How Treatment Providers Can Undermine Access to Care for Binge Eating Disorder

How Treatment Providers Can Undermine Access to Care for Binge Eating Disorder

By Cyndi Eddington, Ashley Solomon, Psy.D., and Angela Woods

Over the last several years, laws in the United States have expanded insurance coverage and made treatment more accessible to individuals with binge eating disorder. While true parity and access to care for marginalized populations remains unrealized, we have seen strides in our country. Providers have in many cases been vocal advocates and helped to push important legislation and change forward. Unfortunately, however, there are still many ways in which providers may inadvertently be working against the process. If you are invested in being one of these individuals, follow our how-to guide below.

1. Failing to recognize how being underinsured may impact your patients.

While the Affordable Care Act has increased access to health insurance in the United States, over 31 million insured Americans continued to face underinsurance through 2014 (Commonwealth Fund, 2015). Even those with plans through their employer are increasingly likely to be underinsured. Being underinsured means that, despite having health insurance, an individual cannot adequately afford the deductibles or other out of pocket costs associated with the plan. The result of this is that even those with health insurance are not accessing care when they need it. We know that patients with binge eating disorder face a myriad of barriers to accessing care, such as lack of early identification and social stigma, and underinsurance is a very real and prevalent barrier as well. For those patients who do start treatment, recognize that underinsurance may play a role in early termination of care or refusal to seek higher levels of care even when needed. Perhaps most frustratingly, dropping out of treatment due to resource constraints like underinsurance further undermines patients’ confidence that treatment could eventually be feasible or effective.

2. Don’t attempt to specialize. Why limit yourself?

Not only do our patients deserve expert care, but we elevate the standards and enhance the legitimacy of our work when we support specialization. Insurance companies take our field more seriously when we can demonstrate the specialized education and training required to effectively treat this population. Even in the absence of “requirements,” we can enhance our own specialization by obtaining additional education through workshops and conferences, attending webinars, reading journal articles and books, obtaining supervision, participating on listservs, and joining consultation groups. Becoming the most knowledgeable clinician you can be is a gift to yourself and to patients with binge eating disorder.

3. Turn a blind eye to the most up-to-date evidence on treatment efficacy. What’s an “RTC” anyway?

Research has limitations, such as, at times, failing to include diverse populations and failing to capture important aspects of the work. However, dismissing the evidence in favor of what we feel works is doing no service to our patients. Many of us get caught in doing the familiar – what we trained on many years ago or what fits best with how we see ourselves. There, of course, needs to be a match between therapeutic style and intervention, but we also must stay abreast of the latest evidence base. The advances in neurobiology and behavioral science are accelerating, and to turn a blind eye means our patients may not be getting the most effective and evidence-based care. It also leads to insurance companies questioning our interventions, and perhaps rightly so in some cases.

4. Assume that obesity and binge eating disorder are essentially the same issue. It makes life easier.

Conflating obesity and binge eating disorder does a disservice to everyone. We’ve observed providers utilizing inaccurate codes, for example that do not appropriately reflect the patient’s diagnosis or work that they are doing. While this may seem to help this particularly patient in accessing the care that they need, it perpetuates dangerous myths, such as that medical issues are of primary importance and behavioral health is secondary. It also leads to inaccurate assumptions, such as that all patients with binge eating disorder are obese or that all obese individuals have binge eating disorder. We know these are not true statements, and it limits our ability to have a more appropriate understanding of each of these realities.

5. Come up with your own criteria for what level of care your patients need.

The American Psychiatric Association’s level of care guidelines (2000) were admittedly not written with patients with binge eating disorder in mind. However, they can be utilized as a valuable resource in conceptualizing a patient’s ability to function and interrupt their symptoms at each level of care. Frequently, patients with binge eating disorder are under-treated for their conditions, due to both difficulty for the patient in honestly disclosing their challenges, as well as providers continuing to treat patients even when the current level of care has failed the patient. Staying attuned to the level of care guidelines can help avoid patient frustration and exacerbation of symptoms, as well as help support our field as a whole in advocating for the appropriate coverage of the necessary levels of care.

6. Treatment plans are for trainees. You know what you’re doing.

Having a formalized process for documenting your planned interventions is imperative. It helps to organize and keep you on track as a clinician. It gives the patient a tangible road map of their care, which they deserve to have. And, it helps us stay accountable to payors and other stakeholders that we are holding ourselves responsible for doing what works. Treatment plans will need to evolve as the treatment progresses and are not meant to be artificially limiting. Everyone involved in the patient’s care deserves to have an outline of what to expect and what you can offer.

7. Just write down the bare minimum. You don’t want those notes subpoenaed!

Some clinicians express concern that more thorough documentation of the care will put patients at risk for confidentiality issues. In fact, some clinicians elect to not accept insurance for just this reason – they cannot guarantee that patient’s records will be kept confidential. On the flip side, there are many cases in which patients rely on accurate and comprehensive documentation, whether for their own understanding, appealing insurance decisions, or for legal matters. It is my belief that judicious and thorough documentation is a benefit to the patient and helps to accurately demonstrate the care that is being undertaken. If it’s not written down, it didn’t happen, after all!

