Should insurance companies cover residential treatment for eating disorders? The price tag is high, about $1,000/day on average, but evidence of treatment effectiveness is astonishingly low. Practically nil, as I’ve recently discovered. Despite spending my free time punching away different keywords into the PubMed search bar, I came up with very little. And you know what I think? I think treatment centers should be embarrassed. And I think, wow, maybe insurance companies have a point? (A scary thought! I don’t actually think they do, though – but then, I just can’t wrap my head around for-profit healthcare, having lived all my life with socialized healthcare, and loving it.)
Carrie over at ED-Bites recently blogged about the fact that there a dearth of evidence-based treatment for eating disorders. It is a complicated issue, I know, but I do think that any organization or center that offers treatment (especially at such a high price) has no excuse when it comes to providing information about the effectiveness of its programs. I’ll repeat that: they have no excuse. So, can I blame heartless insurance companies in denying coverage for pricey, evidence-deficient treatment centres? I don’t know.
But enough ranting. What do we know about residential treatment centres (in the US)?
A study by Brewerton & Costin (2011) examined the long-term outcome of patients who “graduated” from Monte Nido Residential Treatment. They followed-up on patients, on average, 4.6 and 3.8 years after discharge, for anorexia and bulimia, respectively.Overall, the results were OK. The majority of AN and BN patients showed good or intermediate improvement:
- 89% for AN (42% good, 47% intermediate)
- 75% for BN (61% good, 14% intermediate)
But what did the authors consider good and intermediate improvement?
For AN: “good” outcome meant BMI of 18 or above and resumption of normal menses, and “intermediate” outcome meant either a BMI of 18 or above *or* restoration of menses. For BN: “good” outcome meant complete cessation of bingeing and purging, and “intermediate” outcome meant a reduction by at least 50%. Really?
Let me just make this clear: the severity and negative effects of an eating disorder are not captured by BMI, menstruation status, or simply the frequency of bingeing and purging.
And keep in mind: these are people who graduated (successfully completed > 30 days of treatment). What about all the patients who dropped out or were kicked out?
Moreover: there’s no control group. These numbers are relevant only in light of a similar group of patients, evaluated 4-4.5 years later, with no treatment, or non-residential treatment (outpatient, inpatient, day-program).
Finally, the results were gathered using mail-in and Web-based surveys. It is not exactly difficult to fudge your answers (knowingly or unknowingly). I mean, who would really want to admit that after spending 30K+ on treatment (at least!) you are still struggling? Psychologically, that’s hard to do.
Brewerton only evaluated one treatment center.
Maria Frisch however, wanted to find out more about residential treatment centers (RTCs) in general. In particular, she was interested in determining who are the people who seek and partake in this type of treatment? What is the average length of stay and how much does it cost? What therapies and treatment methods to various centers offer? What is the growth rate of residential treatment centers and finally, do they provide any information about treatment outcome?
Keep in mind, the information in this study is from 2004. That’s 8 years ago.
In a 15-year retrospective record review of patients treated at an eating disorders program in a large metropolitan area, Wiseman et al. found a decrease in inpatient average length of stay (LOS) from 149.5 days in 1984 to 23.7 days in 1998. In addition to shortened stays, Kaye et al. found that managed care companies often limit coverage for the treatment of eating disorders, leaving individuals responsible for the cost of more intensive rehabilitation after medical stabilization.
Frisch contacted 22 residential treatment centres that fit the study inclusion criteria. The authors also used information available on the program websites and brochures made available. The list of treatment programs contacted is shown in Table 1 below. “Three programs refused to participate…. one program initially agreed to participate, but then declined after reviewing the required survey, stating they ‘‘did not give out that type of information.’’ The other two programs did not respond to any contact regarding the current study.”
Was anyone else furrowing their eyebrows? I certainly was! To me, it is akin to selling a pharmacological drug and refusing to say how effective it is, what the side-effects are, what the right dosage is, and so on. Frisch didn’t mention which centers refused to participate.
From the 18 treatment centers that were eligible and chose to participate, this is what Frisch found:
SUMMARY OF MAIN FINDINGS
- Eating disorders treated: Only 13 residential programs treated EDNOS (all treated anorexia and bulimia nervosa), 11 treated binge eating disorder (I wonder what the number is now, especially with it being included in the next DSM)
- Males accepted for treatment: only 4 out of 18 programs accepted males. (I wonder what the number is now, thoughts?)
