Eating
Disorders Treatments: Rarely Covered Health Care
-
The Juggling
Act: Hospitalization, Patient Health and Insurance Coverage
Chris J. Johnson, M.D.,
Medical
Director of the Eating Disorders Institute / Park Nicollet, Minneapolis, Minn.
Members of Congress,
Representatives Kennedy and Ramstad, and the Eating Disorders Coalition,
thank you for the privilege to speak with you today about effective
treatment for eating disorders and the barriers that patients face in
getting adequate treatment. The Eating Disorders Institute where I work is
part of Park Nicollet Health Services in Minneapolis. At the Institute, we
are fortunate to offer patients a full continuum of care for the treatment
of eating disorders. This includes an inpatient and day hospital program,
an intensive outpatient and traditional outpatient program, and also the
Anna Westin House, a longer-term residential program. Having all levels of
care is a great benefit to our patients and allows flexibility for
patients to move between the various levels to best support their
recovery. We see approximately 500 new patients each year for initial
assessment of an eating disorder. Of this group, approximately 150 are
admitted directly into our inpatient program. An additional 75 patients
are admitted from other regional hospitals. The most frequent criteria for
inpatient admission are a combination of low weight and medical
instability. Other criteria include the intractable presence of eating
disorder symptoms such as bingeing and vomiting or laxative, diuretic and
diet pill usage.
I am also fortunate to practice in Minnesota, where
many of our patients under state law have insurance that offers the same
coverage for the treatment of mental health conditions as for medical
ones. The major health plans have come to recognize that providing access
to adequate care for the treatment of eating disorders is not only the
right thing to do, but is required of their business. Unfortunately, these
changes did not come about through spontaneous enlightenment in the
offices of health plans. They came about through legislation and
litigation. Sadly, it took the death of a wonderful young woman, Anna
Westin, who was denied adequate treatment by her health plan to bring
about much of this change. I must tell you that despite what has been done
in Minnesota; about half of the patients who present to the Eating
Disorders Institute still do not have adequate coverage for the effective
treatment of their illness.
Eating disorders are serious life-threatening
illnesses that are characterized by a chronic relapsing course often
requiring several years of treatment. Although classified under mental
health diagnoses, they are associated with significant medical
consequences. They carry the highest rate of premature death of any mental
health diagnosis, with a 10% or greater mortality associated with anorexia
nervosa. They also possess the highest rate of short- and long-term
physiological complications to the body. The causes of eating disorders
are multi-factorial and not unlike the multiple factors involved in other
chronic illnesses, such as diabetes and heart disease. Unique to eating
disorders, the illness manifests itself early in life, showing up in
70-80% of cases before the age of twenty. With intervention and treatment
that is early and aggressive, these adolescents and young adults,
predominantly young women, can recover and be free of the disorder. It
does not need to become a lifelong illness. Unfortunately, treatment that
is delayed or is limited to less intensive settings or for too short a
duration results in a cycle of relapse that entrenches the disorder.
So what is effective and adequate treatment for
eating disorders? It is treatment that allows the patient to access the
needed level of care or program structure to support them in their
recovery at a particular point in time. We know that the individual’s
struggle with the eating disorder will be challenging. There will be
periods of progress that sometimes stall or a relapse will occur, then to
be followed by further progress toward the goal of recovery. We know that
the ability to move back and forth between levels of care is essential to
allow placement of the patient in the most effective setting. Until
restored to at least 90% of healthy weight, important cognitive elements
of insight and reasoning remain impaired and limit participation in
essential therapy. All patients do not need hospital care. However, the
ability to access such care when needed is essential. Historically this
has been denied to many patients, as it was to Jessica (not her real name) a 17 year old whose
weight had fallen to 96 lbs. from her usual healthy weight of 126. While
hospitalized for two weeks, Jessica was able to restore 9 lbs., but was
still less than 85% of her body’s healthy weight – her cognition remained
clouded and dominated by eating disorder thoughts. A non-physician
reviewer with her insurance company determined that because of
improvements in her blood pressure and pulse her illness no longer
required inpatient treatment and inpatient coverage was terminated.
Jessica’s parents immediately asked for a review of this decision by a
physician with the insurance company. This could not be arranged for two
days and once completed, inpatient coverage was again denied. Jessica was
discharged to a day hospital program and eventually to an outpatient
program where she has continued to struggle to restore weight. Overzealous
and uninformed managed care guidelines that prompt reviewers to move
patients to “less costly levels of care” at the first signs of improved
laboratory tests or cardiac status miss the essential factors that
maintain the eating disorder.
