Who Gets Treated for Eating Disorders in Los Angeles?

low cost eating disorder treatment Los Angeles County This NEDAwareness week, I’ve been thinking a lot about the theme of “Let’s Get Real.” One stubborn myth about eating disorders is that they affect primarily white, upper-middle-class females.

It would take you just one afternoon at my own Los Angeles practice to discover how untrue this is. My clients are all genders, ages, and ethnicities. I accept some private insurance and one public insurance. Among my patients with eating disorders are non-native English speakers, immigrants from low SES backgrounds, and people on public assistance.

The myth that eating disorders affect only the wealthy not only makes it more difficult for patients who don’t meet the stereotype to recognize that they have a problem but affects the entire system of treatment.

Throughout the US, there is a shortage of publicly funded specialized treatment programs for eating disorders. And specialized eating disorder treatment is expensive! The residential treatment complex only serves the economically privileged.

Carolyn Becker, Ph.D. recently brought attention to the presence of eating disorders in food insecure populations. The research on which she collaborated studied adults receiving food at San Antonio area food banks. Those who had hungry children in their households (representing higher levels of food insecurity) had higher levels of binge eating, dietary restraint, weight self-stigma, worry, and overall ED pathology when compared to participants with lower levels of food insecurity

Within Los Angeles County, eating disorders are a covered diagnosis by the Department of Mental Health (DMH). However, according to a DMH district chief, there are no specialized services for eating disorders within the DMH system. I recently led a training on eating disorders at one of the county community mental health centers and a staff member there told me, “Most patients with eating disorders are seen in primary care and none of us are trained specifically in this… What we need is training in evidence-based treatment.”

A clinical staff member at another DMH clinic said, “Honestly, we don’t have a lot of access to resources for people with eating disorders and aren’t equipped to adequately handle serious cases at this clinic. Referrals have always been difficult and there are no reliable referral sources for our patient population. We have really only been able to connect a few of our most severe cases to any treatment at all.”

I searched the Alliance for Eating Disorder Awareness list of Medicare/Medicaid providers and facilities within 50 miles of Los Angeles and came up with only one Medicare provider and no Medicaid providers or facilities.

This blog post was inspired because as a provider for Anthem Medi-Cal, I am receiving calls from county clinics with referrals of other (non-Anthem) Medi-Cal patients with eating disorders that I can’t see. So, when faced with a patient with an eating disorder and no insurance in LA County, what’s a provider to do?  Here’s what I’ve been able to find. If you have other resources, I’d love to hear about them!

Resources

Hospitals

CHLA takes California Medicaid for patients under age 25 needing medical stabilization.

UCLA takes California Medicaid for patients under age 25 needing hospitalization for eating disorders.

General low-fee counseling centers

Southern California Counseling Center

Maple Counseling Center

The Wright Institute

Cal Lutheran Low Fee Counseling Center

Treatment Scholarships

Center for Discovery and Project Heal provide treatment scholarships.

Source

Becker, Carolyn Black, Keesha Middlemass, Brigitte Taylor, Clara Johnson, and Francesca Gomez. 2017. “Food Insecurity and Eating Disorder Pathology.” International Journal of Eating Disorders 50 (9): 1031–40. https://doi.org/10.1002/eat.22735.

 

Thanks to Rosewood Center Santa Monica for help with the referral list.

March Against ED and Eating Disorder Lobby Day 2015

IMG_5760 7
In front of the Capitol before the March Against ED with travel buddy and colleague, Alli Spotts-De Lazzer

In October I attended the second annual March Against ED (AKA “MOM March”), followed by Eating Disorder Lobby Day for the Anna Westin Act (H.R.2515/S. 1865) in Washington, DC. The Act is the first eating disorders-specific bill to receive bipartisan support at introduction, which is exciting. There is hope that the bill will be passed this session.

On the day of the March, approximately 300 people assembled on the lawn of the Capitol building to use our collective voices to raise awareness about eating disorders. It was one of the most powerful awareness events I’ve attended.

