From Practice to Innovation: Conversations with Mental Health Tech Leaders
The first installment of a two-part series focusing on transparency for clinicians in the mental health industry.
As digital platforms increasingly transform how mental health services are delivered, clinicians face a growing number of companies and platforms to consider. In this rapidly evolving field, transparency has never been more critical.
For clinicians, it is essential to ensure that the companies they partner with align with their values and meet high standards of practice. Transparency in mental health companies means having clear, open information about how these platforms operate, including how they ensure client confidentiality, use technology ethically, and adhere to evidence-based therapeutic principles. It also means understanding how these companies support their therapists and maintain the integrity of client care.
Megan Cornish, LICSW is a Clinical Social Worker, founder of Therapy Trust Collective, and creator of the Fit Check for Therapists, a Facebook group that helps therapists share their experiences working with mental health companies. With her connections and interviews with key players in the mental health industry, she has become a leading voice in shaping the evolving landscape of mental health care. She advocates for increased transparency and promotes that providers partner with the right organizations to support their needs.
Lindy: First tell me a little bit about your background and how you got where you are now?
Megan: I am a licensed clinical social worker. I was working my social work dream job. I was embedded in a school district [in Washington state], so I got to work with middle schoolers and high schoolers all day long, but only during the school year, during school days. It was really ideal. And then the pandemic happened, which is a line in many people’s stories. My husband was a charge nurse at ICU at the time, and he loved the fact that he could make the decisions that were best for patients and the bureaucracy kind of melted away. So when the bureaucracy started coming back, he decided that he wanted to do something different. He wanted to go back to school to become a nurse anesthetist, and he got into school in North Carolina.
North Carolina does not value social workers the way that Washington values social workers, so I was not able to find an equivalent job there. The amount that I was going to be paid was going to be the same I would have to pay for child care. So we decided we’re just going to take out student loans, live off of those until he gets out of school, and then I’ll figure something out. But I’m easily bored and I’ve always had a writing side hustle, just writing blogs and stuff for friends and local small businesses. I thought, I bet I could make some coffee money doing some writing work on the side. And so I started writing, and I said, “I got all this knowledge about mental health. I wonder if mental health companies want writing?” They had marketers for the writing, good writers. They had clinicians who were excellent at their work and understood everything clinically. But they didn’t have anyone who did both, which is what I was able to help them with. So that’s how it all started for me. Just word of mouth got around, and I got to work with so many amazing companies.
What made you decide to come up with the Fit Check for Therapist group on Facebook?
I’ve got all these companies listed on my LinkedIn. I’m constantly getting messages from clinicians asking, “What’s it like to work with this company?” And I unfortunately don’t always know, because I mostly worked with them in a contractor role. I also am privy to many conversations about some of the problematic things happening.
I was approached by a CEO of an organization who wanted me to give him some feedback from clinicians. He felt like maybe they weren’t getting unfiltered views. I had a little bit of a reputation and built some trust with the therapist community. He wanted me to talk with his therapists and find out what they could be doing better. And in that process, I learned a lot about what it means to build a space that works for therapists, and how much it is about fit. When I presented the findings to him and his team, I asked, “Hey, would it be okay with you guys if I published this? I feel like it would be really helpful for anyone considering your company, because this says the good and the bad.” And they said, “Sure.” It just felt like a cosmic, serendipitous way for all my interests and my passions to come together in one cohesive way.
We need better regulation, but regulation moves so slowly. In the meantime, there’s debate over whether we could form a union. But we don’t really need a union if we move our labor to the companies that are doing the right things for the right reasons. Eventually, the companies that aren’t doing the right things are going to have to start because they won’t be able to compete without labor. The first step is being very transparent, so everybody knows what’s going on in all the companies, and every therapist can figure out what fits their practice best.
True, and we can’t always get that information just from the job interview. They’re going to present their company in the best way possible to get you on board. There’s just so many companies out there.
Exactly, I’ve gone into the interviews saying, “I’m gonna hear a bunch of bad things about this company.” But even in the midst of that, I usually find at least one therapist who says something along the lines of, “I pinch myself that I get to work here.” Being a social worker, I’m like, okay, self-determination. I don’t get to tell a therapist that this company is all bad. I can list the reasons why this might not work for you, and reasons that other therapists have left. I don’t get to come in with a moral superiority and say, “You should work here. You can’t work here.” Every therapist gets to make that decision for themselves because it might be a fit for them.
It’s just having the information. Maybe the therapist is more worried about pay and others want large caseloads of 40 clients a week. It depends.
Someone was posting about a job that required a very full caseload and administrative tasks. I’ve known two therapists who could manage that. It’s not me, and it’s not most therapists, but more power to them.
What have you been noticing in the industry that you feel needs to be changed to be more therapist friendly?
