In November 2018, the Residential Eating Disorder Consortium (“REDC”) launched its Standards of Excellence Project (“STEP”). The REDC preliminarily explained STEP as, “ … a collection of works demonstrating REDC’s continued commitment to raising industry standards and professionalizing the field. STEP represents the strongest, clearest declaration yet of the patient-centered values, beliefs, and principles that guide REDC’s members in their work every day.”
First, I strongly believe the REDC members want to help people suffering from eating disorders. I believe that REDC members are professionals, learned in their fields and feel much of the same frustrations that the families afflicted by this disease feel. Within the confines of their current financial reality, where expansion and treatment protocol may be driven by private equity interests, they desire to embrace patient-centered values, beliefs and principles.
Further, it is no secret that I have been a frequent critic of some 0f the policies of the REDC. And yet, when they recognize that problems exist and attempt to address and rectify those problems, they should rightly be commended for attempting to update its standards and solve these problems.
Before addressing the new Code of Ethics, it is also worth noting that previously, a number of discrepancies and curiosities were brought to light regarding the REDC’s officers and Board of Directors. Although the REDC limits itself to those entities which provide residential treatment care as part of their offered services, there were a few officers and directors who were not employed by these entities. Whether this constituted an actual “issue” is subject to speculation. Regardless, the officers and directors of the REDC are now all employed by residential treatment providers. Perhaps a small issue but it was addressed. The REDC should be commended for that action.
Finally, questions should be raised as to whether the STEP program is meant merely as a series of internal guidelines designed to give their members a general blueprint to follow. Or is the STEP program designed to be an enforceable set of fundamental, exigent rules objectively applied and enforced for the greater good and relied upon by families and those who suffer from this disease.
If the former is the intent, at this point one can stop reading. A privately held company or organization can implement whatever guidelines it wishes within the scope and bounds of the law. It only has to face ramifications for implementing these non-enforceable guidelines without concrete consequences.
However, the remainder of this article and future ones addressing the STEP program are based on the premise that the REDC in good faith, intended to implement these rules as binding statements of governance upon which families and patients could rely.
Code of Ethics
In the preamble to the REDC Code of Ethics, the REDC states:
In 2018, REDC codified the principles in its Center of Excellence document into a Code of Ethics specifically for REDC member organizations. REDC’s members understand that just as they seek objective validation of other fields’ claims of high standards, their external stakeholders — members of the public, insurance companies, academics, regulators, and others — are more likely to trust them when they demonstrate a willingness to establish clear boundaries and practices. REDC’s Code of Ethics demonstrates that its members are governed by specific ethical principles.
Indeed, a valid statement of the minimum standards which should be demanded from those whom we entrust to help save the life of our loved ones. And yet, one statement stands out not so much for what it includes, but for what it does not specifically include. That language is as follows: “ … members of the public, insurance companies, academics, regulators, and others — are more likely to trust them when they demonstrate a willingness to establish clear boundaries and practices.” So, who is not specifically mentioned in this sentence … only the most important persons. The families. The parents. The patients. Those whom are entrusted to their care. Those people who are living in fear. Granted, the REDC undoubtedly intended that those incredibly important people were to be included in the abstract as part of the “public,” or “others.” But we are the people who make their existence an unfortunate necessity. We should be at the forefront of their consciousness. Now, was this a mere oversight? Perhaps. But it is a grievous oversight. Families should be placed first and at the forefront of those people who should be taken into consideration and protected and who should be able to rely upon clear boundaries and practices.
The Sections of the Code of Ethics
The Consortium’s Code of Ethics is broken down into nine different definitional sections and an Appendix. These sections are entitled as follows:
- REDC members accurately represent their treatment outcomes.
- REDC members accurately represent their range of services and the qualifications of their staff.
- REDC members offer patients clinical services that are grounded in a three-pronged approach: scientific evidence published in peer-reviewed journals; clinical expertise considered practice-based evidence; and patient values, preferences, and characteristics.
