Private Equity Attempts to Market Eating Disorders ... It Chose Poorly [Screen shot added]

In Indiana Jones and the Last Crusade, the evil antagonist, Walter Donovan followed Indiana Jones into the chamber containing the "Holy Grail," the chalice from which Christ drank at the Last Supper.  The Grail was guarded by a Knight of the Last Crusade. Donovan demanded that the Knight reveal which was the true Grail, the one that could give eternal life.  Instead, the Knight said, "You must choose.  But choose wisely, for as the true Grail will bring you life, the false Grail will take it from you." Donovan allowed his evil cohort to choose for him and she selected a bejeweled, golden chalice.

He drank deeply … waited for a few seconds … and then was wracked with excruciating pain. He rapidly aged, disintegrated into dust and died. The Knight, with subtle eloquence merely stated, “He chose poorly.”

In prior musings, we speculated about the incredible harm which could be imposed upon the eating disorder industry, let alone those suffering from eating disorders committed by treatment centers owned by Wall Street private equity firms. It did not take long to bring that speculation to reality.

On June 28, 2018, CCMP d/b/a Eating Recovery Center purportedly produced a television advertisement on binge eating disorders. Since this type of marketing does not directly involve the medical aspect of operating ERC it stands to reason that CCMP and its minions conceived of this campaign. The marketing campaign at issue emphasized and focused on weight loss as the main element in its binge eating disorder treatment protocol. This marketing was met with a firestorm of contempt and justifiable derision.

A well-respected counselor experienced with treating eating disorders stated, “Selling a focus on weight loss to people in eating recovery is like selling a wine of the month club subscriptions to alcoholics in recovery. This is so NOT ok. You are literally prescribing the problem.”

A parent advocate stated, “I’m shocked and extremely disappointed that they would put something out like this! Weight loss does NOT = recovery! This only contributes to the problem and encourages diet culture.”

Another parent advocate asked, “Why would they even advertise this? So upsetting! Not recovery oriented and definitely not long term recovery oriented at that.”

Another parent advocate stated, “They do know better. They have been given the same feedback again and again.”

Still another parent advocate stated, “The clinical team has been trying to get the website fixed for a long time and are completely ignored.”

Another advocate remarked, “Didn’t we just talk to them about his a few months ago? Tone deaf!”

Another advocate stated, “The fact that we have to worry about a place for recovery will prevent healing from fat phobia and collude with weight stigma is outrageous!”

Still another parent pointed out, ““… weight loss not guaranteed” in the fine print is horrifying and sad.”

A person struggling with her eating disorder said, “oh well … as someone with (mostly recovered) anorexia, this is triggering as fuck.”

A person whose name is well recognized in the eating disorder industry and who is in the industry stated, “Why do experts in the field need to test this? Of course there is appeal to the client population to draw them in with this tactic, however, it is, simply put, wrong.”

Still another advocate stated, “It’s because of money! Not about a person anymore in treatment. Weight loss draws people.”

Another parent advocate stated, “This infuriates me. It perpetuates EXACTLY WHAT IS WRONG IN OUR SOCIETY IN REGARDS TO WEIGHT.”

Still another parent stated, “Holy Moses, what moron marketing team doesn’t have meetings with the clinic team as well. Something smells.”

Another advocate stated, “This is absolutely horrifying! I have had concerns about ERC before in the sense that they seem to be more business focused than client focused, but this is the icing on the cake.”

This is just a small sample of the outrage directed toward CCMP d/b/a ERC and its marketing campaign. CCMP’s response, through various employees before its parent authority reigned in those employees’ actual opinions included these remarks:

“As a dietician on the team, I am reaching out to share my sadness and heartbreak. … I can promise you that our team does not support this Ad. … We couldn’t be more heartbroken.”

“I had not seen this until this am [sic.] and am horrified. As you know this is not who we are. The commercial is our chance to reach people and tell them that dieting and weight loss are not the solutions to BED …”

The firestorm continued to rage unabated on social media. Only then did ERC come out with its “official response.”

“I just wanted to let you know that the above image is not an actual TV commercial. Unfortunately, this was a screen shot from a video never meant for public use. ERC take [sic.] treating eating disorders very seriously, and work [sic.] hard at breaking the dieting mentality and the body shame that accompanies it, for their clients.”

