Articles: Telehealth Training for Mental Health Providers Essential & Venture Capitalists at Odds {Below}

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Telehealth training for mental health providers essential

By Jonathan G. Perle, Ph.D., ABPP

     Broadly defined, “telehealth” is an umbrella term encompassing numerous modalities (including videoconferencing, telephone, messaging programs and email) and functions (including clinical care and training), involving the integration of technology with healthcare services. While additional research is certainly required, contemporary work has suggested both efficacy and effectiveness for remote assessment, intervention, consultation, training and supervision for a wide range of populations and demographics.

     Despite the rapid increase in usage as a result of the COVID-19 pandemic, a growing body of literature has suggested there is a highly variable degree of preparation and knowledge mental health providers hold related to the use of the telehealth modalities. Limited knowledge can reduce the ability of the provider to supply optimal services and raise ethical concerns about practicing outside the boundaries of one’s competence. Fortunately, the expanded adoption of telehealth has resulted in a virtual explosion of literature from guiding organizations, field experts and “boots-to-the-ground” mental health professionals. Unfortunately, many have suggested this information is fragmented and overwhelming to interpret. Providers can be left wondering what aspects of telehealth practice they should focus on, and where they should seek resources.

     Telehealth cannot be viewed as a single competency. It is, rather, a collection of competencies. Proper telehealth education and training require the acquisition of both general knowledge and applied skills. To focus efforts on mental health providers, researchers have highlighted the following:

    * Efficacy and effectiveness research for mental health challenges, including population- and modality-specific factors.

    * Differences between face-to-face and telehealth processes.

    * Care considerations and adaptations, including patient appropriateness evaluation, history taking, assessment, intervention and rapport.

    * Adaptations for provider-to-patient or provider-to-provider communication.

    *Telehealth etiquette, including appearance, reducing distractions and verbal and nonverbal patterns to convey empathy.

    * Ethical considerations, including informed consent.

    * Legal factors, including cross-state practice.

    * Safety planning.

    * Data security, varying by country and including HIPAA, GDPR, PIPEDA.

    * Technology troubleshooting.

    * Practice logistics, including electronic health records and documenting services.

    * Implications of a patient’s culture.

    * Adaptations for special populations, specifically older adults, children and those with disabilities.

     Specific telehealth modalities require additional, specialized knowledge. Mental health providers should supplement the general foci by seeking education on pertinent competencies, such as room setup (lighting, camera angles, room décor, etc.), video-related factors (including platforms, resolution, latency) and telepresence (facilitating eye contact through video for videoconferencing-based practice).

     For providers interested in securing telehealth education, numerous outlets are available. For those already licensed, post-degree education can be secured through the growing number of telehealth training organizations, including Telehealth.org, the Telehealth Certification Institute and the Zur Institute; local or national continuing education programming provided through guiding organizations, such as the American Psychological Association, the American Telemedicine Association, the American Psychiatric Association, the American Medical Association and local branches of mental health organizations; and through self-directed reading of books and journal articles focusing on both the research and application of telehealth methodologies. Mental health-focused book options to learn about the various aspects of a telehealth-based practice include:

    * Perle’s (2021) “A Mental Health Provider’s Guide to Telehealth: Providing Outpatient Videoconferencing Services”

    * Campbell et al.’s (2018) “A Telepsychology Casebook: Using Technology Ethically and Effectively in Your Professional Practice”

    * Goss et al.’s (2016) “Technology in Mental Health: Applications in Practice, Supervision and Training”

    * Tuerk and Shore’s (2015) “Clinical Videoconferencing in Telehealth: Program Development and Practice”

    * Meyers and Turvey’s (2013) “Telemental Health: Clinical, Technical, and Administrative Foundations for Evidence-Based Practice”

    * Maheu et al.’s (2001) “e-Health, Telehealth, and Telemedicine: A Guide to Start-Up and Success”

     While these books may be helpful for readers of any level, graduate students may specifically want to explore Maheu and colleagues’ (2020) graduate text, “Telebehavioral Health: Foundations in Theory and Practice for Graduate Learners.”

     Ultimately, as with any new competency, providers must pursue appropriate education to ensure an ethical, legal and safe practice. Educational activities should combine to give the provider not only an understanding of the research to guide the selection and adaptations of techniques, but also the knowledge of the day-to-day requirements and workflows associated with the integration of the technology. Finally, providers must take care to remain up-to-date on both the research and legality of the practices, as the field of telehealth has been prone to frequent changes, requiring the provider to remain proactive in their education.

Jonathan G. Perle, PhD, ABPP, is a licensed clinical child and adolescent psychologist, associate professor of clinical psychology and Director of Telepsychology at West Virginia University School of Medicine. He has significant experience providing clinical assessment and intervention services within diverse clinical settings and roles. He has developed a specialization in the practice and teaching of telehealth modalities. He may be reached at jonathan.perle@hsc.wvu.edu.

Venture Capitalists at odds

By Michael G. Conner, Psy.D.

and Michaele P. Dunlap, Psy.D.

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     Over the past 20+ years, most health plans failed to provide cost-of-living or cost-of-practice increases in psychotherapists’ compensation. A modest 1.5% increase per year would have yielded a 35% increase in psychotherapists’ incomes.

