Tuesday, March 27, 2012

Parity and Disparity Coast to Coast: A Case Study

Parity and Disparity Coast to Coast: A Case Study

Parity and Disparity Coast to Coast: A Case Study

Merriam-Webster defines par◦i◦ty as, "the quality or state of being equal or equivalent." Derived from the Latin word for equal, paritas, its origin dates back to 1608. Such lineage, however, has done little to integrate the concept of parity into the vocabulary and mind set of the health insurance industry when it comes to approving treatment for biologically based severe mental illnesses such as anorexia nervosa and bulimia.
Our client, Jane Doe, is a 21 year old young woman who suffers from anorexia, purging type, and alcohol abuse. She attempted to obtain precertification from her health plan, Value Options, to admit to residential treatment in California. Value Options denied Jane's request for precertification. The Explanation of Benefits gives no "explanation" as to why the treatment was not being covered other than indicating "0.00" under the "Allowed Amount." A close review of the claim notes in Value Option's claim file discloses, "NO MH BENEFITS FOR: RES," meaning, her plan does not provide any mental health benefits for residential treatment. Jane's Value Options' plan is based in New York. As a result, in order to determine her rights and Value Options' obligations under the plan, an analysis of New York's mental health parity law must be considered.
New York's law can be traced back to Timothy O'Clair, the youngest son of New York State Thruway Authority employee, Joe O'Clair. Timothy was diagnosed with depression, oppositional defiance disorder, and other mental illnesses early on in his life. The O'Clair family soon realized the disparity in Joe's health insurance: adequate benefits for physical illnesses and inadequate benefits for mental illnesses and treatment. The O'Clairs were not able to afford the constant treatment required by Timothy's mental illness.
On March 16, 2001, Timothy committed suicide. It was believed that if Timothy had the opportunity to receive more treatment, his suicide could have been prevented. The tragic reality of Timothy's death galvanized both the O'Clairs and the people of New York to rectify the disparate coverage for mental and physical illnesses in employer sponsored health plans. On December 22, 2006, Timothy's Law was born, when Governor George Pataki signed the new legislation. In short, Timothy's Law (as codified in NY Code §3221) requires equal coverage between mental and physical illnesses.
So, one would think that §3221 helps Jane. This law is expansive, filling 26 pages of single spaced type. It is not until page 15 that we find some guidance,
"(B) (i) Every insurer delivering a group…policy, in this state, which provides coverage for inpatient hospital care or coverage for physician services, shall provide comparable coverage for adults and children with biologically based mental illnesses…" (emphasis added)
So, what is considered "comparable coverage"? Jane's plan provides "inpatient" hospitalization coverage for physical illnesses. But Jane's plan denied benefits for "residential" treatment for her anorexia since it was not "inpatient" and as indicated by the plan, Jane did not meet its inpatient criteria, which was not eating disorder specific. "Comparable coverage" should include residential treatment, since residential treatment for eating disorders is the medically accepted method for treating this disease and thus the equivalent of inpatient care for physical illnesses. We are in the process of filing the appeal and will test the limits and interpretation of Timothy's Law as provided by Value Options.
The story is not over. Jane changed her health insurance carrier midway through her treatment to Anthem Blue Cross. Likewise, her new Anthem CalPERS plan does not specifically provide coverage for residential treatment for eating disorders. Anthem denied Jane's claim for her residential treatment indicating, "This is not a covered expense of the patient's plan." Fortunately, prior to Anthem issuing this denial, our office prevailed on this issue before the 9th Circuit in, Harlick v. Blue Shield of California, 656 F. 3d 832 (9th Cir. 2011) As a result, we are hopeful that Anthem Blue Cross will reconsider its denial of coverage for Jane's residential treatment on appeal.
In conclusion, although the laws of both New York and California require parity in the coverage and benefits provided for both physical illness and severe mental illness, the insurance companies are still attempting to ignore these laws and deny residential treatment.

Monday, March 26, 2012

EDC Board Member, Lisa Kantor, takes on Dr. Oz

Lisa Kantor, Member of the Board of Directors of the Eating Disorders Coalition, and the country's premier lawyer who advocates for patients with eating disorders who have been denied health insurance benefits for treatment, takes on Dr. Oz!

