The Healthcare Reform I Would Love to See

Awhile back, I posted this status update on Facebook:

*Insurance rant*: So our insurance company denied coverage of J's feeding therapy, saying it's not medically necessary. First of all, when did the definition of "medically necessary" get so stringent that it doesn't automatically include teaching a tube fed kid to eat by mouth? And second, how short sighted is it to deny coverage for the one service that is really helping us move closer to getting off the feeding tube, while continuing to pay for all the much more expensive services that maintain the feeding tube (GI doc, nutritionist, weight checks with ped, home health care supplies, etc.)? Banging my head against the wall. But also looking forward to appealing this decision, as fighting insurance companies is what i do for fun these days .

Six months later, we are still fighting to get occupational therapy covered.  We've done an informal appeal, a formal appeal, a review at the state Bureau of Insurance, and now we're exploring our additional options.  The problem is this:  except in rare cases, private insurance companies do not cover therapy services for kids over age three.  (I think our case fits as one of the limited circumstances -- the insurance company, so far, disagrees.)  So the health care reform I would like to see is this:  private insurance companies should cover physical therapy, speech therapy, and occupational therapy for developmental disabilities and other medically necessary situations.  

Of course I'm mostly focused on getting Joshua the feeding therapy he needs, but this is an issue that goes far beyond our family.  The CDC announced earlier this month that 1 in 68 children in the United States is diagnosed with an autism spectrum disorder.  That's a HUGE number of kids who could greatly benefit from PT, ST, OT, and other types of therapy -- but if their family has private insurance, then the family will probably have to pay for the therapy out of pocket, which can add up to thousands of dollars per month.

The benefits of these therapies is huge.  They improve quality of life and functionality in big ways. They provide kids with the tools to move around independently, communicate, eat and drink, and generally better use all the parts of their body.  This helps the kid, the kid's family, and it ultimately helps society because you have more people who are able to do more things, so health care costs go down.  (I'm probably totally butchering this section, so if you are a therapist and want to jump in on the comments section and better explain why you are awesome, PLEASE DO.)

There are several systems in place to provide kids with therapy:  Early Intervention provides therapies  until kids turn age 3; the school system provides therapies after age 3 (but only if they are related to education, only during the duration of the school year, and often the therapy is provided in a group setting rather than one-on-one); and Medicaid covers some therapy services outside of school (but many kids do not qualify for Medicaid, and some therapies are not covered by Medicaid).  These programs are great and they provide much of the coverage that is needed.  But this leaves some huge, gaping, holes:  like a child with a feeding tube who has 4 doctors saying that he needs feeding therapy to learn to eat -- but the child is over age 3, learning to eat is not related to education, and the child is not eligible for Medicaid - so no coverage.

Thanks for letting me step on my soapbox and wave my fists in the air.  A blog is probably not the best way to effect policy change, but it made me feel better to write about it this afternoon, so thanks for reading.