Events

Congressional Briefing
July 15, 2003
U.S. Capitol

Eating Disorders Treatments: Rarely Covered Health Care

The Revolving Door in Residential Treatment: The Consequence of Insurance Practices
William N. Davis, Ph.D., FAED, Vice President of Research for The Renfrew Center Foundation, and Vice President of Outpatient Program Development for The Renfrew Center, Philadelphia, Penn.

PENNY WISE…POUND FOOLISH: HEALTH INSURANCE AND INTENSIVE TREATMENTS FOR EATING DISORDERS

Introduction

· Today my purpose is to discuss current insurance practices as they relate to the intensive treatment of eating disorders.

· I have two goals: (1) to demonstrate the insurance industry is doing a disservice to those suffering from eating disorders, as well as to their families and professionals working in the field; (2) to offer several recommendations that will enhance the availability and the effectiveness of intensive treatments for eating disorders.

Effective Treatment for Eating Disorders

· To begin with, I want to emphasize that there is effective treatment for an eating disorder; people can and do recover.

· At this time, everyone agrees – both the insurance industry and clinicians in the field – that an eating disorder is best treated by individual specialists and specialist facilities.

o Insurers continually seek out specialty providers for treatment.

o Professionals are unanimous that treatment requires specific knowledge.

· Current research suggests that the following factors are associated with recovery:

o Length of illness: the shorter the duration before treatment, the more likely someone will recover.

o Diagnosis: anorexics are less likely to recover than bulimics or binge eaters; and when there is more co-morbidity – other psychiatric disorders in addition to the eating disorder – recovery is less likely.

o For anorexics, the percent of ideal body weight (IBW) at the beginning and especially at the end of treatment is strongly associated with recovery. At least 90% IBW at discharge from treatment is most likely to ensure recovery.

o Level of family pathology and disorganization is often related to recovery – more functional families support better recoveries.

o Treatment retention – the more someone stays continuously in treatment, the better the chance of recovery.

o Very important: data suggests that attaining recovery prevents relapse, i.e. getting better means you are likely to stay better.

Treatment Options at The Renfrew Center

·        The Renfrew Center is unquestionably an expert on effective treatment

·        It is the nation’s largest treatment center for eating disorders. Treated more women (30,000+) over a longer period of time (18 years) than any other facility.

·        Currently, Renfrew offers the following treatment options.

o       Most intensive, Residential Treatment - 24/7 care.

o       Day/Transitional Living Treatment is essentially the same as residential, except most often the Day portion is covered by insurance, while the TL is out of pocket.

o       Day Treatment is five days a week, most often with two meals and with six hours of treatment programming.

o       Intensive Outpatient Treatment (IOP) is usually three evenings a week, for three or four hours of programming each night, including one meal.

o       Less intensive services include traditional outpatient therapies such as individual, family and group, and support groups

· Note that the treatment options provide a range of intensity. Each represents a level of care, and the Center is organized such that patients can either “step-up” to a higher level of care or “step-down” to a lower, less intense level of care

· Taken together, the options form what is called a “Continuum of Care.”

The Continuum of Care for Eating Disorders

· The continuum of care is common in eating disorders treatment today.

· Its development has been driven, in part, by the advent of managed mental health care. Managed care refers to a system developed by insurers to oversee or manage the way in which insurance benefits are utilized by insurance subscribers.

· Theoretically, and ideally, managed care offers an opportunity to carefully and thoughtfully match the needs of an eating disordered patient with the appropriate use of available treatment resources. For example, a particular individual is assessed to need a particular level of care. Then, clinicians and managed care representatives work together to help the patient in the most effective way possible - both clinically and economically.

· In practice, managed care is most often an effort to reduce costs – to reduce the level of treatment intensity or to end the treatment altogether, thereby reducing the treatment expense – with little attention paid to the particular needs of a patient and the recommendations of clinicians.

· At this time, most managed care representatives and most clinicians are in constant conflict over the length and intensity of treatment. Far from a collaboration, it is much more a battle.

Insurance Practices and Intensive Treatments

· Regarding managed care, it is crucial to understand there is a difference between insurance coverage or benefits and access to the coverage or benefits.

o Managed care is a system devised by insurance companies to control access to benefits. So, regardless of the benefits that are stated in an insurance policy, it is necessary to be able to access them before they can be used.

o Thus, managed care representatives are agents of insurers hired to regulate access to benefits.

o Treatment centers must negotiate with managed care representatives in order to offer intensive treatment to patients. Again, in spite of the benefits a policy stipulates, they can’t be used unless and until they are authorized by managed care.

