Happy Q2! I imagine most of the readers of this publication aren’t “business folk”, but if you have friends who are (especially in sales), this past week was a crunch to wrap up the 1st quarter of the year (Q1), and we’re now into the 2nd quarter.

With that crucial information out of the way, let’s get started:

It’s a money game (Research)

As I go deeper down the validation journey of wellbeing & therapists, I’ve started investigating the medical / insurance space to understand how it operates. My friend John recapped the categories that a health tech company could fall into, today on a catch-up call:

1. Employee Assistance Programs (EAP) — These are startups that sell into companies that offer EAPs to their employees. The programs are often touted to improve the wellbeing of the employees, as they can call to get any matter of problem addressed.

   1. Startups supporting this exist in both Canada (Dialogue) and the USA (Modern Health). While many focus on mental & physical health, some (i.e. Dialogue) have expanded to to look at legal & financial, career support, family & relationships, etc.

   2. The draw of these programs is that they “improve productivity, lower turnover rate, and improve absenteeism rates” (Nivati). More on this later.

2. Direct Healthcare Support — This is a model where you pay a monthly fee to get access to specific services, i.e. therapy, physiotherapy, specialist services (i.e. dental), etc.

   1. Most of these companies go through insurance to maximize coverage, i.e. Talkspace. There are some solutions that don’t (largely due to being unlicensed, i.e. BetterHelp).

3. Reimburse for out-of-network — These are solutions to reduce the headache of handling out-of-network billing, i.e. where you see a clinician who isn’t approved by your plan’s coverage (SuperBill).

   1. There are a couple of startups tackling this problem, i.e. ClaimEye and Reimbursify.

4. Share of Insurance Billing — Many solutions in this space will charge a meaningful portion of the provider’s (i.e. therapist) revenue, or have a software (SaaS) fee that they need to pay. Some solutions act like a marketplace but take their revenue from the insurance billables, instead of the provider’s revenue.

   1. Headway is an example of one of these startups, and they’ve made great progress due to taking this innovative approach.

What does this mean for the therapist / mental health solution landscape? Well, first we need to confront the elephant in the room: the medical model wants to ‘fix’ you.

Payers (i.e. health plans, governments) want to minimize the costs that they pay out. Providers (i.e. health systems, clinicians, etc.) are required to abide by this system so that they can get paid for their services. In fact, it’s the admin side that seems to be a huge headache for providers; which is why there are TONS of startups that tackling back office problems for coaches, therapists, physiotherapists, and many other clinicians.

EAPs are no different. Your employer cares about your wellbeing but they are incentivized to get you back-to-work and productive ASAP. Modern Health specifically touts on their homepage the advantage of cost savings against your healthcare plan:

If you can maximize worker productivity, minimize cost to payers, and give objective outcomes to your patients, then everyone (economically) wins.

Going against the grain (Think)

For the sake of time, I won’t play devil’s advocate here: this is bad. The goal is cost minimization and objectivity; how can you limit the amount that payers have to burden, while maximizing the outcomes that a patient receives.

Here’s a quick example, for clarity:

1. You have a heart attack, and in Ontario, get processed through WSIB.

2. You are assessed to need physiotherapy + psychotherapy, and are given time off.

3. Your physiotherapist does an assessment and gives you a treatment plan to follow. Their goal is to minimize your symptoms and get you back to work.

4. Your psychotherapist does the same thing, with the same goal.

This sounds great in theory, but has a lot of holes in practice, namely:

1. Mental Health is often not meant to be solutions-oriented.

   1. You don’t cure depression the same way that you cure cancer. Instead, you implement treatment options to minimize symptoms (Healthline).

   2. You might already have ideas on how this is problematic. If you have anxiety, the goal shouldn’t be to pop a pill every time you encounter a situation that makes you anxious. It’s probably a better idea to understand what drives this anxiety and how you operate as a person. Notice how we’re already moving away from ‘fix it’ to ‘understand it’.