More a rally than a march, the day was well-orchestrated and moving. Most participants wore purple shirts, while green shirts were worn by those who had lost a loved one to the illness. During the program, we were all asked to give a hug to someone in a green shirt. Activist Kitty Westin – mother of Anna Westin – said, “We don’t want anyone else to wear a green shirt.” Participants carried posters with photos of loved ones that they were “marching for.” The stories and photos of lives lost were a sad and poignant reminder of the brutality of eating disorders. Yet each speaker reminded us that with access to appropriate treatment recovery is possible. The overall tone of the day was hopeful: we celebrated the progress made to date and felt the power of our united efforts.

eating disorder advocacy
Former Representative Patrick Kennedy

Speakers included mothers of children both recovered and lost to the illness and recovered, advocates, a pediatrician, and former U.S. Representative Patrick J. Kennedy, the lead sponsor of the Mental Health Parity and Addiction Equity Act of 2008 (“the law that said the brain was part of the body”). Representative Kennedy encouraged participants to continue to fight for insurance coverage. He noted that “Not only do eating disorders have the highest mortality rate of any mental illness, they’re also the most discriminated against.”

Annie Seal, a mother who spearheaded the first insurance-focused eating disorder specific legislation in Missouri, gave a rousing speech. “This is YOUR house!” she said, pointing at the Capitol Building behind her and inspiring us for the day of lobbying ahead.

There were additional both joyful and touching moments. About 25 attendees (including me!) participated in the Shake it for Self-Acceptance flash mob style dance promoting self-acceptance and originality. Professionals, family members, and those in recovery joined together to share in movement and self-acceptance. We also lit candles of hope and set butterflies free.

The following day, 27 delegations comprising 200 advocates lobbied Congress on behalf of the Anna Westin Act. Anna Westin fought a five-year battle with anorexia before committing suicide in February 2000. Her parents and other supporters turned their grief into action, founding the Anna Westin Foundation and the Eating Disorders Coalition for Research, Policy, and Action shortly thereafter.

There are three main components of the Anna Westin Act:

  • Training for health professionals, school personnel, and the public in eating disorder identification and early intervention (using NIMH and SAMHSA funds).
  • Clarification that the Parity and Addiction Equity Act of 2008 covers residential treatment for all mental illnesses and substance use disorders.
  • Requiring the FTC to study whether regulation is needed for digitally altered images in advertising (House bill only).

Lobby Day began early with message training. Following this, we broke into delegations by state. In groups of 5 to 8, advocates attended meetings with our state lawmakers’ staffers, and in some cases the lawmakers themselves. In these meetings, we spoke about why the Anna Westin Act was important to us.

eating disorder advocacy
My fellow California Team One members minus me the photographer

After a lunch break, the delegations assembled to learn more about the importance of the Anna Westin Act from its Senate sponsors, including Senator Amy Klobuchar [MN-D] and Senator Kelly Ayotte [NH-R]. I took pride in standing beside such an engaged, intelligent, and creative group of advocates.

Lobby Day is held twice a year, once in the spring and once in the fall, with the March Against ED held annually prior to fall Lobby Day. If you are connected to eating disorders in some way, I strongly encourage you to go. For further information, follow the Eating Disorder Coalition and the March Against ED.

Special thanks to the organizers of the March and Lobby Day: Becky Henry, Debra Schlesinger, Cherie Bilby Monarch, Johanna Kandel, Kathleen MacDonald, and everyone at the EDC for doing such a great job and being so welcoming to this newcomer.

Winter LACPA Eating Disorder SIG meetings (2015-2016)

Thursday, November 12 at 7:15 pm.

Title: Medical-Legal Aspects of Eating Disorder Treatment with Emphasis on Denial of Care

Presenter: David Rudnick, M.D., Ph.D.

Learning Objectives:

1) Become familiar with the issues in the treatment of eating disorders that are most likely to trigger legal interventions on behalf of patients.

2)  Understand the meaning of parity and the California Mental Health Parity Act as it applies to the treatment of mental disorders generally and eating disorders specifically.

3)  Learn the current categories of level of care involved in the treatment of eating disorders, their relationship to predictors of treatment outcome and the potential impact of insurance denial of the appropriate level.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio:  Dr. Rudnick was born and raised In Los Angeles, California. He received A B.S. in Physics from Stanford University in 1962 and a Ph.D. in Physics from Harvard University in 1968. After 6 years on the UCLA Department of Physics faculty, he switched gears and attended the University Of Miami Medical School in the Ph.D. – M.D. Program. He graduated that program in 1976, and then completed an internship in Internal Medicine at the Wadsworth V.A. Medical Center and a residency in Psychiatry at the UCLA Neuropsychiatric Institute.

