The business models around mental and behavioral health; Panel 1

30:00 -- Unique approach and differentiation?

Russ Glass: Ginger is 24/7. If you have a need in the middle of the night; if you're having a panic attack; we are there for you. One flight attendant had a panic attack, connected with a Ginger coach who got them back to baseline resilience. We start everyone at the behavioral coach level. About 80% of our members can use coaches though we employ more therapists and psychologists than coaches. Our coaches can handle more. We bring therapists in as needed. We also bring therapists and psychiatrists into the care team so the experience is seamless. We then try to step down from that higher level of care as soon as we can. Our coaching is 100% real-time synchronous care. The care is all done via chat. There is a lot of AI to monitor chats and extract key features, such as comorbidities, even tone of voice, combined with PHQ scores and we create a personalized care pathway. We give coaches actions to take and a predictive path for the patient; we're also looking for what might be the requirement if there's acceleration. We also provide smart replies so a coach only has to push one button.

Alex: Two Chairs is focused absolutely on therapeutic relationships. We want a clinical alliance between our patients and therapists. So our matching system is at the heart of our system. We emphasize gathering tons of data from our clients, plus an initial 45-minute appointment. We use this data to make personalized matches.  Because of this matching, we are seeing much higher alliance scores and symptom improvement. Our matching system relies on building an exceptional clinical team. We also full-time employ almost all our therapists. We are vetting folks, training folks of all diverse theoretical orientations. This strong team helps us make better therapeutic matches.

Sandeep: We're all collectively trying to improve access. Octave Health is focused on outcomes. We're betting on the notion that providers who've been trained in evidence-based modalities and have a focus on using measurement in their care will ultimately drive to better outcomes. We target a more acute population. About a half to two-thirds of our clients are dealing with moderate to severe acuity. 

Alon: BetterHelp only has licensed therapists. Our differentiator is we are not innovating because we're bringing the tried and true therapy online and making it more affordable and accessible. The biggest problem isn't that therapy isn't good, it's that the vast majority of people who need therapy don't receive it. We have nearly 20,000 therapists in our network, so with that critical mass, we are very positioned to provide quality matching. But even so, matching is hard because therapy is so personalized. 

Alexi: For BetterUp, we believe 80% of folks don't need therapy because their need can be addressed by coaching. We see ourselves as the top of the funnel. The reality is most people don't need therapy. We don't think it's productive to tell most people they need therapy, nor do I think it's realistic to think we can give people therapy at a global level; nor do I think this should be desirable. If we were good at prevention, most people wouldn't need therapy. If you re-envision therapy as secondary care, then what's primary? It's coaching. It would be evidence-based, informed by CBT, DBT and work by Frankl and Maslow and the human potential movement as well as Martin Seligman and positive psychology. We're focused on self-actualization and resilience. We want to provide clinical rigor to the non-clinical domain.

How are clients perceiving your services? 

Alexi: We were chronologically pretty early. We started in 2013, we had this heroic idea that everyone will flock to supporting the whole person. What we realized at that time, to most people, mental health was stigmatizing. We needed to focus on what are the frustrations of people who do not have acute mental illness and how do they think about their mental health? Our cultural dialogue wasn't doing our users a favor by focusing and branding ourselves as mental health because people thought of that as removing mental illness. So we focused on coaching. Yet what we were actually doing was mental health, resilience, mild anxiety. But by focusing on performance, leadership, promotion and on the outcomes people want when they are healthy, we found use and adoption was off the charts. If rigor is the root of performance, then we said let's make this about performance. For our population, we don't want to burden them with focusing on health as much as what they want from their health. We want to focus on how to get them to be at peak performance.  Now post COVID, we're getting a lot more on the clinical side.

Coaches vs Therapists

Russ: Majority of our providers are therapists/psychologists. We can just handle more people with coaches. Back to the core point of this panel, what we see is that when someone has a mental health condition, they will cost the health system 2.5 times more. As it gets more serious, costs go up. There's a huge cost to the system and there's not enough care. We're trying to change the model so we optimize the cost to manage the majority of people.

Alon: You don't have to be severely depressed or clinically diagnosed to see a therapist. Therapists help people across a wide spectrum of situations. Coach vs therapy is a murky line. A lot of peeling back from coaching. Coaches are less expensive and less in demand, from an inventory point of view. We should not confuse when someone needs a therapist. They should see a therapist and not a coach.

Russ: The notion that it's a murky line is antiquated. Maybe a decade ago. It's highly data driven. In fact our systems can predict when someone is going to need the interventions that a licensed therapist can provide. In order to scale care, we have to be more careful that making sure those therapists that have that ability to provide those interventions are being used for people who need them. We published peer-reviewed results that show coaches are just as effective as driving GAD and PHQ-9 down and resilience up. 

Sandeep: It's not just cost, it's a function of access. We've identified at this event that there's 50-100 mln people who have a need and we don't have enough licensed providers. I suspect 80% need coaching to none of them need coaching; it's our collective duty to make sure we get that right. We're trying to work with primary care doctors and physicians. By nature of the fact that we're taking insurance, we're working with people with less options. We weren't always accepting insurance. 

Business model

Alex: We are direct-to-consumer and we also work with payers. Our model is a fee-for-service one but we all want to get to value-based care. We're working with the current systems in place.

Sandeep: We primarily get reimbursement from payers. It is fee-for-service with a bit of risk as our fees are contingent on achieving outcomes. We thought about episode-based payment, but this puts us at odds with our clients because sometimes you need therapy for a clinical need, and sometimes you need one when there is no clinical need. Fee-for-service at risk around quality. 

Russ: There are two core payment models. Enterprise pays pe/pm (per employee/ per month) for unlimited access to coaching, content and there's a fee-for-service for clinical needs that gets billed back to their health plan. We also have a new value-based model that combines coaching, therapy and psychiatry and over half of our client acquisitions are selecting this option. We also signed our first national payer Cigna, which will be reimbursing for coaching.

Alon: We are a direct to consumer model at $200-$300 a month for weekly sessions with therapist plus unlimited messaging; traditional model of 45 minute sessions. We also work with employers and universities. But our main business is direct to consumer.

Alexi: We sell to corporations though we have a D2C which is newer. We have two areas. Buyers that focus on talent are structured in a SaaS model. When we sell into benefits, it's a price-per-participant model. We don't want people to think of healthcare as entitlement but as an investment. When we started back in 2013, there were no dollars in benefits for wellness really. It was clinical or nothing. But they're more open now. As for performance and outcome metrics, we can map our services to sales performance, attrition, turnover, mindset, civic behavior and creativity. 

Adoption and working toward a more gym-membership model?

Alexi: When we started, we wanted to build a gym for mental health (original pitch); it can work, people use coaching for years because it's not clinical care; we know how the number line works. We know how far the negative goes. We don't know how positive the number line gets to human flourishing. When you're pursuing self-actualization then it can be an multi-decade journey. As for adoption, it's very high for talent - around 60-70% because it's aspirational. When we do the benefits deployment it's about 15-20%. 

Russ: We're in the mid-teens with enterprise engagement. We look at this as all about behavioral change. We're trying to change behaviors so they ultimately have their own resilience. they learn how to eat well; in an ideal world, we'd see everyone for as long as they need to build those habits. Then they'd move on. Turns out, 20% are longitudinal more than a year. Some are more episodic. Some they just want a 3-month period and learning a new set of skills. 

Listen to more discussion at the end regarding how the companies attract coaches/therapists and what they're paying for them.  

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