· Since managed care is primarily an effort to contain and reduce the cost of intensive treatment, it is not surprising that at Renfrew and other eating disorders facilities treatment intensity is associated with:

o More frequent reviews, to keep tight control over the duration of treatment.

o More secretiveness about managed care decisions, to minimize clinician influence over reviewers and thus retain maximum control over length of treatment.

§ The concept of “medical necessity” is used by managed care to establish whether or not a particular treatment or level of care is appropriate for a particular patient.

§ Many times, most often the definition of medical necessity used by managed care is kept vague, as if it is proprietary information.

o More frequent conflicts between reviewers and clinicians.

o Consequently, the more intensive the treatment:

§ The more difficult it is to receive authorization for continued stay.

§ The more the average length of stay is reduced. Residential is less than Day/TL, which is less than Day, which is less than IOP.

Short Term Effects of Managed Care

· The beginning of appropriate intensive treatment is often delayed until sufficient need (medical necessity) has been established.

· Once intensive treatment starts patients frequently become anxious about what “their insurance will say,” interfering with treatment and exacerbating symptoms.

· Clinicians are frequently exasperated by managed care decisions, provoking resentment, frustration and burnout; as a result, conflict with managed care can interfere with the effectiveness of treatment interventions.

· Due to premature and/or rapid discharges from one level of care to another, or from one treatment facility to another patients can experience multiple changes in providers and/or treatment locations, interfering with and confusing the process of ongoing treatment.

· Intensive treatment can be prematurely interrupted when continuing access to benefits is completely denied, a result of “insufficient” medical necessity.

· Families are frequently not prepared for the abruptness of managed care decisions, to discharge from treatment altogether, or to “step down” from one level to another, causing undue anxiety and dysfunction.

· Patients are at greater risk to drop out of intensive treatment prematurely, due to uncertainty about managed care decisions and discontinuities in the treatment process.

Managed Care and Effective Treatment

· A comparison of the short-term effects of managed care and the factors that are associated with recovery suggest that managed care practices can serve to undermine the process of treatment and prolong recovery.

· So, for example, if there are delays in the start of intensive treatment, this will increase the duration of illness, which may lower the chances for recovery.

· Similarly, if patients become anxious, and providers frustrated by the uncertainties surrounding managed care reviews, this may interfere with ongoing participation in treatment.

· Also, when managed care practices contribute to patients dropping out of treatment, this obviously makes it more difficult to achieve recovery

· And very important, when anorexic patients are forced to leave intensive treatment before they can reach a weight that is close to their IBW, their chances for recovery are diminished.

· Finally, when families are disrupted by managed care decisions this makes it more difficult to offer support to the family member who is eating disordered, which in turn tends to interfere with the process of recovery.

Long Term Effects of Managed Care

· Over time managed care tends to reduce both the quality and quantity of care because it increases staff frustration, burn out and turnover, decreases the average length of stay and diminishes the richness and intensity of clinical programming.

· The short-term focus on reducing the length of any one stay in intensive treatment tends to create a pattern of multiple treatment episodes.

· As a result of reduced quality and quantity of care and the tendency to force repeated treatment interventions, managed care inadvertently fosters chronic psychological and medical illness, which may contribute to the extremely high rate of mortality among anorexic patients (up to 20%).

· In turn, chronic illness vastly increases the direct costs (medical and psychological treatments) and the indirect costs (reduced work, school and family capacities and productivity) of eating disorders.

· Not to mention the enormous, ongoing stress and emotional toll that an eating disorder exacts from everyone it touches.

Managed Care and The Renfrew Center

· The two columns of pre and post managed care refer to the experience of the residential treatment program at The Renfrew Center, prior to 1994, before the beginnings of managed care, and during the last three years, when managed care practices have had a profound effect on as many as three out of every four Renfrew residential patients.

· There is a dramatic drop in length of stay, a 250% increase in Renfrew readmissions to residential treatment and a 500% increase in prior hospitalizations among incoming residential patients in the managed care period as compared to the pre managed care era.

o The COC after length of stay in the managed care period refers to the total number of days in Renfrew intensive treatments. The actual amount of residential treatment only is about 15 days, or 1/3 the amount of treatment Renfrew was able to provide before managed care.