8. Leave it to your patients to figure out how to advocate with their insurance companies. It’s not your job to deal with that.

When insurance fails to cover treatment, not only does it potentially prevent or halt the important care that a patient is receiving, but it sends a subversive message to the patient: your illness isn’t serious enough to cover. This is one of the many reasons that a provider must support a patient in advocating for the necessary care. As providers, we are not simply sounding boards; we are active change agents that have the privilege and duty to advocate for those in our stead. We can do this from the outset of treatment by creating a process to explain insurance to our patients in understandable and empowering terms. If challenges do arise with coverage, help guide patients through the process and understand their rights as a consumer. As we know this process can be overwhelming, strive to involve support persons in the process, as well. And make yourself available for writing a letter, conducting an appeal via phone, or talking through the process.

9. Stay siloed in your office and complain about insurance companies on Facebook.

Just as we instill in our patients, change – both at the individual and social level – begins with action. Our frustration with the insurance process will leave us – well, frustrated – unless we harness our energy to elicit real change. This means, first and foremost, getting educated on our healthcare system. Understand your own and your patients’ rights as healthcare consumers. 2016 saw landmark progress in mental health reform in large part because the eating disorder community was advocating tirelessly on its behalf. Real change happens when we educate ourselves, connect with others who are passionate as well, and use our voices.

10. You don’t understand insurance, it’s way too complicated – that’s not what you went to school for! You want to provide therapy, not file insurance claims.

How much do you charge for your most utilized service? How much does your most utilized insurance company pay for that service? We have been living in an age of health insurance transition for the past few years, and we have been promised further transition in the future. Oftentimes, providers will be separated from the billing and insurance process. As providers, we can relate to the consistently confounding task that can follow health insurance coverage. Similar to the old saying, ‘it takes a village to raise a child,’ the same group effort requirement is felt when attempting to understand today’s health field. Transparency can start at the reception desk, but it should continue in the doctor’s office. We would not only be advocates for good mental health and well-being, we would also benefit our patients by providing reliable information about our own billing process.

Next, we need to help our neighbors understand insurance and billing procedures. What are the best sources for reliable updates on the health field and the mental health field? Share them with your fellows. What benefits or concerns are coming from the most recent legislation passed? Offer training for your coworkers, or put together a quick webinar for anyone interested. By working together, we can help each other understand, at the very least, how much we don’t know. Read insurance guidelines, build relationships with the insurance utilization reviewers, celebrate the calls that get coverage, and appeal, appeal, appeal.

Many difficulties are coupled to the Binge Eating Disorder that are not immediately evident. Fewer earnings, diminished workplace productivity, and lower probability of being employed are all potential by-products of the Binge Eating Disorder. The best way to recommend and advocate for appropriate treatment is to understand what it means clinically, as well as financially for the patient. Insurance is supposed to ease this stress, yet the utilization review process can often be a stress-inducing part of treatment. We cannot truly advocate for well-being if we are ignoring the highly stressful process of insurance authorization, finances, and appeals.

11. Patients using their insurance should be very concerned about a mental health diagnosis being listed in their permanent record. That’s a primary reason not to work with insurance, we need to protect our clients.

As healthcare providers we should question how helpful and perhaps antiquated it is to endorse shame, fear, and concerns of self-incrimination for doing what individuals do every day – use their insurance to assist in payment for medically necessary care by healthcare experts.  The medical community does not villainize the ICD-10 and, conversely, the behavioral health community should not utilize DSM 5 as a tool for fear mongering.   Continued endorsement of this credence only serves to further stigma and shame for those needing mental health care.  As reported by Psychological Medicine, 2014, stigma ranked as the 4th highest of 10 barriers to mental health care.

12. The insurance panels are full and they pay poorly. It’s impossible to work with them.

How much medical care would you and your family receive if you didn’t use your insurance to pay for services provided by participating providers, e.g., family practice doctor, pediatrician, orthopedist, cardiologist?  Likely, many of us would not be receiving necessary medical care.  The same is true for those needing quality mental health care – in the February 2014 issue of JAMA Psychiatry, Bishop et al., found that in 2009/2010 a lower percentage of office-based psychiatrists accepted health insurance (55.3%) compared to other office-based specialist physicians (88.7%). Bishop et al. also report the rate of participation in health insurance networks has declined faster among psychiatrists in recent years than among other specialists. We need to improve access for those clients who need your expertise.

Specialty medical providers often create IPA’s (individual practitioner associations) which support investments in improving contractual reimbursement, streamlining credentialing, and insurance communication.   It is time for eating disorder experts to band together and advocate for reasonable reimbursement for expert care at all levels of service.  Remember, “There is always strength in numbers.  The more individuals or organizations that you can rally to your cause, the better.” Author Mark Shields.

Disclaimer:  Numbered statements are intended to be provocative and exaggerated as a means of engaging the reader in the subject matter.  The authors have the utmost respect for the professionals who provide care on a daily basis to those with Binge Eating Disorder.