   3. No Bad Parts has a great example on this: 30 rheumatoid arthritis patients were compared against another group, where one group got educational info (how to control symptoms) and the other got therapy to understand what was driving the pain. After 6 months, the group that tried to understand it (IFS) had much better outcomes, including physical (transcript from Sounds True)

   4. I also hypothesize that this is why a lot of people say “therapy isn’t for me”. They come expecting a solution, in many cases they’re provided one, and when it doesn’t work, they assume that it’s them that’s the problem.

2. Mental Health is difficult to measure objectively.

   1. Sure, you can use tests to measure levels of depression, anxiety, etc. (PHQ). However, that is a very isolated look; it doesn’t factor in environment, shifts over time, etc.

   2. Going back to our medical model problem, there is a need to measure it objectively (like physical health). This has led to a rise in certain modalities of therapy, i.e. Cognitive Behavioural Therapy (CBT), that can produce rapid results and hinges on changing your thinking patterns (APA). It measures your thoughts over time and can therefore show improvement of them.

   3. This is problematic because changing your thinking patterns doesn’t solve underlying issues. I.e. learning how to calm yourself when you are stressed is helpful, but if you don’t ask “what is causing this stress” then you never get to the root cause.

   4. As a side note, I understand why the insurance codes for Remote Therapeutic Monitoring (RTM) that were introduced were specifically for CBT. If insurance companies are paying for ‘progress’, then they would naturally be most in favour of modalities that can clearly measure that progress.

As I talk to more therapists, I’m hoping to get a clearer view on how they see a solutions-based approach, the song and dance of getting it covered by insurance, and how this all tracks back to patient outcomes. To be transparent with my thinking, I am most interested in improving how patients experience therapy and better enabling the therapists to do their best work, through the lens of the ‘work’ that’s done in-between sessions.

Validating my ideas (Build)

I mentioned in my last post that I planned to start conducting interviews with both therapists and end users (clients) to learn more about their experience. I put together a list of questions that are fairly flexible, backing into my core hypotheses, and have been re-reading The Mom Test to ensure I’m approaching user research the ‘right’ way.

I’ve been going through Psychology Today, a database of therapists that are categorized by location, modality, presenting concern (i.e. stress, career, etc.), and other factors. I’ve done (2) rounds of outreach and plan to do a couple more every week, with the goal of getting to 20 interviews.

The response has been good so far: I’ve conducted (3) interviews and have another (6) booked, for a total of (9). Not bad for my first week! To recap some of my thinking here:

• I expect that I’ll change my approach after ~ 10 interviews. This is because I’ll start to find patterns and get more direction on where to focus for the ensuing interviews.

  • This may include looking at specific populations (i.e. therapists who work with high-achieving professionals, students, couples, etc.) and going deeper on their respective experiences

  • While everyone’s experiences will vary, I’m hopeful that there will be more similarities when I get more specific

• I have deprioritized coaches for now. This is a massive market (see BetterUp) and there is also a lot of variety here. I.e. career coach, life coach, relationship coach, etc.

  • My plan is to focus on clinicians because I think they are facing the most acute pain the medical model, and because I believe that the regulation around how they practice (modalities, supervision, etc.) will make it easier to pattern match and solve similar problems.

  • I did have a conversation with a US-based coach who was a clinician for many years, and she helped to show me that there are lots of coaches who operate like therapists (i.e. not solutions-based), but also lots of therapists who do the opposite (which can be problematic)

• Talking to clients is a secondary concern. Given that I see this as a B2B2C product (going through therapists), I think it’s important to gain an understanding of what clients / patients are open to, and the experiences they have, but trust that therapists know their clients well.

  • This is a stark contrast to my previous ideation on B2C / habit apps, where talking to individuals was a key part of my findings.

With that being said, I’ll recap some of my asks:

• If you’ve been to therapy (now, or in the past), please message me as I’d love to interview you!

• If you’re a clinician (psychotherapist, psychologist, etc.) in Canada or the USA, I’d love to interview you!

• If you are operating in the mental health space, i.e. building a startup and/or investing in startups, working with payer/provider systems, etc., please message me!

As a wrap, we’re only a day late and coming in around 1,600 words. Talk about ‘progress’, as long as we’re not solutions-oriented 😉