Following completion of his residence in 1980, he became Medical Director of the UCLA Neurobehavior Clinic and opened his private practice in Santa Monica. His interest in eating disorders began during his residency, when together with Joel Yager, M.D., he started the first adult outpatient eating disorders program at UCLA. Since completing his residency in 1980, he has supervised this program in its many inceptions. His interest in medical-legal issues began in the context of criminal offenders who were evaluated in the Neurobehavior Clinic for underlying neurological and neuropsychiatric disorders. It extended to the neuropsychiatric aspects of brain injury, leading to multiple assignments as an expert consultant and witness in brain injury cases. It was then a natural evolution to marry the interest in eating disorders to participation as a medical-legal expert in cases involving treatment issues.

Dr. Rudnick has evaluated and testified about many aspects of eating disorder treatment that have come under legal scrutiny, and will talk to us about those experiences with emphasis on the, currently, hotly contested issue of denial of care.

RSVP to Dr. Lauren Muhlheim at drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Wednesday, December 2 at 7:15 pm – joint with Sport & Performance SIG

Title:   When Fit Becomes Foe: Excessive Workout Supplement Use as an Emerging Eating Disorder in Men

Achiro

Presenter:  Richard Achiro, Ph.D.

Description:  Dr. Achiro will discuss his recent study which provides preliminary evidence that excessive over-the-counter workout supplement use is a variant of disordered eating in gym-active men. This work—which has received international recognition from sources such as Reuters, WebMD, The Huffington Post, NPR, CBS News, and the BBC—is timely due to the drastic increase in workout supplement use in recent years. Although consuming protein powders, creatine, and caffeinated “boosts” have become standard lifestyle practice for a significant subset of the male population, misuse of these products has remained largely overlooked as a potential risky body change behavior. Dr. Achiro will highlight psychological factors found to be associated with misuse of workout supplements, with an emphasis on gender issues and implications for assessment and treatment.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio: Richard Achiro, Ph.D. is a psychotherapist and published researcher who received his doctorate in clinical psychology with an emphasis in health psychology from the California School of Professional Psychology, Los Angeles. He has maintained several leadership positions, including past service on the Los Angeles County Psychological Association (LACPA) Board of Directors. Dr. Achiro provides treatment to individuals and couples as a Registered Psychological Assistant supervised by Stephen Phillips, J.D., Psy.D. in Beverly Hills.

RSVP to Dr. Lauren Muhlheim at drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Wednesday, January 20 at 7:15 pm

Title:   Elimination is Oppression – The Ill-Advised Fight Against Obesity

Presenter:  Ragen Chastain

Description: You can’t have a “War on Obesity” without creating a war on fat people. There is no non-stigmatizing way to say “The world will be better when no one who looks like you exists.” The shame, stigma, bullying, and oppression that have arisen from massively failed attempts to “eradicate” obesity have far-reaching negative health effects on people of all sizes, including those struggling with Eating Disorders.  The solution is not to double down and do more of the same. The research is clear that body size and health are not the same, and that a focus on body size in healthcare does a disservice to people all sizes.  We can, and we should, create complete, thriving public health programs without the use of eliminationist language, without creating a culture of appearance-based stigma and oppression, and without waging war on anyone.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Bio: Ragen Chastain is an internationally recognized thought leader in the fields of self-esteem, body image, Health at Every Size, and corporate wellness.  She is a sought after speaker on the college, corporate, and conference circuits who has set the stage on fire everywhere from Google Headquarters to Cal Tech to the Models of Pride Conference.  She is the author of the blog DanceswithFat,  the book Fat: The Owner’s Manual, a columnist for Ms. Fit Magazine, and frequently appears as a topic expert on television and in print media. Ragen is a featured interviewee in the documentaries America the Beautiful 2 – The Thin Commandments, Ragen’s More Cabaret, and A Stage for Size.  She lives in Los Angeles with her partner and their adorable dogs and in her free time she is training for her second marathon and her first IRONMAN triathlon.

RSVP to Dr. Lauren Muhlheim at drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

July LACPA Eating Disorder SIG Meeting

I am so excited to confirm the next speaker for the Eating Disorder SIG who will be joining us from Washington, DC.

