Eating
Disorders Treatments: Rarely Covered Health Care
-
Mission Impossible: Getting
Needed Services for Patients in Private Practice
Raine Weiner-Hollies, Ph.D., Clinical Psychologist, Eating Disorders
Center of Potomac Valley Psychotherapy Associates, Rockville, Md.
As a clinical psychologist specializing for 15 years in the treatment
of eating disorders, I have experienced the slow and steady deterioration
in patients’ access to effective, life-sustaining care due to increasing
limitations imposed by insurance companies. While research indicates that
patients can successfully recover from eating disorders, this cannot be
achieved without intensive, well-monitored, comprehensive treatment.
Denial of a treatment plan can cost more than money, it can cost lives.
Sue was a 19-year-old college student at the time I saw her in the early
1990s. She was a straight A student on a full athletic scholarship as a
runner. By the time she began treatment with me, Sue was 5’2” and weighed
71 pounds. She had been amenorrheic for four years and had osteoporosis
and stress fractures in both legs. She had already been to several other
therapists who were listed as providers on her HMO. She was unable,
however, to find someone on her plan with a specialty in the treatment of
eating disorders. This led to her mother’s decision to pay out-of-pocket
for her sessions with me, and I agreed to reduce my fee. She had been
suffering from anorexia since the age of 13 and began purging, as much as
five times a day, when she was 16. Despite her low weight and the pain in
her legs, she refused to stop running for fear of losing her
scholarship and gaining any weight.
I put a therapeutic plan into effect, and within several months we saw
some improvement. She was started on anti-depressants, as prescribed by
her physician, and seemed more hopeful about her future. She was eating a
little more, purging a little less and, with the nutritionist’s support,
was able to gain three pounds. The pain in her legs worsened, however, and
Sue was told by her coach that she would no longer be permitted to run on
the team. She was devastated.
Shortly after meeting with her coach, Sue described in a session with me
that she was tired of living with her eating disorder and seeing herself
as a “hopeless case.” I was becoming increasingly concerned about her
emotional and physical safety. Her physician was equally worried. We
then discussed her need for hospitalization or residential placement. Sue
agreed to go to an inpatient facility, although she was concerned that she
would be found “incurable.” I called her insurance company for
pre-authorization and was told that she would have to be evaluated by a
psychiatrist participating in her HMO. Unfortunately, there were no
psychiatrists specializing in eating disorders, so she was referred to a
random provider. I left numerous messages to speak to him about Sue but
never received a call back. The insurance company’s professional informed
Sue that hospitalization or residential treatment was denied due to the
lack of “medical necessity.” No contact was made with Sue’s physician or
me.
When I saw Sue the next day, she had not eaten in 24 hours, telling me
that she must be even fatter than she thought or the psychiatrist would
have hospitalized her. She said, “I’m not even good at being
anorexic. I’m a complete failure at everything.” She threatened to commit
suicide. I immediately called her insurance company, stating in even
stronger terms that Sue was in imminent danger. I was told that I must be
incorrect as their psychiatrist had disagreed with me. A battle ensued, in
which I was eventually permitted to speak with “a supervisor.” She told me
that the best she could do was authorize a second evaluation with another
psychiatrist. This occurred the following day. Unfortunately, the second
psychiatrist agreed with the first one despite my pleading with him.
Late that evening, I received a phone call from my answering service. It
was Sue. She informed me with slurred words that she had taken every
medication she could find in the house. Thanking me for my help, she hung
up before I could say more than a few words. I called her back, but her
mother told me she was not home. I then contacted the police. Sue was
found at 2:00 a.m. walking down a snowy residential street, naked. She was
rushed to the hospital and barely survived. When her medical condition was
stabilized, Sue was transferred to a psychiatric hospital for one week,
day treatment for two weeks, and then to once weekly individual
psychotherapy with a therapist connected to the hospital.
Several years later, I received a phone call from Sue’s mother. She told
me that Sue had died from complications of her eating disorder. She wanted
to know if I was aware of any forums in which she could speak to insurance
representatives, professionals and parents about her daughter’s battle
with her anorexia and with her HMO.