Lisa S. Kantor: An Open Letter to Dr. Oz
By Lisa S. Kantor

Posted: 7:53pm on Mar 19, 2012; Modified: 7:58pm on Mar 19, 2012

LOS ANGELES, March 19, 2012 — /PRNewswire/ -- Along with countless professionals and families dealing with the physical, emotional and financial consequences of eating disorders, I am deeply disturbed by the way your recent program, "Dying to Be Thin: Meet the Skinniest Women in America," had the unintended effect of glamorizing the deadliest of all mental illnesses. Rather than documenting the tragedy associated with eating disorders and providing encouragement to sufferers to seek help, you perpetuated myths about the disease and provided harmful information to millions. I believe this show did more harm than good. As a physician, you have a responsibility to improve your coverage of eating disorders in future shows.

"Dying to Be Thin," while tantalizing, serves to perpetuate one of the deadliest misconceptions about eating disorders. People with eating disorders are not necessarily "skinny" or "thin," and certainly not everyone who dies from an eating disorder is underweight. In fact, many people die at a very normal weight, especially if they have bulimia. You mentioned on your show that the "more acute cases" were the "thinner" women. That myth is also dangerous to disseminate. Those who weigh less than others are not necessarily "more acute" than others at a "healthy weight." That misconception has long created stigmas associated with eating disorder sufferers and has often led to under-treatment by physicians who think that because a woman is not thin, she is not as acute. Your focus on thinness did a grave disservice by failing to educate your audience scientifically about what eating disorders really look like.

In giving air time to the Pro-Ana movement, you referred to it as "a dangerous new trend that helps women be skinny at any cost." The Pro-Ana movement is not new. Pro-Ana (and Pro-Mia) sites have been around since the dawn of the Internet. Far from being "trendy," they are a very dangerous facet of an eating disorder underground that preys on the mentally ill. Had you consulted an eating disorders expert, you would never have offered your audience direct access to the websites and their images. Studies show that doing so causes harm. One study, on college-aged women (none of whom had eating disorders), discovered that after viewing pro-eating disorders websites, 84% reduced their calorie intake by more than 2,000 calories per week. Only 56% of the women realized they were eating less. Results of the study also indicated that the women exposed to the pro-eating disorders website had decreases in self-esteem and perceived attractiveness.

My days are spent in and out of federal courts battling insurance companies that deny benefits for seriously ill women and men who seek adequate treatment for their diseases – even though a federal law and many state laws mandate that insurers provide similar levels of treatment for mental illnesses as they provide for physical illnesses. Shows such as the one you aired trivialize this disease and undermine the progress well-respected groups such as the International Association for Eating Disorders Professionals, the Eating Disorders Coalition, the National Eating Disorders Association, and the Binge Eating Disorder Association have achieved. Still, getting the national media to take eating disorders seriously without parading dangerously thin women across the television screen is about as difficult as getting an insurance company to pay for a therapeutic length of stay at a residential treatment facility.

It is hard for me to believe that either you or your staff did any legitimate research about eating disorders before planning the programs. Were you aware that professionals in the eating disorder field were in touch with producers at your show in recent months offering the benefits of their expertise free of charge should you plan to air segments about eating disorders? Those calls and e-mails appear to have been ignored.

You owe it to your many viewers to correct the harm your recent program caused. First, please remove all material from your website and blog that mentions the Pro-Ana movement. Second, work with some of the many excellent professionals at reputable facilities around the country to plan follow up segments to properly educate your audience about how people can recover from eating disorders and lead productive and fulfilled lives not centered on food. You have an opportunity to teach millions across the country, including other physicians who might watch your show, the real skinny about eating disorders. I hope you will do the right thing.

About Lisa S. Kantor

Lisa S. Kantor, a Los Angeles lawyer and member of the Board of Directors of the Eating Disorders Coalition, is the country's premier legal advocate for patients with eating disorders who have been denied health insurance benefits for treatment. In 2011, the 9th U.S. Circuit Court of Appeals ruled for her client in Harlick v. Blue Shield, creating one of the most influential decisions ever in mental health parity litigation and paving the way to making treatment and recovery for severe mental illnesses more attainable. For more information, go to http://www.kantorlaw.net/.
Read more here: http://www.bradenton.com/2012/03/19/3949249/lisa-s-kantor-an-open-letter-to.html#storylink=cpy

