A recent Data & Society research report titled, “Doing the Work: The Future of Therapeutic Labor, Teletherapy, and the Platformization of Mental Health Care”, provides interesting insights from the provider perspective regarding direct-to-consumer (DTC) telehealth, or as referred to in the report, platform therapy. The author, Livia Garofalo, interviewed over 50 mental health professionals with teletherapy experience; some working solely with DTC platform companies, others in private practice, as well as providers working with community health agencies. Overall, the report examines the DTC platform work environment to showcase impacts and implications that are important to the overall telehealth landscape.
As covered in CCHP’s last newsletter (dated 5/28/24), there seems to be preferences toward telehealth hybrid models where providers offer both in-person and virtual services to ensure continuity of care. Nevertheless, the recent rise of DTC telehealth platform companies still offers the opportunity to assess the additional access to care that DTC platforms provide and present considerations for providers, patients, and policymakers to take into account when analyzing their specific types of services. For instance, when referring to telehealth generally it helps to understand the different ways it may be implemented and affected by public policy. The Data & Society report focuses on DTC telehealth which operates differently than traditional telehealth implemented by providers who have established in-person care. In addition, there are various telehealth platform business models ranging from the client-centered DTC companies to those that are more provider or third-party-centered, such as insurance contracted telemedicine platforms. Most often, however, these companies do not offer in-person services and remain unconnected to a patient’s in-person providers. Additionally, as ultimately noted in the research report, these platforms have effectively restructured the labor of therapy for providers, building on the concept that care can now be provided anywhere, and at any time, as well as the dynamics of platformization, which the report describes as combining a clinical profession with a new labor arrangement focused on algorithmic management, productivity incentives, and machine learning augmentation.
For teletherapy providers interviewed for the report, while DTC platforms seek to provide a way for therapists to find new patients, lessen workload, and bring in additional income, the reality often brings more fractured schedules, constant client turnover, and unpredictable payment structures. Additionally, while the platforms seek to increase access for patients, given that companies are unable to increase the number of mental health providers in the workforce, they must adopt strategies that instead include time-limited sessions and promote high caseloads. For instance, DTC telehealth providers, or platform providers, reported challenges in the study regarding the lack of control over how the DTC platform algorithm, as the mediating agent, filled their schedule – rewarding providers with availability and penalizing those restricting it, which seemed to undermine the promise of flexibility and ability to determine an appropriate client load and compensation. The time limits applied to sessions, in addition to word counts on texting sessions, reportedly left providers feeling extra pressure and fragmentation in their communications with patients. The ultimate concern providers reported was that the process seemed to undermine the importance of the therapeutic relationship and overall ability to provide quality care. This concern was underscored by high client turnover and the number of patients that simply stopped responding to platform providers, often leaving providers feeling as if they were unable to help patients reach the root of their issues. Several providers suggested that in order for the business decisions to be more in sync with the clinician work, companies should ensure more clinical involvement in their leadership.
Some platform providers in the study also highlighted the line between company and provider liability, noting that the responsibility still falls on the provider to ensure practice compliance, since the company doesn’t typically know the provider practice requirements for each state. According to the report, the platform’s algorithm does seek to ensure that the patient is matched with a provider licensed in the patient’s state and some telehealth companies will also help pay for licensing exam fees and continuing education credits for providers. As a reminder, regardless of where the provider, or the organization that they work for, is located, telehealth is considered rendered where the patient is located at the time of the virtual visit. Therefore, a provider typically needs to be licensed in the state the patient is located in in order to be able to provide care, although varying exceptions do sometimes exist in specific states and circumstances (see CCHP’s cross-state licensing page for more information). It is important to note that additional professional requirements may apply to providers delivering care in a patient’s state, such as policies related to consent and use of different modalities to establish a provider-patient relationship. Platform providers should not assume that the company they are working with is aware of and ensuring practice compliance with the additional regulatory requirements specific to their particular license.
The issue of ensuring individual provider compliance with privacy obligations within platform professional arrangements should also be noted. Recently, we have begun to see some telehealth companies come under scrutiny for sharing private health information, amongst other issues. Cerebral, a platform company that offers DTC medication, reportedly shared patient data of over 3 million patients with advertisers (and has also been under investigation by the US Drug Enforcement Administration for its prescribing practices). In addition, BetterHelp was reportedly ordered by the Federal Trade Commission to pay users millions of dollars over allegations of sharing user health data. Further, another platform company, Talkspace, was recently sued for allegedly misleading consumers into subscriptions for services that the company was unable to be meet as a result of the insufficient therapist labor force. The study notes that such company practices have been increasingly coming to light as platforms have begun to expand into state-based public care spaces, such as recent partnerships between New York City and Talkspace to provide a teen mental health program, as well as the California Department of Health Care Services’ partnership with Brightline to provide free mental health care for California children and families. Additionally, in 2022 the U.S. Department of Health and Human Services, Office of the Inspector General (OIG) released a fraud alert specific to questionable telemedicine company practices, highlighting characteristics that could possibly indicate a heightened risk of fraud, including the company not ensuring subsequent follow-up with patients. Nevertheless, OIG stated that the fraud alert was not necessarily regarding telehealth itself, or providers utilizing telehealth, rather it was specific to the potentially dubious arrangements with purported telemedicine companies (see the CCHP Newsletter on the OIG Fraud Alert (dated 7/26/22) for more information).
It remains important to parse out the nuances between types of telehealth delivery, information, and implementation, especially as policymakers consider reported telehealth data to inform the adoption of long-term policies. Often when telehealth is studied, considered, and regulated in a very general way, it can fall short because the reality of the different dynamics involved ultimately warrant different applications and interpretations. Overall, the providers in the study and the study itself underscore the differences between teletherapy and platform therapy (DTC telehealth), noting the many benefits of using telehealth as a modality to provide and receive mental health care. Platforms can also deliver access to care that patients would potentially not otherwise receive. The primary concerns raised in the study were with the professional arrangements required as part of working with a platform company, highlighting the continued importance of separating the practice and business of health care no matter the provider arrangement or technological advancement to ensure that the ultimate goal remains the provision of quality care through all modalities.
For more information on the study, read the report in its entirety, watch the recorded online panel (featuring CCHP Executive Director, Mei Kwong), and engage with the animated short. |
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CCHP knows that telehealth policy can be a complicated subject and from time to time questions about policies related to your specific situation may arise. You’re in luck…We’re here for you! Just submit your question via our easy to use contact us form, or send an email to info@cchpca.org
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