- REDC members only admit patients whose needs are appropriate for the type of treatment provided — and for the level of care provided — at their programs.
- In marketing their services, REDC members employ messaging that is truthful, fair, non-deceptive, capable of being substantiated, and in all respects lawful.
- REDC members do not pay or receive anything of value in exchange for patient business.
- Prior to admitting a patient, REDC members clearly communicate the cost of treatment that may be required in both the short term and the long term.
- REDC members disclose financial relationships and any potential conflicts of interest that might affect patient care.
- When participating in media interviews, REDC members are focused on educating the public and raising awareness about eating disorders.
A brief overview of each section follows to give a more complete picture.
REDC members accurately represent their treatment outcomes.
In this section, the following language is included: “REDC members accurately represent expected outcomes so that patients understand what they are “buying.” They do not exaggerate services or promise unrealistic outcomes. … Members must accurately represent measures, including providing details about sample sizes and response rates such that stakeholders can understand the degree to which reported outcomes represent a patient population.”
This section is crucially important for families. More often than not, parents are researching these facilities online. As they watch their loved one deteriorate physically, mentally, emotionally, fear and desperation grip them. There are precious few objective resources a family can rely upon in evaluating treatment facilities. There is no federal or state oversight as to what information is or should be included.
This has resulted in outlandish claims. For example, one REDC member currently represents on its website: “99% of parents of child/adolescent patients report that treatment at Center X was helpful, and 97% would recommend Center X to other families in need of treatment.” There is no detail about sample size. There is no detail about response rate. I have yet to encounter any professional who believes those numbers. And yet, desperate families cling to the faintest hope.
Again, if the STEP program is designed merely to be general internal guidelines with no enforcement policies in place, so be it. Advice families of this limitation. If the STEP program represents a strong, enforceable vision for the future, what are its officers prepared to do to bring all members within compliance?
REDC members accurately represent their range of services and the qualifications of their staff.
In this section, the following language is included: “REDC members understand the limitations of their service offerings and never claim to treat certain conditions, including any co-occurring conditions, for which they are not qualified. All providers should have the appropriate education, training, and experience, and should limit their practice accordingly. Providers may practice up to the full scope of practice as defined by their license(s).”
This section is direct and to the point.
REDC members offer patients clinical services that are grounded in a three-pronged approach: scientific evidence published in peer-reviewed journals; clinical expertise considered practice-based evidence; and patient values, preferences, and characteristics.
This section includes the following material language: “Treatment is grounded in the available research, while also focused on spurring innovations (e.g., from clinical practice, academic literature, and so forth). In addition, in keeping with The Joint Commission and CARF International standards, patient values, preferences, and characteristics are also taken into account, along with families’ perspectives. Taking patient preferences into account should not be construed as allowing patient preferences to override the clinical expertise/medical judgment of treatment providers.”
This subsection includes the most complex issues within the Code of Ethics. Every treatment center utilizes the phrase, “evidence-based treatment” within its treatment regiment. This is usually a reference to Cognitive Behavioral Therapy or Family Based Therapy being utilized at those centers. But, families are left to wonder the percentage of time during the week in which actual “evidence-based treatment” is being utilized and whether it is being utilized in the manner resembling the protocol in place during the testing/evaluation/analysis stages. Patient preferences are very difficult to measure, as one must have the necessary expertise to determine the times when the patient is talking. And when it is the disease talking through the patient.
Treatment and recovery are the very heart of the industry. Further, the use of the term “evidence-based” has become incredibly subjective and can be defined in so many different ways. And whereas the use of, “scientific evidence published in peer-reviewed journals” is one of the legs in the three-prong approach, even this is amorphous.
Clinical expertise, as demonstrated by a research study conducted by BYU and Emory University, is often colored by confirmation bias which can result in overestimation of the effectiveness of treatment protocols.
But, what are the options? Collaboration with university and academic researchers as mentioned by the REDC in this subsection is a good starting point. Being open to university based programs and working with organizations like the Academy for Eating Disorders are other progressive actions which can be undertaken.