I’m guilty of blaming everything on investors and venture funding, which I think are not necessarily positive for us right now, but I think that I need to be more vocal about the payers. The only reason I don’t talk more about the payers is because it’s so mysterious. Nobody knows what goes on there, and since I don’t work directly with insurers anywhere, I always get it through three levels of information. I think there’s a sense right now, and I’ve heard this from multiple leaders, that the payers who, a few months or a few years ago, were all about access, are now starting to feel what happens when you say, “Yeah, we should pay for mental health care.” It’s that people wanted their mental health care paid for, and they’re realizing that they’re gonna have to pay for it out of their money that they want to keep for themselves. And now there’s a lot of stuff that’s happening.
For example, there’s this article about United Healthcare. They’re imposing a prepayment review for mental health treatment where they’re coming back and saying that they won’t send any money before they get detailed records. They don’t necessarily need the detailed records, but I think it is one way to avoid having to pay out, because eventually some clinicians are just gonna give up and eat the costs.
What’s worse though is UHC just had that ransomware attack. They weren’t paying therapists while they were trying to get that figured out.
Exactly. And a few people have wondered if something had shifted during that time. Who knows what goes on, but it seems like in the age of parity laws, they’re realizing how much of a need there is for behavioral health. They are trying to do anything they can to avoid actually paying for behavioral health. This is affecting the companies as well as clinicians, but there’s not very clear communication, so clinicians get frustrated with the companies. Companies are frustrated with the payers, and nobody really knows what’s going on, and so there’s just a lot of anger. I try really hard not to be a fear-monger. That’s not my intention. I just feel like there needs to be more shown about what’s happening so everybody knows, and nobody can get away with anything.
Maybe insurance companies can pay therapists better while they’re at it, too?
I know, right? I’m sure you saw that article about why therapists are leaving the network, and I hate to say it, because people need access, but I think it’s a good thing. I think eventually it’s going to get to a point where insurers realize they can’t claim to have mental health coverage because they don’t have therapists, no therapist will work with them. They’ll have to come back and raise rates and maybe sell a yacht or two. It’d be really rough.
What do you think the right fit means in the context of working for a mental health company? What do you think are the factors in that?
There are a lot of factors. I have this mental model of the industry right now. It’s more of a Venn diagram. On one side, you’ve got the companies that work for you, on the other side are companies you work for. And then in the middle, there’s some that kind of do both. So if you want to be a W2 or some 1099 models, you’re going to work for them. And you are subject to their rules, their hours, their documentation criteria, you’re going to bill through their group practice. If you don’t want to do admin stuff, then that might be a great fit for you. You just need to be willing to weed through what doesn’t work for you in terms of schedules.
On the other side, you’ve got the companies that work for you — that will just handle your billing or will help you with finances, that kind of stuff, as you start your own private practice. And there are a few that live right in the middle. Alma works for you and the money flows to them from the therapist and back from them to the therapist. It’s complicated, but just knowing what you can handle in terms of not having control over your own caseload and your own care of your clients is a big deal.
A big thing right now is how some companies are starting to ask therapists to give them their notes when previously that wasn’t necessary. They want access to client information but then it’s like, are we working for you now? Or is this related to quality?
I just had to put this out there into LinkedIn land. This is what I think is going on based on what I know. I got a lot of feedback from companies saying, “Actually, what’s happening is this new practice from United Healthcare.” Companies are not getting any reimbursement without providing tons of notes.
My suggestion to these companies would be, why don’t you tell therapists? Either they can handle sending every single note to insurance themselves, or they can just submit it to you and have you do it, and they can opt in or out. It’s great for therapists to have a team to do it for them if they’re comfortable with it, but asking for notes without any context as to why should be alarming for the therapist because we’re trained to be very protective of documentation notes. I also understand how some of these teams are asking, “How are we going to manage this? Our therapists are mad at us, but we can’t get the money to pay our therapists because we are in healthcare, and these other insurance companies are pulling this to try not to pay.” I think more communication is needed.
Transparency is important because we don’t want another incident where a company is selling our information and client information to third party companies, but we also want to work with these companies to make sure that we’re getting paid and getting our clients taken care of.
Absolutely. And I don’t really know many therapists who would, if presented with the option of handling all this billing themselves or working with the company, say, “Sure, I’ll take five hours of my week to just send ridiculous amounts of documentation over.” That sounds like a great role for a company to have, but if therapists don’t know what’s happening, then how are they supposed to feel okay with it?
What advice would you give to therapists who are currently evaluating potential employers?
I would say the Fit Check for Therapists group obviously, shameless plug. The community is really great. Ask to talk to someone individually who’s worked at the company. There are therapists who are so generous with their time and their knowledge and their information. This is kind of like a buddy system, where you talk to someone who’s not sent by the company to ask your questions first. I also would encourage therapists to be mindful, because there are some people who have had really bad experiences. I don’t invalidate that; those stories need to be told, but just because they had a terrible experience doesn’t mean that was everyone’s experience.
