Topic Suggestion

1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?

Proposed Topic: How does the current model of care delivery for eating disorders affect quality of care, equitable access to care (especially for publicly insured patients), and affordability of eating disorders treatment.

1. The current care delivery system for patients with serious eating disorders does not provide for equitable access to high quality, evidence-based care for many of the most seriously ill and for publicly insured patients. Many states lack intensive treatment programs for eating disorders that accept the publicly insured altogether.
2. University and nonprofit treatment programs for eating disorders are closing under financial pressure while the delivery of care is increasingly provided by private for-profit residential programs that do not routinely accept Medicare or Medicaid.
3. Nonprofit programs who accept Medicare and Medicaid shoulder increasing financial burden because they see fewer privately insured patients, rendering them financially not viable.
4. We are far from a model in the field which would provide high-quality care to all patients and families in every state.

In summary recent changes in the delivery of intensive treatment for eating disorders raise two major concerns.

1. First, there is now grave concern that publicly insured patients who comprise a majority of our most severe cases do not have equitable or affordable access to care. Another concern is that males, transgender patients, children, and patients in larger bodies face declining access to high-quality care with few programs nationally who accept these groups.
2. Second, the disappearance of university-based programs has consequences not only for patient care but also for training opportunities for licensed professionals across disciplines and who serve all age groups. Most medical professionals including psychiatrists and general medical practitioners have no or very brief exposure in their training to patients with eating disorders and typically lack a more in-depth understanding of the needs of patients with eating disorders. Very high quality of psychotherapy delivered by psychologists requires training in accredited training programs that include internship and postdoctoral positions. Those training opportunities are provided by university-based programs and there is a concern that those training opportunities are declining.

2. Why are you struggling with this issue?

1. Access to evidence-based expert care is central to every individual affected by an eating disorder and in need of treatment. Despite anorexia nervosa having the highest mortality of any psychiatric disorder, and high rates of medical and psychiatric morbidity across eating disorder diagnoses, the patients with eating disorders remain underserved. Many of the sickest patients are locked out of care by most treatment programs.  For others, prolonged treatment stays exhaust insurance benefits in for-profit programs from which patients are often discharged still unwell. Families are known to re-mortgage their homes and incur substantial debt to pay for treatment that may not be evidence based. Despite many anecdotal reports of individuals not receiving care, data is needed to support or refute this grave concern. Similarly, there is a need for data on patient outcomes. For anorexia nervosa, weight restoration is necessary for recovery and weight gain is a primary goal of intensive treatment and an easily measurable outcome metric. Despite this most programs do not publish or report their weight restoration outcomes. This and other outcome metrics including readmission rates would be extremely useful to payors and families in comparing treatment programs.
2. Second, we as an organization for eating disorder professionals are highly concerned that there will be a shortage of highly qualified psychotherapists and medical providers in the near future, which will dramatically reduce the availability delivery of high-quality care for patients with eating disorders.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

1. There is a need to evaluate the eating disorders treatment landscape with attention to changes over the last decade in accessibility to, and the delivery of, care. Differential access to care for the publicly insured as well as the burden of care in non-specialist settings (emergency rooms, community hospitals, general medical units, and general psychiatric units) accounted for by patients with eating disorders is needed.
2. There is a need to assess current and projected gaps in the training of eating disorders treatment professionals.
3. An AHRQ report would help address important questions about the extent to which the current treatment landscape is evidence-based and provide documentation to encourage lawmakers and insurers to develop and support equitable treatment models that do not disenfranchise a substantial portion of the eating disorder population.
4. We believe that there is the need to develop a treatment system that ensures viability of both for-profit and nonprofit programs that does not exclude patients based on income, and ensures that publicly insured individuals have access to treatment. Moreover, changes in landscape must ensure that the next generation of practitioners can receive training in evidence-based care of eating disorders. We will know that the issue is improving once treatment delivery and outcomes become transparent, and patients and parents are able to make treatment decisions based on data, not marketing.
5. As with other fields of medicine and behavior, there is a need to incorporate data-driven information to inform therapists about etiology and treatment and establish standards for training and competency. Eating disorder programs should be required to gather post-discharge outcome data on their patients to demonstrate efficacy. This is rarely done at present (Friedman et al., 2016) and when performed, tends to measure outcome at discharge only, which does not show whether treatment results in lasting improvement.

4. When do you need the evidence report?

Wed, 09/30/2020

5. What will you do with the evidence report?

1. We will use this report to establish collaborations between public and private eating disorder treatment programs to develop models for health care delivery that is more equitable and affordable and reaches all individuals afflicted with an eating disorder.
2. We will use this report to collaborate with educators and training programs to increase the training opportunities for especially physicians, psychologists, and other mental health professionals to be prepared and well trained to work in the eating disorder field.
3. We will work with lawmakers to review whether laws need to be changed or initiated to provide the regulatory basis for more equitable and affordable health care delivery and improve training opportunities for the next generations of eating disorder professionals.

Supporting Document

Title or short description: Supporting Document: Eating Disorders Care Delivery (PDF, 28 KB)

(Optional) About You

What is your role or perspective?

I am psychiatrist and eating disorder expert who is a member of the Academy for Eating Disorders.

If you are you making a suggestion on behalf of an organization, please state the name of the organization:

Academy for Eating Disorders

May we contact you if we have questions about your nomination?

Yes