith's consent. He said coverage decisions are reviewed by two levels of physicians and a board of directors committee.

"This is a huge issue," said Erica Nader of Bloomfield Hills, who was injured in a 2001 auto accident. She has been undergoing intensive therapies since, and in March 2003, she became the first American to undergo experimental stem-cell surgery in Portugal.

For five years, her therapy at the Rehabilitation Institute of Michigan has been paid for through her auto insurance.

"This isn't a six-month to 12-month rehab process. Look at Mike Utley," she said, referring to the former Detroit Lions player paralyzed from the middle of his chest down during a game in 1991. "We need long-term aggressive therapies that make us less dependent."

Intensive physical therapy for spinal cord injury is most associated with the late actor Christopher Reeve, the one-time movie Superman who became a champion for a cure after being paralyzed in a 1995 horse-riding accident.

Advanced treatments costly

Now, all over the United States -- and particularly in metro Detroit, where the Rehabilitation Institute of Michigan has become a world leader in intensive therapies -- patients once told they'd never walk again are participating in rigorous regimens, three times a week, three hours at a time.

They use high-tech braces, upright walking devices and other machines to build strength, coax paralyzed muscles to move, stand upright without falling and even walk with help from trainers or equipment.

Many health plans offer companies options to purchase physical therapy coverage, but a typical plan limits lifetime benefits to about 60 hours.

A decade ago, that was sufficient for many patients who never expected to walk again. Now, some patients want long-term therapy.

"This is becoming a whole new way to treat people with neurological injuries," said Polly Swingle, director of the Recovery Project, a Livonia-based intensive-therapy program. "There's so much more research out there to support the importance of being upright."

Conventional physical therapy costs about $75 an hour, compared to $325 for three hours of intensive therapy at the Recovery Project, Swingle said.

That's nearly $1,000 a week for three days of therapy, or more than $50,000 a year.

Willingness to pay is growing

Michigan has no-fault auto insurance that establishes a fund to pay the medical bills of people injured in auto accidents. The coverage may pay for operations abroad, intensive therapies three times a week, home accommodations, high-tech power wheelchairs and more.

By comparison, someone without that coverage may get as little as three weeks of outpatient therapy after an accident, a basic wheelchair and little or no accommodations at home, said Cathy Lysack, associate professor of occupational therapy at Wayne State University. She has a $1.1-million grant from the National Institutes of Health to understand how people can return to independent lives after a catastrophic injury.

She sees setbacks, not progress, as insurers seek "to compete and remain profitable."

Paula Denison, administrative director of specialty services at the Rehabilitation Institute, has seen health plans show more willingness to pay.

She estimates that 85% of the institute's patients receive some insurance reimbursement, up from 25% to 30% two or three years ago. Laura Kling, a case management worker with Robert B. Ancell and Associates in Southfield who works with auto insurance companies, said the key to getting insurance companies to pay for therapy is a physician's prescription and documentation of progress. "As long as it can be explained, and you provide them with the reasons, the insurance companies can be reasonable."

Jim Nugent, director of reimbursement for the American Physical Therapy Association, a 65,000-member organization based in Alexandria, Va., said health care workers and insurers must find new ways to pay for therapies as patients live longer.

"If you step back, it's a wonderful thing," he said. "But it's surely not time to dust off our hands. There's lots more work to be done."

By: PATRICIA ANSTETT