The response from eating disorder advocates, concerned parents and patients was again, immediate and scathing. And understandably so. ERC’s first attempted response was a mere deflection and left many unanswered questions. This necessitated a more substantive mea culpa from ERC as follows:

First of all, thank you for your passionate responses over the last day. We’d like to explain and apologize for any misperceptions generated by a screen shot from an exploratory video and assure you that this is not and ad for Eating Recovery Center’s (ERC) Binge Eating Treatment and Recovery (BETR) program.

First, we would like to provide some background and context. ERC’s mission is to take the very best care of patients, families and providers of care in the treatment of and recovery from eating disorders and related conditions. To fulfill this mission, we must connect prospective patients with the care they need. Early in the stages of marketing and research efforts, it is common to make use of consumer and patient panels made up of participants from relevant sectors to respond to ideas and assist with messaging. To assist in marketing the BETR program, ERC contracted with a third- party agency was asked a consumer research panel of 100 people to preview a rough cut of a video which portrayed several different perspective and different messages. We did this to ensure that our messaging for the treatment of Binge Eating Disorder (BED) was accurate, understood and well received. This rough cut was offered to the consumer panel before showing it to, and incorporating feedback from, our clinical experts.

Unfortunately, a screen shot of this draft video was distributed on-line, out of context. Many unfortunate assumptions have been made regarding the content after seeing such a small part of this work.

We sincerely apologize for our mistake and the part we played in allowing for such a post. We understand our role in the understandably negative and emotional reaction. We are very sorry if we unintentionally hurt the very people we are trying to reach out to and to help.

The treatment of BED involves providing support in understanding and interrupting binge eating behaviors and treating the medical and emotional consequences of these symptoms. We are committed to providing our patients with BED with an expert multidisciplinary approach including expert psychiatric and medical care, psychotherapy with seasoned and compassionate therapists and individual nutritional planning that supports the goals of a comprehensive treatment plan. We do aim for weight loss as a treatment goal for our patients with BED. Rather, we target quality of life improvements and improved psychiatric and psychosocial functioning. Our intent in collecting feedback from the group of 100 consumer expert reviewers was with this end in mind.

When we are ready to advertise the BETR program on a broad scale, it will incorporate what we’ve learned from today’s conversations, the feedback of the reviewers and our own clinical experts.

We very much appreciate the feedback received today. Please don’t ever hesitate to share your experience and your wisdom with us.

Susan McClanahan PhD, Chief Clinical Officer

Anne Marie O’Melia MS MD Chief Medical Officer

Doug Weiss, MBA, Chief Marketing Officer

For any additional questions, please feel free to reach out directly to our leadership, please email Doug Weiss at: Doug.weiss@eatingrecovery.com

The replies to this attempted apology and explanation were insightful. One person legitimately questioned how such a clueless marketing angle even got past brainstorming, why this message was not off-limits to the marketing company to begin with and why this message did not first go through the clinical team. This advocate wisely pointed out, “Your repeated generic response is not enough. Even having the audacity to “test” this ad with a select audience is unethical and goes against every standard of treatment in eating disorder recovery.”

Still another advocate replied to CCMP d/b/a ERC’s response as follows: “This attempt to save face by claiming the ad was in its infancy is a straw man defense. The fact that it was even piloted suggests that it was considered as potentially viable.”

There are numerous other responses to CCMP d/b/a ERC’s attempted marketing campaign and to a person, all are understandably scathing.  This type of attempted marketing is about forcing the strongest impact possible on the most vulnerable prospective patients, increasing ERC’s patient population not for the sake of improving the understanding and research into this insidious disease but to simply increase the profit margin for the private equity firm which has a majority ownership in ERC.

One must also question whether the marketing firm who composed this campaign is the same entity that assured CCMP d/b/a ERC that it was perfectly acceptable to boast on its website of a 99% satisfaction rate amongst its patient population even though it has been illustrated that that number is grossly inflated, inaccurate and in fact, was debunked by clear and convincing evidence.

This ill-fated marketing campaign, and the false advertising on CCMP d/b/a ERC’s website regarding its “success rate,” perfectly illustrate the reasons supporting the rationality of the Corporate Practice of Medicine Doctrine and why there is such a disconnect between Wall Street PE firms and medical practices. One cannot dispute there is a direct correlation between the most recent marketing campaign and the misrepresentations on its website and in fact, both have the same motivation … that is, to bring in the greatest number of patients so that CCMP d/b/a ERC can continue to grow its bottom line thereby making it a more favorable target for the next acquisition.

