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Persuasive Information for Insurance Companies

Securing Eating Disorders Treatment:
Unfortunately, some patients and families frequently have to fight to get the appropriate and necessary treatment for eating disorders. Here are some arguments to use when trying to secure treatment from an insurance provider or another third party.

Provided by the National Eating Disorders Association, NEDA
Ammunition for Arguments with Third Parties
by Margo Maine, Ph.D.

Arguments:

1. A full-course of treatment is cost-effective for eating disorders.

Between 1985 and 1998 re-admissions of ED patients have increased steadily as the length of stay has become briefer and weight at discharge has been lower. Halmi et al (2000)

Patients with anorexia who reached 98% of their initial body weight prior to discharge from inpatient less likely to relapse than those who only achieved 83% of their initial body weight. (Program completion means= abstinence from bingeing and purging and maintaining their weight for two weeks). Halmi and Licino (1989)

A comparison study of 14 patients with anorexia nervosa who achieved normal weight (96% of their initial body weight) to eight patients who reached only 76% of their initial body weight concluded that achieving IBW has better clinical course and may be more cost-effective in long run, especially in light of costs of medical problems (osteoporosis, infertility, dehydration, electrolyte imbalances, cardiac and other compromises). Baron et al (1995)

96%
Length of stay: 116 days
Menstrual disturbances: 21%
Rehospitalization: 7%
Persistent anorexic symptoms: 19%

76%
Length of stay: 46 days
Menstrual disturbances: 62%
Rehospitalization: 62%
Persistent anorexic symptoms: 57%

2. Specialized treatment for eating disorders is preferable and cost effective. Specialized treatment reduces mortality. Crisp, Callender, Halek and Hsu (1992)

3. Recovery takes place over a long period of time. "The course of anorexia nervosa is protracted" p.339.

76% of the sample that was studied for 10-15 years after admission met criteria for full recovery, but time to recovery ranged from 57-74 months; 10% met criteria for partial recovery. Strober, Freeman, Morrell (1997)

4. Treatment of bulimia is effective.

Patients with bulimia demonstrate a better recovery rate if they receive treatment early in their illness.

If treated within the first five years, the recovery rate is 80%.

If not treated till after 15 years of symptoms, recovery falls to 20%. Reas et al (2000)

5. Even successful treatment has an uneven course.

Six year follow-up of 196 female bulimic patients indicate 59.9% had achieved a good outcome; 29.9% poor, and 1.1% deceased.

The course of recovery is uneven, with a decline during the two years after intensive inpatient treatment, then later improvement and stabilization. Fichter and Quadflieg (1997)

6. Eating disorders are serious and lethal.

An analysis of 42 different studies of patient mortality, finding 178 deaths in 3,006 patients. 54% from complications of ED, 27% suicide, 19% other/unknown.

This mortality rate of is 12 times greater than the general death rate for women aged 15-24 and the suicide rate is 75 times greater. Sullivan (1995)

7. The mortality rate increases with the duration of symptoms.

The mortality rate at 5 years is 5%, increasing to 20% at 20 year follow-up. APA (2000)

8. Comprehensive and long term treatment does "pay off."

Outcome studies following patients for 5-10 years indicate a mortality rate of 5%. Studies of patients followed for 20-30 years find 18% mortality rate from anorexia or suicide.

Treatment is useful! Of those followed 5-10 years, up to 50% of the sample had recovered, 25% improved with some residual symptoms, and 25% remain ill or die. Garfinkel (1995)

9. Younger patients require intense and aggressive treatment.

"Because of the potentially irreversible effects of an eating disorder on physical and emotional growth and development in adolescents, because of the risk of death, and because of the evidence suggesting improved outcome with early treatment, the threshold for intervention in adolescents should be lower than in adults". P. 477. Irreversible risks include growth retardation, the delay or arrest of puberty, impaired acquisition of peak bone mass, and an increased risk of osteoporosis. Society for Adolescent Medicine (1995)

10. Utilization of mental health benefits may offset high medical costs associated with eating disorders.

APA Practice Guidelines (1993)
The APA American Psychiatric Association reports these medical findings:

The physical consequences of eating disorders include all serious consequences of malnutrition, especially cardiovascular compromise.

Prepubescent patients may have arrested sexual maturity and a failure to grow.

Even those who "look and feel deceptively well", with normal EKG's may have cardiac irregularities, variations with pulse and blood pressure, and are at risk for sudden death. Prolonged stoppage of menstruation, called amenorrhea (>6 months) may result in irreversible osteopenia, or low bone density and a high rate of fractures.

Abnormal CT scans of the brain are found more than 50% of patients with anorexia.

Bulimic behaviors may result in electrolyte, fluid and mineral imbalances, which may present cardiac risk; gastric irritation and bleeds; large bowel abnormalities; dental enamel erosion; peripheral muscle weakness, weakness of the heart muscle (cardiomyopathy); and a dangerously low metabolism (hypometabolism.)

Despite normal weights a bulimic can be starving and severely malnourished.