- Average length of stay: 83 days
- Average age: 22; Average youngest: 14; Youngest: 8; Average Oldest: 40; Oldest: 65
- Average cost/day (2004 #’s): $956 US Dollars
- That means, in 2004, the average cost of residential treatment was: $79,348
Types of staff employed
(Data is available for only 16 RTCs here)
- All staffed nonpsychiatric physicians and registered dietitians
- One RTC did not have a psychiatrist on staff, and one RTC did not have a registered nurse (could be same RTC)
- 13 had doctoral-level therapists, 11 had staff with a Master’s of Social Work
- 9 had “holistic staff” (I put that in quotes because I don’t understand what that means)
- 8 had teachers, and 6 had bachelor’s level social workers and doctoral-level researchers
Most commonly employed traditional and alternative therapies
- All RTCs (18) had individual, group and arts-based therapy.
- Traditional therapies: 16 offered cognitive-behavioural therapy (CBT), 15 provided family therapy, 9 had a 12-step program, 6 and 3 provided dialectical-behavioural therapy (DBT) and interpersonal therapy (IPT), respectively.
- Alternative therapies: 13 had dance, 12 provided yoga, and 7 and 5 provided music and equine therapy, respectively.
- 17 out of 18 RTCs incorporated “spirituality” into their treatment
- 2 RTCs based their treatment on a specific religious belief
Although almost all centers offered CBT, the average amount spent on CBT a week was a meager 29 minutes. Compare that to art-therapy: 262 minutes, on average, or the 12-step program: 208 minutes. Spirituality, recreational therapy, meditation, yoga, nutrition, dance, equine, music, journaling and “food/feelings” therapy average out to more minutes a week per patients than CBT, DBT, family or relapse prevention.
Really? Need I say more? Now, I’ve never done any of that, but, I think it is not unreasonable to expect more time spent in therapies that have shown some promising results, like CBT and family therapy, compared to the religious-based 12-step program, or art therapy.
Art is great, don’t get me wrong. I used to do lots of it and I love it. But, this is treatment, not a vacation. No wonder people do well: they are in a controlled, relatively stress-free environment. Can you really do 262 minutes of art therapy once you leave treatment? Combined with all the other alternative therapies? I have my doubts.
What about building skills and tools to deal with real-life stresses, relapses (which are likely to happen), and eating when there’s no one there to watch you and lock the bathrooms after meals?
I started out by stating that I’m pretty baffled at the lack of transparency and accountability on the part of RTCs, and judging by the tone, I think Frisch agrees:
Sixty-one percent of all programs reported using some type of data to evaluate the effectiveness of their treatment program. Of these 61%, 63.6% of programs used self-report surveys to gauge treatment effectiveness, 36.4% used outcome studies, 18.2% used laboratory tests, and 18.2% used program-initiated telephone calls. Some programs used more than one of the previous listed methods.
Greater than one third (36.4%) of the programs evaluating treatment effectiveness relied only on client-initiated posttreatment telephone calls for effectiveness measures. Thirty-nine percent of all programs did not provide information on the measures used to determine treatment effectiveness.
You’ve got to be kidding me.
Here’s my advice (and it is the same advice I gave on picking a charity): look for transparency, accountability and evaluation of treatment effectiveness when picking an RTC for treatment. If you are going to spend money on treatment, be as confident as you can be that it is effective. Be very suspicious if someone at the RTC tells you that “they don’t give out that kind of information” or that they “don’t collect that information”.
Frisch concludes with this,
One third of all programs evaluating treatment effectiveness relied only on client-initiated, posttreatment telephone calls as a measure of treatment effectiveness.
Although this may meet the requirement of treatment outcome research within some programs, it does not meet the standards of more universal claims of effectiveness… It is important for both patients with eating disorders and their families to appeal that such studies be conducted. Given the length and expense of residential treatment, effectiveness data are crucial.
I completely agree.
But back to question of whether insurance companies should cover RTCs: I think despite the lack of research on the utility and effectiveness of RTCs, it is evil and immoral to deny treatment that does benefit the majority of patients to those who desperately need it. It is a complex topic, and not one I can fully unravel in a few paragraphs, but my general opinion is that RTCs, if anything, are good for symptom stabilization. And, spending a few month in a stable environment is rarely a negative, mentally or physically. Are they all they are made out to be? Probably not. Can they improve? Of course. But, it is evil to deny someone treatment for an illness that can, frankly, kill them, especially if other avenues are unavailable or haven’t been successful.
Readers, I’m really interested in hearing about your experiences with residential treatment centers. Have they been of benefit to you/your loved ones? Please share any positive or negative experiences you’ve had.
(Sidenote, this entry is US-centric, because, well, the studies I found were limited to RTCs in the US.)
Brewerton, T.D., & Costin, C. (2011). Long-term outcome of residential treatment for anorexia nervosa and bulimia nervosa. Eating Disorders, 19 (2), 132-44 PMID: 21360364
Frisch, M.J., Herzog, D.B., & Franko, D.L. (2006). Residential Treatment for Eating Disorders International Journal of Eating Disorders, 39, 434-442 DOI: 10.1002/eat.20255