January 1st, 2012

Insurance fight for eating disorder patients continues

Some New England companies support population

For 10 years, James Greenblatt, M.D. has fought a near-daily occupational hazard. It has followed him from his last job to his current one and has robbed him of hours he’ll never get back while highlighting unfairness in the country’s managed care system – case by upsetting case.

As the new medical director of the Cambridge Eating Disorder Center in Massachusetts, instead of spending more time with patients who need CEDC’s aggressive residential care, Greenblatt is often subsumed with arguing the severity of their cases to prove that their diagnosis of having an acute eating disorder warrants a bed at the center. He also argues that not only will the bed probably save the patient’s life, it deserves to be covered by insurance. Often, it’s not.

“It’s been a major part of my career,” says Greenblatt, who joined CEDC in November after seven years in the same position at Walden Behavioral Care in Waltham, Mass.

“Insurance companies have done a very aggressive job of limiting treatment based on parameters they have that sometimes are not always looking at the patient’s best interest,” he says. “Outpatient doctors are trying to get patients in hospitals; insurance will say no, almost on a daily basis.”

The media has publicized the battle to secure coverage for eating disorder patients across the country whose acute disease has wreaked havoc on their internal organs. Articles have relayed cases about claims being accepted or denied for stays in residential programs that some experts deem necessary and some managed care organizations don’t.

In October, The New York Times reported on a California case that ultimately forced the state to pay for residential treatment of eating disorders and other serious mental illnesses under the state’s mental health parity law. It was a win for eating disorder advocates that the parity law required companies to cover expenses for mental and behavioral disorders as they would any other illness.

“The parity piece is such a big issue,” says Patrice D. Lockhart, M.D., medical director of the New England Eating Disorder Program at Mercy Hospital in Portland, Maine. “We’ve seen this swing back and forth several times. Especially for [eating disorder] residential treatment, it falls in a grey zone about determining who residential care is most useful for.”

These experts argue that in some cases, that grey zone is decidedly black and white. With a chronic diagnosis of anorexia nervosa, for example, Lockhart says a patient who has suffered for years can be so malnourished, the strain on the heart, kidney and liver functions requires intense help to break the cycle. Consistent purging can drop electrolytes low enough to cause death. Many patients can’t heal alone and can relapse after treatment if not properly supported at home or during further treatment.

“I think all of the articles I’ve read, the cases are both striking and horrifying; but I don’t think people understand the magnitude of the problem,” says Greenblatt. “This is the most life threatening set of diseases we have in psychiatry.”

While eating disorders don’t always lead to suicide or mortality, they can. Yet sometimes the sole criteria insurance companies use to determine whether they will cover a residential stay – often needed to provide around-the-clock care to regulate a patient’s medical condition, food intake or mental state during healing – is their weight.

For some, patients carrying below 75 percent of their ideal body weight are deemed critical. But where a certain percentage on one patient can look different on another, it’s nearly impossible to show how ill they are on the inside or the strain their mental disease has had on their lives.

Unlike other parts of the country, however, several New England insurance companies support this select population. Neil Minkoff, M.D., is the medical director of the Massachusetts Association of Health Plans, which is a non-profit voice representing 13 health plans across the state.

According to Minkoff, MAHP plans (which include United Healthcare, Harvard Pilgrim, Fallon Community Health Plan and others) have historically been a market that’s ahead of the curve for its widely covering residential programs for eating disorder patients when medically needed.

“I do think that some insurance companies get very aggressive. But we have always worked under the condition that this therapy is medically necessary,” says Minkoff.

Health insurance company, Anthem has praised Lockhart’s program at Mercy for its efficacy and cost-effectiveness. The New England Eating Disorder Program offers three- to six-week stays in its “partial hospitalization” program. Patients receive intensive care by day but go home at night to “practice” the eating habits and psychological tools they are learning to facilitate healing. Lockhart says Anthem named Mercy an “Institute of Excellence.”

Blue Cross Blue Shield of Massachusetts has also taken a supportive stance. “Eating disorders are complex illnesses that often require a combination of medical, nutritional, and behavioral treatments,” says Jeffrey L. Simmons, M.D., medical director for Behavioral Health at Blue Cross Blue Shield. “Based on nationally recognized clinical criteria, we provide coverage for a variety of eating disorder programs, including residential care, when a treating clinician recommends this level of care for their patient.”

In spite of their frustration, both Greenblatt and Lockhart express understanding of the between-a-rock-and-a-hard-place position managed care often finds itself. Insurance companies need research and trials to support what they cover. There are few on the books to prove or disprove the benefit of residential stays for severe eating disorder patients.

“I do understand,” says Greenblatt, who has written several books on using nutrition and depression research as ways to treat eating disorders. “The insurance companies point-number one is that there is no research that says that being in a hospital is helpful. Everyone is frustrated by the lack of knowledge base.”

Greenblatt’s work attempts to counter the lacking research. The founder and medical director of Comprehensive Psychiatric Resources, a private integrative psychiatric practice, Greenblatt published a paper with colleagues in Neuropsychiatric Disease and Treatment describing using an electroencephalograph (EEG) to determine what, if any medication could be prescribed to an eating disorder patient co morbid with depressive or bipolar disorder.

Through these referenced-EEGs, Greenblatt’s hope and others’ is to reduce inpatient, residential and partial hospitalization days for eating disorder patients by using EEG data to better treat some of the psychological diagnoses that can cause the disease.

“Care at residential facilities across the country provide very positive environments, but we still have to answer questions about how to stop the illness,” says Greenblatt. “What medical professionals are doing is just making educated guesses [about the cause of eating disorders]. Reference EEG is able to demonstrate that eating disorder patients follow a pattern over a number of years.”

By Jennifer E Chase

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