Maybe Don't Read This if You're Politically Inclined

Time for a non-speech related update about Joe's speech therapy.  I debated not writing about this issue since it can be kind of sensitive to some, but I'm selfish and it will help me to know that other people out there are aware of what we're dealing with on this one.

It probably won't come as a shock to you that private speech therapy lessons aren't free - in fact, they are pretty absurdly expensive.  The reason Joe and I drive all the way up to 635 and Hillcrest twice a week for two 25 minute speech classes is that the office up there is the closest one that accepts our insurance.

To back up a bit.  Back in August, we got Joe's hearing tested by a pediatric ENT.  Joe's hearing was fine, thank goodness, but the ENT was adamant that we get him in speech therapy, like, yesterday.  The ENT's lecture to me was the kick in the pants I needed that instigated the original blog post about speech therapy.  Anyway, the ENT told us that we had two options for speech therapy for Joe.  Private speech classes, which is expensive but more often than not covered by insurance (according to this guy) or Early Childhood Intervention (better known to some of you as ECI).  ECI is a state-sponsored program where a person comes to your house to evaluate, and later treat, your kid for developmental delays, including speech therapy.  This service is a ridiculously good benefit of living in Texas.  The ENT we used, however, made the point that ECI is sort of a 50/50 proposition.  Since it's free, and state sponsored, you don't always know what kind of help you're going to be getting.  He was adamant that there are plenty of highly qualified speech therapists working for ECI - but he was just as adamant that there are plenty of less qualified speech therapists working for ECI.  You're sort of rolling the dice.  He suggested we at least investigate our private therapist options before committing to ECI. 

So, right after the good news that Joe's hearing was fine, I called our insurance company to make sure that speech delay was covered by our insurance policy (assuming that we met all of the red tape requirements associated with filing a claim).  The lady I spoke with on the phone assured me that speech therapy for speech delay would be covered by our policy if speech therapy was determined to be "medically necessary."  So, I scheduled an evaluation of Joe at the speech therapist's office.  At the same time, I called ECI to see if we could get on their schedule for an evaluation.  They told me that the earliest they could have anyone contact me (contact me, not come out to evaluate Joe) was seven business days from my phone call.  Yikes.  Seven business days is not much in the grand scheme of things, of course, but to me it was sort of indicative of the whole "state-sponsored" quality of service we'd be getting.

After Joe's evaluation at the private speech therapist, he fell into the "severe speech delay" category of their magic evaluation tools.  Which makes sense, since he was completely silent 99% of the time at that point in his development.  Actually, to quote the letter the speech therapist sent to the insurance agency:  "Joe presents with a severe expressive language disorder...that will not likely correct on its own."  (By the way, I'm not naive enough to be ignorant of the fact that the speech therapist has an incentive to write these kinds of reports so that they can get clients whose appointments are paid for by insurance.  But try using that kind of logic when it's your own kid's development at stake.)

So we started with the private speech therapist.  Unfortunately, it takes them about a month to get their evaluation written, sent off to the insurance company, processed by the insurance company, and responded to by the insurance company.  They assured us, though, that almost no one with Joe's level of speech delay gets denied coverage.  So, we agreed to pay the speech therapist out-of-pocket for each appointment during that month while everything was getting processed, and the speech therapist agreed to reimburse us everything we'd paid out-of-pocket once the insurance company approved coverage.   Joe started speech classes with Kristen, and as you know from being a loyal blog follower, he thrived under her tutelage.

I'm sure you can see where this is going.  Six weeks into speech classes, we got the news that the insurance company had denied our claim.  "No worries," says the speech therapist, "we'll appeal the decision to the insurance company and they'll probably cover you.  Just get a letter of medical necessity from Joe's pediatrician, and send it on over."  Okay, no problem.

We head to the pediatrician for a consult about this letter of medical necessity.  The doctor asks me a stock list of questions about his speech development -- which basically comes down to "how many words can he say."  I was honest (stupid me.), and said that as of that time, after about 7 weeks of speech therapy, he could say about 30 words.  The doctor looked at me like I was the biggest idiot and the most paranoid, over-involved mom to ever walk into his office, and said, "Well, then he's on track.  He doesn't need speech therapy for speech delay."  ...seriously?  So no letter of medical necessity from him.

So, to recap: Joe isn't talking, so, according to several different and disinterested medical professionals, he needs speech therapy.  Speech therapist evaluates and agrees that speech therapy is necessary.  Insurance claim takes time to process, so Joe starts classes before coverage is guaranteed.  By the time coverage is denied, Joe has been doing so well with speech therapy that he is now on track to meet his two year old speech-related milestones.  So the doctor won't write the letter of medical necessity, which means the speech therapist can't appeal the denial of coverage, which means that John and I continue to pay the ridiculously exorbitant out-of-pocket cost to the speech therapist.   The conspiracy theorist in me thinks that maybe the insurance company knows that this is the typical order of things, and knows this exact situation will happen in a lot of cases because speech therapy can be so helpful to kids like Joe.

Of course, the reason John and I agreed to pay out-of-pocket in the first place is that we are very, very on board with how important these speech classes are to Joe.  At first, this may have been just blind hope in the process, but now the results have been so great (and continue to be so great) that the importance and success of these class is impossible to deny.

So we are left with two poor options.  Either we continue to pay almost every cent of our truly disposable income (seriously) to the speech therapist every month, or we sign up for the free state-sponsored ECI services.  Which, of course, also entails pulling Joe out of classes at the place where he is currently thriving, with a teacher that he has clearly bonded with (and as you know, Joe doesn't bond that easily to grown ups).  And entails rolling the dice on getting someone who may not be as good, and therefore may not be as helpful to Joe. 

For me and John, the choice is clear.  Our kids are the most important thing in the world to us - more important than wine to John (I know, right?!) and more important than shoes, clothes, and vacations to me.  We are fortunate enough to be in a financial situation that even allows us to have the option to pay for private speech therapy.  Making the sacrifices for Joe is the easy part.

But my main question, and the reason I've been hesitant to post our experience in this area, is: WHY?  Why is this the way our whole insurance situation in this country works?  I can assure you I'm neither right wing nor left wing, and in fact I'm pretty politically ambiguous, so please don't think I'm making this a political matter.  But our experience with Joe's speech therapy has just been a shining example to me of how our insurance situation is broken.  The state obviously recognizes that these developmental delays are an important enough issue that they offer free services to anyone to help fix them (which I know is something that plenty of people will think is a waste of state money in the first place, but again, that's a political issue that is neither here nor there to my checkbook).  The insurance company, on the other hand, to whom I pay a ton of money every year in premiums, does not acknowledge that this kind of developmental delay is worthy of their help paying for, even though I pay the insurance company money so that they willhelp me pay for things like this.

Ignoring all the political rhetoric: I pay loads of money to the insurance company so that they will help me pay for the really expensive healthcare stuff that will come up with me and my family.  Joe's speech delay is, according to two pediatricians, a pediatric ENT, and a speech therapist, a severe developmental issue.  So please fill me in, Aetna: what exactly am I paying you premiums for?  Thank you for helping pay for Ian (helping to pay, let's be clear, not paying) but how about next year, when I don't have a baby and, God willing, everyone remains relatively healthy?

Healthcare and insurance are broken.  Someone has to fix them.  Please do it soon so that I can retire before I'm 95.