Eating disorders are tenacious. In its secretive, compelling way, bulimia can hang on undetected for years. Its sufferers overwhelmingly women binge and purge in private. Even after they seek help and improve, bulimics frequently relapse. Anorexia holds on even longer, with nearly 70 percent of anorexics still preoccupied with weight and dieting 12 years after their initial diagnosis, according to a recent study. Yet, in this era of managed care, treatment for these chronic problems is increasingly short-term, many think dangerously so.
Consider one patient's experience. Let's call her Marie. At 19, she has been hospitalized more than 40 times in her six years with anorexia. None of her hospital stays has lasted more than a month, and the treatment usually consisted simply of being fed through a tube, then being discharged as soon as she was out of dire physical danger. "My therapist said I needed long-term, but we couldn't get it with our insurance," she says with a disaffected shrug. "Once they got you over that initial hump, the insurance would be like, OK, we're not going to cover that anymore."
Curled in a chair in the New York State Psychiatric Institute, Marie looks childlike and painfully thin. Still, she is much healthier than when she entered this in-patient program at 78 pounds about three months ago and healthier than she has been when other facilities have discharged her in the past. This extended stay is possible because the institute, through an unusual grant-funded program, is able to offer free, long-term treatment for girls and women who participate in its eating-disorder research. Without insurers breathing down their necks, patients spend an average of three to four months at the institute, getting individual, group, and family therapy and learning to eat and cook normally.
Getting eating disorders taken seriously and paid for was never easy. To maneuver around insurer bias (after all, patients are seemingly inflicting their misery on themselves), specialists have long employed various ruses. "You had to learn how to phrase it," says Ira Sacker, a physician and director of the nonprofit Helping To End Eating Disorders. Even with old-style insurers, Sacker was careful to submit claims for malnutrition instead of anorexia, which involves self-starvation. For bulimia, or obsessive purging, he might term the problem an electrolyte imbalance or recurrent vomiting.
Now, under managed care, Sacker says it is even more difficult to get approval for long-term treatment. Although studies have shown that patients who are released from the hospital at normal weights do better than those who are released prematurely, the tendency these days is to release patients before they hit their ideal weight and before they deal with some of the root causes of their illness. "Often times what [insurers] are looking for is if the vital signs are stable," says Sacker. "Maybe you can admit them for a week or so."
Part of the problem is that eating disorders, which clearly have both an emotional and physical component, are being shunted into the realm of mental-health insurance, where the dollar value of benefits has plunged more than 54 percent in the past decade. Despite physical symptoms, including heart irregularities and reduced brain size for anorexics, and for bulimics internal rips and bleeding that can result from repeated purging, treatment is often paid for out of these restricted behavioral benefits.
Federal law passed in 1996 forbade insurers from limiting the amount they would pay for mental-health coverage. But many companies quickly got around that constraint by replacing dollar limits with caps on the length of hospital stays and the number of treatment sessions. Now New York State legislators have proposed a bill that would outlaw those limits as well. And state Senator Carl Kruger is drafting another bill that would specifically require insurers to grant in-patient coverage whenever a doctor deems it necessary.
Kruger, who fancies himself the public advocate for Brooklyn, has intervened on behalf of three constituents who were denied in-patient treatment for their eating disorders. As a result, says Kruger, Empire Blue Cross/Blue Shield reversed its denial for long-term care of one patient; Oxford, the insurer of the other two patients, has so far stood by its decisions.
But even those patients who get treatment one way or another still have to fight an intense inner battle to get well. For Marie, who's eager to return to college, that means not only gaining weight, but also somehow tending to the part of her that so desperately fights her desire to be well. Of course, she's made some headway with this inner demon before. Many times. But she's still hopeful that this hospital stay might be the last one.
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