Wednesday, July 22 at 7:15 pm  headshot from Lobby Day Kathleen

Presenter:  Kathleen MacDonald

Title:   Advocacy and the Eating Disorder World:  Why Clinicians Matter

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

Description:  Capitol Hill, Advocacy and Eating Disorders –what possible connection do all three of these things have and why should you care about how they intersect?  Together we’ll discuss the answer to this question and discover how clinicians have a major role to play in eating disorder advocacy.  You will learn concrete ways to advocate for eating disorder legislation –ways that will not take up too much of your precious time, but ways that WILL make a difference.  You will also learn how to empower your clients, when they’re ready, to advocate for eating disorder legislation –a process that can be cathartic, empowering and life-changing.  And perhaps most of all, you will learn how one voice can make a difference on Capitol Hill –how the impact of one voice has the capacity to send ripples out beyond the halls of Congress, and into the lives of millions who suffer the insidious diseases we call eating disorders.  

Bio:  Kathleen MacDonald is Director of Social Media & Advocate Relations for the Eating Disorders Coalition for Research, Policy & Action (“EDC”) and a Health Insurance Advocate at Kantor & Kantor, LLP.   She believes that eating disorders education, along with early intervention and identification of symptoms and behaviors that can lead to the development of eating disorders is central helping to prevent people from suffering these deadliest of all mental illnesses.  Some of Kathleen’s professional experience includes: Patient Advocate for those impacted by eating disorders; FREED Foundation College Speaking Tour; assisting in the EDC’s creation and drafting of the Anna Westin Act of 2015 and the FREED Act (the Federal Response to Eliminate Eating Disorders Act), the first comprehensive bill in the history of Congress to address eating disorders research, education, prevention, and treatment; and writing appeals against the denial of insurance benefits for eating disorder treatment.  Kathleen has been involved in eating disorder advocacy since 2002.  She currently lives in the Washington, DC., area with a few English Setters, a few cats and a loved one of the two-legged variety.

RSVP to:  drmuhlheim@gmail.com

SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

This is a really unique opportunity to hear from someone who has worked on eating disorder policy.  New members can join LACPA in July and get 14 months of membership so encourage your nonmember friends to join now and take advantage of this amazing speaker!

Who Killed the 50 minute session?

What Consumers Should Know about Changes to Psychotherapy Sessions in 2013

By Lauren Muhlheim, Psy.D., CEDS and Kantor & Kantor, LLP

Unbeknownst to most mental health consumers, a change went into effect in January, 2013 that may have far-reaching ramifications for those receiving outpatient psychotherapy.  For the first time in 15 years, changes were made to the coding system used to describe and bill for mental health treatment.   This change has resulted in chaos for many mental health professionals who bill their patients’ insurance.  Nationwide, many mental health providers have reported problems with filing and receiving timely reimbursement for claims filed under the new coding system.

Why were the Current Procedural Terminology (CPT) codes changed?  The Centers for Medicare and Medicaid Services (CMS) establishes the Current Procedural Terminology (CPT) codes that providers use to communicate with insurance companies.  The CPT codes are periodically reviewed in partnership with the American Medical Association (AMA).  For the last several years, the AMA and the American Psychiatric Association (APA) advocated for changes in the codes that would treat (and reimburse psychiatrists) like other physicians.  Psychiatrists have traditionally been on the low rung of physician pay scales.  The changes allow (and now require) psychiatrists to bill separately for the different services they frequently provide in the course of a single session (medical examination, psychotherapy, and medication management).  The hope was that the new codes, in providing more flexibility in session length, would highlight the complexity and diversity of what psychiatrists do.  There are additional “add on” codes for “complexity” as well as for crisis management.  Since all mental health providers use the same psychotherapy codes, non-psychiatrists have had to adopt these as well.

For the majority of recent psychological treatment history, the standard 50- minute therapy session was billed to insurance under the CPT code “90806”, and was officially described as “individual therapy 45-50 min.” In practice, most therapists have scheduled patients on the hour and allocated one hour per patient, spending approximately 50 minutes face to face.  This often stretches to 55 minutes by the time one handles payments and schedules the next appointment and allows a few minutes between clients for notes, bathroom breaks, and checking messages.  In 2013, the 90806 code was eliminated and replaced with several alternatives:

  • 90832 – psychotherapy 30 minutes
  • 90834 – psychotherapy 45 minutes
  • 90837 – psychotherapy 60 minutes

Practitioners were informed about the change in October 2012, but given little specific information on how to use them.  The American Psychiatric Association provided the following interpretation:

Note: Since the new psychotherapy codes are not for a range of time, like the old ones, but for a specific time, the CPT “time rule” applies. If the time is more than half the time of the code (i.e., for 90832 this would be 16 minutes) then that code can be used. For up to 37 minutes you would use the 30 minute code; for 38 to 52 minutes, you would use the 45-minute code, 90834; and for 53 minutes and beyond, you would use 90837, the 60-minute code.

