The next wave of third-party payers
I’m pretty sure if you asked any blogging expert, they would not recommend almost a year between blogs as an ideal frequency. That said, here I am.
When I last posted, I didn’t know that within a month, I’d lose my mom and buy a new house and within six months, move to a few acres away from the city. The dust has settled as much as the dust ever settles with kids and pets and a pandemic and I’m back.
I came up for air after a heck of a year and discovered that a ton of tech companies have jumped into the mental health industry, trying to find more people care for cheaper. These are good goals but when a ton of new tech startups enter the market to solve a problem, it’s usually because there’s money to be made. I’m going to break down the different approaches I’ve seen and their strengths and weaknesses:
The EAP+ Model
Some companies provide more robust Employee Assistance Programs (EAPs) in which they compensate mental health practitioners about as well for EAP work as insurance companies do for medically necessary mental health treatment. EAP work (treating stress and other short-term mental health concerns) is usually paid at 60%-80% of typical insurance company payments. The EAP+ model meets the mental health needs of many employees/clients and EAPs can limit sessions per year to a particular number. Insurance companies can’t do this due to mental health parity restrictions that say mental health must be covered as any other health condition is covered. If a client needs 52 sessions a year, health insurance must pay for it. EAPs can limit sessions to 12 or 20.
I actually think this model is really good as it improves access without a ton of sub-optimizations to care quality. However, it’s expensive for companies to purchase this type of coverage in addition to health insurance, which is SUPPOSED to cover this kind of therapy but struggles to do so. And of course, only certain companies provide this benefit. How does payment work? In this model, the Company pays the EAP and the EAP pays the therapist.
Flow of Money:
Employer —> EAP —> therapist.
EAP+ Care Management Model
Other companies may have started with the “EAP+” model but pivoted to a model in which they function as both EAP and as an intermediary with clients’ medical insurance companies, effectively acting as gigantic group practices contracted with insurance companies. For example the EAP+ may cover 12 sessions a year of EAP but then, cover more sessions by passing sessions over 12 through to the client’s medical insurance company. In this model, the company pays the EAP and the EAP pays the therapist. But after 12 sessions (for example), the company pays the insurance company who pays the EAP who pays the therapist.
Flow of Money:
Sessions 1-12: Employer —> EAP —> therapist
Sessions 13+: Employer —> Insurance —> EAP —> therapist
The extra “hop” that money must take to go from the company to the therapist means therapist income is reduced but also because insurance companies hold the EAP liable for maintaining records, most EAPs who bill through to insurance companies are starting to demand that therapists provide them a LOT more data about client care (even though insurance company audits are rather rare when insurance companies contract directly with therapists).
The price of convenience is that EAPs are demanding of therapists, much more information on client care than insurance companies do, thus compromising client privacy.
Mental Health Technology Companies
This category includes many companies that offer artificial intelligence tools, mindfulness meditation, apps, tutorials, etc. to support or improve mental health and wellbeing. I love apps and tools but generally these companies have absolutely NO privacy protections and aren’t covered by HIPAA as covered entities, since these tools aren’t considered “healthcare delivery” or “health records.” Users of these tools voluntarily provide the company with health data in exchange for technology services. I actually don’t have much of a problem with this because no professional therapists are involved directly. There’s no illusion of privacy. It’s you and the computer.
Flow of Money:
Employer/Client —-> MH Tech Company
Combination Companies
More recently, there seem to be companies that are combining automated tools with licensed therapists. These companies are those that provide text-based therapy or on demand connections with licensed therapists. Others have written better articles than I can hope to write on this subject. These services are TERRIBLE for therapists and consumers. It’s badly compensated therapy that is, in my experience, so much lower quality than what we provide in the “real world.” Read more about it on TherapyDen.
Flow of Money:
Employer/Client —-> Tech Company —> Underpaid therapist
Data Privacy in the Context of Mental Health
First, let me say that I’m not a privacy expert nor am I paranoid about online privacy. Anyone can easily find my social media profiles, my wedding pictures, and my home address. Clearly, I really don’t care about MY information. But I do care about my CLIENT’S information and my agreements with them about how it is used.
Like many other therapists, I specifically state in my informed consent documents, that I reserve the right to conduct “research” using de-identified data from my own practice. I never have done this but I could for purposes of a Ph.D. dissertation, research paper, or commenting on general trends across my practice. But I’m never going to sell my clients’ information for profit or to advertisers.
Insurance companies have a ton of your data too but we generally know what they’re going to do with it. They employ teams of actuaries and data people to understand trends in risk and profit so they can make more money. They also rarely ask for detailed client data EXCEPT when they suspect a therapist or practice of fraud or other unethical/illegal acts. They are looking for larger trends and don’t usually warehouse whole client records.
EAP+Care Management companies, however, want your whole chart available to them in real time. That is where I draw the line. They say it’s so they can be ready to justify therapist billing to insurance companies but that feels like a good excuse for getting their hands on entire patient charts, something insurance companies never ask for except in the most extenuating circumstances. Since most EAP+CareManagement companies are tech companies, I figure they’ll do what tech companies do, which is de-identify/anonymize data and then sell it to the highest bidder. I happen to think that PATIENTS should retain those rights as much as possible.
So this increasing trend to ask for entire patient charts, is making me upset. And being upset makes me want to write… somehow I at least want companies to know that when they hire EAP+CareManagement companies, they sacrifice employe privacy in significant and new ways. We have to fix this…