WASHINGTON, D.C. (October 28, 2019) – The US Department of Labor, US Department of Health and Humans Services, and the US Department of the Treasury released guidance last month entitled, “FAQs About Mental Health and Substance Use Disorder Parity Implementation and the 21st Century Cures Act Part 39,” providing additional direction to insurance plans, issuers, and outside stakeholders in an effort to promote compliance with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The Eating Disorders Coalition for Research, Policy & Action (EDC) applauds the Departments additional guidance, including new clarifications that will enhance insurance coverage for eating disorders as a result of the Anna Westin Act provisions included within the 21st Century Cures Act (P.L. 114-255).The EDC has worked tirelessly to educate federal agencies on the barriers to care for individuals and families with eating disorders. This work has included submission of public comments on previous federal guidance documents in September 2017 and June 2018; Congressional letters of support in 2017 (House/Senate) and 2018 (House/Senate); and participation in a July 2018 and a January 2019 federally hosted forums with stakeholders and federal agencies to discuss MHPAEA implementation. The most recent guidance from the Departments includes victories for our community regarding the following:
- Coverage of Sub-group Disorders: When a plan or issuer provides benefits for a mental health condition/substance use disorder, benefits for that condition or disorder must be provided in every classification in which medical/surgical benefits are provided. Insurance plans are in violation of MHPAEA if coverage for eating disorders does not extend to all sub-types including, anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding or eating disorders (OSFED).
- Shifting the Burden of Proof for Fail-First Policies to Payers: It is incumbent upon the insurance company, not the patient, to prove they’re in compliance with step therapy protocols and are able to demonstrate evidentiary standards were utilized comparably to develop step therapy requirements between mental health/substance use disorder benefits and medical/surgical benefits.
- Residential Care Classified as Inpatient, Covered Benefit: Residential eating disorders treatment is classified as a sub-category of inpatient care to ensure the patient receives their inpatient covered benefit just as skilled nursing facilities, nursing home care, and hospice are considered sub-categories of inpatient care.
- Rights to Receive Medical Necessity and Denial Information: Insurance plans must provide current/potential patients and contracted providers with free of charge information regarding claim denials and related documents on medical necessity requirements to file within 30 days of a participant’s request.“The recent guidance from the Departments provides further clarity to individuals and families with eating disorders, treatment providers, and insurance companies to fully comply with the Mental Health Parity and Addiction Equity Act as intended,” said EDC Board President Chase Bannister, MDIV, MSW, LCSW, CEDS. “Our coalition has worked diligently to fight for equitable treatment under the law. We will remain steadfast in our mission to continue having a seat at the table as we educate the Departments on MHPAEA violations and work together to drive change for those in need of treatment.”The EDC recognizes that parity enforcement and compliance both remain a work in progress, therefore we will continue to use our collective voice to provide expertise to the Departments as they release additional implementation guidance on a rolling basis.The Eating Disorders Coalition for Research, Policy & Action (EDC) is a Washington, DC-based, federal advocacy organization comprised of advocacy organizations, academics, treatment providers, family/loved ones of children with eating disorders and people experiencing eating disorders nationwide. The EDC advances the recognition of eating disorders as a public health priority throughout the United States. Additional resources can also be found at www.eatingdisorderscoalition.org.
A patient’s initial self-image had an impact on outcome a year later.
Self-image, or the way we view ourselves, has real predictive value in treatment outcome, according to findings at the Karolinska Institute in Stockholm, Sweden. A trio of researchers led by Dr. Emma Forsén Mantilla came to this conclusion after a year of following a large clinical sample of adult women with eating disorders (n=2221) (J Eat Disord. 2019; 7:15). Participants were from five diagnostic groups: 457 women with restrictive-type anorexia nervosa (AN-R); 228 women with binge-purge type AN (AN/BP); 861 women with BN; 505 with other specified eating disorders (OSFED), and 170 with binge-eating disorder (BED).
The authors used data from the interpersonal Structural Analysis of Social Behavior(SASB) self-image or introject, which captures both the valuation of self-esteem and self-directed actions, or how one treats oneself as a result of interpersonal learning. Previous studies had shown that a negative self-image predicted poor treatment outcome, dropping out from treatment, and suicidal behavior. Participants also completed number of questionnaires, including the Eating Disorder Examination Questionnaire (EDE-Q).
Dr. Forsén Mantilla and colleagues’ goal was to extend the findings by Birgegård et al. (Int J Eat Disord. 2009; 42:522) by studying the predictive value of the SASBon 12-month outcome among patients with DSM-5eating disorder diagnoses. Data were taken from the STEPWISE clinical database, an Internet-based data collection system for specialized eating disorders care in Sweden. STEPWISE has been in use since 2005 (Eur Eat Disord Rev. 2010; 18:251). The authors hypothesized that self-control, self-blame and, inversely, self-acceptance, could be used to strongly predict outcome in AN, whereas variables related to affiliation, as in self-love/attack would moderately predict outcome among patients with BN.
Results for AN/BP, AN/R
For patients with AN/BP, lower self-neglect scores predicted a more positive clinical outcome. For those diagnosed with AN/R, higher self-love and lower self-blame scores predicted a more positive clinical outcome at 12 months. Among those with OSFED, higher scores on self-love and lower self-blame and self-control scores predicted a better outcome; for those with BED, higher self-love scores predicted a better outcome at 12 months.
The authors also reported that AN/R patients with less severe baseline eating disorders, younger ages, and higher self-love scores do better after one year in specialist care. One intriguing finding was that higher scores on Self-examination were associated with still having an eating disorder after a year of treatment. The authors pondered whether accepting oneself “as is” when ill, by allowing the self to remain static and to follow current impulses, can be detrimental even though the SASB variable is positive at face value. This might be a reflection of the “anorexic self” rather than the “authentic self,” and might encourage resistance to change.
Compared to previous findings, the authors’ results among AN patients were not clearly related to Self-control. Instead, the dimension of affiliation was prominent and led to the addition of Self-control in those with AN/BP and OSFED. A strength of this study, compared with earlier reports, was the authors’ attempt to include the entire eating disorders diagnostic spectrum, as represented in the DSM-5. Thus, AN subtypes were included as well as previous EDNOS (eating disorders not otherwise specified) patients in AN and BN groups. Two limitations of the study were: (1) that relevant follow-up data were not available for 40% of the complete patient sample follow-up data (a large number), and (2) as a minor limitation, the authors attempted to construct the DSM-5diagnostic categories based on DSM-IVdiagnostic data.
The authors concluded that self-image aspects may provide clinically useful information at the beginning of treatment, especially in those with AN, because self-image are clinically relevant and may predict outcome.