There’s a lucrative cottage industry in the U.S. for the residential treatment of almost anything you can imagine. Everything from “Internet addiction” and drug and alcohol problems, to eating and mood disorders. If you can treat it in an outpatient setting, the thinking goes, why not treat it in a “residential” setting for 30 or more days where you control every aspect of the patient’s life?
The “residential” treatment approach has long been available for eating disorders, since the treatment of these disorders tends to be long and complicated. Andrew Pollack writing for the New York Times notes how these kinds of programs have now become the focus of insurance companies looking to cut back on treatment options.
It’s no surprise, really. With the rollout of mental health parity — requiring that insurance companies can no longer discriminate against people with mental disorders for their treatment options — those companies are looking for other places they can cut costs. Residential treatment for eating disorders appears to be one obvious area.
So is residential treatment a legitimate modality for helping people with eating disorders? Should insurance companies cover the costs of such care?
According to one study (Frisch et al., 2006), the average length of stay in a residential treatment center for an eating disorder is 83 days. That’s nearly 3 months of full-time, round-the-clock treatment and care. The cost for such care? On average, it’s $956 per day. You read that right — nearly $1,000/day is the average cost for such care. That means a single patient at such a treatment center is bringing in, on average, $79,348.
Proponents of residential treatment admit there’s little research to back its use for eating disorders, but are adamant such programs are effective and needed:
Dr Anne E. Becker, president of the Academy of Eating Disorders and director of the eating disorders program at Massachusetts General Hospital, said that despite a paucity of studies, “There’s no question that residential treatment is life-saving for some patients.”
Okay. But so is spiritual healing, according to many spiritual healers. What separates belief (the mainstay of religion) from fact (the mainstay of science) is data. Without data, we operate in a vacuum of knowledge.
Ah, but we apparently do have some data. Just not the kind that a residential treatment center wants to hear:
Ira Burnim, legal director of the Bazelon Center for Mental Health Law, which litigates for better mental health treatments, said that while he was not familiar with eating disorders, “study after study” had shown that residential centers for other mental or emotional disorders were not as effective as treatment at home. […]
“There’s a wide variation in licensing across the country,” said Jena L. Estes, vice president for the federal employee program at the Blue Cross and Blue Shield Association. “There’s a lack of oversight of many of those residential treatment centers.”
There is some research data in the literature. But surprisingly very little, and nothing approaching a randomized controlled study — the gold standard of research. For instance, in Bean et al. (2004), the researchers did a 15-month phone followup with folks who had anorexia who had stayed at their residential treatment center. According to this study, women experienced a 7 lb weight gain, while men experienced an average of a 19 lb weight gain.
But we have no idea whether these are good or bad numbers. Would someone in outpatient treatment over the same time period experience more or less weight gain? Are these numbers even accurate, given they are self-reported by the patient over the telephone (and the research was conducted by biased researchers at their own treatment center)? So we have “data” here, but without context, it’s next to meaningless.
Another study by Bean & Weltzin (2001) showed that after a 6 month followup, anorexic and bulimic women retained some, but not all, of the improvements they made while in treatment. Again, without an outpatient or control group, it’s hard to say whether this is a good or bad finding.
There’s also a few dissertations that offer similar evidence — when pre- versus post- measures are used in a residential treatment program, most patients are improved at discharge. This is hardly a surprising finding. But is it due to the “treatment” portion of the program, or the “residential” component — or some important combination thereof — remains unanswered.
So I hate to say it, but the insurance companies in this case appear to have a pretty good case, at least based upon the paucity of research. I always say to people, if you want to shut up an insurance company, show them the research that your treatment modality works (and works better than cheaper treatment X).
For better or worse, judges don’t have to care about the research, and in this case ruled against the insurance company where the issue of paying for residential treatment for an eating disorder was brought to court:
The Ninth Circuit Appeals judges, based in San Francisco, ruled that residential treatment was medically necessary for eating disorders, and therefore had to be covered under the state’s parity law, even if no exact equivalent existed on the physical disease side.
Eating disorders are unique, and perhaps even more unique than drug and alcohol problems — therefore deserving of special treatment. After all, unlike alcohol or drugs, we all have to eat. The way eating disorders wrap themselves up into the person’s mind and their body image is very difficult to untangle.
But if we want people to have access to residential treatment centers to help with their eating disorders, shouldn’t the industry support far more well-designed, scientific studies to examine the effectiveness of this modality? I don’t think anybody would question these centers if such research existed today, but the fact that it doesn’t after more than 25 years raises more than just a few eyebrows.
Read the full article: Ruling Offers Hope to Eating Disorder Sufferers
References
Bean, Pamela; Loomis, Catherine C.; Timmel, Pamela; Hallinan, Patricia; Moore, Sara; Mammel, Jane; Weltzin, Theodore; (2004). Outcome Variables for Anorexic Males and Females One Year After Discharge from Residential Treatment. Journal of Addictive Diseases, 23, 83-94.
Bean, P. & Weltzin, T. (2001). Evolution of symptom severity during residential treatment of females with eating disorders. Eating and Weight Disorders, 6, 197-204
Frisch, Maria J.; Herzog, David B.; Franko, Debra L.; (2006). Residential Treatment for Eating Disorders. International Journal of Eating Disorders, 39, 434-442.
