Memorandum
Date: July 26, 2017
To: Laurel Fuller, ASPE at parity@hhs.gov
From: Katrina Velasquez, Policy Director, Eating Disorders Coalition
Re: July 27th, 2017 Public Session Plan for Oral Comments
Thank you for this opportunity to speak on behalf of treatment providers as well as families and individuals affected by eating disorders. The Eating Disorders Coalition is a national nonprofit comprised of eating disorders treatment providers, researchers, advocacy organizations, and individuals and families affected by eating disorders. Eating disorders affect over 30 million Americans during their lifetime and have the highest mortality rate out of any psychiatric illness. This illness is very complex, requiring intensive medical surgical and mental health treatment to help patients reach a full state of recovery.
A. Eating Disorders/Insurance Exclusions
Sadly, when it comes to insurance coverage for people affected by this deadly disorder, we are often the disorder that faces the highest rate of parity noncompliance. As the White House Parity Task Force report noted, there is a general lack of awareness of the need for mental health and substance use disorder services, in particular for eating disorders. One listening session highlighted insurance regulators from three states with rural populations noting the cultural believe that these disorders are true medical issues, leads to automatic denial for many insurance claims. We regularly see this for eating disorders, with some insurers placing eating disorders under excluded categories related to weight loss, instead of the mental illness as they are designated in the DSM 5.
B. Need for Implementation Regulations—21st Century Cures Section 13007
The issues we are discussing today related to enforcement strategies for mental health parity under Cures are directly entwined with Section 13007 which clarifies mental health parity protections for people affected by eating disorders, including the receipt of residential treatment. While we are pleased to see that the Department of Labor issued FAQs clarifying that eating disorders are a mental illness and should in turn receive mental health parity protections, we still need more protections and rulemaking to improve enforcement. We encourage HHS to amend existing regulations to both include those eating disorders FAQs in the regulation.
Additionally, we encourage HHS to heighten enforcement for life-saving intermediate care services by moving the intermediate care provisions within the preamble that affect residential treatment for both eating disorders and substance use disorder to the underlying mental health parity regulation. While there are insurers who go above and beyond to provide parity for eating disorders, we need stronger regulation for those bad apples to enforce what HHS and DOL already believe to be protected under the current mental health parity law for people with eating disorders.
C. Additional Enforcement for New Loopholes
Lastly, we encourage the federal and state commissioners to be in-tuned with and provide additional enforcement for the loopholes these bad apples are using to avoid parity. While there are many different instances we see, I’d like to discuss three loopholes we regularly see:
Examples of Noncompliance
- One example we are often seeing, despite FAQ clarifications, is a reliance on the interim final rules to argue that residential treatment for eating disorders does not need to be covered under mental health parity. This point has been clarified under the final regulations of mental health parity and with later FAQs, however, we continually face battles in court and authorization arguments with insurers that openly make this argument.
- Another example includes insurance providers only writing the primary diagnosis within their systems, and then not providing parity compliance for secondary diagnosis. Eating disorders have a high rate of co-occuring mental illnesses, including 50% of patients with co-occuring substance use disorder. Treating and providing parity for only one of the co-occuring illnesses will provide inadequate treatment and likely lead to re-lapse, and as we often see for people with eating disorders given the medical surgical conditions associated with the illness, will end up in the emergency room.
- And finally, we often see insurers requiring in-person authorization for higher levels of care, while the same requirements are not required on the medical surgical side and instead allow a local provider to authorize treatment. Given that the number of specialized eating disorders treatment centers are limited in the United States, this is a very large program. We have a collection of stories from patients and providers in that the insurers will require ill patients to fly across the nation to receive in-person pre-authorization for treatment before actually authorizing the treatment. This is a huge financial burden to patients and their families and a direct violation of mental health parity.
In conclusion, we need your help now to make the promises of mental health parity real for people with eating disorders. Past agency actions with FAQs, guidance, and loose regulations weren’t enough to keep these promises, so we ask for you to take the next steps to help all the families across the nation who are counting on you to act.
August 10, 2017
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
c/o Ms. Laurel Fuller
U.S. Department of Health and Human Services
200 Independence Ave SW, Room 424E
Washington, DC 20201
Re: Eating Disorders Coalition — Public Listening Session on Strategies for Improving Parity for Mental Health and Substance Use Disorder Coverage
Dear Ms. Townsend, Ms. Turner, Ms. Weiser, and Mr. Mayhew:
On behalf of the Eating Disorders Coalition (EDC), we thank you for the opportunity to provide public comment on improved Federal and State coordination related to section 2726 of the Public Health Service Act (42 U.S.C. 300-gg-26), section 712 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185a), section 9812 of the Internal Revenue Code of 1986, and any comparable provisions of State law. We were encouraged to see participation at the July 27th listening session from health insurance issuers, providers of mental health and substance use disorder treatment, employers, and patients and their advocates. Particularly the presence of federal panelists from ASPE, DOL, Treasury, and CMS were all indications of the current Administration’s determination to enforce and improve existing mental health parity law so to help improve both current opioid epidemic and mental health crisis in our nation.
