Author: APA

Editor’s Note: “From the Therapist’s Chair” is intended to be a forum for professionals in the field. We invite you to forward articles or papers to : ANAD, Newsletter Editor, Box 7, Highland Park, IL 60035.

Insurance companies, faced with the rising costs of health care and reduced profits over the past decade or so, developed new types of coverage – HMOs, PPOs, and related managed care vehicles. Many businesses and individuals, in purchasing insurance for their employees, bought the new types of coverage as an attempt to reduce the cost of premiums, deductibles, and co-insurance fees, thinking the quality of care would not be compromised, yet unaware of the sometimes-dangerous sacrifices consumers would be making with managed-care coverage.

The intention of the insurance companies has always been to reduce their payments to the health care providers, but that is not, of course, the pitch they make to potential customers. They applaud themselves for what they call excellent quality of care at reduced cost to the consumer and increased profit to them: the cherished “win-win” situation. Too good to be true? Of course! What the managed-care companies are deeming “excellent quality of care” is measured by their yardstick and is not an assessment of quality measured by the consumers or providers of care. What managed-care companies do not tell the consumer about are the restrictions to care that often dangerously hamper treatment availability, duration, and ultimately, quality. Obviously, the focus is not to manage care but to manage cost. They are not interested in the person, the nature of a patient’s illness or the way in which one person with depression may differ from another; or how one patient might be in need of inpatient treatment, while another with bulimia might appropriately be treated on an outpatient basis.

The process of attempting to hospitalize a patient with an eating disorder presents multiple obstacles for outpatient clinicians and serious potential emotional and further physical damage to bulimics and anorexics in need of inpatient care. To managed-care companies, the symptoms of an eating disorder per se are not sufficiently life-threatening to warrant hospitalization. Unless a patient is actively suicidal, the managed-care companies state that the person’s psychological symptoms are not sufficiently acute and that inpatient treatment “is not medically necessary.” The exception to this rigid, and often irrelevant, criteria occurs only if a patient’s physical examination or lab results indicate severe physical, metabolic or organ system complications from the eating disorder, enough to warrant inpatient medical treatment.

The psychological crisis is never of sufficient severity to warrant hospitalization unless the patient says she/he is suicidal. I was once told by a managed-care medical reviewer, when I was trying to hospitalize a bulimic who purged 15 times a day, was severely depressed and no longer left the house, “We don’t hospitalize attitude problems.” As many know who work with or have experienced an eating disorder, a patient can often be severely out of control with binge/purge or restricting behavior, yet their blood work and physical exam can appear normal. Managed-care companies, with their impersonal checklist of criteria for what comprises disorders, and their lists of criteria for when hospitalization is necessary, fail to understand the critical and life-threatening natures of eating disorders. They are ignorant of the insidious, all-consuming chronic behavioral symptoms of eating disorders and fail to recognize the connection between long-standing symptoms and the poor prognosis for recovery. The managed-care templates for treatment of eating disorders is too simplistic: globally assuming all bulimics are alike and all anorexics are alike and that all should be treated on an outpatient short-to-intermediate-term basis with antidepressants and cognitive-behavioral treatment. They fail to recognize that, in some, the self-destructive behavior may be beyond behavioral control in an outpatient setting, and may have to be treated in an inpatient setting in order to redirect the behavioral dyscontrol, reduce the chances of chronicity and enhance the prognosis for long-term success. Bulimics and anorexics may not be overtly suicidal, but eating disorders lead to death more often than any other psychiatric condition, even major depression.

What can you do to help change these insufficient and life-threatening policies? Write or call your insurance company administrators when any kind of care, inpatient or outpatient, is not authorized based on their indirect, impersonal, non-specific medical review. They do not know you or your patient. No matter how specific their checklist or their knowledge of the literature on disorders is, they do not work with the specific individual in need of the treatment requested by the professional. Don’t hesitate to contact legislators in your district and inform them of insurance controls over your health care that limit treatment inappropriately. Don’t take no for an answer when you know what you need!

Marla M. Sanzon, Ph.D., P.A. Annapolis, MD