For many people with borderline personality disorder (BPD) or chronic emotion dysregulation, finding comprehensive dialectical behavior therapy (DBT) is harder than it should be. Waitlists can be long, qualified programs can be difficult to find, and many comprehensive DBT programs operate outside of insurance, putting treatment out of reach for people who cannot afford to pay out of pocket. There are many reasons for this shortage. One of them is built into the way our healthcare system pays for treatment.

Comprehensive DBT requires more than a weekly therapy session

Insurance reimbursement was not designed around everything it takes to provide comprehensive DBT.

Comprehensive DBT is a structured treatment that includes individual therapy, skills training, between-session phone coaching, and a consultation team for DBT providers. Providing it well also requires substantial training and ongoing supervision. That means a DBT program has expenses that may not be visible when someone walks into a therapy appointment.

Clinicians may spend hours each week in consultation team meetings. Newer DBT therapists need training and supervision, which can include experienced clinicians reviewing recordings of their sessions. Skills groups require significant clinician time, and comprehensive programs use two leaders for group sessions. There is also documentation, administrative work, phone coaching, and the ongoing investment required to train and retain clinicians.

A DBT provider we interviewed described a weekly two-hour consultation meeting as just one example. Multiply those two hours across approximately 50 weeks and an entire treatment team, and a program is dedicating hundreds of hours of clinician time each year to an essential part of comprehensive DBT that may not be directly reimbursed.

Most clinicians don’t need to be convinced that people with BPD are worth treating. Many of them are deeply committed to providing this care. The problem is whether organizations have the resources to build and sustain the system that comprehensive DBT requires.

When reimbursement falls short, patients feel the consequences

These financial limitations can affect how much of the comprehensive DBT model a program is able to provide.

One DBT provider we interviewed recalled working at an insurance-based program where reimbursement for DBT skills groups was too low for the program to staff them with two leaders, as called for in the comprehensive model. Instead, one clinician ran the group alone. The clinicians were not choosing to provide lesser care. They were providing the best care they could within the resources available to them. The reimbursement simply did not support every component of comprehensive DBT.

This distinction is important. Many excellent clinicians incorporate DBT skills and principles into their work, and DBT-informed treatment can be valuable care. It is not the same as comprehensive DBT. For patients and families searching for treatment, that difference can be extremely difficult to recognize. A provider may say they offer DBT because they teach DBT skills or use tools such as diary cards. A person seeking treatment may reasonably assume that means they are receiving the comprehensive treatment they have heard or read about. Our healthcare system should make it easier, not harder, for people to understand and access the treatment they are seeking.

A billing code can help recognize what comprehensive DBT actually requires

Currently, the billing system does not adequately account for the full structure and resources required to provide comprehensive DBT.

That is why one of BPD Alliance’s advocacy priorities is pursuing a dedicated billing code for comprehensive DBT. A dedicated code could give insurers a way to recognize comprehensive DBT as the specialized, multi-component treatment that it is rather than trying to fit it into billing structures that do not reflect the full model. It could also create an opportunity for reimbursement that better accounts for the clinician time, training, supervision, consultation, and other resources required to provide comprehensive care.

A billing code alone will not solve every DBT access problem. It does not automatically guarantee coverage or adequate reimbursement, and workforce shortages, training costs, geographic disparities, and other barriers will still need attention. It is one important piece of a much larger effort to make evidence-based treatment more accessible.

Where this advocacy stands now

BPD Alliance’s Advocacy Committee has already pursued this issue with the Centers for Medicare & Medicaid Services (CMS). Our first application for a dedicated code was not approved, and the work is continuing. We are working with professional organizations and lawmakers to explore additional pathways toward appropriate recognition and reimbursement for comprehensive DBT. We are also meeting directly with insurance companies to advocate for better coverage of evidence-based treatment and fewer barriers to accessing qualified providers.

At the federal level, we are building on previous congressional advocacy, exploring additional legislation, and planning a congressional briefing to increase understanding of BPD and the treatment-access barriers people with BPD and their families face. Changing the way a healthcare system pays for treatment is not a quick process. It requires insurers, policymakers, clinicians, people with lived experience, and families to make the problem difficult to ignore.

This is where advocacy comes in

While insurance reimbursement can sound like an issue for clinicians and billing departments, its consequences are much more personal. It affects the person who finally learns that comprehensive DBT may help and discovers that the nearest program does not take their insurance. It affects the family sitting on a months-long waitlist. It affects community programs trying to provide high-quality treatment with resources that do not cover what the treatment requires. And those experiences can help policymakers understand why change is necessary.

BPD Alliance will continue sharing opportunities to take action as this work moves forward, including opportunities to contact policymakers, participate in advocacy efforts, and share lived experiences with barriers to DBT care. We can’t do this alone. To find out how you can help with this or other advocacy efforts, fill out this survey.