· In addition, there is evidence to suggest that patients entering Renfrew now are in more medical/psychological crisis than they once were, and that they are more severely disturbed – in terms of both eating disorders symptoms and additional psychiatric problems.

· Moreover, more patients are leaving residential treatment against medical advice than they once did.

· In the post-managed care era Renfrew has been forced to reduce the intensity of its clinical programming and it has experienced a tremendous increase in staff turnover.

· Although patients still assess their residential treatment experience as very helpful to their recovery, there is no question but that the Renfrew “culture” - the atmosphere that pervades the patient and staff community is less coherent, more frantic and disorganized than it was ten years ago.

Pound Wise…Future Recommendations

· What needs to be done, immediately, to begin to solve some of the problems that managed care practices have brought to the intensive treatment of eating disorders?

· And what can be done to promote positive long-term consequences?

· First, as the Eating Disorders Coalition has advocated, eating disorders must be included in the parity legislation now before Congress, and the entire bill should be passed into law as soon as possible. This is a necessary step towards ensuring that eating disorders patients and their families will have an opportunity to receive all the treatment they deserve.

· Perhaps just as important however, we must find a way to induce all insurance companies and their managed care representatives to publish their criteria for admission into, continued stay in, and discharge from intensive treatment programs for eating disorders. Furthermore, a standardized set of criteria should be devised, with input from clinical experts, so that there is a common understanding of medical necessity for the various levels of intensive treatment throughout the country and the insurance industry.

o In other words there is an urgent need to force managed care companies to expose and standardize their definitions of medical necessity so that everyone – patients, families and providers – will understand what is likely to be the course of an intensive treatment.

o As a result, treatment course is likely to be more predictable and we should have a genuine opportunity to forge a collaborative relationship with managed care representatives – with a primary focus on the health and well being of eating disorders patients.

· Another extremely important initiative, with profound implications for the future of intensive treatment is research on effective treatments and treatment outcomes. This may be the most significant step we can take. If we have good information about what helps to ensure recovery, on both a short and a long term basis, we have two things:

o Hope for those who suffer from eating disorders.

o Hard evidence to present to insurers that this or that treatment intervention for this or that amount of time is essential to eating disorders recovery.

· Health care parity for eating disorders, standardized definitions of medical necessity and substantial research on intensive treatment for eating disorders will only happen in the context of increased public support. So, finally, we must work to acquaint everyone with the very serious and potentially deadly nature of eating disorders.

William N. Davis, Ph.D., is Vice President of Research for The Renfrew Center Foundation and Vice President of Outpatient Program Development for The Renfrew Center. Dr. Davis has worked for several decades to expose and resist the socio-cultural forces that contribute to anorexia and bulimia. He received his doctorate from Harvard University and a certificate in psychoanalysis from the William Alanson White Institute in New York City.

Dr. Davis founded and directed the Center for the Study of Anorexia and Bulimia, one of the first outpatient treatment organizations for eating disorders in the country. He is a founding member and past president of the National Eating Disorders Association and a founding member of the Academy of Eating Disorders. Dr. Davis has contributed significantly to the development of the feminist treatment philosophy at The Renfrew Center, a perspective that makes it unique in the eating disorders field. He is editor of The Renfrew Center Foundation Perspective and is a committee member of The Renfrew Center Foundation conference, the largest annual professional conference for eating disorders in the country. Currently, he co-edits The Renfrew Working Papers, a series of articles written by experts in the field.

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.

Congressional Briefing July 15, 2003 U.S. Capitol

Eating Disorders Treatments: Rarely Covered Health Care

The Revolving Door in Residential Treatment: The Consequence of Insurance Practices William N. Davis, Ph.D., FAED, Vice President of Research for The Renfrew Center Foundation, and Vice President of Outpatient Program Development for The Renfrew Center, Philadelphia, Penn.

PENNY WISE…POUND FOOLISH: HEALTH INSURANCE AND INTENSIVE TREATMENTS FOR EATING DISORDERS

Introduction

· Today my purpose is to discuss current insurance practices as they relate to the intensive treatment of eating disorders.