The Eating Disorders Coalition is a coalition of eating disorders treatment providers, advocacy organizations, researchers, and families and individuals affected by eating disorders across the nation. Members include national patient advocacy, health insurance appeals law firms, and trade organizations such as National Eating Disorders Association (national association, based in NY), Residential Eating Disorders Consortium (national), the Alliance for Eating Disorders Awareness (located in FL), Kantor & Kantor, LLP (located in CA), Wrobel & Smith, PLLP (located in MN), Gail R. Schoenbach FREED Foundation (located in NJ), Binge Eating Disorder Association (national association, based in MD), The International Association of Eating Disorders Professionals Foundation (IAEDP; international), International Eating Disorder Action (IEDAction; international), Multi-Service Eating Disorders Association (located in MA), the Eating Disorders Coalition of Iowa (EDCI; located in IA), Eating Disorders Foundation (located in CO), FEAST (international association, based in WI), International Federation of Eating Disorders Dietitians (international), The National Association of Anorexia and Associated Eating Disorders (ANAD; national association, based in IL), and Harvard University’s public health incubator- Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED; located in MA). Membership also includes eating disorders treatment centers of all treatment levels including Clementine (located in FL, NY, and OR), Eating Recovery Center (located in CA, CO, IL, OH, SC, TX, and WA), The Emily Program (located in MN, OH, PA, and WA), Monte Nido (located in CA, MA, NY, OR, and PA), Oliver-Pyatt Centers (located in FL), Veritas Collaborative (located in GA, NC, and VA), The Renfrew Center (located in CA, CT, FL, GA, IL, MA, MD, NC, NJ, NY, PA, TN, and TX), Reasons Eating Disorder Center (located in CA), Remuda Ranch (located in AZ), Center for Change (located in UT), Laureate Eating Disorders Program (located in OK), Timberline Knolls (located in IL), Cambridge Eating Disorder Center (located in MA and NH), Castlewood Treatment Center (located in AL, CA, and MO), Center for Discovery (located in CA, CT, FL, GA, IL, NJ, NY, OR, TX, VA, and WA), Eating Disorder Center of Denver (located in CO), Eating Disorder Hope (located in OR), Mirasol Eating Disorder Recovery Centers (located in AZ), Park Nicollet Melrose Center (located in MN), Rosewood Centers for Eating Disorders (located in AZ), Walden Behavioral Care (located in CT, GA, and MA), Aloria Health (located in WI), Casa Palmera (located in CA), Eating Disorder Therapy LA (located in CA), The Eating Disorders Center at Rogers Memorial Hospital (located in WI), La Ventana Treatment Programs (located in CA), McCallum Place Eating Disorder Centers (located in MO and KS), and West Virginia University’s Disordered Eating Center of Charleston (located in WV).
A. Eating Disorders Overview:
Eating disorders affect over 30 million Americans during their lifetime1, including people of all ages, races, sizes, sexual orientations, ethnicities, and socioeconomic statuses.2 In particular, studies show that our military servicemembers and veterans have a high prevalence of eating disorders.3 These disorders have amongst the highest mortality rate of any psychiatric illness.4
B. Eating Disorders Can Be Successfully Treated with Appropriate Interventions & Levels-of-Care:
Eating disorders are very complex, biologically-based illnesses including the specific disorders of anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding or eating disorders.5 Eating disorders can be successfully treated with interventions at the appropriate durations and levels-of-care, however, only one- third of those with eating disorders receive any medical, psychiatric, and/or therapeutic care.6 According to the American Psychiatric Association Practice Guidelines, best practice treatment of eating disorders includes patients, their families, and a comprehensive team of professionals such as social workers, mental health counselors, primary care practitioners, psychiatrists, psychologists, dietitians, art therapists, and other specialty providers.7
Successful treatment of eating disorders includes treatment at all levels of care including inpatient, intermediate care, including residential treatment8, partial hospitalization, day program, and intensive outpatient program, and outpatient treatment.9 Particularly, we want to highlight that the intermediate levels of care have been proven to be evidence-based and effective for treating individuals affected by eating disorders, including day programs10, intensive outpatient programs11, partial hospitalization12, and residential treatment.13 For example, one study showed that residential treatment for bulimia nervosa had a 75% success rate over a five year period from treatment.14 Additionally, residential treatment centers for eating disorders abide by very stringent standards of care similar to our nation’s hospitals and behavioral health care organizations, being certified by independent, not-for-profit accreditation organizations including the Joint Commission (JACO) and CARF International.15 The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States including hospitals and behavioral health care centers, and CARF International accredits 50,000 health care programs including rehabilitation and behavioral health centers.