One can also wonder whether it is mere coincidence that while a marketing firm was working on that ill-fated campaign, CCMP d/b/a ERC announced that it was expanding to a new location in Seattle, Washington, which in addition to its existing Bellevue site, allowed them to “… expand our residential, PHP and IOP levels of care to those in the greater Puget Sound area.” Granted the drive from Seattle to Puget Sound is a grueling 30 miles but on the other hand, those goals in the incentive based contract held by the primary medical directors in ERC’s Denver corporate headquarters are not going to be achieved by themselves!

If the primary motivation of a corporation is to rapidly expand for the purpose of making it a more favorable target for reacquisition, especially in an industry that is for the most part unregulated, which is flying beneath the radar of politicians, and which has no third parties to provide a system of checks and balances, then that corporation is emboldened to make misrepresentations on its website and to market its services to vulnerable persons whose health, if not very lives hang in the balance.

CCMP d/b/a ERC continues to provide examples of why state’s attorney generals or state boards of medical examiners must pick up the mantle of investigating bad faith conduct and to enforce the rule, if not the very spirit of the Corporate Practice of Medicine doctrine.

And so, we await with great eagerness the next misstep taken by the private equity overlords at ERC so with the subtle eloquence exhibited by that Knight of the Last Crusade, we too can say, “They chose poorly.”

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Mental Health Parody -- Ask Not For Whom the Bell Tolls ...

Many people have heard and even used the expression, “Ask not for whom the bell tolls; it tolls for thee.” In doing so, those same persons misquote the original statement and in all likelihood, do not fully understand the original intent of the words.

In 1624, John Donne, then the Dean of St. Paul’s in England penned, “Devotions Upon Emergent Occasions and severall steps in my Sicknes.” As part of his musings upon life and death, Donne wrote,  “… any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls, it tolls for thee.”

It is believed that Donne wrote this missive while suffering from a severe case of spotted fever and believed his death was imminent. The meaning of his work was that each individual is part of a greater whole such that the death-bell has deep and significant meaning for all who hear it.

Because of its repeated almost universal erroneous usage, the incorrect statement is believed by most to be accurate. And yet, it is not. Indeed, no matter the number of times we may incorrectly or inaccurately use a saying, an expression, a law or belief, if the usage is false or otherwise not accurate, it remains false and inaccurate.

So too, is the conundrum of the Mental Health Parity and Addiction Equity Act (“Act”) passed by the United States Congress and signed into law by President George W. Bush in October 2008. On its face, this Act was designed to prevent group health insurance plans and health insurance companies whose policies provide mental health benefits from imposing less favorable benefit limitations on mental health benefits than on medical/surgical benefits.

The insurance industry repeatedly points to those insurance providers who now provide some coverage for mental health issues as proof of their good faith compliance with the Act. They trumpet the dollar amount they have paid on mental health claims as further supporting evidence. And all the while, they would have us believe the accuracy of, “Ask not for whom the bell tolls.”

In November 2017, in a national study published by The Milliman Group, one of the world’s largest actuarial and consulting companies, , Milliman found:

1.    In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care;

2.     Insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists.

In addition, higher co-payments and separate deductibles for mental health treatment remain an on-going issue for insureds.  When combined with the gross disparity of patients seeking mental health care out-of-network, the Milliman report paints a bleak picture of severely restricted access to much needed addiction and mental health care.

In response to the report, Kate Berry, a senior vice president at America’s Health Insurance Plans, the insurance industry’s main trade group, brings new meaning to the term, “naïve bordering on offensive deflection” when she states the problem is not within the insurance industry but instead says the real problem is the shortage of behavioral health clinicians.

Ms. Berry’s ludicrous statement and the insurance industry’s position is further contradicted by a second, independent analysis issued by RTI International and its health economist, Tami Mark, PhD. In December 2017, the RTI report not only corroborated the Milliman report but further revealed that higher rates are paid to physical health doctors than to psychiatrists, even for those patients whose primary diagnosis is a mental health condition.

