When payers don’t agree with us on a UR, it is normally because they feel the patient does not meet criteria for the recommended LOC. We agree most of the time but sometimes we agree to disagree- based on the criteria and medical necessity, which is not always black and white.  Welcome to the world of mental health.  Outcomes help but some of these things are simply open to interpretation and for as long as we are dealing with brain diseases where most of the time we can’t actually see the disease in the brain, this will remain the case.

Recently, however, we have had several utilization reviews with payers where our patients are being denied the recommended level of care not because they do not meet criteria for that level of care but rather because they are identified as patients who are not making “enough progress” in order to substantiate continued care.  Needless to say, this is both infuriating and heartbreaking.  Hearing that anyone has given up on one of our patients is like a dagger to the heart.  It sucks the wind out of everything that we are trying to do and everything that we believe; namely, these diseases can be deadly and yet recovery IS possible as long as we all work together and don’t give up.

Take for instance the following case- patient X: BMI: 17, weight:  104 (height ~ 5’5), Diagnosis: Anorexia, Bulimia, PTSD.  Most recent TX History: 4 weeks in Residential.  Current symptoms: Purging at least once daily, losing weight slowly.  Home living environment: Not conducive to recovery, currently living in sober living.   Financial situation: No job, limited resources.   Recommended LOC: SCH recommending at least 5 day per week PHP.   Insurance company is recommending outpatient (like once weekly for an hour).  Stated reason- BMI is “above 17”, patient is “stable” and off the record, “patient has been in and out of treatment for years, showing no evident signs of progress…. more treatment won’t help”.

A few observations and comments.  First of all, though we may not agree with it, it is fairly simple to understand where this perceptive comes from.  After all, if the insurance company taking this position is subject to the same expectations as every other company on the planet, they are bound by a duty to spend their money wisely and prudently.  If they see an “investment” in treatment not paying off, why keep throwing “good money after bad”?  Sounds awful- we agree!  However, understandably these guys are skeptical of many providers in the industry, as they get told all sorts of different stories from all types of providers every single day.  If based on what they are told, what they can see from 500 miles away having never met the patient and probably doing dozens of these reviews every single day, can we blame them for sometimes just wanting to cap their losses and move on to the next patient?  We can be furious and disappointed, but at least we can kind of understand their position.

Yes, some of this makes sense but only for a split second.  Then we remember we are dealing with human lives, people with families and kids and friends and jobs.  People with potential, people who may be sick now but don’t have to be sick forever.  People who have fallen prey to a disease, not because they choose to be sick or because of some moral failing but rather because they are sick.  These are not diseases of choice or of moral failing.   These are diseases of the brain, and people who suffer from them deserve the same support they would receive as if they were suffering from something like cancer.  PERIOD.

Back to patient X: Are we saying we should just let patient X in this case die, or maybe the person needs to end up in the emergency room before they can get more care?   Unfortunately, that is what will happen most likely.  These diseases are progressive and they are deadly.  If left untreated, people get worse, or they die.  One trip to the ER costs about as much as one month of outpatient treatment, if the patient doesn’t die.  Not treating the disease isn’t only amoral, it also makes no sense- financially or otherwise.  Just because treatment does not look (or sound) like it has been successful in the past does not mean it has not actually been successful in the past.  Unfortunately measuring success in this field is not as simple as watching a broken bone heal by looking at X-Rays over 6 weeks. We remind patients every day that the road to recovery is often not a straight line upward.  Relapses, for example, do not mean a person has failed in treatment.  When this happens or when treatment is not progressing as we would like, we try and understand why and what we can do to help, and we continue onward.  Sometimes this means people revert to higher levels of care for a period of time or maybe they try a different type of treatment.  The good treatment centers are able to recognize when a patient needs more or something different, and they help the patient try to find it.  Further, in this line of work we never know when recovery is going to “stick”.  If we keep trying, it often does.   If we give up, however, recovery doesn’t happen.

Another question we ask as we ponder this is, “what defines and who gets to define whether or not treatment is or has been successful”?  Is it us, is it the patients weight, their time in treatment, the person on the other end of the phone who has never met the patient????  This is where standardized outcomes that matter to patients would make all the difference in the world.  If two professional UR people can’t agree on a recommended course of care for a patient because one side says there isn’t enough progress to justify continued care, why not get the patient’s perspective by reviewing the outcome surveys they are completing every week while in treatment?  In the case of patient X, we have patient reported data that tells us whether or not there is statistically relevant improvement in this patient’s symptom distress, interpersonal relations and social role.  If there is improvement in these areas as reported by the patient, is this not arguably enough to at least overcome the hurdle of “there isn’t enough progress to justify continued care?”  Yes, the lost weight is a sign that things may not be going as well as we would like but if the patient is feeling significantly better, feeling supported by friends and family and feeling as though their symptoms aren’t dominating their lives as much, THIS SHOULD MATTER!

Notwithstanding the fact that we don’t believe anyone should ever give up on humans who are struggling with any form of mental illness, when two professionals agree to disagree the one thing we should all be able to revert to is the data.  In this case if the data shows there is progress, and the patient is reporting data that says they are feeling there is improvement, then let’s all keep working on it.  If, however, the data agrees with the insurance company and we don’t see progress, let’s discuss other options that may work for the patient.  Either way, we should never give up and the data will help.  This, we should all be able to agree on.