Effective Treatment for Eating Disorders

· To begin with, I want to emphasize that there is effective treatment for an eating disorder; people can and do recover.

· At this time, everyone agrees – both the insurance industry and clinicians in the field – that an eating disorder is best treated by individual specialists and specialist facilities.

o Insurers continually seek out specialty providers for treatment.

o Professionals are unanimous that treatment requires specific knowledge.

· Current research suggests that the following factors are associated with recovery:

o Length of illness: the shorter the duration before treatment, the more likely someone will recover.

o Diagnosis: anorexics are less likely to recover than bulimics or binge eaters; and when there is more co-morbidity – other psychiatric disorders in addition to the eating disorder – recovery is less likely.

o For anorexics, the percent of ideal body weight (IBW) at the beginning and especially at the end of treatment is strongly associated with recovery. At least 90% IBW at discharge from treatment is most likely to ensure recovery.

o Level of family pathology and disorganization is often related to recovery – more functional families support better recoveries.

o Treatment retention – the more someone stays continuously in treatment, the better the chance of recovery.

o Very important: data suggests that attaining recovery prevents relapse, i.e. getting better means you are likely to stay better.

Treatment Options at The Renfrew Center

· The Renfrew Center is unquestionably an expert on effective treatment

· It is the nation’s largest treatment center for eating disorders. Treated more women (30,000+) over a longer period of time (18 years) than any other facility.

· Currently, Renfrew offers the following treatment options.

o Most intensive, Residential Treatment - 24/7 care.

o Day/Transitional Living Treatment is essentially the same as residential, except most often the Day portion is covered by insurance, while the TL is out of pocket.

o Day Treatment is five days a week, most often with two meals and with six hours of treatment programming.

o Intensive Outpatient Treatment (IOP) is usually three evenings a week, for three or four hours of programming each night, including one meal.

o Less intensive services include traditional outpatient therapies such as individual, family and group, and support groups

· Note that the treatment options provide a range of intensity. Each represents a level of care, and the Center is organized such that patients can either “step-up” to a higher level of care or “step-down” to a lower, less intense level of care

· Taken together, the options form what is called a “Continuum of Care.”

The Continuum of Care for Eating Disorders

· The continuum of care is common in eating disorders treatment today.

· Its development has been driven, in part, by the advent of managed mental health care. Managed care refers to a system developed by insurers to oversee or manage the way in which insurance benefits are utilized by insurance subscribers.

· In practice, managed care is most often an effort to reduce costs – to reduce the level of treatment intensity or to end the treatment altogether, thereby reducing the treatment expense – with little attention paid to the particular needs of a patient and the recommendations of clinicians.

· At this time, most managed care representatives and most clinicians are in constant conflict over the length and intensity of treatment. Far from a collaboration, it is much more a battle.

Insurance Practices and Intensive Treatments

· Regarding managed care, it is crucial to understand there is a difference between insurance coverage or benefits and access to the coverage or benefits.

o Managed care is a system devised by insurance companies to control access to benefits. So, regardless of the benefits that are stated in an insurance policy, it is necessary to be able to access them before they can be used.

o Thus, managed care representatives are agents of insurers hired to regulate access to benefits.

o Treatment centers must negotiate with managed care representatives in order to offer intensive treatment to patients. Again, in spite of the benefits a policy stipulates, they can’t be used unless and until they are authorized by managed care.

· Since managed care is primarily an effort to contain and reduce the cost of intensive treatment, it is not surprising that at Renfrew and other eating disorders facilities treatment intensity is associated with:

o More frequent reviews, to keep tight control over the duration of treatment.

o More secretiveness about managed care decisions, to minimize clinician influence over reviewers and thus retain maximum control over length of treatment.

§ The concept of “medical necessity” is used by managed care to establish whether or not a particular treatment or level of care is appropriate for a particular patient.

§ Many times, most often the definition of medical necessity used by managed care is kept vague, as if it is proprietary information.

o More frequent conflicts between reviewers and clinicians.

o Consequently, the more intensive the treatment:

§ The more difficult it is to receive authorization for continued stay.

§ The more the average length of stay is reduced. Residential is less than Day/TL, which is less than Day, which is less than IOP.

Short Term Effects of Managed Care

· The beginning of appropriate intensive treatment is often delayed until sufficient need (medical necessity) has been established.