     One reason psychotherapists have not adopted alternative payment methods (APM) such as measurement-based care (MBC) and outcome-informed care (OIC) is that they cannot afford the costs. Another reason is that the Affordable Care Act (ACA) of 2010 offered incentives for adopting MBC/ OIC applied to medical providers, not clinicians who offer psychological, counseling, or behavioral health services.

     Health plans’ customers are employers and state funding sources that want data which demonstrates the value and effectiveness of Health plan paid services. Health plans are not satisfied by research that has repeatedly confirmed the economic worth of psychotherapy. Health plans want current data to offer value-based plans to employers and government programs.

     Psychotherapists understand that psychotherapy must center on the individual circumstance of each patient and recognize that effective patient-therapist alliance is the most significant factor in psychotherapy outcome.

Venture capital companies in the mental health marketplace

    The economic worth of psychotherapy for the healthcare sector is that psychotherapy reduces medical costs.  Medical cost-offset research has demonstrated this fact for decades. Recently, Cigna’s research found that when psychotherapists treat patients for at least 3 appointments and fewer than 14 appointments, the savings to the health plan in medical and prescription costs is between $755 to $1377 per person the first year. Improvements for 75% of patients occurred in the 3 -14 session window. 25% of patients continued for longer terms. Medical cost-offset calculations for care beyond 14 sessions were not part of the Cigna report. (Pre-pandemic data.)

     Restricting the average duration of treatment provides net savings. One thousand providers each treating 25 patients per week in the 3 to 14 session pattern can save a health plan 18.9 to 34.4 million dollars.

     New Venture Capital (VC) companies have recently emerged. These million and billion-dollar digital platform companies compete for patients with independent-practice mental health professionals. VC companies have marketing and advertising resources private practice clinicians do not.

     The VC companies have come into the market to employ therapists, to compete with health plans for employers’ dollars or hope to be purchased by health plans.  How many of these VC companies have health plans among their investors is not clear.

     Some new VC companies offer mental health providers digital services including billing, assessment, appointment scheduling and teletherapy portals. They also offer public prescription services, coaching, text or email contacts, counseling and brief psychotherapy.

     Digital mental health services funded by venture capital cannot be just “successful.” They must win big or will fail because of the hyped investor expectations they create.

     The only way that huge profits can happen requires the VC companies to take control of psychotherapy services, reduce psychotherapists’ fees-for-service and/or increase the number of patients treated in brief episodes.  VC companies cannot afford to address psychotherapists’ ethics, values or the importance of relationships created with clients.  VC companies will not hesitate to create policies that inflect moral injury on patients and psychotherapists. Psychotherapists are responsible for the policies they follow, not VC companies and health plans.

     Can VC increase access to care, improve outcomes, coordinate care with physicians and make a fortune at the same time? What will happen to patients and employed therapists when a VC company fails or is purchased by another company? 

     VC companies work to convince health plans they can manage every aspect of psychotherapy practice, asserting that their technology and management strategies will dramatically improve outcomes. They assert that the management demands they place on psychotherapists will save millions of dollars.

     The increase of profits and value that these VC companies seek depends upon their convincing therapists to leave independent practices and become employees of the VC companies.

Digital mental health “unicorns”

     Unicorn is a term used in the venture capital industry to describe a new company with a value of more than $1 billion. The term was coined in 2013  by venture capitalist Aileen Lee.

     According to the APA, venture funding is pushing technology to a central spot in the mental health landscape. APA believes there is an opportunity to ensure that these interventions are ethical, inclusive, live up to their claims and help people get better.  How to do that has not been codified.

     Valuations of seven mental health start-up unicorns are:

1.      Lyra Health $5.85 billion

2.      Cerebral $4.8 billion

3.      Ginger $3.1 billion

4.      Genoa $2.5 billion

5.      Modern Health $1.2 billion

6.      Calm $2 billion

7.      Talkspace $1.4 billion

For current funding and valuations information see:  www.CrunchBase.com

      Among the many areas of concern about these VC ventures is a lack of legal mandates or available avenues for clinicians to report their negative experiences working for companies funded and directed by VC investors.

      Health plans are financially motivated to possess all patient-provider data possible. Venture capital investors want the highest return on their investment. VC companies are paid to provide health plans with patient-provider data.  Some require real-time visible access that VC companies are happy to provide for a price.

     Asking themselves the following questions can help mental health professionals choose wisely when they consider digital platform employment:

     Can psychotherapists maintain patient-centered ethics and standards of care when they choose VC employers?

Can psychotherapists entrust their licenses and reputations to VC companies?

     Ethically, psychotherapists must retain 100% control over confidential health information to protect and advocate for patients. So, ask: What does this company’s contract stipulate concerning responsibility for clients’ private information? (i.e., their symptom reports, and their clinical change data.) 

References available from authors

    

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Michael G. Conner, Psy.D., is a psychologist in private practice and owner of Private Practice Cloud LLC, a healthcare operations business that supports mental health professionals’ associations. He is a member of the Board of Mentor Research Institute (MRI).

Michaele P. Dunlap, Psy.D., is a psychologist in private practice and President of MRI. Contact the authors at www.MentorResearch.Org

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