Civics Lesson in New York State

There have been a number of discussions on eating disorder sites lately about the settlement between the health insurance company Cigna and the state of New York regarding the reimbursement for nutritional counseling sessions. The case in question involved a 14 year-old patient with anorexia nervosa whose family was informed that nutritional counseling was not covered by their insurance company, even though it was a prescribed part of the patient’s treatment plan. The courts found that Cigna had violated the state’s mental health parity (i.e., Timothy’s) law.

Timothy’s law went into effect in 2006 following the suicide of a 13-year-old boy in New York State who had been denied ongoing coverage for mental health treatment. The law requires that mental illnesses, including eating disorders, receive equivalent coverage to that of other medical illnesses when individuals have insurance policies that cover both medical and behavioral health.

This most recent settlement is about more than one family’s struggle to receive adequate coverage for prescribed care. It is about the struggle of many patients to receive appropriate treatment and the corresponding coverage. The office that notified me of the Cigna settlement was the office of Eric Schneiderman, New York State’s attorney general. In the past year, I have received several calls from A.G. Schneiderman’s office with background questions regarding treatment for eating disorders: What levels of care are used to treat eating disorders? How do clinicians decide when to admit and when to discharge patients with eating disorders? How do health care insurance companies negotiate reimbursement for care?

Eating disorders, including anorexia nervosa and bulimia nervosa, are severe illnesses that are associated with significant medical problems, psychological problems, functional impairment and very high rates of death. While most Americans know someone who has had an eating disorder, these illnesses are often misunderstood. Eating disorders are unusual conditions because they include medical as well as psychological disturbances, yet our health care system and the insurance policies that pay for most clinical services generally separate medical health care from behavioral health, making the evaluation and treatment of eating disorders particularly difficult.

Take a young woman with anorexia nervosa whose food restriction and fear of fat lead to seriously low weight together with slowed heart rate, low blood pressure with dizziness, and deteriorating bone health with a risk of developing stress fractures. Does this person belong on a medical unit where her cardiac status may be monitored and her fall risk managed? Or does she belong on a specialized psychiatric unit where she will receive more focused care to help in achieving behavioral change, improving her eating behavior, and managing her anxiety? Our current health care system makes it hard to find all parts of eating disorders treatment under one roof.

According to my contact in the attorney general’s office, they receive many phone calls from New York State residents wishing to report some infraction, problem, or injustice related to the treatment of mental illness. The office carefully considers these claims to determine whether a legal issue is present, and if so, what type of response is appropriate. Leading up to the most recent settlement, the attorney general’s office had received a large number of phone calls about insufficient coverage for eating disorders treatment in New York State.

Legislation such as Timothy’s Law evolves thanks to individuals and families speaking up about what they need.  But Timothy’s Law would never have been passed without some heavy lifting by legislators and other elected officials who were actually listening to their constituents. The attorney general’s office actively responded to the calls from state residents, recognizing that some of his constituents’ concerns could be addressed by considering whether health care coverage was being delivered appropriately in the context of laws that aim to protect consumers. Their analysis found that patients with eating disorders were not receiving their due.

I have spent nearly 25 years trying to help individuals with eating disorders and their families. I do this in my clinical work, my research activities, and, most recently, in my work advocating for the needs of individuals with these challenging conditions. I was delighted that New York State’s attorney general’s office took a difficult case and brought its questions to the judicial system for a response.

I’m glad that our state has such good listeners. With their voices, patients and their families can make a powerful difference.

Written by Evelyn Attia, MD.

Photo credit: Creative commons by Sam Howzit

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