At the Eating
Disorders Institute, we have found the combination of early inpatient
admission with an adequate length of stay to allow for restoration of at
least 90% of the individual’s healthy weight is essential to reduce
relapses and provide the patient with the best chance for recovery. In
recent years the major health plans in Minnesota have become receptive to
guidelines that allow for earlier and more intensive treatment. This is
allowing our team to utilize the various levels of care more promptly to
meet patients’ needs. Specifically, we are able to intervene when a
patient is struggling in the outpatient setting, her weight declining or
her body showing early signs of medical instability. Is this type of care
more costly? We believe not, and our data shows trends toward lower
lengths of inpatient stay for these patients, not because of increased
pressure by health plans to limit stay, but because we are able to
intervene with treatment at an earlier stage. In most cases this is
followed with the partial or day hospital program that maintains a high
level of structure and intensity in treatment and allows patients to
continue to restore weight to 100% of their healthy goal before
transitioning to an outpatient program.
So if everything is
going so well in Minnesota, why am I here today? Yes, the situation has
improved for about half of our patients – those whose insurance coverage
is regulated under the state’s mental health parity law. They are able to
receive coverage for adequate treatment for eating disorders and other
mental health conditions and the Minnesota based health plans have learned
through litigation that inappropriate denial of such benefits is costly.
The other half of our patients still struggle to receive coverage for
adequate treatment.
Approximately one
third of our patients are covered under ERISA self-insured employer plans
that escape state regulation. These plans typically limit benefits to
lower levels of coverage with higher deductibles and co-pays, or limit
inpatient care to 30 days per year or a 60-day lifetime maximum. Paul
(again, not his real name) is a
14 year-old suffering with anorexia nervosa - only 5% of patients with
anorexia are boys or men. His weight had dropped 25% below a minimum
normal level for his age and height. His insurance coverage limited mental
health inpatient benefits to only 30 days. Previously, he had been
admitted to another hospital for a stay of 12 days, so when he came to us,
he had only 18 remaining days of coverage. He made steady progress, but at
the end of those 18 days his weight was still low and vital signs not
normalized. Requests for extension of benefits were declined. His parents
chose to self-pay for an additional 10 days of inpatient treatment before
he was ready for discharge to the day hospital program. He completed that
program and after 30 days his weight was restored to 95% of his goal.
Patients and families with limited mental health coverage, like Paul’s,
juggle the decision to leave inpatient care too early or self-pay to
receive the care they need.
Another 10–15% of our
patients have insurance where the insurer is not based in Minnesota. I
think their situation is most similar to what exists for the majority of
Americans – limited and inadequate coverage with frequent denial of needed
admission to more intensive settings. Many of these health plans continue
to utilize outdated managed care guidelines that indicate the expected
length of stay for treating anorexia should not exceed 4 days. Despite
hours of work by care managers and physicians trying to convince the
insurance reviewers of the necessity of care, the needed care is
frequently denied. A short while back, a 20-year-old woman with an
abnormal ECG due to her state of malnutrition was denied inpatient eating
disorder treatment by her insurance company. Their recommendation was that
she be put on a cardiac floor until the problem with her heart was cleared
up and then discharged to an outpatient program.
So despite some very
positive changes that have happened in Minnesota over the last 2 years –
and I do want to say that our local health plans have come a long way in
understanding what adequate treatment is for eating disorders – many of
our patients still struggle, and they need your help. So, on behalf of the
hundreds of patients at the Eating Disorders Institute and the millions of
other Americans who do not have insurance coverage that allows for
adequate treatment of eating disorders I ask you to help with your active
support of the full mental health parity bill as written – to bring it to
the floor and to pass it. This bill needs to be inclusive of all mental
health diagnoses including eating disorders. Analysis had shown that
mental health parity does not significantly increase insurance premiums
and we do know that getting patients the right treatment in the right
setting with the right providers saves money. Thank you.
We thank Representative Jim Ramstad (R-MN)
and Representative Patrick Kennedy (D-RI) for hosting this briefing.
This
briefing is made possible by the generous support of the Eating Disorders
Institute, Park Nicollet Health Services, St. Louis Park, Minn. (Click
here to visit the Eating Disorders Institute.)
Additional financial support was donated by EDC Board
Member Mary Gee in memory of her mother, Wai-Kwan Ho Gee.
