Anorexia nervosa is the third most common chronic illness among women ages 15 to 19 and potentially life-threatening. Despite the potential consequences of the condition, there is a disconnect between outcomes data and insurance reimbursement.
That’s the view of David Garner, PhD, president and CEO of River Centre Clinic, a treatment facility in Sylvania, Ohio. Insurers use analytics extensively to assess outcomes and resulting formularies for medical reimbursement, but when it comes to mental illness, analytics plays virtually no role, he said during a session at Health Data Management’s Healthcare Analytics Conference in Chicago.
In the medical care environment, insurance coverage is driven by actuarial data and analytics, but in the mental health arena, reimbursement is much more subjective, and the reimbursement decision often is a denial of payment, Garner said. Insurers view too much weight as a disorder, but frequently don’t see that people who are too skinny also have a disorder. Often, patients who have anorexia nervosa are not provided with the duration of treatment needed for full recovery.
The core behavioral issue with anorexia is an intense fear of gaining weight, Garner explained. Among patients admitted to his facility, 40 percent of patients have a mild case of anorexia, 20 percent have a moderate case, 18 percent have a severe case, and 22 percent have an extreme case. Male patients account for only one in 20 cases of the disease.
Insurers focus on two variables related to treatment of anorexia—daily rates and length of stay in a treatment facility. The daily rate depends on the structure of a program, which often does not address what the patient really needs. Consequently, Garner says, daily rates do not reflect value. Further, insurers do not understand that weight at admission to a treatment facility requires different lengths of stay to achieve a target body mass index at discharge. Further, insurers often require discharges before appropriate BMI is reached.
If an anorexic patient gets treatment and gains weight, an insurer may say that she is fine even though she is vomiting daily because the behavioral problems may persist. Or an insurer may reimburse less, believing that the patient now is not as ill, even if the patient remains sicker than she appears to be.
Insurers, Garner contend, also are not adequately assessing the quality of anorexic treatments. Uniformed or inadequate treatment can result in a mortality rate of as much as 22 percent, while good treatment leads to mortality rates as low as two percent.
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