Do Venture-Capital Investors Think Psychotherapists are Dumb?

  • Ethically, psychotherapists should retain 100% control over confidential health information to protect and advocate for patients.

  • Several new companies, funded by venture capital are offering digital services including billing, assessment, appointment scheduling, prescriptions, counseling, psychotherapy and teletherapy portals. Their goals may include creation of provider networks, maintaining low provider reimbursements, and sale of their company or network to a larger network or a Healthplan.

  • One of the many areas of concern involves the lack of legal mandates for clinicians to report their negative experiences working for such companies funded and directed by venture capital investors.

  • Healthplans are financially motivated to have all the patient-provider data possible. Venture capital investors want the highest return on their investment and giving Healthplans just that is also among their highest priorities, if not the highest.

  • Healthplans’ data collection and reporting companies are not transparent with psychotherapists and offer visibility into provider and patient data.

  • Healthplans have used several different strategies to manage, and direct psychotherapy interventions, procedures, processes, modalities, levels of care, duration of treatment and more.

  • When psychotherapists treat patients for at least 3 appointments and fewer than 14 appointments, the savings to a Healthplan in medical and prescription costs is between $755 to $1377 per person in the first year. Restricting the duration of treatment provides a net savings. 1000 providers treating 25 patients per week in this pattern can save a Healthplan 18.9 to 34.4 million dollars.

  • Healthplans, while unwilling to give costs of living fee raises to psychotherapists, at the same time want psychotherapists to contract with digital platforms that support measurement-based care. If Healthplans choose to increase an average psychotherapy fee by $30 for those who do measurement based care, and manage patients with 3 to 14 appointments, they can increase their profits by more than 1350 percent!

  • Are insurance companies in the venture capital business?

  • Private practice psychotherapists cannot collectively boycott those Healthplans who won’t pay a fair reimbursement rate, but they can refuse to give their data to Healthplans for free. Psychotherapists would need to be pretty dumb to not want fair compensation for adopting MBC and OIC.

  • Rather than accept a trivial reimbursement rate for adopting MBC and OIC, psychotherapists should collaborate to gather, combine, analyze and monetize their own dis-identified patient data. If Healthplans want psychotherapists’ data, they would be within their right to charge a Healthplan for deidentified information.

The Financial Value of Digital and In-person Mental Health Services Has Just Skyrocketed

Less than two months after Olympic gymnastics star Simone Biles of Texas joined mental health startup Cerebral. Taking on the role of chief impact officer, Biles helped the company raise $300 million in venture capital. That much money vaulted Cerebral to a valuation of $4.8 billion.

Cerebral claims to offer Expert Help for Your Emotional Health for $30 a month ($85 per month after the first month). For that consumers are told they will receive,

Help for anxiety, depression, insomnia, and ADHD. Online prescriber visits, care counseling, and prescriptions delivered to your door.

Cerebral offers…

One plan for Regular assessments, video/phone appointments with your prescriber, medication management, and medication delivery are all included in the price of your subscription.

Cerebral provides a comprehensive online mental and behavioral health assessment.

The company does not provide a HIPAA notice. The terms of use allows the company to share information as they see fit. Cerebral offer direct to consumer mental health assessment and for the time being does not reply on health insurance reimbursements.

For $85 a month Cerebral promises:

  • Reduced wait times

  • Affordable Pricing

  • Coordinated Care

  • Data-driven treatment

  • Tracking clinical outcomes continuously at scale across PHQ9, GAD, ISI, etc.

  • Reduced Stigma

  • Virtual care that lowers barriers

  • Discreet delivery of medication

Cerebral, Inc. is San Francisco-based company, launched in January 2020, and operates a mobile app and monthly subscriptions. Cerebral hopes to be an in-network resource for all insured Americans by the end of 2023.

Cerebral’s SMART approach prioritizes the use of actionable data and therapeutic relationships to improve access to high-quality, long-term mental health.

Cerebral is designed to manage private practice and they have over 1.4 billion dollars so far to do just that.

