‘Investigational’ treatments see cutbacks

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The Kansas City Star

Nineteen months after suffering a stroke, Margaret Tretbar was shocked last August when she heard the news from her speech and language pathologist.

Tretbar, a 40-year-old Kansas Citian who practiced law before her stroke, was told that her health insurance company was dropping coverage of cognitive rehabilitation, which is used to improve some brain functions in stroke victims and other patients.

Tretbar said the therapy had helped her recover her ability to speak, read and understand language, and had improved her ability to process and remember information.

“I couldn’t understand why they would stop covering a crucial part of my therapy that had been so helpful to me during the first months after my stroke,” she said.

Cognitive therapy includes treatment such as memory exercises. Tretbar’s health insurance company, Blue Cross and Blue Shield of Kansas City, says it stopped covering the therapy because it had been characterized as investigational by the Chicago-based Blue Cross and Blue Shield Association and had not been shown to be effective for conditions such as stroke.

Blue Cross and Blue Shield of Kansas City provides coverage for services and supplies that are medically necessary in accordance with the terms of our member and provider contracts,” said company spokeswoman Susan M. Johnson.

She added that Blue Cross does not provide coverage for treatments considered “investigational” or “experimental.”

Blue Cross continues to cover speech therapy received by Tretbar.

Tretbar’s case is not unusual. Mark Whiting, a principal in the Kansas City office of Mercer Human Resource Consulting, said most health insurers and companies that self-insure “are reviewing to see if there are any services that aren’t warranted or cost-effective. Costs are continuing to increase at double digits, so they’re doing everything they can to better manage costs.”

Jamie Court, president of the Foundation for Taxpayer and Consumer Rights in Santa Monica, Calif., said insurers “generally have tried to escape from all sorts of procedures until Congress or a legislature has forced them to cover a specific treatment. The insurance industry concedes very little without demand, and it’s up to legislatures to demand that they cease these cuts in coverage.”

But Mohit Ghose, a spokesman for America’s Health Insurance Plans, a Washington-based trade association, said covered treatments “are usually negotiated with employers, based on what an employer wants to have covered or not. And increasingly, what you find across the industry is there is a growing reliance on evidence-based care, so that the care being provided is the right care in the right setting at the right time.”

John Bluford, president and chief executive officer of Truman Medical Centers, said many health insurance companies are refusing to pay for bariatric surgery for chronically obese patients, or are paying at a much reduced rate.

Whiting said many health plans are excluding coverage of treatments for morbid obesity.

“If the obesity is not controlled, then it could lead to another condition that’s equally expensive or even costs more,” he said.

But changes in benefits don’t always mean coverage cuts. Johnson said Blue Cross has recently enhanced several benefits or is in the process of doing so.

For example, Blue Cross previously covered the first pair of standard glasses or non-disposable contact lenses following cataract surgery. Johnson said Blue Cross has broadened coverage under its standard plans to also cover refractive keratoplasty corrective eye surgery following cataract surgery, if a member chooses that option over glasses or contact lenses.

Meantime, Tretbar worries that losing her cognitive therapy will prevent her from returning to law practice some day.

“I’ve gotten to the point where I can read fairly well, but I can’t remember what I’ve read,” she said.
To reach Julius A. Karash, health-care reporter, call (816) 234-4918 or send e-mail to [email protected]

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