Insurance: The Greatest Barrier to Recovery

I wondered whether it was too early to write about this topic here, seeing as I’m still building, persuading, cajoling, and outright begging a following for this blog. But because this issue is so critical, I will probably end up writing about it again anyway (and again, and again, and again…).

Insurance coverage.

In the eating disorder world, I have yet to see a bigger obstacle to recovery.

That might sound hyperbolic, but I assure you it is the truth. Eating disorders are insidious, complex, deadly illnesses that are notoriously difficult to shake. As far as anorexia goes, an estimated 5-10% of anorexics will die within 10 years of contracting the illness, 18-20% will die within 20 years, and only 30-40% will ever fully recover. Bulimia and EDNOS are no less deadly. In general, eating disorders have the highest mortality rate of any mental illness. Moreover, these illnesses do not resolve on their own—left untreated, they will get worse.

Thankfully, treatment exists. This typically involves a team consisting of a therapist, nutritionist, physician, and possibly a psychiatrist to address the psychological, physical, and nutritional needs of eating disorder patients. In serious cases, patients require aggressive, systematic interventions that involve descending levels of care. Patients begin either on an inpatient unit or in a residential care facility, and then move down to partial hospitalization programs, intensive outpatient programs, and finally outpatient care.

However, treatment is prohibitively expensive—a single day of residential treatment can cost well over $1,000, and many patients require weeks or even months in these facilities before stepping down. All said and done, treatment can plunge patients or their families into hundreds of thousands of dollars in debt.

And most private insurance companies do not even come close to sufficient coverage.

In her article “A Time to Heal: Eliminating Barriers to Coverage for Patients with Eating Disorders Under the Affordable Care Act,” law student Sarah Hewitt writes that insurance companies use several tactics to get around costs, for instance, by treating mental illnesses differently than physical illnesses and setting stringent criteria just to qualify for treatment. Many companies make decisions about which level of care they will cover based on the “medical necessity” for a patient’s treatment (a vague term that seems to draw the line somewhere around “not close enough to death”).

If they opt to cover any treatment at all, insurance companies typically limit the number of covered therapy sessions, days in treatment facilities, and appointments with nutritionists and psychiatrists. When I was in residential treatment, it was not uncommon for a woman to arrive at our facility only to be cut be by her insurance company a mere week, and sometimes just days, later. Her team would appeal the decision, but they almost never won.

If all of this is not bad enough, insurance representatives sometimes blatantly misinform patients about coverage (as Hewitt says, “either willfully or due to insufficient training”). This was the disheartening reality in my case. For an extremely stressful two weeks in January, my treatment team fought with my insurance company, Empire Blue Cross Blue Shield, to allow me to use a benefit called “transitional living” (a benefit that was already in my plan). This meant that Empire would cover program costs and meals, and I would pay for my room and board (not cheap, mind you). For some reason, Empire kept denying me this option. Losing hope, I called my case manager to advocate for myself and explain why I needed this care. The case manager not only denied that my treatment team asked to use that benefit, but very sweetly told me that my team had never recommended residential treatment at all.

(NOTE: I will write another post detailing the fight my team and I put up to get me into residential treatment—it’s quite the story.)

The Affordable Care Act has made strides in improving coverage for mental health services, but there remain gaping loopholes when it comes to eating disorders—the deadliest of all psychiatric illnesses—and insurance companies are experts at finding and using them.

These companies have vastly too much say in what are literally life and death decisions. Even now, every woman in my current program fears the words “insurance review”—the day her team needs to ask insurance for more days in treatment—because this means that the future of her recovery hangs in the balance. Her team will make every possible argument in her favor, emphasizing the importance of seeing treatment through to the end, yet these recommendations seem to fall on deaf ears. Decisions are instead made based on whether a patient is in imminent physical danger. And this assessment is based not on clinical observations and expert opinions, but rather, on pure numbers—whether a patient is at a dangerously low weight, or whether she is just slightly underweight or even at a healthy weight.

In the end, the majority of the women who leave our treatment program are discharged not because they have made any significant steps toward recovery, but because their insurance companies cut them off. Some of these women promptly relapse and wind up right back in treatment (which, I imagine, hardly saves costs on the insurance company’s part).

And I see this happen over, and over, and over again.

How are we supposed to break free from our obsession with weight and numbers if that is what our benefactors exclusively focus on? How are we supposed to admit that we are sick and need help (which many of us don’t admit) if these authorities are telling us precisely the opposite? How are we supposed to recover if we are not even given a chance?

The insurance coverage situation needs to change, and it needs to change now.

---

© The Middle Ground, 2014. Unauthorized use and/or duplication of this material without express and written permission from this blog’s author is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to the article’s author and The Middle Ground with appropriate and specific direction to the original content.