The provision of behavioral health treatments that are not based on scientific evidence is surprisingly common in the United States, where outcomes lag behind those of other developed nations (Cookson, 2009, McGlynn et al., 2003, Wang, 2009 and Wang et al., 2006;). For some years, insurers have expressed concerns about providing reimbursement for treatments that have not been proven effective (Garber, 2001). Utilization of evidence-based treatments (EBTs) in behavioral health has been determined to be important in containing the escalating costs of health care (Luke, 2011). To promote use of EBTs toward the goal of reducing costs, Congress has established the Patient-Centered Outcomes Research Institute (PCORI) as part of the Patient Protection and Affordable Care Act. The mandate of the PCORI is to conduct and review effectiveness research and to influence public and private health care delivery (Clancy & Collins, 2010).
Even though the importance of EBTs is increasingly being recognized, the implementation and delivery of EBTs to clients in community mental health centers and small private clinics continues to be fraught with barriers (Drake et al., 2001, Herschell et al., 2009 and Mancini et al., 2009), including low reimbursement rates, denied reimbursement, and limited number of sessions (Keefe, Hall, & Corvo, 2002). The 2008 Mental Health Parity Act, intended to reduce barriers to mental health services, specifically states that “standards for provider admission to participate in a network, including reimbursement rates” must be comparable to medical/surgical services (United States Department of Labor, 2011, p. 2). According to the American Psychological Association, state and national psychological associations are challenging recent dramatic cuts in reimbursement rates, such as the 42% cut by Humana in Illinois of reimbursement of procedure code 90806, the designation for 50 to 60 minutes of outpatient therapy, to $58, by saying these cuts violate parity law and will limit the availability of mental health services (APA Practice Central, 2011). Similar dramatic cuts in reimbursement rates for behavioral health services in Ohio, Kansas, and California have also affected service delivery (Ragusea, 2012 and Wolfe, 2012). Cuts in reimbursement rates seem likely to result in further decreases in access to EBTs in the community by discouraging clinicians offering specialized treatment from accepting insurance reimbursement.
Clinicians providing EBTs may have additional reimbursement problems not faced by those providing 50 minutes of nonspecific psychotherapy. For example, several aspects considered integral to Dialectical Behavior Therapy (DBT), including phone coaching and weekly case consultation between individual therapists and skills group leaders, may not be reimbursed by insurers. Furthermore, DBT requires two trained clinicians to lead skills groups, which are typically limited to 10 or fewer participants.
DBT is an evidence-based treatment for borderline personality disorder (BPD), developed by Marsha Linehan and colleagues at the University of Washington and described in the treatment and skills training manuals (Linehan, 1993a and Linehan, 1993b). Randomized controlled trials supporting the efficacy and effectiveness of DBT have been conducted by Dr. Linehan at the University of Washington (Linehan et al., 1991, Linehan et al., 1993, Linehan et al., 1999, Linehan et al., 2002, Linehan et al., 2006 and Linehan et al., 2008) and at other sites in North America (Koons et al., 2001, Lynch et al., 2003, Safer et al., 2001 and Telch et al., 2001) and in Europe (Bohus et al., 2004, Van den Bosch et al., 2005 and Verheul et al., 2003).
In the state where the authors practice, most behavioral health services are delivered by private agencies, both nonprofit and for-profit. There are few community mental health clinics throughout the state and only one state hospital. The standard reimbursement rate for procedure code 90806 (individual therapy 45 to 60 minutes) averages approximately $65 for a master’s-level clinician and approximately $80 for a doctorate-level clinician, rates that have not increased in 14 years. Reimbursement by the state Medicaid provider for procedure code 90853 (group psychotherapy) is $24.25, an increase of $3.25 in the past 6 years. One of the two major private insurers currently reimburses at $21.31, an increase of 24 cents in 10 years. This rate applies regardless of the length of the group or the number of therapists leading the group.
The state contracts with private insurers to manage delivery of Medicaid benefits and close to 25% of insured persons are covered by Medicaid (Jennings, 2012, para. 2). Twenty-eight percent of the people in the state are uninsured (New Mexico Selected Health Statistics, 2009). For those who do have behavioral health coverage, many have plans with high yearly deductibles, high co-pays, and limits on the number of sessions per year.