C. Exclusion of Eating Disorders
When it comes to insurance coverage for people affected by this deadly disorder, we are often the disorder that faces the highest rate of parity noncompliance. As the White House Parity Task Force report noted in their October 31, 2016 report, there is a general lack of awareness of the need for mental health and substance use disorder services, for eating disorders. 16 One listening session highlighted insurance regulators from three states with rural populations noting the cultural believe that these disorders aren’t true medical issues, leading to automatic denial for many insurance claims. We regularly see this for eating disorders, with some insurers placing eating disorders under excluded categories related to weight loss, instead of the mental illness as they are designated in the DSM 5.
D. Recommendations
The issues of enforcement strategies for mental health parity under Cures are directly entwined with Cures Section 13007, which clarifies mental health parity protections for people affected by eating disorders, including the receipt of residential treatment. While we are pleased to see that the Health and Human Services, Department of Labor, and Treasury issued FAQs on June 16, 2017 clarifying that eating disorders are a mental illness and should, in turn, receive mental health parity protections17, we encourage more protections and rulemaking to improve enforcement for both equal coverage of eating disorders and for life-saving intermediate care services.
- We recommend that HHS amend existing regulations to include the Department of Labor, Health and Human Services, and Treasury “Treatment for Eating Disorders” FAQs issued on June 16, 2017 into existing MHAPEA final regulations.
- We encourage HHS, DOL and Treasury to heighten mental health parity enforcement for life-saving intermediate care for substance use disorder and eating disorders by moving the intermediate care provisions within the current final regulation preamble to the underlying mental health parity regulation. This action will strengthen the parity enforcement nationwide.
While there are health insurers who go above and beyond to provide parity for eating disorders at all treatment levels, we need stronger regulation for the “bad apples” who are actively not complying with parity for eating disorders to improve their bottom line.
Additionally, we encourage the federal and state commissioners to provide further guidance and additional enforcement to address the new loopholes that some insurers are using to avoid mental health parity for people with eating disorders and other mental illnesses.
Examples
Using Mental Health Parity Interim Final Rules: One example we are often seeing, is a reliance on the interim final rules, instead of the final mental health parity rules18, to argue that residential treatment for eating disorders does not need to be covered under mental health parity. This point has been clarified under the final regulations of mental health parity and within later FAQs, however, we continually face battles in court and authorization arguments with insurers that openly make this argument.
No Parity for Secondary Diagnosis: Another example includes insurance providers only writing the primary diagnosis within their systems, and excluding the secondary diagnosis. In turn, parity compliance does not occur for the secondary diagnosis. Eating disorders have a high rate of co-occurring mental illness, including 50% of patients with co-occurring substance use disorder.19 Treating and providing parity for only one of the co-occurring illnesses will provide inadequate treatment and likely lead to relapse. Given the medical surgical conditions associated with eating disorders, these patients will often end up in the emergency room upon relapse. One study showed that when eating disorders treatment was discontinued without full treatment through the continuum of care, nearly half of the patients relapsed over a year time period.20
In-Person Pre-Authorization: We often see insurers requiring in-person authorization for higher levels of care, while the same requirements are not required on the medical surgical side, and instead allow a local provider to authorize treatment. Given that the number of specialized intermediate care eating disorders treatment centers are limited in the United States, this is a very large problem. We have a collection of stories from patients and providers in that the insurers will require ill patients to fly across the nation to receive in-person pre-authorization for treatment before actually authorizing the treatment. This is a huge financial burden to patients and their families and a direct violation of mental health parity.
E. Conclusion
Thank you again for the opportunity to provide comments on this important action plan under 21st Century Cures. Upon more rulemaking and enforcement of the current mental health parity law, the EDC believes the Administration’s actions will significantly increase access to MH/SUD treatment for our nation’s families. We applaud HHS, DOL, Treasury for effectuating the listening session in such a timely manner. We look forward to working with you in any way we can to ensure the swift and thorough implementation of 21st Century Cures and related enforcement.
Sincerely,
Dr. Bryn Austin
Board President, Eating Disorders Coalition
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