According to a June 29th article by Sam PK Collins for Thinkprogress.org., “last week, Missouri Gov. Jay Nixon (D) signed a bill that explicitly states the types of eating disorder treatments insurance providers must cover. The new law builds on the mental health parity law by expanding the definition of “medically necessary” to include mental health treatment. It will also ensure that weight no longer serves as the sole determinant for whether someone may continues treatment. Insurance companies have until 2017 to implement the changes.”
Virtually every day our Medical Director, Dr Moshtael, and I have stressful, time consuming and pointless “peer-to-peer” conversations with insurance doctors (typically adult psychiatrists) whose job it appears is to limit their employer’s (i.e. the insurance company’s) exposure to payment for medically necessary treatment. Leaving aside the likely motivation (money, perhaps?) for a physician acting in the interest of an insurance company rather than in the interest of young patients, (which I have written about before), in our extensive experience insurance coverage for Partial Hospital (aka day treatment) or Intensive Outpatient level of care is commonly denied based solely on weight of the patient.
For example, even if we have successfully weight restored – or even partially weight restored a child – insurance companies will often refuse further care, despite the fact that the patient is still tortured by their illness: refusing and/or hiding food, depressed, refusing to eat or socialize with other kids, having temper tantrums, over-exercising secretly or even openly. In vain do we argue with the insurance company’s medical mercenaries that – critical as weight restoration is – anorexia nervosa is not just about weight! In order for a patient not immediately to begin restricting again on discharge, psychological healing and parental understanding of the safeguards must be in place. This takes time and can be difficult to accomplish, one of the reasons these are such serious illnesses.
To assert that care is not “medically necessary” is disingenuous. What do they mean when they say “does not meet ‘medical necessity’ criteria?” Mostly they mean “she’s/he’s not thin enough.” Well, that attitude is all very well for someone who knows nothing about mental illness, brain disorders in general or eating disorders in particular, but it is totally unacceptable in a psychiatrist, in my opinion. To anyone who treats eating disorders, it is clear that a person’s weight is only one measure of how affected they are.
And the situation is much worse for children, teens and young adults who have binge eating disorder or bingeing and purging eating disorders. If they are not severely underweight the insurance companies often denies them care. We argue – usually in vain – that bingeing and purging will not usually result in severe underweight (absent restricting), and yet are a dangerous form of the illness. Mostly they do not care. “Not being underweight enough” is merely the concrete excuse they hang their hat on in order to deny paying for treatment, under the guise of not being “medically necessary”. And now it would appear that, in one legal blow, Missouri has been freed of this farce.
Oregon? Washington? Idaho? California? Are you listening? Parents and providers: time to call your elected representatives!
