DBT Needs Help, Please Read
Welcome to the LifeWork, LLC blog, Wednesday edition. Normally, we publish on Mondays. I was in Jefferson City (Missouri's capitol) on Monday and thought I'd be able to post while I was waiting for things to happen. Swing and a miss there.
I went to Jefferson City to testify in front of the House Health and Mental Health Policy committee. In front of the committee was HB1123, which would establish a DBT Task Force to implement DBT more fully across the State and would establish rules requiring insurance companies to fully cover DBT treatment.
Several weeks ago, I was asked if I would be willing to testify and I said 'yes', not actually thinking that it would really happen. If you know anything about getting bills passed in the legislature, you know it is typically a multi-year process.
We ended up having 5 people testify in support of the bill and there was 1 person in opposition (a lobbyist for several insurance companies). It was pretty exciting to get the opportunity to talk with our lawmakers about DBT and the need for some government intervention to make this live saving, life giving treatment available to all those who really need it. The committee members were engaged and asked a lot of questions, so I was very happy with that.
Of course, there were lawmakers who seemed to be in support of the treatment, some who became more curious about it, and those who were much more skeptical. All in all, a great first step toward making this evidence based treatment more accessible. And it's going to be a long road, most likely. Please read on to hear about the difficulties with providing DBT and how you might be able to help.
When we started LifeWork 13 years ago, we were a private pay practice. A couple of years into the practice, I felt a sense of responsibility to get DBT out to people who really could not access the treatment, those with private insurance. It may sound crazy, but there are no mechanisms without the private insurance system for fully covering the treatment so most providers are simply private pay in order to make a living doing the therapy.
DBT, for those of you who do not know, includes 4 components: Individual sessions, groups skills training classes, access to phone coaching in between sessions, and consultation team for the providers. DBT was originally designed for people who were chronically suicidal, and has been found to be very effective for anyone whom has large deficits in regulating emotions and behaviors. So, we treat people who are often very dysregulated. What does that mean? It means that DBT is really treating people who are impulsive, engaging oftentimes in reckless or dangerous behaviors. DBT reduces or eliminates those life threatening/risky/reckless/dangerous behaviors.
The insurance system does not have a way currently to include all the components for reimbursement. The codes that all providers use to get paid haven't really been updated in forever. So, the system hasn't kept up with research or the provision of mental health care much at all. And there's the biggest problem that I see. This treatment works and we cannot get reimbursed through insurance for what it takes to competently provide this treatment.
A DBT skills training class does not even qualify as 'Group Psychotherapy' under the current writing of the codes. There is no way to get reimbursement for phone coaching, which has been shown to be crucial in actually putting the skills learned in DBT into practice. And the consultation team, which is critical in making sure the treatment gets provided in an effective manner is not considered.
So what's the point of me sharing all of this? If this therapy is going to be accessible long term to folks accessing insurance for their treatment, something in the system will have to change. Otherwise, we will continue to have a system where certain people get access to critical treatment and others don't get it at all. In this case, there is limited access for folks in the Medicaid and State systems and limited access for those with the financial resources to pay out of pocket. Then there's everyone else in the middle.
And when we talk with insurance companies, they say, "We have DBT providers." The problem there is that they have almost no providers that actually do all components of DBT. And we don't have any evidence that DBT prevents suicide or self harm or hospitalization without all components applied. There's very little incentive in the system right now to provide all components of DBT, and we really need this vital therapy.
There's a lot more to it than just that, but I'll stop there for now.
Here's the ask: If you have any access to the decision makers at any of the insurance plans (Anthem, Optum, Cigna, Aetna especially), I would be super appreciative of getting connected to any of those folks. If you have any relationship with your own insurance company and would be willing to call them and say that we really need a way to get evidence based mental health care. And if you have ideas beyond what I'm asking and would like to reach out to me, I would welcome that as well.
jbrenneman@lifeworkstl.com