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Eating Disorders

Review decisions relating to eating disorders, a subset of mental health appeals in our study, illustrate some of the dangers of an over-reliance on outpatient treatments in today's managed care environment. During the six month period of our study, IROs considered 11 eating disorder appeals and overturned seven of them.

According to the American Dietetic Association (ADA), more than 5 million Americans suffer from eating disorders. Five percent of females and one percent of males have anorexia nervosa, bulimia nervosa, or binge eating disorder. An estimated 85 percent of all eating disorders, now the third most common chronic illness in adolescent females, begin during adolescence.(1)

Eating disorders involve both physical deterioration and mental illness, such as depression, anxiety, and obsessive behavior. As a result, treatment for these disorders must focus both on mental and physical health. The ADA recommends an interdisciplinary team composed of professionals from medical, nutritional, and mental health disciplines to manage and assess eating disorders. According to the ADA, medical nutrition therapy and psychotherapy are two integral parts of treating eating disorders, especially since the patient may require continued psychological support even after recovering medically in order to sustain the change.(2)

Like those appeals involving mental illness or substance abuse cases, reviewers based their decisions heavily on the patients' history and chance of recovery outside an inpatient or residential treatment settings. If the patients showed insight into their illnesses, improved mentally and physically during their time spent as inpatients, and had supportive families, the reviewer would uphold the HMO's denial.

But some HMO guidelines appear to rely primarily on weight gain as the trigger to end inpatient care. Independent reviewers looked at both physical and mental capacity to return to a more normal life. In one case, a IR reviewer wrote that while the patient had gained weight and maintained caloric intake, she remained "extremely anxious" about this weight gain, and continued to have obsessive and "distorted illness thoughts." Leaving inpatient care would have been very detrimental to her recovery.(3) According to the ADA, "weight restoration alone does not indicate recovery, and forcing weight gain without psychological support and counseling is contraindicated."(4)
Patients released prematurely from inpatient treatment may land right back in the hospital, even more ill. A 21-year-old woman entered an inpatient care facility on Nov. 21, 2000 due to complications resulting from her eating disorder and depression with suicidal thoughts. The HMO covered nine days of inpatient treatment then discontinued her certification. A TMF reviewer upheld this decision, claiming that due to lack of documentation of her suicidal intent and the fact that her eating disorder was no longer acute, any days after Nov. 30 were not medically necessary.("5)

Within two months the woman was readmitted. According to a new assessment of her case, after leaving the inpatient setting for residential treatment the first time, she felt anxious and overwhelmed when seeing food in the refrigerator and pantry. Her anxiety continued to grow as she gained weight over the next few weeks. Her practice of binging and purging resurfaced, her depression increased, and she attempted suicide in the shower. The residential facility determined that she should return to an inpatient setting on Jan. 30, 2001. The HMO denied the request, but this time the independent reviewer overturned the denial.

"Insurance companies, in general, have failed to recognize the seriousness of eating disorders, which have mortality rates in chronic patients, of up to 20 percent," said the reviewer. This particular patient probably should have stayed longer in her initial inpatient treatment program, as she "manifested most of the risk factors associated with bad outcome and death in this patient population," according to the reviewer, adding that she was unsafe in a residential care facility.(6)

One indicator of inadequate hospital treatment or discharge planning is rapid hospital readmission after discharge. According to a 1996 study of quality indicators in the managed behavior health care industry (and cited by the U.S. Surgeon General), rapid readmission occurred in 2 percent to 41 percent of discharges depending on the managed care plan. Despite methodological problems, the Surgeon General warned in 1999 that these kind of indicators "raise concerns about real differences in quality" among managed behavioral health plans.(7)

One HMO denied inpatient care to three different women with eating disorders. All three denials were overturned. The IRO found that these patients feared returning home and being around food, continued to express compulsive desires to exercise, and remained depressed and/or suicidal. The reviewers concluded that the women needed to improve in these areas before they could successfully battle their eating disorders in an outpatient or residential setting.(8)

The ADA believes that patients with eating disorders usually progress along these stages: precontemplation, contemplation, preparation, action, and maintenance. The organization warns that "frequent backsliding" among these stages usually occur during a patient's recovery. Thus, premature release from a treatment setting, no matter what that setting may be, could be harmful to the patient.

Because relatively few patients actually pursue independent review of their insurance denials (see discussion, p. 8), we believe that the number and severity of eating disorder cases that came before reviewers during the short period of our study warrants further research, and may indicate a need to examine managed behavioral health plan utilization guidelines for this disease.

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Footnotes:

1. "Position of the American Dietetic Association: Nutrition Intervention in the Treatment of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders not Otherwise Specified," Journal of the American Dietetic Association, Volume 101, No. 7, July 1, 2001, pg. 810. (ADA Statement)

2. ADA Statement, pg. 810.

3. Independent Review, Inc., IRO Decision Letter, Corphealth, 8/24/2002.

4. ADA Statement, pg. 810.

5. Texas Medical Foundation, IRO Decision Letter, BCBS/Magellan, 4/4/2001.

6. Independent Review, Inc., IRO Decision Letter, Magellan, 4/4/2001.

7. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, "Mental Health: A Report of the Surgeon General - Executive Summary," 1999, p. 425. Independent Review, IRO Decision Letter, Pacificare, 6/13/2001. Envoy, IRO Decision Letter, Pacificare, 9/26/2001.

8. ADA Statement, pg. 810.