By “time,” the APA means face-to-face time with the client.

So what’s the hitch?  The 50-minute session suddenly no longer exists, and that creates a problem. Many practitioners assume the 45-minute session is the intended replacement for the 50-minute session.  However, they fear that reducing time spent with patients will both reduce treatment efficacy, as well as be used as justification by insurance companies to reduce reimbursement rates.  Remember, reimbursement rates haven’t been raised in 18 years and are typically only half of what a patient would pay if they didn’t have insurance.  The other option, the 60-minute session, makes it harder for therapists to complete paperwork and take bathroom breaks unless they space clients further apart, complicating schedules for everyone involved.  And it’s not even clear whether insurers will choose to cover the 60-minute session.   It appears that some insurers are not.

For psychiatrists, the new codes are extremely complicated. The 2013 Medicare fee schedule reveals that reimbursement for psychiatric evaluations with medical services – those done by psychiatrists – will be lower than reimbursements for psychiatric evaluations done by social workers and psychologists.  “This makes no sense, and seems to run counter to the premise that creating a comprehensive system of coding services would create an appreciation for the complexity of the medical aspects of treating mental disorders, address parity, and decrease the stigma to seeing a psychiatrist.”[1]

The CPT changes have thus far resulted in confusion and delays in processing mental health claims because insurance companies were not prepared, equipped, or organized for this change.   Insurance companies had not yet set rates for the new codes, nor had they decided which codes they would accept.  As a result, claim processing since the first of the year has been slow, impacting patients, therapists, and insurance companies.   Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan told NBC News, “The amount of changes and the work involved was much bigger than … the folks involved anticipated.”[2]

Around the country, mental health providers have reported problems with insurance reimbursement.  Some are reporting financial difficulty due to the delay in cash flow.  The biggest worry, however, is that this coding chaos will affect care for millions of vulnerable patients.

What does this mean for providers? In simple terms, less pay, delayed payment, and financial hardship.  “We are ethically bound not to leave patients hanging,” Steven Perlow, president of the Georgia Psychological Association and a psychologist in private practice said. “I will personally see people for a sliding scale … there have been situations where I’ve seen people for free.”[3] Additionally, providers may experience disincentives to stay on insurance panels.  Lastly, these factors may affect providers’ ability to deliver quality care.

What does this mean for patients? To start with, session lengths could be reduced by 10%, meaning less treatment.  Furthermore, patients may have increased difficulty finding practitioners who are willing to accept insurance. Therapists may very well be waiting to see what is happening with reimbursement rates before accepting more insurance patients, or may leave panels altogether.

These outright denials of payment and system wide delays have caused chaos among providers and their patients, and could last for months.  This disorder and confusion has the potential to jeopardize access to care for millions of mentally ill Americans, who depend upon the stability of treatment from their mental health providers.

Action Plan

If you feel that the 2013 psychotherapy CPT codes have negatively affected how you are able to deliver or receive patient care, let your voice be heard:

http://www.realpsychpractice.com/2013-cpt-codes/

Lauren Muhlheim, Psy.D., CEDS

Lauren Muhlheim, Psy.D., CEDS is a psychologist and certified eating disorder specialist practicing in Los Angeles.  She specializes in providing evidence-based psychotherapy for adults and adolescents.  www.laurenmuhlheim.com

About Kantor and Kantor                                                                                                                             

Kantor & Kantor is one of the most experienced and highly respected law firms dealing with the prosecution of claims against insurance companies. If your insurance company has unfairly denied payment for benefits, we can help. Call (800) 446-7529 or log on to www.kantorlaw.net.


[2] JoNel Aleccia, NBC News, Glitch in medical code threatens mental health care, therapists warn, http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care#.URPN_3hBLqc.twitter (February 7, 2013).

3 JoNel Aleccia, NBC News, Glitch in medical code threatens mental health care, therapists warn, http://vitals.nbcnews.com/_news/2013/02/07/16842490-therapists-change-in-medical-coding-threatens-mental-health-care#.URPN_3hBLqc.twitter (February 7, 2013).