8 comments
There is a randomized controlled trial comparing inpatient (hospital, not residential treatment center) to outpatient care for anorexia in the UK. Hospitalization by randomization was associated with poorer outcomes. In addition, patients who began treatment as outpatients and needed to be hospitalized did poorly. Full text here:
http://bjp.rcpsych.org/content/191/5/427.long
Another RCT comparing inpatient vs day hospital for bulimia nervosa in Germany found similar outcomes for both with more symptom instability after discharge in the inpatient group.
Psychother Psychosom. 2009;78(3):152-60. Epub 2009 Mar 9.
Inpatient versus day clinic treatment for bulimia nervosa: a randomized trial.
Zeeck A, Weber S, Sandholz A, Wetzler-Burmeister E, Wirsching M, Hartmann A.
Source
Department of Psychosomatic Medicine and Psychotherapy, University of Freiburg, Hauptstrasse 8, Freiburg, Germany. [email protected]
Abstract
BACKGROUND:
In bulimia nervosa, more intense treatments are recommended if outpatient treatment fails. This is the first randomized controlled trial comparing the options of inpatient versus day clinic treatment.
METHOD:
Patients with severe bulimia nervosa were randomly assigned to inpatient or day clinic treatment of similar length and intensity. Specific and general psychopathology was assessed at the end of treatment and a 3-month follow-up.
RESULTS:
Fifty-five patients were randomized; 22 day clinic patients and 21 inpatients started the program. At the end of treatment, a significant reduction of general and specific pathology was found in both settings. Following discharge, there was more deterioration in bulimic symptoms after inpatient treatment, but overall, results were comparable.
CONCLUSIONS:
Inpatient and day clinic programs are effective treatments for severely disturbed bulimic patients with similar results at the 3-month follow-up. Further follow-up will show if a higher instability of results after inpatient treatment is of importance in the long term.
It’s not apples to apples since the studies looked at hospitals, not residential treatment centers, but not encouraging findings.
I would not hold out much hope of residential facilities in the US doing substantive research. The industry is struggling. Remuda Ranch (which used to claim 99% recovery rates in its advertising until recently) closed their Virginia location.
Mirasol declared bankruptcy, in debt to eating disorder patients and other creditors. http://azstarnet.com/business/local/article_eb53e7cd-8937-57de-b607-f22b04399f09.html
Just to be clear, I think Remuda’s recovery stats were totally bogus.
To be sure, one size does not fit all in the realm of treating eating disorders. This may also apply to levels of care. That said,almost all credible residential eating disorders programs are “regulated” and licensed by most state professional regulatory agencies [e.g. in Florida it’s the Agency for Healthcare Administration]and carry an accreditation for a national organization such as the Joint Commission. That said, most insurers require proof of residential licensure and Joint Commission Accreditation before providing reimbursement for treatment as well as “managing” treatment via “UM” or medical necessity criteria. The “cottage industry”referenced pertains to free standing, usually unlicensed, programs that are “self pay” or are reimbursed at outpatient [e.g. IOP or PHP] levels of care. As for Remuda’s recovery stats-well that speaks volumes about that particular program’s credibility. It does not represent those programs that due look at legitimate outcome data. Lastly, but no least, outcome needs to measure variables such as improvements in depressive symptoms [we use pre and post Beck Depression Inventories to quantify outcome on this variable] as well as measurable variables that go beyond “self reports” and/or weights alone. Anorexia represents a minority of patients with DSM IV [snd DSM V] eating disorders for one thing – with bulimia, binge eating, and ED, NOS representing the majority of patients benefiting from access to ALL levels of care based on presenting symptoms and medical necessity.
I have worked at two residential treatment centers in the past 15 years. I have watched women struggle, and yes some of them require more than one hospitalization, but I have witnessed many women win their fight with their eating disorder and are able to enjoy life!!! Eating Disorders are a biologically based mental illness and has the highest mortality rate.
People are treated for cancer and the first round of chemotherapy may not do the trick. They need repeated hospitalizations and multiple rounds of chemotherapy and radation. Many patients are given a small chance for survival. Do these doctors tell them, sorry, we can’t treat you because we don’t think you can be cured? Thousands and Millions of dollars are spent to save these patients lives, when the doctors know the outcome is very poor.
Wake up people. These men and women who have eating disorders do not choose to have this horrible disease anymore than a patient with cancer.
Everyday Eating disorder patients struggle to force themselves to eat, to not purge their food, or to not binge. They are filled with shame and guilt. Why should they be punished from receiving treatment?
Since the parity act was passed I have waatched insurance companies take away the residential benefit, and I have seen case managers who think that just because their weight is restored they are cured and need to go home, only to have to be readmitted time after time because they are kicked out of treatment based on one persons decidion, who most of the time does not have any education about eating disorders. I have watched loved ones sell their homes, cash in their 401K’s and deplete their savings and retirement accounts to save their loved ones lives.
Shame on you people who stick your head in the sand and ignore these people who deserve to live, just as anyone else with a medical condition! And many of you judge these people and know knowing about eating disorders.