Cerebral’s telehealth platform matches patients with the most appropriate care team and care plan based on patient preference and clinical need. These care plans ensure that patients get the right level of care at the right time. All patients have access to the Cerebral smartphone app, which is equipped with mindfulness exercises and cognitive behavioral therapy (CBT) modules designed to reinforce the work done during clinical sessions. Multiple streams of data are monitored regularly to ensure quality. Clinical outcomes are recorded by monthly assessments sent to patients based on their presentation (e.g. PHQ-9 for depression, GAD-7 for anxiety, etc). Patient engagement levels are quantified by patients’ participation in surveys, meaningful use of Cerebral’s smartphone app, and adherence to appointments and treatment plans, among other measures. Metrics for clinical processes such as wait times for appointments, response times to patient outreach, and patient satisfaction, are closely monitored.

Cerebral will monitor patient and provider performance.

Cerebral provides clinicians with personalized monthly reports with actionable and relevant data in an effort to continually empower them to improve their care. These reports include their patients’ ratings of care and written feedback, patient’s adherence to care, and clinical outcomes, among other metrics.

Cerebral will audit charts monthly.

Through the audit process, providers are given a score from 1-5 measuring the quality of their documentation, along with guidance on how to improve. This audit assesses for quality of clinical reasoning and completeness of documentation, with a focus on providing actionable feedback. Each chart is audited using a proprietary scoring system. Chart auditing has led to an improvement in clinical documentation across Cerebral, with 81% of providers improving their audit score between first and last audits.

Cerebral plans are priced as:

  • Medication and Therapy: $325 per month. The first month is $139 with code START139.

  • Medication and Care Counseling: $85 per month. The first month is $30 with code CARE30.

  • Therapy: $259 per month. The first month is $99 with code START99.

For more information see:
Patient Reviews of Cerebral
Simone Biles-backed mental health startup vaults to $4.8 billion value
2021 Get Cerebral Review: Should You Try It?

Treating Behavioral Health Conditions Reduces the Total Cost of Care

Evernorth Behavioral Health (November 2021). Cigna Behavioral Health is now Evernorth.

According to Kate Jennings, a staff writer covering healthcare for Forbes,

Investors poured $1.5 billion into the market in 2020, but technology alone won’t solve long standing problems like low reimbursement rates and provider shortages.

Despite federal laws requiring mental health to be reimbursed at the same rates as physical illness, many people with insurance still face hurdles, from long wait times to denial of claims battles. Around one in four Americans don’t have access to in-network therapists, according to the National Alliance on Mental Illness. Many mental health providers choose to operate out of insurance networks, since the reimbursement rates are so low. Given the spotty coverage,

For more information see:
Venture Funding For Mental Health Startups Hits Record High
As Anxiety, Depression Skyrocket.

Why is Cerebral, the company Simone Biles represents, valued at 4.8 billion dollars?

According to Cigna health …

If people diagnosed with a behavioral health condition, such as anxiety, depression or substance use disorder, receive outpatient care, costs are reduced by up to $3,109 per person over a two-year period. Specifically, regular behavioral care in an outpatient setting, such as a psychologist’s office, can lead to fewer emergency department visits and inpatient hospitalizations, decreasing costs by up to $1,377 in one year and up to $3,109 over two years.

On average, if psychotherapists treat patients for at least 3 appointments and fewer than 14 appointments, the savings to a Healthplan in medical and prescription costs (after paying for psychotherapy) is between $755 to $1377 per person. If 1000 providers each treat 25 patients per week this can save a Healthplan more than 10.6 million dollars. Patients’ increased well-being and the cost saving from psychotherapy services is a benefit to Healthplans.

As an example, let’s assume a psychotherapist is paid $120 for a standard 90836. Healthplans want psychotherapists to contract with a venture capital company that provides measurement-based care (MBC). For that the company will pay $130 for the same 90836 and take care of your claims submission, schedule appointments for the psychotherapist, and pay the psychotherapist directly. The payer will also give you a $3000 signing bounus, The psychotherapist receives an 8% increase in revenue but is expected to spend additional time administering and interpreting the results of progress and outcome questionnaires. Healthplans know that 75 to 80% of all patients seeking psychotherapy use less than 12 sessions.

Healthplans say they are marketing MBC to employers as a means to reduce costs and improve patient outcomes. That is a half truth. While that is likely the case, according to Cigna (now Evernorth), Healthplans will save 10.6 million dollars in healthcare costs if 1000 psychotherapists treat 25 patients for 3 to 14 sessions. If 1000 therapists see their patients no more than 14 times, those therapists will be paid, at most, an additional $140,000. The payer’s savings in healthcare costs will be 10.6 million dollars.  The return on their investment of $140,000 is at least 755%. 