Yeah, It may be important to talk to more than one person and get some different feedback for an overall view.
Exactly right, and ask the recruiters a lot of questions, get it all in writing. It needs to be in your contract. But also know that in your contract, in a few months they might try to change your contract. Sometimes the people who wrote the contracts don’t even work for that company anymore, so try to stay flexible. It’s a pain.
I think eventually a few companies are going to get the hang of it and they’re going to stick around. The other ones are probably going to fade away or pivot.
I’m a big proponent of keeping your options open in terms of just running your own practice. I’m trying to build some partnerships to have a robust referral network for people who are in the Fit Check community, who are ready to go out on their own- you know, here are three companies who can at least get you started, or can educate you on what you need to know.
What recommendations would you offer to the mental health companies who are trying to improve their fit for therapists?
That’s a good question. I was talking to a mental health leader last week, and he told me that for every therapist they lose and have to replace, it’s $30,000 in revenue, including the price of the lost labor in that time. So I would say to the leaders that they need to communicate with their investors about these numbers. I know that changes don’t happen when investors are involved without justifying the finances. So I work really hard to find those numbers. Try to make the therapist experience, therapist retention, translate into dollars.
There is a financial cost to losing therapists. Therapists’ loyalty is going to be to their profession first and foremost, especially when they don’t have stock options. When you hire a developer at an early stage in a company, they are loyal to the company, because they know when the company succeeds, they succeed. But that’s not true for therapists. They’re going to take their labor where they know their clients are safe, where they know that they can have work-life balance and a sustainable career. So you have to make it work for them in other ways. And don’t expect them just to stick with you, because their success is not tied up as yours.
What changes in industry practices could help improve the fit for therapists and contribute to a better workplace environment?
Caseloads are really huge. There are payers showing a little bit more acceptance of paying more for higher quality, which is great. One of those industry leaders I was talking to made the analogy to Mayo Clinic. Mayo Clinic is paid more because they’re not the Urgent Care down the street, because they’re giving the best care. So I think that focusing on that as a way to increase revenue is a great option, and part of that, in mental health, is improving the work experience, lowering cases, not raising them. Obviously, companies have to make money. If you can only see five to 10 patients — I fully support knowing your limits, but you’re probably not going to find it with these larger companies, because in order to stay in the black, they have to have a critical mass and a minimum number. It’s just kind of the way it works. If they’re not able to maintain that average number, then they don’t have a business model anymore. There are companies that will just work with you whatever your amount is, those are probably a better fit for therapists who want to have a low caseload. But yeah, quality over quantity.
Can they meet the numbers by attracting more therapists rather than having higher caseloads?
In theory, yeah, but it depends. Every company is so different, and obviously they don’t like to send me their formulas and spreadsheets. There are different models, like Alma, for example. The therapists pay Alma. I see therapists online complain that Alma charges, but I don’t think therapists understand that that’s actually a protective factor for therapists, because it makes therapists their customer instead of the product, which is great.
Other models really rely on, “We need to make X amount from a therapist,” which means they need to work this amount. And you can’t go very low. If the average amount they need is 24 clients per therapist, you can’t have one person go down to 10 and one person go up to 38. It has to make sense on paper. I’m not convinced yet that, in the long term, it’s going to be as profitable as investors have been promised it will be. We’ll find out.
What are some key takeaways or lessons that you’ve learned that you believe would benefit both therapists and mental health companies in the future?
The first thing is to remember what the enemy is, which is not people, even people who are making bad choices. It’s actually greed, I think, that is the enemy, and it can pop up in any organization. And I’m not even talking about the desire to be comfortable, to be wealthy. I’m talking about greed, like, let’s make billions. Let’s make enough money to swim in. Let’s make the GDP of a small nation. That’s the enemy. I don’t think that it’s possible to provide quality health care and make that kind of money, because every penny that you’re keeping in your pockets is a penny that’s not going up to help people get better.
Look for the helpers. Even in some of these giant wealth and massive organizations, there are people who want to do the right thing. Connect with those people and ask them to help find solutions.
Second chances, I think, are really important. Giving companies and people second chances. I hate using the words “cancel culture” because some people need to absolutely be canceled, but also we need to celebrate leaders, especially people in power, being able to say, “I did that wrong. I’m gonna do things differently now, and I’m gonna try and make amends.” And not saying, “Nope, too bad it’s too late,” because if they don’t see a pathway for them to be able to rewrite the narrative of their life, why would they even try? So I think giving companies space, not holding them always to be the bad guy, but saying we’re willing to give you a second chance to do things right, is going to be very important in pushing forward.