Thanks to the Eating Disorder Coalition who continues to fight for eatings disorders and saving lives. EDC is proactive in tryiing to pass the first bill (FREED Act) in the history of Congress to address eating disorders through research, treatment, education and prevention. I would hope that those of you who think you know and understand eating disorders would take a look at this bill, and read more about eating disorders and its complexity, I would hope this would help you to understand this disorder before you pass judgement.
Dr Grohol — I think we have lost touch with the focus of the court decision.
The issue was the level of care. Blue Shield had chosen to write all treatment in any facility licensed as “residential” as excluded from benefits. The plaintiff’s argument was based on the level of care provided by the facility. Based on staff credentialing and services provided, the care she received was equal to services provided in skilled nursing facilities which would be covered under her policy provisions. Therefore, BS did violate the parity law and needed to pay for the treatment.
How is it that this has become a discussion of the worthiness of Ms Harlick to receive care because of previous treatment?
How has it become a condemnation of an entire level of care? We all know that not all treatment programs are created equally. We know that hospitals in most small communities in American do not offer the level of care provided at the premiere hospitals in the US. Yet their reimbursement by insurers is not determined by their “cure” rates.
Levels of care, staff credentials, staff to patient ratios, JCAHO credentialing, etc should be the basis of any discussions regarding the quality of care offered at a facility that is licensed “residential”. Licensing should not be the only factor considered. However, by doing so, the insurance company could realize a substantial financial gain.
Quoting the uninformed (Burnim – unfamiliar with eating disorders) and a BCBS executive (the defendant who lost the appeal process with a definite conflict of interest), to draw conclusions and condemn an entire level of treatment while ignoring the facts/basis of the court decision is irresponsible.
Ms Harlick paid insurance premiums and has a right under the CA parity law to collect the benefits under her contract with the insurance company based on the level of care she received at the eating disorders facility.
We really do not expect the media to be an impartial fair judge of this process. They are interested in their story, volume of readers, sensationalism etc. Dr Grohol, the standards of expectations are different for those of us who know the field and the complexities of recovery and treatment. I was very disappointed that you allowed yourself to be of this fragmented discussion and lose sight of the real issues in the court’s decision and its impact on the victims of the insurance company greed.
You suggest that the thinking is, “if we can treat it in outpatient, why not treat in residential?”. This misses the point for many patients, who would actually prefer NOT to have to go to residential, but who are FAILING in an outpatient setting. For these patients, for whom their treatment teams says that residential is a “medical necessity,” being able to receive residential care can be the difference between life and death. Regardless of what any future research statistics might show about recovery rates at different points of time in the future after discharge from residential treatment, you can’t ignore the fact that first and foremost residential care may be necessary to ensure that a patient can become nutritionally restored, which is essential for patients to be able to address the other (psychological, emotional) issues that underlie the problem. Even in PHP programs or IOPs, where the patient is required to make some of their meals, if their eating disorder is so entrenched, they may struggle to force themselves to consume enough for those meals, and not be able to improve, or worse.
Denying residential care, when deemed medically necessary, for an eating disorder, could very well allow the eating disorder to become further entrenched, and could spell death.
Secondly, with regard to the issue of licensing and lack of oversight, these issues should be addressed, but they shouldn’t be an excuse for insurers to deny treatment, when people’s lives are hanging in the balance. Those could so easily become strategies used to detract from the life and death issues sufferers and their families are facing when time is often of the essence in ensuring a patient gets proper care.
Finally, insurance companies should not be allowed to approve or deny insurance coverage for residential based on whatever any future statistics may show about recovery rates. With an illness such as this, where recovery is known not to follow a straight trajectory, where lapse and relapse are part of the process, using numbers to deny coverage is faulty logic. Since sufferers mostly don’t want to disrupt their lives to enter residential treatment in the first place, and since physicians and other treatment professionals stand to gain nothing by suggesting residential treatment is a “medical necessity” (or perhaps better stated as a “medical and clinical” necessity), why not just trust the professionals who make those determinations, since they are the ones most intimately involved in the care of their patients?
I would like to request that people who don’t understand the nature of eating disorders, or who haven’t been touched personally by these tragic situations refrain from making judgments about these matters on forums such as these. It just mucks up the conversation.
I have an eating disorder and have been at 2 residential treatment centers, as well as multiple day treatments, intensive outpatient treatments, and outpatient care. In my opinion, residential treatment is helpful for some people because patients are stuck there and monitored 24/7. This means that many eating disorder behaviors, such as purging, will lessen or be eliminated as soon as a person comes into residential (it’s hard to purge when staff flushes the toilet for you every time you use the bathroom). However, there are MANY problems with residential, including the fact that it isolates a person from the outside world as well as their family and friends for months at a time. For residential treatment to be effective in the long run for more than just a few people, changes need to be made and patients need to transfer through the various levels of care before returning back to outpatient. Being in residential did save my life for the time being, but I don’t think I’m any better in the long run for it (in some ways, I’ve actually been negatively impacted). See my blog for more insights and information: eatingdisorders25.blogspot.com
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