What Healthplans seem unable to acknowledge is that therapists are not willing to be paid less than other providers who are paid more money. A psychotherapist would have to be very dumb to see a high number of patients for Healthplan that pays 60% less than another Healthplans. Why would anyone work for Cigna if they can double their income by seeing patients in another Healthplan.

There are many reasons why psychotherapists should not give Healthplans their patients’ Assessment and Outcomes Data. The first reason is that psychotherapists should retain 100% control over confidential health information to protect and advocate for patients. A second reason is that psychotherapy saves Healthplans a great deal of money. That data has financial value. Psychotherapists would need to be pretty stupid to not want fair compensation for their skill and good work. And while private practice psychotherapists cannot collectively boycott Healthplans that won’t pay a fair reimbursement rate, they can refuse to give their data to Healthplans for free.

Psychotherapists who participate in measurement-based care, funded and directed by Healthplans, are empowering plans to govern psychotherapy interventions, procedures, processes, modalities, levels of care, duration of treatment and more.

Healthplans want the small number of psychotherapists in the U.S. to see more patients and to see patients at least 3 times and no more than 14.  Utilization review has limited the number of sessions, but has failed to improve access to care and outcomes. Healthplans are increasingly required to achieve parity for mental health and medical services. To accomplish this, Healthplans will need to increase reimbursement rates, referred to as reimbursement parity. Requiring MBC is the best way to increase reimbursements, and it is a good way to ensure a target treatment duration of 3 to 14 sessions. 

Do venture capital investors think psychotherapists are dumb? You decide.

Psychotherapists Should Avoid use of Technology Provided by Companies that have Venture Capital Investors

Marlene Mahue, PhD, et al., wrote an article titled Caution: Direct-to-Consumer Digital Care – All That Glitters Is Not Gold.  She stated…

Opportunistic corporations are exploding into the telemental health niche blasted open by COVID, which prompted inexperienced investors to race pell-mell into direct-to-consumer teletherapy. Unscrupulous investors …are strategically positioned to exploit a potentially critical weakness in the U.S. healthcare system at the very time when interventions are needed in unprecedented numbers. Treatment control has traditionally been exercised through reimbursement in mental health and addiction.

Dr. Mahue goes on to say…

Administrators and clinicians now face the challenges of investing in, buying services from, or working for new digital health companies with an unabashed profit motive. All too many of these companies are run by executives who rarely give evidence of understanding the full range of vulnerabilities in the mental health and addictions populations they purport to serve.

In the last 18 months alone, investors have poured several billion dollars into the telemental health field, creating enticing digital jobs for counselors, MFT’s, social workers, psychologists, and psychiatrists, among others. Administrators and clinicians now face the challenges of investing in, buying services from, or working for new digital health companies with an unabashed profit motive. All too many of these companies are run by executives who rarely give evidence of understanding the full range of vulnerabilities in the mental health and addictions populations they purport to serve.

One of the many areas of concern involves the lack of legal mandates for clinicians to report their negative experiences working for such companies. Equally concerning is the lack of visible official effort to assess and analyze the risks entailed by an overnight substitution of electronic visits for in-person psychotherapy since the start of COVID. Direct-to-consumer and self-pay teletherapy are now in full stampede, spurred by commercialization and the excessive freedoms that have become the entrenched norm.

For more information see:
https://www.telehealth.org/digital-care

Psychotherapists should not work with venture capital funded companies that gather, aggregate, analyze and report data to Healthplans. These companies are not transparent and will make patient and provider data visible to Healthplans using dashboards that allow comparisons among providers and patients. Venture capital investors exert pressure on founders and managers to act in ways that would be unethical for licensed psychotherapists. They are guided by what they can get away with, not the ethical and professional standards professionals practice by. Psychotherapists (as covered entities) are legally and ethically responsible to perform their due diligence before enrolling in a healthcare operations support service. As venture-capital enters the Healthcare business space, psychotherapists must consider that many of these companies are driven by exit and profit strategies. The inner workings and the influence of venture capital investors can disrupt healthcare operational support services. They can also disrupt providers’ practices and cause patients to be abandoned by providers who have no choice but to terminate or accept termination of their contracts.

Patient Reported Outcomes & Performance Measures (PROM)

Patient Reported Outcomes Measures (PROMs) are patient self-reports about their own health outcomes. They include symptom burden, health-related quality of life (including functional status), experience with care and health behaviors. PROMs also include progress, alliance and/or satisfaction measures. PROM data can be aggregated for providers and an accountable healthcare entity. For example, PROM data might be used to describe the percentage of patients whose depression score, as measured by the PHQ-9, have improved.

The healthcare industry promotes the use of Patient Reported Outcome Measures (PROMs) which engage patients in giving information to their health care providers about patients’ responses to care for their health conditions, medical and mental health symptoms, pain, substance use, level of functioning, etc. PROMs permit health care providers to have valuable feedback concerning their patients’ well-being, health behaviors, experience of care, and their physical, emotional, and functional status.

PROMs use standardized questionnaires and scales completed by patients to obtain quantitative and qualitative measures regarding one or more domains of care.

For more on PROMs see:
The Role of Patient Reported Outcome Measures in Mental Health?
https://www.mentorresearch.org/the-role-of-patient-reported-outcome-measuress-in-mental-health

For-Profit Venture Capital Software for Measurement-Based Care

There are 3 measurement systems required by the Oregon Health Authority, dissatisfaction with these led to the decision to create and develop the CollaborativeOutcomes model. Those measurement systems are:

  1. ACORN: https://www.acorncollaboration.org/

  2. PCOMs: https://betteroutcomesnow.com/

  3. MyOutcomes: https://www.myoutcomes.com/

For more information see:
Managed Behavioral Health: Measurement
www.amha-or.com/managed-behavioral-health-measurement

Non-Profit CollaborativeOutcomes Offers Data Gathering, Aggregation, Analysis and Reporting for Outcome Informed Care (OIC)

The AMHA CollaborativeOutcomes model offers a growing list of questionnaires (19 are available 5/10/21) which can be administered electronically using SMS text, email, a patient portal or manual entry for paper and pencil collection. The questionnaires available include a variety of screening, progress, outcome, satisfaction, and therapist-patient alliance measures. The library of questionnaires is being expanded to address various populations, problems, and clinical approaches. Questionnaires can be created that, based on patient responses, can skip to specific relevant questions. Text boxes can be inserted. Based on a patient’s response to a question a follow up question along with a text box can be opened for the patient to enter a narrative response.

Secure links to Questionnaires can delivered by SMS text, email, or using a key code that links the question to a psychotherapist’s personal secure online electronic dashboard. Questionnaires work on smart phones, tablets and desktop computers. Questionnaires and measures available as of May 10, 2021 include:

  1. ACE Adverse Childhood Experience

  2. ACE-PC Adverse Childhood Experience - Parent/Caregiver

  3. PSC-35 Pediatric Symptom Checklist - Comprehensive v1.8

  4. Comprehensive Mental Health Screening v1.3

  5. Mental Health Progress and Alliance v1.3

  6. GAD7 Generalized Anxiety Disorders

  7. OCD-25 OCD Thoughts and Behavior v1.2

  8. PHQ-9 Physical Health Questionnaire (Depression)

  9. PHQ-2 and GAD-2 Brief Screening for Depression and Anxiety v1.0

  10. Attention Deficit & Hyperactivity Disorder Questionnaire (ADHD) v1.9

  11. AUDIT-10 Alcohol Screening Questionnaire (AUDIT) v1.1

  12. Traumatic Life Events v1.2

  13. PCL-5 (20) Post-Traumatic Stress Disorder Check List DSM-5 v1.0

  14. COVID-19 Comprehensive Infection Risk Screening v1.33

  15. COVID-19 Routine Screening v1.0

  16. Viral Post Infection and Long COVID Symptoms v1.5

  17. Social, Psychological, and Pandemic Determinants of Health v1.4

  18. Suicide Risk Screening - Past 2 Weeks v1.02

  19. Suicide Risk Screening - Past Month v1.01

  20. Suicide Risk, Progress and Alliance - Past 2 Weeks v.1.21

The CollaborativeOutcomes approach is a feedback informed, patient reported treatment and measurement-based care system reliant on evidence and best practices. CollaborativeOutcomes software is integrated.

For more information see:
Screening & Questionnaire Research
www.mentorresearch.org/screening-questionnaire-research

CollaborativeOutcomes Incorporates a Comprehensive Quality Improvement Program.

