Legislation

Testimony in Support of H. 936, An Act Providing for Certain Standards in

Type:  Testimony 

 

Chairman Buoniconti, Chairman Koutoujian, and Members of the Committee, I would like to thank you for the opportunity to submit testimony before the Committee.  I am writing in strong support of H. 936,An Act Relative to Providing for Certain Standards in Health Care Insurance Coverage.  This bill, if enacted, would require that health insurance policies issued in Massachusetts include full parity coverage for all eating disorders.  In addition, the legislation strengthens critical consumer protections under current Massachusetts Mental Health Parity Law (MHPL).
Over eleven million Americans will suffer from an eating disorder in their lifetime.  Eating disorders include anorexia nervosa (characterized by food restriction, extreme weight loss and excessive exercise), bulimia nervosa (defined by binge eating followed by purging behaviors aimed at preventing weight gain), and binge eating disorder (consisting of binge eating without purging behaviors).  Left untreated, these disorders can lead to severe medical complications, including dehydration, tears in the esophagus and stomach, osteoporosis, cardiac arrhythmias and death.  Young women are at highest risk for developing an eating disorder, but these illnesses can occur in individuals as young as 7 and as old as 70, in women and men, and cut across race and socioeconomic class.
Eating disorders stem from a combination of biological, psychological and socio-cultural factors. In addition to emotional suffering, eating disorders cause serious medical complications. The mortality rate for anorexia nervosa is the highest of all psychiatric disorders, and more than 12 times the death rate of young women in the general population.  Of primary concern are life-threatening cardiac abnormalities. Also, the suicide rate is five to six times greater for women with anorexia nervosa than for healthy women of similar age and background.  Most young women with anorexia nervosa lose bone density, placing them at high risk for fractures and disability.  Many young adults with eating disorders are high achievers who hide the severe impact of the illness on their lives until it has reached an acute, or life threatening, stage.  
With professional help, many patients recover. Treatment programs commonly combine psychotherapy, and medication. Patients with eating disorders need medical monitoring and nutritional counseling. Individuals who are acutely ill as a result of extensive weight loss or complications require hospitalization. For younger patients, an essential part of treatment includes family therapy. 
Historically, mental illness was subject to discriminatory treatment by insurers, receiving far lower benefits than illnesses considered “physical” in nature.  The Massachusetts State Legislature recognized this disparity and passed the Mental Health Parity Law in 2000 to ensure fairer treatment of mental illnesses.  Under the 2000 MHPL, only “biologically-based” mental disorders are entitled to equal benefits with physical illnesses.  Eating disorders were not designated as biologically-based under the original law.  Yet clinical evidence demonstrates that eating disorders indeed have a biological basis.
Often insurance companies will cover the physical complications of eating disorders.  However, once an insurance company deems an individual “medically stable,” the carrier will frequently limit coverage for the post-acute physical and mental symptoms of an eating disorder.  Providing full insurance coverage will save lives and preempt costly medical complications.
 In the previous legislative session, chapter 256 of the Acts of 2008 expanded the Commonwealth’s MHPL to cover disorders included in the Diagnostic and Statistical Manual of Mental Disorders. This encompasses eating disorders which are in the most recent edition; however there are still some serious limitations on insurance coverage for these disorders. Due to the utilization review process and adverse determination appeals process, insurers often refuse or limit coverage for eating disorders.  This forces families to pay thousands of dollars out-of-pocket for essential treatment of their loved ones.
H. 936 would change the utilization review process, by requiring greater transparency, consumer protection and the use of applicable standards. A newly defined utilization review with enhanced standards would ensure a fairer process for those seeking treatment for mental disorders. H. 936 would shift the burden of proof for an adverse determination, by requiring that the insurer prove that treatment is not medically necessary. Under the current system, a medical provider must justify that treatment for an eating disorder is medically necessary. H. 936 would require that an insurer provide a notification of adverse determination. This notification would contain specific information including the factual basis that the determination was bases upon; specific reasons why the medical evidence fails to meet the relevant medical review criteria; any alternative treatment option offered by the carrier; and identification of medical experts whose advice was obtained by the carrier. This change would allow the licensed mental health professional the autonomy they deserve in making medical decisions about their patients with mental disorders.
Finally, H. 936 amends chapter 176O, the managed care patient protection law, to better protect patients denied health insurance coverage for treatment of both mental and physical conditions. This would require that the Office of Patient Protection have at least three objective review agencies consisting of qualified clinical decision-makers who are experienced in the determination of medical necessity. These panels would consider written documents submitted by the insured, information from the involved parties and information obtained from any informal meeting held by the parties. The insurance carrier would have the burden of providing reliable evidence in support of its adverse determination, and may not rely on any basis not previously stated in its adverse determination.

The inclusion of these changes would provide for greater consumer protection for patients, and require that insurance carriers make informed decisions regarding medical necessity when dealing with mental disorders, including eating disorders. Thank you for your consideration of this most important matter.  I strongly encourage the Committee to adopt a favorable report for H. 936 as expeditiously as possible.