Monday, March 19, 2012

Great Letter from Advocate

Hi everyone --below is a letter from EDC advocate Rebekkah, to her Representative (Member of Congress in the House). Please take a look at her letter to see an example of how to personalize the Eating Disorders Coalition's "sample letter". We're looking forward to receiving many more cc'd letters in our inbox. We need millions more to write in if we want to pass the FREED Act. 
Go to: http://www.eatingdisorderscoalition.org/letter-writing-campaign.htm
for information on how you can write a letter, too! ~ Thank you, the EDC


Dear Congressman Heck,

As a constituent of your district who has personally suffered from the living hell of an eating disorder, I am writing today to ask you to cosponsor the Federal Response to Eliminate Eating Disorders Act, (the FREED Act, H.R. 1448). The FREED Act is the first comprehensive bill in the history of Congress to address eating disorders. The FREED Act focuses on research, treatment, education and prevention of eating disorders and
serves as a beacon of hope for the millions of people in our country  currently suffering from binge eating disorder, anorexia, bulimia, and eating disorder not otherwise specified (EDNOS).

Estimates suggest that more than 11 million Americans suffer from eating disorders.  I am one of them.  I am one of those girls who lost herself, and almost her life.  More than once, I ended up in the hospital from
electrolyte imbalances and blood work that told the ER doctors that my  heart shouldn’t be beating.  More than once, I prayed and hoped that my heart would, in fact, stop beating.  And without recovery, without the
extensive treatment I had, those prayers would have been answered. 

I can write to you today because of the treatment I received.  In a month and a half I will be graduating law school, because of the treatment I  received.  Everyday I enjoy friendships and gratitude, because of the
treatment I received.  I am alive today because of the treatment I received.

Eating disorders affect every single system of the body and are associated  with serious medical complications including cardiac arrhythmia, cognitive  impairment, osteoporosis, infertility, heart failure and death. In fact,
left untreated anorexia nervosa has the highest death rate of all mental disorders, upwards of 20%. However, when a person suffering from anorexia  receives proper treatment, the death rate falls to between 2-3%.

Research demonstrates that eating disorders CAN be successfully overcome when early detection and adequate and appropriate treatment take place.  And I write to you as verification of that fact!
Unfortunately, at this point in time, eating disorders are all too often  undiagnosed or completely misdiagnosed by health professionals, and access to treatment is limited. Less than 1/2 of all people with eating disorders
receive the treatment they both need and deserve. The FREED Act will save lives by providing for better access to proper  treatment, research dollars to understand the etiology and effective  treatment of eating disorders, grant programs to ensure more medical health  professionals and school personnel be trained on eating disorders prevention and treatment, as well as PSA's to broaden awareness of eating disorders.

Currently the FREED Act has bipartisan support. I ask that you sign on today as a cosponsor of the FREED Act (HR 1448), as a cosponsor of hope, as this bill has the ability to save thousands of lives.  I have vowed to never be an eating disorder death statistic: please help ensure that same  promise, for the thousands of others who are suffering!

I look forward to hearing from you soon.

Graciously yours,   Rebekkah Beth Bodoff

picture courtesy of: photobucket.com/

Thursday, March 15, 2012

Mental Illnesses a "Civil Rights Issue!"

The EDC attended a luncheon at the National Press Club in Washington DC today with mental health parity champions former Congressmen Patrick Kennedy and Jim Ramstad.  Even after leaving Congress both Ramstad and Kennedy remain passionate about ensuring the implementation of a strong Final Rule for the 2008 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) in a way that eliminates discrimination against those with mental illnesses.
EDC Policy Director & Former Congressman Jim Ramstad

The EDC was able to ask a question of the Congressmen regarding insurance tactics used to discriminate against those suffering with eating disorders. Here is a link to the video of the question and responses:
(the entire video is interesting and worth watching, but the question re: Eating Disorders is addressed beginning at: 47.58)

The two are launching Parity Field Hearings in many cities throughout the country to draw attention to the continued exclusions and inappropriate insurance denials. The EDC spoke with Kennedy directly and we will be bringing people with eating disorders who have been denied treatment to testify at these hearings.

Monday, March 12, 2012

Member Org F.E.A.S.T. on EDC National Lobby Day

Thank you to EDC Member Organziation F.E.A.S.T. for sharing about EDC National Lobby Day in your recent blog.
We are grateful to have your support that offers many voices and perspectives, of care-givers & parents especially. Please take a moment to read the F.E.A.S.T. blog: