Reflections From the Couch
Earlier today I came across this post on LinkedIn that got me thinking,
"Most psychologists and mental health providers have moved to telehealth. Blue Cross/Blue Shield and Aetna have waived copays for online psychotherapy. Medicare now covers therapy via telehealth. Also, telephone sessions are covered for those without access to other forms of technology. There is a lot of anxiety and depression and family tension, so please get help if you need it."
Susie, Founder and CEO
The truth is that Medicare has reimbursed for telebehavioral health in many states for years now. It just went primarily unnoticed until recently. I would know, I have been an in-network telebehavioral health provider with Medicare and 20 other Insurance Companies, in four states, since 2016. Another truth is most therapists haven't actually made the move to telehealth. Unlike us, they don’t have 130 pages of Standard Operating Procedures and Policies guiding their practice, most are providing a temporary service until the pandemic is over and will face problems if they don't use this time to understand and implement telehealth policies and procedures for clinical services, billing and reimbursement. I am the Founder and CEO of Telebehavioral Health.US. We are an established telebehavioral health provider located in Grand Rapids, we have been in operation for four years.
I have been a Clinical Social Worker since graduating from Grand Valley State University with my Masters Degree in 2004. My career in social work has consisted of long hours that regularly extended into the evenings and included numerous “side gigs,” to make a sustainable living. Whether I was teaching classes at a local university, providing on-call case management with an insurance company, facilitating speaking engagements or professional development courses, or moonlighting as a clinical supervisor, I was left with less and less time with, and for, my children. Putting food on the table and a roof over our heads was necessary, having time with my children was a luxury. I love being a social worker and like most social workers will tell you being a social worker is more than a job or career, it is a calling. Unfortunately the field does not leave much room for life outside of social work.
A "Workforce Crisis"
Social workers are one of the largest groups of professional Mental Health and Substance Use service providers in the United States. The lifetime burnout rate for social workers is 75%. Systemic reviews of this industry have identified the “biggest indicator of burnout to be the stressful workforce environment.” Ironically, the mental health field has paid relatively little attention to the health and well-being of its own workers. (NIMH)” In 2019, The Office Group published a comparison of industry "burnout" and found “when compared to all other industries Social Workers are most likely to suffer from work-related stress, depression and anxiety.”
The national annual median salary for a Master of Social Work is an average of$20k less than their non-social work counterparts with similar levels of education and experience. In addition to the salary gap, social workers are expected to work long and typically non-traditional hours, in often unsafe working conditions. They are consistently exposed to vicarious and secondary trauma and frequently experience wage freezes in the nonprofit sector.
Eighty percent of social workers are women.Women are more likely to also bear the responsibility of what sociologist Arlie Hochschild identified as “the second shift.” These duties consist of unpaid tasks around the house such as meal preparation, housekeeping, home economics, and care taking of others in the home. In the field of social worker, there is very little opportunity for workers to set their own hours and productivity standards. Production standards are also frequently increasing and constantly changing depending on program funding. For this female dominated workforce these industry conditions exacerbate a massive provider shortage for the leading source of disease burden in the United States (SAMHSA).
The Leading Source of Disease Burden
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), mental illness is "the leading source of disease burden in the United States." Over the past few years suicide has gone from being the second leading cause of death for Americans ages 14-24 years old to the second leading cause of death for 10-34 years old. "Deaths of Despair" are a thing, and they are on the rise in the midst of a massive opioid crisis. At the same time, over the past two decades the United States has had a growing Mental Health Provider Shortage with 40 Million Americans who need treatment each year not having access to it. The shortage is so immense that Congress refers to it as a “workforce crisis.” 111 million Americans live in Federally Designated Mental Health Provider Shortage Areas (MHPSA). Prior to the Covid-19 pandemic the behavioral health workforce was expected to have a provider shortage estimated to be 250,000 workers short of the projected need by the year 2025.
A Call to Action Unheard
Over the past decade, the National Institute of Mental Health, The Substance Abuse and Mental Health Services Administration, the American Medical Association, the American Psychological Association, and the American Telemedicine Association have engaged in a national call to action for mental health and substance use providers to utilize telehealth through a nationally supported “Direct to Consumer” model of care. Since 2016 The Health Resources and Services Administration has been reporting, to anyone who would listen, how "the unmet need in mental health care was too large to be addressed without leveraging technological innovations." This call to action was heard, just not by providers. Unfortunately software developers were listening. In the same time frame, numerous Platform-Based Companies advertising "on-line therapy," "e- counseling," and "web-therapy," have raked in a combined estimated annual revenue of over $500 million by licensing their platform to almost 10,000 therapists in the United States. All having absolutely no impact on the disease burden or provider shortage, they both have only gotten worse, and here is why.
Is it the "Same Therapy?"
As consumers, we are led to believe these Platform-Based Companies (PBC) are “healthcare organizations,” and are legitimately providing telebehavioral, or telemental health services, but they are not. Websites like MDLive, Talkspace, Betterhelp, Insight+Regroup, AmWell, Teledoc, AbleTo and Open Path Psychotherapy Collective are not healthcare organizations, they are software companies. Telemedicine, by definition, requires the same procedure or service that would be provided in a brick and mortar setting, be delivered using a secure telecommunications platform. It must be the same service.
The services offered by Platform-Based Companies do not meet the definition of telehealth, and this is according to the Platform-Based Companies. While on the front end of their websites, every single one of them claims the are providing a health services, every single one of them has back end disclaimers that refer to their services as "for informational purposes only, how services are “not a replacement for therapy,” their organization is "not a healthcare provider" and how their therapist will not diagnose, provide recommendations or provide treatment. Diagnosis, planning and providing treatment are the main tenets of therapy and why therapy works. Furthermore, therapy also "works," because of privacy and confidentiality laws required by the Federal Government, these laws include HIPAA and HITECH, which these companies are not regulated under, because they are software companies and not healthcare organizations. You will find in almost every single one of their disclaimers a statement identifying they are not legally bound to these laws that protect confidentiality.
Perhaps the most concerning and egregious common practice of Platform-Based Companies is the lack of oversight they provide to the almost 10,000 clinicians they contract with. Every single Platform-Based Company has a disclaimer explaining how there is no oversight of the services being provided and how they also have no relationship with the therapists providing the services. Not providing oversight of clinical services creates a level of risk that is not acceptable in healthcare and puts vulnerable populations at greater risk.
Here are some common practices of Platform-Based Companies that further explain how there services do not qualify as the "Same Therapy."
Almost all services provided by Platform Based Companies are not reimbursed by insurance, and neither Medicare or Medicaid will contract with these companies.
Platform Based Companies “cherry pick” clients by enforcing numerous unnecessary client restrictions The practice of “Cherry Picking” restricts access to services for those often with the most in need. In fact research has proven there is no population served that is harmed by telehealth. In fact we have been using telehealth with our most at risk folks since the 1970's via the National Suicide Hotline.
Platform Based Companies do not allow their therapists to coordinate or integrate care with other providers or organizations involved in the client’s care. Integrating care with primary care providers, writing Emotional Support Animal Letter, providing recommendations for educational or occupational accommodations and testifying on behalf of a client in court are all integral to making therapy “work.”
Some of theses websites, like Open Path, also identify in their terms and conditions that they are not bound to HIPAA or HITECH compliance which is a fundamental requirement when it comes to protecting people's electronic protected health information.
The solution is not in duping consumers into thinking licensed platforms sold by software companies are providing healthcare services. It isn't even that complex. In order to address the leading source of disease burden and national workforce crisis we have to start addressing the specific workforce conditions and needs of this female dominated profession by creating opportunities for higher wages and more flexible hours. Right now, many of us are celebrating how telehealth expands the reach of services, reduces barriers, saves time, saves money, helps those with transportation problems and in light of the national pandemic keeps clients and providers safe. What many don't realize is that telehealth also provides opportunities for higher
wages and more flexible hours and by doing that addresses the supply side provider shortage for the leading source of disease burden in the United States. The astronomically low overhead of telehealth means that we can pay our providers almost twice the national average and a worker who is scheduling 32 clients a week making average of $50k/year at a brick and mortar practice can now earn over $90k by partnering with us, while also working from home and setting her own productivity standards.
In September of 2016, just a few months after Michigan expanded telehealth to include social workers, I left my brick and mortar practice and opened the first telebehavioral health practice in Michigan with the goal of increasing access to those in Mental Health Provider Shortage Areas while also addressing the provider shortage by creating opportunities that improve workforce conditions and address the specific needs of a female dominated workforce. I wanted to create a business and practice model based on one main tenant; to take care of the providers needs so they can provide care to those in need.
I started the company on my own with no investment, other than my own “sweat equity.” I carried a low volume of patients and scraped by financially so I could build the practice in a way that felt like building a sand castle, one grain of sand at a time. I was one of the first providers in the country to adopt the American Telemedicine Association and American Psychological Association “Direct to Consumer” model using a Video Telecommunications Platform. Being the first meant forging a lot of new territory with payers and consumers. For starters, when I started, there was no one to assure me that I would be able to get reimbursed, telehealth was such an unknown. I would spend hours on the phone with the insurance company's service reps who had never heard of anyone doing what I was trying to do resulting in unbearably slow reimbursement. I remember a time, two years after I started the practice, I received a monthly newsletter from United Behavioral Health, announcing to Licensed Clinical Social Workers how we could “now start billing for telebehavioral health services.” United had been reimbursing me for telebehavioral health for almost two years.
In 2019 Steve Rotary joined me as a “co-founder” and Chief Operations Officer to help me with the business operations. Steve's education in entrepreneurship and experience in human resources were instrumental in identifying the operational needs of Telebehavioral Health.US and implementing a sustainable and scale-able business model. In January of 2020 Corey Hart joined as a co-founder and Chief Marketing Officer. Corey is the creative genius behind our brand, fundraising and managing our team of marketing coaches who work with the clinicians on their professional development, individual branding and program development. Between 2016 and 2020, the primary barrier to growing the practice by adding other clinicians was the cost of insurance credentialing and paneling, a required step to third party reimbursement. The credentialing cost of getting other providers set up with just three (out of 20) payers was $850 per clinician. In February of 2020 I figured out a way to leverage technology to cut the cost of credentialing from $850 per clinician down to $35, we were In-Network with over 20 payers and we were ready to scale.
A New Normal
When the Covid-19 pandemic hit the United States I could see how this workforce was on the road to de-stabilization because of the national shut down and how the pandemic was going to drive an increased demand for services. So, in response Steve, Corey and I decided to commit to on- boarding as many clinicians as we could, without compromising clinical care. We made a commitment to help stabilize the workforce, by offering clinicians opportunities to practice on-line with an established and branded telehealth organization, which would in turn, increase access to those in need. We announced we would be hiring the first week of the nation wide shut-down and within three weeks we had 50 resumes.
From There To Here
As of today, Telebehavioral Health.US has 25 therapists and a Nurse Practitioner and we are providing services in five states. All of our clinical services are covered by insurance including Medicare and Medicaid. We have added Medication Management, Group Therapy, Senior and Caregiver services, Peer Coaching for First Responders, and psycho-educational daily groups to help students create structure during the day, learn independent living skills and give parents a break.
In July of 2020 we piloted the first ever on-line clinically supported art class for senior citizens. “Art for the Young at Heart” combines social engagement, mindfulness, trauma informed care and technology engagement for seniors ages 65 and up. In August we will be piloting “Boomer to Zoomer” programming to seniors in Michigan, Colorado, Pennsylvania, and Florida with the goal of providing clinical support to seniors citizens who are living in isolation due to the pandemic, while also increasing their digital literacy so they can engage socially on-line with peers and loved ones. Both programs are fully reimbursable by Medicare.
We are now an affiliate of Grand Valley State University to help Bachelor and Master level social work students have access to safe internship opportunities that will also help prepare them for the "New Normal" in behavioral healthcare. We are in the process of applying for ACE accreditation with the ASWB to provide Continuing Education Units for Social Workers already in the field. Since 2018 Telebehavioral Health.US has been a Certified Woman Owned Small Business and a Registered Vendor in the System for Award Management, we are constantly on the lookout for disaster relief and small business contracts with the Federal Government.
What We Have Learned So Far
Maslow teaches us about how we have a hierarchy of needs and if our basic physical, social, and emotional needs are not being met, we can not self actualize and live our true potential. We can not keep requiring this workforce to earn a high level of education only to be underpaid and overworked and not expect consequences such as having mental illness be the leading source of disease burden. We have to take care of our workforces that service our vulnerable populations including our female dominated ones.
And to my fellow social workers. Please, for the love of all that is mighty, PLEASE, when "they" tell you becoming a social worker means you will, "make no money," do not respond by saying this is essentially, "okay" because you are "called to do it." I am here to tell you, you are in demand, your services are valued and you deserve to earn an income that matches your education and experience that doesn’t conflict with the other important roles in your life. Mostly, I am here to say, we would love to have you join our movement.
Susie Rigas-Morozowich, LMSW, LCSW
Founder and CEO