· Once intensive treatment starts patients frequently become anxious about what “their insurance will say,” interfering with treatment and exacerbating symptoms.

· Clinicians are frequently exasperated by managed care decisions, provoking resentment, frustration and burnout; as a result, conflict with managed care can interfere with the effectiveness of treatment interventions.

· Due to premature and/or rapid discharges from one level of care to another, or from one treatment facility to another patients can experience multiple changes in providers and/or treatment locations, interfering with and confusing the process of ongoing treatment.

· Intensive treatment can be prematurely interrupted when continuing access to benefits is completely denied, a result of “insufficient” medical necessity.

· Families are frequently not prepared for the abruptness of managed care decisions, to discharge from treatment altogether, or to “step down” from one level to another, causing undue anxiety and dysfunction.

· Patients are at greater risk to drop out of intensive treatment prematurely, due to uncertainty about managed care decisions and discontinuities in the treatment process.

Managed Care and Effective Treatment

· A comparison of the short-term effects of managed care and the factors that are associated with recovery suggest that managed care practices can serve to undermine the process of treatment and prolong recovery.

· So, for example, if there are delays in the start of intensive treatment, this will increase the duration of illness, which may lower the chances for recovery.

· Similarly, if patients become anxious, and providers frustrated by the uncertainties surrounding managed care reviews, this may interfere with ongoing participation in treatment.

· Also, when managed care practices contribute to patients dropping out of treatment, this obviously makes it more difficult to achieve recovery

· And very important, when anorexic patients are forced to leave intensive treatment before they can reach a weight that is close to their IBW, their chances for recovery are diminished.

· Finally, when families are disrupted by managed care decisions this makes it more difficult to offer support to the family member who is eating disordered, which in turn tends to interfere with the process of recovery.

Long Term Effects of Managed Care

· Over time managed care tends to reduce both the quality and quantity of care because it increases staff frustration, burn out and turnover, decreases the average length of stay and diminishes the richness and intensity of clinical programming.

· The short-term focus on reducing the length of any one stay in intensive treatment tends to create a pattern of multiple treatment episodes.

· As a result of reduced quality and quantity of care and the tendency to force repeated treatment interventions, managed care inadvertently fosters chronic psychological and medical illness, which may contribute to the extremely high rate of mortality among anorexic patients (up to 20%).

· In turn, chronic illness vastly increases the direct costs (medical and psychological treatments) and the indirect costs (reduced work, school and family capacities and productivity) of eating disorders.

· Not to mention the enormous, ongoing stress and emotional toll that an eating disorder exacts from everyone it touches.

Managed Care and The Renfrew Center

· There is a dramatic drop in length of stay, a 250% increase in Renfrew readmissions to residential treatment and a 500% increase in prior hospitalizations among incoming residential patients in the managed care period as compared to the pre managed care era.

o The COC after length of stay in the managed care period refers to the total number of days in Renfrew intensive treatments. The actual amount of residential treatment only is about 15 days, or 1/3 the amount of treatment Renfrew was able to provide before managed care.

· In addition, there is evidence to suggest that patients entering Renfrew now are in more medical/psychological crisis than they once were, and that they are more severely disturbed – in terms of both eating disorders symptoms and additional psychiatric problems.

· Moreover, more patients are leaving residential treatment against medical advice than they once did.

· In the post-managed care era Renfrew has been forced to reduce the intensity of its clinical programming and it has experienced a tremendous increase in staff turnover.

Pound Wise…Future Recommendations

· What needs to be done, immediately, to begin to solve some of the problems that managed care practices have brought to the intensive treatment of eating disorders?

· And what can be done to promote positive long-term consequences?

o In other words there is an urgent need to force managed care companies to expose and standardize their definitions of medical necessity so that everyone – patients, families and providers – will understand what is likely to be the course of an intensive treatment.

o As a result, treatment course is likely to be more predictable and we should have a genuine opportunity to forge a collaborative relationship with managed care representatives – with a primary focus on the health and well being of eating disorders patients.

Congressional Briefing
July 15, 2003
U.S. Capitol

The Revolving Door in Residential Treatment: The Consequence of Insurance Practices
William N. Davis, Ph.D., FAED, Vice President of Research for The Renfrew Center Foundation, and Vice President of Outpatient Program Development for The Renfrew Center, Philadelphia, Penn.