CollaborativeOutcomes generates dis-identified statistics including a reliable change index, and rate of change, and can provide visual displays identifying value by contrasting standardized cost vs effect size. Normalizing costs allows CollaborativeOutcomes providers to see which providers and Healthplans provide the greatest value regardless of reimbursement rates. For example, data analyses might determine that Healthplan A, which has a lower reimbursement rate, can show greater value for each dollar spent than a Healthplan that provides a higher reimbursement. CollaborativeOutcomes’ capacity and ability to gather data across Healthplans allows participants to see where psychotherapists provide the greatest value and potentially show ways to provide greater value. CollaborativeOutcomes can support coordination of care in an efficient and inexpensive manner. CollaborativeOutcomes can efficiently support provider-led outcome and quality research in a cost-effective manner.

HIPAA & Patient Privacy Issues.

CollaborativeOutcomes provides greater patient privacy because the data is under the control of each psychotherapist, not a Healthplan or other for-profit company. In the event of a data breach the Healthplan providers may still be held responsible for incident and breach investigation, mitigation, and notification to their patients. CollaborativeOutcomes’ data collection system offers HIPAA assurance, a BAA and liability insurance for cyber attacks.

From therapists’ perspective, payer-required use of PCOMS or ACORN, is not a healthcare-operations support activity. The requirement to use a static system is intended to release protected health information for payers’ cost management purposes. Insurance payers, as an industry, have the highest number of HIPAA security breaches.

Legal, Ethical and Financial Considerations when Dealing with Coordinated Care Organizations (CCO)

Measurement systems are interventions and become an integral part of the treatment process. Their intended purpose is to inform patients and providers and to improve services, outcomes, and patient satisfaction. CollaborativeOutcomes is a model which: (1) integrates measurement into services in a clinically useful and efficient manner, (2) has value to providers and patients and (3) can efficiently support coordination of care.

Licensed professionals are legally and ethically responsible for the services they provide. As such they must have authority to select the specific processes that gather confidential PHI from patients as well as the methods by which they determine the effectiveness of their services. Requirement to determine the effectiveness of services, using ACORN or PCOMs as interventions, has financial value to a healthcare payer. A contractual relationship that requires a specific treatment process, advantageous to a CCO, provides a hidden benefit to the CCO, paid for by Federal Medicaid and State funds. CCO contracts should not disallow providers’ use of data collection systems and processes that are preferable to patients and psychotherapists.

PHI provided to Healthplans has value; it can be monetized and sold without providers’ consent. This benefits payers not patients or their psychotherapists. The cost-risk-benefit in contracts using interventions required by CCO’s are inequitable to providers and may in fact harm patients. It is simple for a provider to support patients’ resistance to using ACORN and to offer an option which supports better provider services. The patient always has a choice. Providers are ethically and legally obligated to hold benefit to patients as their highest priority.

Anti-kickback laws apply broadly to prohibit knowing and willful remuneration to induce or reward patient referrals or the generation of business involving any item or service payable by Federal health care programs. The Federal Trade Commission considers remuneration to include anything of value such as passing on costs, or providing items or technology of value to reduce financial obligations. A CCO that requires providers use measurement software from which they benefit financially and from which neither patient nor provider has benefit are in effect, structuring “kickbacks” to the CCO.

Psychotherapists who are NOT employed by a CCO may receive referrals from that CCO in exchange for providing valuable data and using required treatment methods that incur costs. The contract requirement relieves the CCO of financial obligations they would otherwise have. To receive referrals, providers subsidize the CCO’s data collection costs.

CCOs are secondary payers for health care services pass-throughs for State and Federal funding (i.e. Medicaid and OHP). CCOs which require their network of healthcare providers to use specific static feedback informed treatment (FIT) models are operating in ways that benefit the CCO.

Psychotherapists who use measurement methods with equivalent or greater consumer benefit at less expense may not be allowed to contract with a CCO. A specific requirement to use PCOMs or ACORN or other static measures may be in violation of Antitrust Laws (e.g., restraint of trade). An equitable solution would be to require CCOs to support creative and procompetitive providers and contracts that significantly benefit patients.

For more information see “Guide to Antitrust Laws”
https://www.ftc.gov/tips-advice/competition-guidance/guide-antitrust-laws

References

CollaborativeOutcomes™ is a trademark of the American Mental Health Alliance – USA

The authors of this publication are:

Michael G. Conner, PsyD and Michaele P Dunlap, PsyD.

The Board of Directors of AMHA-OR have reviewed this publication.