I must admit that I cringe slightly every time I try to think about healthcare from an economics perspective. To me, this comes a little close to putting a dollar value on human beings, which feels uncomfortably post-humanistic to me. Nonetheless, there is no ignoring the ways in which economic concerns factor into policy decisions that drive our human services, including health care.
There are also a number of pragmatic reasons for thinking about the costs associated with illnesses; talking in dollars and cents can make for a convincing argument when seeking funding to do research on a particular illness, for example. The ability to reduce healthcare costs is incredibly compelling in a time of fiscal restraint.
Crow (2014) published a short article about the economic costs of eating disorder treatment. In this article, he highlights some recent studies that have examined factors related to “the economics of eating disorders” and suggests avenues for future research in this area.
I will preface my analysis by noting that healthcare economics are not my area of expertise, and I doubt that my university introductory micro- and macro-economics courses prepared me to present an in-depth deconstruction of healthcare costs for individuals vs. systems. I can, however, logic out some of the basics of “eating disorder economics” in a way that I hope will be thought-provoking, and I am open to discussion in the comments.
The conclusion that eating disorders cost a lot seems perhaps an obvious one. Ignoring, for now, the non-financial costs of eating disorders, anyone who has sought private treatment for eating disorders can tell you that it is not cheap.
Costs for individuals vs. costs for systems vary widely based on where you live and what kind of health care and insurance you have available. One example that comes to mind when I think about the costs of treatment is a recent (and ongoing) Indiegogo campaign, where a mother sought to raise $60 000 to enable her daughter to seek intensive treatment for chronic anorexia. Keep in mind that this is a Canadian example; some who has joked about “moving to Canada” for the “free health care” might be surprised to learn that “universal healthcare” does not mean that all services are covered, 100% of the time.
I was asked, when this campaign came out, whether this amount of money seemed standard for four months of treatment. Sadly, the only answer I could give was yes. Though my own treatment was covered by the Ontario Health Insurance Plan, I was always aware that this treatment was not “free”; somebody is always paying, be it the government, the individual, or a third party insurance company. Psychiatric care, dietician consultations, meal services, and other therapy all cost; often, they cost quite a bit.
This huge digression is all to say: it’s complicated. When you talk about money and health, you’re bound to stumble upon irreconcilable differences about who should be footing the bill. I will try to refrain from injecting too much opinion about this particularity, and move now to Crow’s article.
How much does eating disorder treatment really cost? As I alluded to above, I’ve found some to be a bit incredulous that 4 months of treatment could possibly cost $60 000. Crow introduces studies that have looked at this, primarily from a cost-effectiveness standpoint.
Cost-effectiveness analysis in some ways avoids the kind of “ick” factor I feel about monetizing people; instead, analysts compare different methods of delivering healthcare and look for a ratio of the costs to produce a gain in health over the health gains (e.g. years of life).
Ultimately, however, the studies Crow introduces look to determine what direct and indirect costs are involved in care for eating disorders. These studies might be helpful, for example, in determining whether one form of treatment is more cost-effective than another, resulting both in financial savings and more effective treatment.
In the context of a larger randomized controlled trial of individuals being treated for anorexia nervosa, Stuhldreher et al. (2012):
- Looked at direct (e.g. cost of hospitalization, etc.) and indirect (e.g. being absent from work, etc.) costs linked to eating disorders
- Found that costs totaled 5866 per patient per 3 months, and were mostly direct and related to hospitalization (approximately 3374 Euros)
Looking specifically at a randomized controlled trial of bulimia nervosa treatment, Crow et al. (2013):
- Compared cognitive behavioral therapy treatment (with or without Fluoxetine) and stepped care (from guided self-help, to Fluoxetine, to CBT) over 62 weeks
- Found that the cost for stepped care cost $12 146 (US dollars) per patient and CBT cost $20 317 per patient
Examining cost in a German health care setting, Haas et al. (2012) explored costs associated with hospitalization for AN and:
- Noted a mean cost of 4647 euros per patient
- Of this, 40% was allocated to nursing costs, 20% to overhead, 16% to therapist costs and 12% to physician costs
Wang et al. (2011) looked at a prevention program aiming to simultaneously reduce the incidence of disordered eating and obesity (Planet Health). They were interested in projecting the costs saved by preventing cases of bulimia. To be honest, I am not sure how much I buy into a projection analysis of the impact of prevention programs- to me there are far too many other factors that could impact the long term impact of these programs, especially a program targeted toward girls 10-14.
Nonetheless, the authors are fairly conservative in their estimates, arguing that this program would likely prevent 1 case of BN, saving $33 999 and 0.7 years of life, adjusted for quality of life. The Crow article reports on the article’s broader conclusion that a combined eating disorder and obesity prevention program would net $14 238 in savings and 4.8 years of life gained; I imagine that this thus reflects results for “obesity prevention.” Again, I would be very cautious in using these results to support arguments for the long-term effectiveness of prevention initiatives.
Societal Perspective Analysis
Looking beyond dollars and cents, Crow notes that eating disorders may also have indirect costs like lost time. Citing a study by Raenker et al. (2013) that focuses primarily on the parents and partners of individuals with eating disorders. Raenker and colleagues found that, in the month prior to hospital admission:
- Mothers spent an average of 90.6 hours providing care
- Fathers spent an average of 72 hours providing care
- Partners spent an average of 72 hours providing care
Though the Raenker et al. study has implications for indirect costs of eating disorders, the authors also focused on the type of support caregivers providers (primarily emotional) and received, and how this impacted their own feelings of distress.
Beyond the results of this particular study, it takes only a glance at the literature on quality of life and well-being for individuals with eating disorders and their loved ones to reveal compelling arguments for the non-financial costs of eating disorders.
Crow also discusses ongoing steps toward better understanding cost effectiveness and eating disorders. These include:
- A study by Goddard et al. (2013) about the Experienced Carers Helping Others (ECHO) study, a self-help intervention for day and in-patients with AN
- A study by Schmidt et al. (2013) about the MOSAIC study, wherein adults with AN are randomized to Maudsley model anorexia nervosa or Specialist Supportive Clinical Management
- A study by Bulik et al. (2013) comparing online vs. face-to-face CBT for BN
Overall, it would appear that researchers and policy makers are interested in learning more about the costs associated with eating disorders. I am still reticent to assign dollar values to eating disorder cases and treatment; to me, the human costs are much more compelling. I can’t begrudge this kind of work, however, because I do think that a fiscal argument tends to be compelling, especially to those who decide what funding goes where (primarily, the government…).
If these kinds of studies help to demonstrate the toll that eating disorders can take not only on individuals’ lives but on individual and national pocketbooks and thus direct more funding toward finding more effective solutions for eating disorders, I think they are well warranted.
What I would caution against, however, is reducing eating disorder “costs” to the financial. I do not believe that any of the studies Crow refers to, nor the Crow article itself, is doing this; I am worried about how these arguments could be taken up. I would also be cautious in advocating for one form of treatment over another because it is more “cost-effective.” Just because a type of treatment is “cost-effective” for one (or many) people does not mean it will work for all. Because I like to be a broken record, I will reiterate: one size simply does not fit all, in eating disorder treatment.
So, readers, what do you think of taking an economics perspective on eating disorders? Do the figures surprise you, or are they in line with what you would expect?
Crow, S. (2014). The economics of eating disorder treatment. Current psychiatry reports, 16 (7) PMID: 24817201