Sue is one of numerous patients with whom I have worked in which the
treatment was negatively affected by the limitations dictated from
insurance companies. People suffering from anorexia, bulimia, and binge
eating disorder struggle with a myriad of emotional and life-threatening
medical issues. There is no quick fix. Patients typically require multiple
types of care including individual psychotherapy, nutritional counseling,
medical monitoring, psychopharmacological assessment, and family
therapy. The healthcare system as it currently exists does not allow for
this multi-dimensional treatment plan, particularly given that 1) cost
cutting measures are a major focus in determining authorization for
therapy, and 2) the mental health parity laws have not as yet been passed.
While the American Psychiatric Association has delineated criteria for
this multi-dimensional continuum of care in the treatment of eating
disorders, many insurance companies refuse to authorize payment for it. As
a result, increasingly fewer people are able to recover and the chances of
relapse are high. I believe this system is not only an unethical one, but
it is also a dangerous one given the high mortality rate of patients with
eating disorders.
Eating disordered patients tend to deny that they are medically at
risk. For those suffering from anorexia or bulimia, the denial is so
strong, that no matter how low their weight dips, they are convinced they
are fat. Therefore, when reviewers at insurance companies deny treatment,
patients take this information as proof that they are not sick enough or
thin enough. They often become determined to eat less and purge more.
Patients with binge eating disorder are usually taken even less seriously.
Despite the fact that the research
has found obesity to be an “epidemic” (United States Department of Health
and Human Services, 2001) and that over-eating in response to depression
and anxiety is common, third party payers are even more likely to refuse
reimbursing patients with binge eating disorder. How can a person
reviewing a case of someone whom they have never met be allowed to
determine another human being’s future? This is how our healthcare system
works today. It is an abomination.
Private practice is not what it used to be when, as in medical
practice, patients were given the treatment deemed necessary to help them
recover. Forms of treatment, including group therapy, family therapy,
couple therapy, medication assessment and nutritional counseling, could be
recommended as needed. If necessary, inpatient and day treatment stays of
30 to 60 days or more could
be part of the plan for those needing more intensive care. Those
days are long gone. Many insurance companies allow only 20 to 26
out-patient sessions per year and reimburse only a small percentage of
what they call the “usual and customary” fee (around 50% or less of what
is the actual average fee per session). Insurance companies require
therapists to prove medical necessity for
further treatment, which involves completing lengthy treatment forms and
receiving frequent denials. Privacy is thrown out the door when third
party payers require therapists to give intimate details about patients;
information that was once kept confidential. When inpatient stays are
authorized, patients are generally discharged within a very short period
of time and against the recommendations of the hospital or residential
treatment facility. As a result, patients who are now seen in
private practice are more medically at risk and are receiving treatment
not nearly frequently enough given the severity of their symptoms.
They are also faced with the financial and emotional stress
resulting from having to fight for their treatment.
I have made significant changes in my practice to contend with the changes
in our healthcare system. Patients now pay me at the time of each session
and are reimbursed when possible by their insurance companies at whatever
amount they can garner. I am no longer a provider for any HMOs or PPOs. I
could not survive financially on the increasingly reduced fees for
service. In addition, working with managed care companies became an
endless battle, one which I usually lost, as I tried to convince whomever
answered the phone to allow me to treat my patients in the ways my
experience told me were optimal for their recovery. Unfortunately, these
battles continue. Even though I am not a provider on these plans, I am
still required to fill out increasingly longer and more frequent treatment
forms about my patients. This has led to a great deal of energy expended
on my part in attempting to complete paperwork and plead with insurance
companies when my time would certainly be better spent helping my
patients.
In the years I have worked with eating disorders, I have seen so
many teenagers and adults leave therapy as healthy, productive, energetic,
and optimistic people. Recovery means providing each patient access to the
treatment modalities and the time-frame needed to help that individual.
Psychotherapeutic interventions cannot be separated from and deemed less
valuable than medical
interventions, and therefore the parity laws must be passed. Psychotherapy
cannot be dictated and formulated by insurance evaluators. This is a
dangerous policy. Do only those who are wealthy enough to afford treatment
have the right to work toward a full recovery? This would be immoral,
prejudicial, and criminal.
It was an honor to speak with all of you in the Capitol today. Many of my
patients know that I am here and are cheering me on. During a time
in which both therapists and patients have been made to feel powerless by
a healthcare system which fails us, today has brought a brief period of
empowerment. The existing inequity needs a legislative remedy. I
thank you for listening.
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.