REDC members only admit patients whose needs are appropriate for the type of treatment provided — and for the level of care provided — at their programs.
This section states: “REDC members strictly adhere to guidelines from the American Psychiatric Association (APA) regarding the appropriate levels of care, and they are committed to treating at the most appropriate level of care required to meet a patient’s needs. If the program is not able to appropriately meet the clinical and medical needs of the patient, it guides the patient to more clinically and/or medically appropriate alternative treatment resources.”
This subsection in essence states that REDC members have accepted the DSM-V guidelines set forth by the APA and will strictly adhere to same. If this section is enforced as written and as obviously clearly intended, the families which come to you for assistance should feel a sense of relief. Objective guidelines and treatment parameters reduce the likelihood of confirmation bias and give a greatest awareness and transparency.
In marketing their services, REDC members employ messaging that is truthful, fair, non-deceptive, capable of being substantiated, and in all respects lawful.
This section states in material part: “REDC members ensure that marketing messages communicate substantive, critical information about their therapeutic services — and are not simply an enticement to choose one facility over the competition. All express marketing claims must be substantiated or capable of substantiation with appropriate evidence when made.”
The remarks and concerns set forth in section 1 are applicable to this section. Often the first, substantive information about treatment centers is gleaned from reviewing the center’s website. A deeper dive may include employee sites like glassdoor.com, the groups on social media and parent advocacy groups like F.E.A.S.T.
The language utilized by the REDC in this subsection is effective, straightforward and substantive.
But, what is the REDC prepared to do in order to enforce that language? What investigative procedure do they have in place to review complaints from families? How far is the REDC prepared to go to stand behind these principles and if necessary, expel a member (and thereby lose revenue) if a rogue member refused to comply with those standards?
REDC members do not pay or receive anything of value in exchange for patient business.
This section contains some perplexing inconsistencies. For example, the section begins with the following language: “REDC members are committed to relying upon objective facts and open, honest communication — not financial enticements — as a way to engage stakeholders. REDC members do not offer financial incentives of any kind to patients, referral sources, or anyone else for the purpose of inducing (or rewarding) the referral of business.” [emphasis added]
But then, almost immediately thereafter, the following language appears:
“Travel: Reimbursement for travel, accommodations, and meals must be “reasonable.”
On the one hand, the REDC sets forth a standard that no financial incentives of any kind will be offered for the purpose of the referral of business. It then seemingly contradicts itself by reimbursing “reasonable” travel, accommodations, meals, gifts of $25 or less and production bonuses to W-2 employees.
The REDC then identifies that transportation scholarships and subsidies can be utilized but only sparingly.
It is not difficult to ascertain what the REDC is attempting to undertake in this subsection. It is attempting to establish an environment of open competition while providing direction to its member institutions as to what conduct is acceptable and that which is not. And yet in doing so, the families who would review this subsection could understandably be left confused.
Cleaning up the language in this subsection would not be painstakingly difficult and could provide clarity.
Prior to admitting a patient, REDC members clearly communicate the cost of treatment that may be required in both the short term and the long term.
The pertinent language of this subsection includes the following: “Treatment programs in our industry often must admit patients without full information about what payers will and will not cover. This lack of transparency in health-insurance reimbursement makes it difficult to predict the out-of-pocket burden on patients and their families. Despite this challenge, REDC members should do everything in their power to ensure that patients and families are as well-informed as possible about the cost of services and patients’ and families’ financial responsibility for those services, such that patients and families can make informed decisions about how that financial obligation is likely to affect them in both the short term and the long term. Prior to admitting patients, REDC members have honest conversations with patients and families about recidivism rates and the typical illness duration and course of care that may be required over a patient’s lifetime. REDC members accurately communicate regarding their prices, expectations about patient out-of pocket costs, and how long a patient is expected to require treatment.”