Marvin Ventrell, Executive Director of the National Association of Addiction Treatment Providers and Parity Implementation Coalition Co-Chair stated, “In the wake of these two reports, it is clear that we simply do not have mental health and addiction parity in this country as our law and policy dictate we should.” He later said, “These analyses show a pattern of insurers avoiding their obligations and then unfairly blaming mental health and addiction treatment providers for the problem of lack of care delivery.”

This disparate treatment continues even as litigation continues to rise. In late 2017, Los Angeles based attorney Lisa Kantor instituted class based litigation against Kaiser Foundation Health Plan alleging that Kaiser violated both the Federal Mental Health Parity Act and the State of California Mental Health Parity Act by and through its coverage/treatment decisions of the named plaintiff.  The inaction and coverage decisions made by Kaiser in that case would be grossly comical … if the potential results were not life threatening.

In May of 2017, Banner Health was named as a defendant in class based litigation in an Arizona federal court for violations of the federal parity act for its across the board denial of “applied behavior analysis therapy” from coverage for autism spectrum disorder on the grounds that it was experimental or investigative.

In May of 2016, Blue Shield of California and Magellan Health Services were sued in a California federal district court for wrongfully restricting patients access to out-patient and residential mental health treatment. In June of 2017, the court granted a request for class action status.

In September of 2016, a federal district court in California certified a nationwide class against United Behavioral Healthcare. In that case, UBH’s insurance coverage criteria was at issue.

Insurance coverage regarding residential treatment centers is an ever growing source of dispute in federal courts.  The number of cases has risen from seven (7) cases in 2014, to sixteen (16) cases in 2015, to forty-seven (47) cases in 2016. And whereas 47 cases may not seem like a tidal wave, one must consider that in most cases, a patient must first navigate through the muddy and maddening administrative process imposed by ERISA before filing litigation. And while the volume of case filings has increased, the source of the coverage dispute is fairly constant: whether residential treatment is medically necessary and whether the patient could be treated in a less intensive setting, such as an outpatient level of care.

In great part, disparity arises because insurance providers are allowed to create their own treatment criteria and protocol without any governmental, regulatory or objective oversight. One cannot dispute that generally accepted guidelines are neutral, transparent and based on thorough research.  And yet, according to Dr. Anita Everett, president of the American Psychiatric Association, when insurance companies create their own standards, "[t]he process is often not transparent, conflicts are not disclosed, and the standard is generally more restrictive which suggests a focus on cost, rather than patient outcome."

Mental Health Parity. Say it enough times. Say it multiple times… Mental Health Parody. Truly if one says it enough times, it appears to echo with a ring of noble humanitarianism.  And yet, that resonating echo is merely the "Siren's Call" seductively drawing one towards the rocks in the same manner as, “Ask not for whom the bell tolls.”

Residential Treatment Centers ...

Residential Treatment Centers in the United States which provide treatment for eating disorders are an evil which need to be completely exorcised from the industry! A bold statement. A strong statement.  A statement steeped in ... complete and utter nonsense.

Nothing could be further from the truth.

A well-run and professionally operated residential treatment center saves lives. Its professionals give hope, strength and faith to those suffering from eating disorders. Parents justifiably rave about those specific facilities. As so shall I.

By way of example, two residential treatment centers will be highlighted. On the surface, these residential treatment centers could not be more different. One center exists in the fourth largest metroplex in the United States. It is supported by an army of professionals, is part of an ever expanding chain of treatment centers and its parent company has access to multi-million dollar funding from private sources. It has contracts with the vast majority of the largest insurance providers in the United States. By contrast, the other center exists in the 751st largest city in the United States. It is independently owned, has minimal private funding and few contracts with insurance providers. It fights ferociously to have Single Case Agreements approved while having to fight on-going battles with the largest insurance provider in the United States. However, these two treatment centers share one very important commonality ... a commonality that binds them and enables parents to place their faith, their trust, and the lives of their loved ones under their care.

The first of these residential treatment centers is ... The Eating Recovery Center --- in Dallas. Yes, ERC Dallas (technically Plano). Yes, I am aware that my more recent articles could be construed as "slightly, perhaps mildly" critical of private equity firms coming into the eating disorder industry, particularly CCMP Capital Advisors d/b/a The Eating Recovery Center. Nonetheless, quality and professionalism are elements that know no boundaries and where they exist, should be highlighted for the welfare of those millions of people who suffer from this insidious disease.  

