There’s a lucrative cottage industry in the U.S. for the residential treatment of almost anything you can imagine. Everything from “Internet addiction” and drug and alcohol problems, to eating and mood disorders. If you can treat it in an outpatient setting, the thinking goes, why not treat it in a “residential” setting for 30 or more days where you control every aspect of the patient’s life?

The “residential” treatment approach has long been available for eating disorders, since the treatment of these disorders tends to be long and complicated. Andrew Pollack writing for the New York Times notes how these kinds of programs have now become the focus of insurance companies looking to cut back on treatment options.

It’s no surprise, really. With the rollout of mental health parity — requiring that insurance companies can no longer discriminate against people with mental disorders for their treatment options — those companies are looking for other places they can cut costs. Residential treatment for eating disorders appears to be one obvious area.

So is residential treatment a legitimate modality for helping people with eating disorders? Should insurance companies cover the costs of such care?

According to one study (Frisch et al., 2006), the average length of stay in a residential treatment center for an eating disorder is 83 days. That’s nearly 3 months of full-time, round-the-clock treatment and care. The cost for such care? On average, it’s $956 per day. You read that right — nearly $1,000/day is the average cost for such care. That means a single patient at such a treatment center is bringing in, on average, $79,348.

Proponents of residential treatment admit there’s little research to back its use for eating disorders, but are adamant such programs are effective and needed:

Dr Anne E. Becker, president of the Academy of Eating Disorders and director of the eating disorders program at Massachusetts General Hospital, said that despite a paucity of studies, “There’s no question that residential treatment is life-saving for some patients.”

Okay. But so is spiritual healing, according to many spiritual healers. What separates belief (the mainstay of religion) from fact (the mainstay of science) is data. Without data, we operate in a vacuum of knowledge.

Ah, but we apparently do have some data. Just not the kind that a residential treatment center wants to hear:

Ira Burnim, legal director of the Bazelon Center for Mental Health Law, which litigates for better mental health treatments, said that while he was not familiar with eating disorders, “study after study” had shown that residential centers for other mental or emotional disorders were not as effective as treatment at home. […] “There’s a wide variation in licensing across the country,” said Jena L. Estes, vice president for the federal employee program at the Blue Cross and Blue Shield Association. “There’s a lack of oversight of many of those residential treatment centers.”

There is some research data in the literature. But surprisingly very little, and nothing approaching a randomized controlled study — the gold standard of research. For instance, in Bean et al. (2004), the researchers did a 15-month phone followup with folks who had anorexia who had stayed at their residential treatment center. According to this study, women experienced a 7 lb weight gain, while men experienced an average of a 19 lb weight gain.

But we have no idea whether these are good or bad numbers. Would someone in outpatient treatment over the same time period experience more or less weight gain? Are these numbers even accurate, given they are self-reported by the patient over the telephone (and the research was conducted by biased researchers at their own treatment center)? So we have “data” here, but without context, it’s next to meaningless.

Another study by Bean & Weltzin (2001) showed that after a 6 month followup, anorexic and bulimic women retained some, but not all, of the improvements they made while in treatment. Again, without an outpatient or control group, it’s hard to say whether this is a good or bad finding.

There’s also a few dissertations that offer similar evidence — when pre- versus post- measures are used in a residential treatment program, most patients are improved at discharge. This is hardly a surprising finding. But is it due to the “treatment” portion of the program, or the “residential” component — or some important combination thereof — remains unanswered.

So I hate to say it, but the insurance companies in this case appear to have a pretty good case, at least based upon the paucity of research. I always say to people, if you want to shut up an insurance company, show them the research that your treatment modality works (and works better than cheaper treatment X).

For better or worse, judges don’t have to care about the research, and in this case ruled against the insurance company where the issue of paying for residential treatment for an eating disorder was brought to court:

The Ninth Circuit Appeals judges, based in San Francisco, ruled that residential treatment was medically necessary for eating disorders, and therefore had to be covered under the state’s parity law, even if no exact equivalent existed on the physical disease side.

Eating disorders are unique, and perhaps even more unique than drug and alcohol problems — therefore deserving of special treatment. After all, unlike alcohol or drugs, we all have to eat. The way eating disorders wrap themselves up into the person’s mind and their body image is very difficult to untangle.

But if we want people to have access to residential treatment centers to help with their eating disorders, shouldn’t the industry support far more well-designed, scientific studies to examine the effectiveness of this modality? I don’t think anybody would question these centers if such research existed today, but the fact that it doesn’t after more than 25 years raises more than just a few eyebrows.

Read the full article: Ruling Offers Hope to Eating Disorder Sufferers

References

Bean, Pamela; Loomis, Catherine C.; Timmel, Pamela; Hallinan, Patricia; Moore, Sara; Mammel, Jane; Weltzin, Theodore; (2004). Outcome Variables for Anorexic Males and Females One Year After Discharge from Residential Treatment. Journal of Addictive Diseases, 23, 83-94.

Bean, P. & Weltzin, T. (2001). Evolution of symptom severity during residential treatment of females with eating disorders. Eating and Weight Disorders, 6, 197-204

Frisch, Maria J.; Herzog, David B.; Franko, Debra L.; (2006). Residential Treatment for Eating Disorders. International Journal of Eating Disorders, 39, 434-442.

Little Research Supports Residential Treatment of Eating Disorders