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Behavioral Health Tech Products Can Function Well Without Professional Controls
Many behavioral health tech products are effective without clinician oversight. Yet some argue for inserting professional controls, and consensus is lacking. An excellent place to begin this debate is with Pear Therapeutics. Their digital therapeutic tools were available by prescription only—a less consumer-friendly approach than open access based on eligibility—until they went bankrupt in 2023.
Pear’s business model presented prescriptive platforms as superior to “over-the-counter” ones. Its success could have threatened non-prescription products. The need for restricted models like Pear’s is dubious—several fine digital self-help products are available without a prescription, often as an employee health benefit disseminated by a vendor or health plan.
Pear relied on familiar ingredients. Along with other platforms, it used well-validated techniques derived from cognitive behavioral therapy (CBT) and other clinical models. Was this an effort to protect the public from poor quality or a medically based strategy to dominate the digital therapeutics market? Regardless of intent, its distribution method limited the availability of self-help tools that merit wide distribution.
Other companies have entered this prescription niche and met with similar failures. Akili, Inc. announced in September that it was transitioning from a prescription to a non-prescription business model. An upbeat forecast notes that their remaining digital services reduce “reliance on intermediaries.”
The “intermediaries” (i.e., professionals) are not deterred by these setbacks. On the contrary, their ranks have expanded to include non-prescribing clinicians seeking to manage consumer digital use. Their primary battle currently is compensation. Clinicians want Centers for Medicare & Medicaid Services (CMS) billing codes for 2 services: 1) guiding clients on use and 2) monitoring responses remotely. They want payment for their CBT expertise.
Clinicians want CMS billing codes for each step of the work— introducing a device or software application to the client, onboarding the client, and remotely monitoring client response. Some have argued that such monitoring is tantamount to measurement-based care (MBC). Given the growing demand for MBC, the implication is that we can advance MBC by paying for these processes.
This should inspire more worry than praise. Billing processes could complicate MBC’s clinical monitoring. MBC should be integrated into all outpatient care as a standard process. Billing incentivizes the growth of separate charges (e.g., data analysis, clinical feedback) that add complexity, and it promotes tying monitoring to specific therapies (e.g., CBT). If MBC is to become the norm, it needs simplification.
Viewing Tech Products Through an Executive Lens
It might be argued that professional control improves tech products, but the evidence is weak. We know consumers can use digital therapeutic tools safely and effectively with little oversight. MBC has been delayed for decades due to clinician resistance, and clinician compensation for MBC presents another hurdle. We will need to rely on executives to lead the integration of MBC into outpatient care.
While executives share the clinician’s focus on client-level outcomes, they embrace a systems perspective clinicians often lack. Executives want nothing to stand in the way of consumer products being easily accessible and routinely used, and they want outcomes aggregated at the level of clinical programs and populations to assess performance.
Executives understand that tech products often need a “human touch” to guide and support people. A bit of personal encouragement goes a long way, and research suggests this support can take many forms other than professional input.
Executives want efficient systems. While clinicians may share that desire, they also want to maximize billing opportunities—this priority will soon be a relic of fee-for-service (FFS) healthcare. Value-based care (VBC) arrangements are slowly replacing traditional billing, and this model thrives on efficiencies while improving outcomes. The FFS mindset will disappear over time.
Executives will guide us along a twisting path to VBC and help us abandon FFS’s volume-driven focus. Many clinicians will cling to the vestiges of FFS until the bitter end. This is understandable since they must earn a living as these funding structures change. However, it is critical that new digital tools not become stuck in billing minutiae nor that MBC systems get separated into piecemeal solutions.
This may be an uphill battle. Tradition and entrenched interests will push for moving digital therapeutics and MBC into the procedural grind of FFS care. It will be argued that new CMS billing codes simply ensure clinicians get reimbursed for their services. However, FFS care has a long history of complicating innovation, and in this case, it could interfere with 2 advances:
- Digital tools can supplement traditional services to address countless unmet behavioral needs.
- MBC reverses our history of ignoring results by embedding clinical outcomes into everyday care.
While new revenue for clinicians is not a trivial matter, the amounts here are not substantial. The real question is priorities. A marginal revenue increase pales next to solutions advancing our field’s essential goals. Behavioral health tech products can play mission-critical roles alongside therapeutic services that professionals alone can provide.
Many clinically based tech products warrant our trust. They should be allowed to function efficiently and effectively without onerous professional controls.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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