On October 24, 2016, after previously being open and treating patients on an IOP and PHP basis, ERC Dallas opened its new Inpatient Treatment Center. This was a mere 6 days before eating disorders claimed the life of my beloved daughter, Morgan. In fact, had Morgan been able to medically stabilize, she would have entered this program due to the tireless work of one ERC employee, its medical director.

That medical director at ERC Dallas is Dr. Stephanie Setliff. Dr. Setliff, who had previously been the medical director over the children's psychiatric program at Children's Medical Center in Dallas, was the first doctor to oversee Morgan's inpatient treatment. In fact, we twice entrusted Morgan’s life to Dr. Setliff.  And if given the opportunity to make those decisions again, without reservation, we would have once again entrusted the life of our daughter to Dr. Setliff. 

Along with Dr. Setliff, ERC Dallas includes Dr. Tyler Wooten as a medical director.  A number of years ago, Dr. Wooten saw Morgan on a few occasions. We both remembered the office of Dr. Wooten, who was then in private practice as being “very well appointed.”  We also fondly remember Dr. Wooten as an excellent, insightful practitioner. 

Finally, ERC Dallas also includes Dr. Michael Lutter as a physician/scientist and attending psychiatrist. Dr. Lutter’s research focuses on the genetic and neurobiological basis of eating disorders. He would be a welcome addition at any treatment facility specializing in eating disorders.

Similarly, ERC Dallas’ counselors and support staff strive for excellence. And whereas no facility, business or individual is perfect, ERC Dallas is a shining example of what a residential treatment program could be.

The second residential treatment program is Avalon Hills located in the 751^st largest city in the United States, Logan, Utah.  Its chief medical director is Dr. Nina Jorgensen, a pediatrician and adolescent medical provider who has an outstanding team surrounding her.  With five therapists on staff being overseen by its clinical director, Tera Linsegrav-Benson, the patients entrusted to Avalon Hills are receiving more individualized assistance than most centers.

Avalon Hills is also a pioneer for utilizing neurofeedback as part of its treatment protocol.  The MUSE device, which is a neuroregulation device worn on the forehead is geared toward developing mindfulness, focus and anxiety regulation.

Avalon Hills’ founder and CEO is Benita Quackenbush, Ph.D. Dr. Quackenbush embraces her founding principles of independence, compassion, and strength while being the heart and soul of Avalon Hills.

In the face of opposition and obstacles created by well-financed third parties, Avalon Hills has acquired the reputation of having success helping those patients who unsuccessfully received treatment elsewhere, those people diagnosed with “treatment-resistant” eating disorders. Because in large part Avalon Hills is “independent,” and because of a lack of treatment facilities in that part of the United States, Avalon Hills fights ferociously with insurance entities for single case agreements.  These agreements allow it to treat patients, to save the lives of those suffering from this disease when all else has failed.

Two treatment centers that could not be more different in size, location, staff, funding, and ownership.  And yet, these two treatment centers share one very important commonality, a commonality that binds them together. That commonality is an uncompromising demand for excellence from their apex professionals. Dr. Setliff has fought many wars against so-called “peer-to-peer” doctors employed by insurance providers who make medical decisions based not on the patient’s medical needs but on the language in an insurance policy. Dr. Quackenbush has fought battles in which so called “outside medical professionals” have contacted patients and their families and spread scurrilous prevarications steeped in flights of fantasies. Above all, these two providers place the needs of their patients first and foremost and do not accept anything less than the absolute best from themselves and others. They remember why they chose to go into this field of medical treatment and remain true to their ideals.  They have chosen to not be “the jack of all trades and masters of none.” They do not toy with the notion of being mergers and acquisitions specialists or Wall Street business tycoons. They save lives, not for their own glory and accolades, but because of their souls' recognition of the Power of the Message.

This commonality, which is anything but common, shows a shared purpose that for Dr. Setliff … that for Dr. Quackenbush, clearly demonstrates the incredibly important reality that it truly is about embracing the Power of the Message. And in embracing the Power of the Message over the Image of the Messenger, they have not just the ability, but their soul’s calling for them to save lives. Our lives. The lives of our loved ones.

And that is what draws us to them. That defines them. And that can define us all, and which by its very nature, constitutes the very best of us.