APA Practice Guidelines (January 2000)
Level of Care Criteria for Patients with Eating Disorders

APA Practice Guidelines (January 2000)
Level of Care Criteria for Patients with Eating Disorders (A) (B)
Characteristic Level 1:
Outpatient
Level 2:
Intensive Outpatient
Level 3:
Partial Hospitalization

(Full-Day Outpatient Care)
Level 4:
Residential Treatment Center
Level 5:
Inpatient Hospitalization
Medical complications Medically stable to the extent that more extensive medical monitoring, as defined in levels 4 and 5, is not required. Medically stable to the extent that intravenous fluids, nasogastic tube feedings, or multiple daily laboratory tests are not needed. For adults: heart rate less than 40 bpm; blood pressure greater than 90/60 mm Hg; glucose less than 60 mg/dl; potassium less than 3 meg/liter; electrolyte imbalance; temperature less than 97.0 F; dehydration; or hepatic, renal, or cardiovascular organ compromise requiring acute treatment. For children and adolescents;: heart rate in the 40s; orthostatic blood pressure changes (less than 20 bpm increase in heart rate or greater than 10-20 mm Hg drop); blood pressure below 80/50 mm Hg; hypokalemia or hypophosphatemia.
Suicidality No intent or plan Possible plan but no intent Intent and plan
Weight as % of healthy body weight (for children, determining factor is rate of weight loss)(C) less than 85% less than 80% less than 75% greater than 85% greater than 75% (for children and adolescents; acute weight decline with food refusal even if not less than 75% below healthy body weight)
Motivation to recover, including cooperativeness, insight, and ability to control obsessive thoughts Fair to good Fair Partial; preoccupied with ego-syntonic thoughts more than 3 hours a day; cooperative Poor to fair; preoccupied with ego-syntonic thoughts 4-6 hours a day; cooperative with highly structured treatment Very poor to poor; preoccupied with ego-syntonic thoughts; uncooperative with treatment or cooperative only in highly structured environment
Comorbid disorders (substance abuse, depression, anxiety) Presence of comorbid condition may influence choice of level of care Any existing psychiatric disorder that would require hospitalization
Structure needed for eating/gaining weight Self-sufficient Needs some structure to gain weight Needs supervision at all meals or will restrict eating Needs supervision during and after all meals or nasogastric/special feeding
Impairment and ability to care for self; ability to control exercise Able to exercise for fitness, but able to control compulsive exercising Structure required to prevent patient from compulsive exercising Complete role impairment, cannot eat and gain weight by self; structure required to prevent patient from compulsive exercising
Purging behavior (laxatives and diuretics) Can greatly reduce purging in non-structured settings; no significant medical complications such as ECG abnormalities or others suggesting the need for hospitalization Can ask for and use support or use skills if desires to purge Needs supervision during and after all meals and in bathrooms
Environmental stress Others able to provide adequate emotional and practical support and structure Others able to provide at least limited support and structure Severe family conflicts, problems, or absence so as unable to provide structured treatment in home, or lives alone without adequate support system
Treatment availability/living situation Lives near treatment setting Too distant to live at home
A. Adapted from La Via et al. (245)

B. One or more items in a category should qualify the patient for a higher level of care. These are not absolutes, but guidelines requiring the judgment of physicians.

C. Although this table lists percentages of healthy body weight in relation to suggested levels of care, these are only approximations and do not correspond to percentages based on standardized tables. For any given individual, differences in body build, body composition and other physiological variables may result in considerable differences as to what constitutes a healthy body weight in relation to "norms." For some, a healthy body weight may be 110% of "standard," whereas for others it may be 98%. Each individual's physiological differences must be assessed and appreciated.

Bibliography

American Psychiatric Association (1993). Practice guideline for Eating Disorders. American Journal of Psychiatry, 150 (2). 212-228.

American Psychiatric Association (2000). Practice guideline for the Treatment of Patients with Eating Disorders (Revision). American Journal of Psychiatry. 157 (1). January Supplement 1-39.

Baran, S.A. Weltzin, T.E., Kaye, W.H. (1995). Low discharge weight and outcome in anorexia nervosa. American Journal of Psychiatry. 152. 1070-72.

Crisp, A.H., Callender, J.S. Halek, E., Hsu, K.G. (1992). Long-term mortality in anorexia nervosa: A 20 year follow-up of the St. George's and Aberdeen Cohorts. British Journal of Psychiatry. 161 104-7

Fichter, M.M. and Quadflieg, N. (1997). Six-Year Course of Bulimia Nervosa. International Journal of Eating Disorders. 22 (3). 361-84.

Garfinkel, P.E. (1995). Eating Disorders. In H.I. Kapper, F. (2000). The Changing epidemiology of hospitalized eating disorder patients. Paper presented at Academy of Eating Disorders, NY, May 4-7, 2000.

Halmi, K., Licino, E. (1989). Outcome: Hospital program for eating disorders, in C.M.E. Syllabus and Proceedings Summary. 142nd Annual meeting of American Psychiatric Association, Washington, D.C.

Mehler, P.S., Anderson, AE (1999). Eating Disorders: A Guide to Medical Care & Complications. Baltimore, MD: Johns Hopkins University Press.

Reas, D. L., Williamson, D.A., Martin, C.K., Zucker, N.L. (2000). Duration of illness predicts outcome for bulimia nervosa: A long-term follow-up study. International Journal of Eating Disorders. 27 (4) 428-34.

Society for Adolescent Medicine (1995). Eating Disorders in Adolescents: A positoin paper of the Society for Adolescent Medicine. Journal of Adolescent Health, 16. 476-80.

Strober, M., Freeman, R., and Morrell, W. (1997). The Long-Term, Coruse of Severe Anorexia Nervosa in Adolescents: Survivial Analysis of Recovery, Relapse, and Outcome Predictors Over 10-15 Years in a Prospective Study, International Journal of Eating Disorders, 22 (4). 339-60.

Sullivan, P.F. (1995). Mortality in Anorexia Nervosa, American Journal of Psychiatry, 152. 1073-74.
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