Lauren Muhlheim, Psy.D., CEDS and
Alli Spotts-De Lazzer, LMFT, LPCC, CEDS
This guest post was written for Kantor & Kantor as the first of a series examining insurance and outpatient treatment providers. Check back soon for more.
If you found out that that your in-network oncologist checked a box that he/she treats cancer, and the insurance company required no further verification of this specialization, how would you feel? What if you found out that the person you trusted to treat your diabetes had no more than minimal training in diabetes management?
This can happen with some in-network providers who are listed as treating eating disorders.
Eating disorders are serious mental illnesses that are often accompanied by physical consequences. Anorexia nervosa has the highest mortality rate of any psychiatric disorder; bulimia nervosa and binge-eating disorder also have elevated death rates (Fichter & Quadflieg, 2016). It has been well documented that medical and mental health professionals tend to receive limited, if any, eating disorder training in their educational programs (Gurney & Halmi, 2001a, 2001b; Linville, Benton, O'Neil, & Sturm, 2010; Linville, Brown, & O'Neil, 2012; Mahr et al., 2015; Wilson, Grilo, & Vitousek, 2007). Wilson and colleagues (2007) described the eating disorder training typically provided to doctoral candidates in the United States as "insufficient" and "inadequate" (p. 207). With the risk for potential lethality, it would be reasonable to assume that insurance companies require that treating professionals do more than check a box to verify their competence in treating eating disorders. However, this is often not the case.
An informal study by parent advocate James Cameron provides an illustration of the unknown competence levels of insurance-designated eating disorder providers in the Los Angeles (LA), California area. "In an extensive examination of nearly two hundred therapists in the LA area we conducted in the summer of 2013, we found that a great many of the in-network therapists listed as having a specialty in eating disorders by a well-known insurer had little or no published credentials or training in that area" (J. Cameron, personal communication, August 27, 2015). According to Cameron's data, 63% of a total of 103 in-network self-reported eating disorder providers demonstrated either no online presence at all except a contact number, or in those that did have an online presence, there was no mention of the words, "eating disorder," in their marketing profiles. Thus, the levels of specific eating disorder training and competence were often unknown and not easily discerned.
A number of insurance companies seem to rely exclusively on a clinician's self-report when choosing their eating disorder providers. This can offer a potentially inaccurate measure of competence. According to Eva and colleagues (2004), clinicians often do not know what they do not know.
Below we summarize the procedures used by four well-known insurance companies to select their providers who will accept eating disorder patients. Photos of the applications are available here.
- This insurance provider asks applicants to "check up to 8 areas of focus."
- Their list includes 49 potential areas of focus (e.g., eating disorders, women's issues, parenting issues, etc.).
No additional verification of eating disorder training is requested.
Blue Cross/Blue Shield:
- This insurance provider asks applicants to "check your primary areas of practice focus."
- Their list of options includes 48 areas of practice focus (e.g., eating disorders, divorce, domestic violence, etc.).
No additional verification of eating disorder training is requested.
- This insurance provider has a separate process for joining one of their "specialty networks"; among the areas of specialty are eating disorders, alcohol and substance use, autism, and EMDR.
- Specialty network applicants are asked to ensure they meet one of the following criteria:
1. Certification by a nationally recognized certifying organization.
2. An internship, fellowship, or formal training program in an accredited institution focusing on treatment.
3. An accumulation of continuing education units or course work focused on current treatment.
4. Significant work experience focused on current treatment of one of the designated disorders or groups of patients. "The depth and breadth of experience must demonstrate that you have gained the knowledge and skills to be considered a specialist."
Verification in the form of required documentation is collected later.
- This insurance provider asks applicants to examine the provided treatment categories and "check all that apply."
- Their list of treatment category options includes 37 conditions (e.g., eating disorders, anger management, blind/visually impaired, etc.) and 4 modalities (e.g., family, group, etc.).
- No additional verification of eating disorder training is requested.
For three of the four carriers that we reviewed, there seems to be no process—other than a checkbox self-report—to gauge or verify a clinician's level of eating disorder treatment competence.
For potentially effective treatment, it inevitably falls to the consumer to vet their potential therapist's skill in treating eating disorders. Levels of eating disorder treatment specialization range from a minimal amount of eating disorder training all the way to specialized certifications. Clients also have varying treatment needs; one person's diagnosis, symptom severity and frequency, and psychological readiness for change may indicate need for a true eating disorder specialist, while another's may not.
Some questions that we invite anyone seeking eating disorder treatment to ask a potential provider:
- What is the eating disorder therapist's training, background, and experience in treating eating disorders?
- What is this provider's treatment philosophy? (You may want to check if it is delineated on their web site.)
- Which eating disorder or other continuing education conferences has the provider attended in the last two years?
- What percentage of the therapist's total client load is (or has been) people struggling with eating disorders?
An effective pairing with a therapist can be vital to the healing process and to the client's improved quality of life and health. Sometimes a specialist's eating disorder knowledge may even help to save a person's life. Additional and detailed resources for vetting potential therapists include: F.E.A.S.T. Guide: Port in a Storm: How to Choose a Treatment Team for a Loved One with an Eating Disorder in the USand
NEDA's Questions to Ask When Interviewing A Therapist.
We acknowledge that there is more advocacy work to be done in the area of outpatient provider networks. In the meantime, consumers will likely benefit by appraising their potential eating disorder providers. Research has shown that intervention, as early as possible, can be important for the recovery process. Full recovery from eating disorders is possible (Bulik, 2016).
Eva, K. W., Cunnington, J. P., Reiter, H. I., Keane, D. R., & Norman, G. R. (2004). How can I know what I don't know? Poor self assessment in a well-defined domain. Advances in Health Sciences Education, 9, 211-224. doi:10.1023/B:AHSE.0000038209.65714.d4
Fichter, M., & Quadflieg, N. (in press). Mortality in eating disorders – Results of a large prospective clinical longitudinal study. International Journal of Eating Disorders.
Gurney V. W., & Halmi, K. A. (2001a). Developing an eating disorder curriculum for primary care providers. Eating Disorders, 9, 97-107. doi:10.1080/10640260127716
Gurney V. W., & Halmi, K. A. (2001b). An eating disorder curriculum for primary care providers. International Journal of Eating Disorders,30(2), 209-212. doi:10.1002/eat.1074
Linville, D., Benton, A., O'Neil, M., & Sturm, K. (2010). Medical providers' screening, training and intervention practices for eating disorders. Eating Disorders, 18, 110-131. doi:10.1080/10640260903585532
Linville, D., Brown, T., & O'Neil, M. (2012). Medical providers' self perceived knowledge and skills for working with eating disorders: A national survey. Eating Disorders,
20, 1-13. doi:10.1080/10640266.2012.635557
Mahr, F., Farahmand, P., Bixler, E. O., Domen, R. E., Moser, E. M., Nadeem, T., . . . Halmi, K. A. (2015). A national survey of eating disorder training.International Journal of Eating Disorders, 48, 443-445. doi:10.1002/eat.22335
Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist,
62, 199-216. doi:10.1037/0003-066X.62.3.199
Lauren Muhlheim, Psy.D., CEDS is a Psychologist and Certified Eating Disorders Specialist practicing in Los Angeles. She specializes in providing evidence-based psychotherapy for adults and adolescents.
Allison Spotts-De Lazzer, M.A., LMFT, LPCC, CEDS is a Licensed Marriage and Family Therapist, Licensed Professional Clinical Counselor, and Certified Eating Disorders Specialist practicing in the San Fernando Valley, Los Angeles area. She is also the creator of #ShakeIt for Self-Acceptance!™