This language is clear, concise and arguably should be posted on the wall of the financial director’s office where the parents or patients will be meeting to make payments and to discuss financing of the treatment being provided. But, parents and patients also need to be advised of additional information. They need to be informed of the peer-to-peer process, the manner in which insurance entities process claims, that insurance entities can stop payment for treatment with 24 hours notice or less, that families may be forced to make immediate and often expensive travel plans to bring their loved ones home with little or no notice.
This type of information feeds into the requirement of, and necessity for discharge planning beginning the very first day of treatment. (As was cited in the 2012 AED Clinical Practice Recommendations.) With this additional information, families and patients will have a better understanding of possible unexpected costs and the financial pitfalls which could arise.
REDC members disclose financial relationships and any potential conflicts of interest that might affect patient care.
The entirety of this subsection states: “REDC members alert patients about any internal or external relationships, financial or otherwise, that their programs have that might affect patient care. If a REDC member directs a patient from one program to another in which the member has a financial interest, patients should be informed of that fact. It is unethical for programs not to disclose to patients any relationships and/or financial incentive arrangements that might affect patient care. [See section 5, “Sound and Ethical Business Practices,” in the “Center of Excellence” document. Also see the “Marketing Best Practices” document.]” [emphasis added]
This section imposes on the REDC members a requirement of open and honest transparency. The issue then is to discern and define those relationships which “might affect patient care.”
In the past, several articles have brought to light the manner in which private equity firms have taken over the residential eating disorder treatment centers. The majority of the information has focused on the negative aspects of this type of ownership. No governmental oversight. No state regulatory oversight. Acquisition transactions kept secret. Treatment that results in greater reimbursement opportunities being pursued over treatment that may be more effective but result in lesser financial gains.
But there are certainly positive aspects. New financial resources directed toward treatment means more people receive treatment. Additional media outlets are informed of the deadly nature of this disease. Greater credibility and ability to bring financial weight to bear against insurance providers seeking to prematurely release patients because those insurance providers do not adhere to the DSM V or APA guidelines. These private ownership relationships are perceived to provide a more stable financial foundation in the present. As such, for reasons both good and bad, private equity ownership clearly and unequivocally, might affect patient care.
Therefore utilizing the REDC’s own wording and own criteria, the private equity ownership of these treatment centers might affect patient care, both in a positive way and negative manner. And yet, they are not disclosed to patients and families.
When participating in media interviews, REDC members are focused on educating the public and raising awareness about eating disorders.
This section states in material part: “REDC members embrace opportunities to participate in responsible and authoritative interviews aimed at educating audiences and raising awareness about eating disorders. Treatment programs have a solemn responsibility to be good citizens in all forms of media in which they participate.”
This is certainly an admirable statement and sets forth what should be the bare, minimum standards. But, in terms of “educating audiences,” does that also include informing families that there is a paucity of actual, evidence-based medicine in the world of eating disorders. That there is not a lot of medical professionals doing clinical trials with a large enough patient population. That the field of psychiatry has not developed to the point where it can reasonably assign empirical probabilities to different recovery outcomes.” Certainly, life skills, counseling and valuable treatment can be received at residential treatment programs and these programs in one way or another will be valued commodities in the eating disorder industry for the foreseeable future. But, as part of the educational process, certainly all options need to be presented even if in carefully vetted brief sound bites. Integrity of the message must predominate over financial gain.
Observations and Conclusions
Mental health in the United States has reached a crossroads. The Affordable Care Act is on life-support and in its current format, is not expected to survive. Business as usual cannot last.
The REDC is to commended for these steps. But, the question remains … is this merely a recitation of flexible, internal guidelines or is this intended to be the genesis of hard and fast rules upon which families and patients can rely? Is this the first map to a bold, new frontier where patients and families are placed first?
If so, implement procedures to enforce these guidelines. Turn these guidelines into rules. Empower families to interact with you at the highest levels. Give families a strong voice in the treatment process. Enforce these guidelines through administrative procedures and demand compliance from your members.
REDC, be the leaders you aspire to be. Do not just say the words. Undertake the actions openly, honestly, democratically. Through your actions, show you place your patients and their families first. If you do these things, people will support and follow you. I know I will.