CVS HealthStarting in January 2021, CVS Health began offering retail therapy sessions online or in private consultation rooms in 17 of their Minute Clinic stores in 4 states: Florida, New Jersey, Texas, and Pennsylvania. They will be expanding into 34 additional locations in July. As a result, CVS brings a whole new meaning to the phrase “retail therapy,” sometimes jokingly used by clients to describe a type of coping strategy.

Pandemic Drives a Shortage of Therapists

Historically, pre-pandemic, the majority of telehealth use was for mental health issues. See TBHI’s CMS Congressional Report: 85.4% of all Telehealth Providers Used Mental Health CPT Codes. However, since the onset of the pandemic, therapists have been in even higher demand both in-person and via telehealth. A shortage of providers exists and is likely to continue. A survey completed by Aetna, the Aetna Mental Health Pulse Survey Results 2021, showed that 65% of Americans are concerned about their own mental health or someone else’s that they know.

Walk-in Counseling or Telehealth?

CVS Health’s stated goal is to deliver improved overall health and well-being. Therefore, CVS health plans to have licensed social workers and therapists do on-the-spot retail counseling, assessments, as well as ongoing therapy sessions if a client desires to do so. Telehealth, as well as referral services, are also available if more specialized care is needed. Clients must have Webex software on their computer or the Webex meetings app on other devices they choose to use for their sessions to access telehealth.

One-Stop Total Care

CVS sees the process as a way to integrate care. For example, if the client needs medication, they can be referred to an in-store practitioner. Then they can get their prescription filled at the pharmacy, resulting in one-stop shopping.  CVS isn’t the only retail company offering therapy services. Since September 2019, Walmart opened Walmart Health. Walmart health clinics in Georgia have been offering 60-minute therapy sessions for $60. Insurance is also accepted.  Potential clients can sign up for an in-person or virtual appointment for individual, couples, or family counseling on Walmarthealth.com. These clinics also offer multiple other services such as immunizations, dental, optometry, hearing, and other medical services.

And CVS isn’t the only retailer entering the behavioral health space. The Amazon behemoth is not to be neglected. As reported by TBHI in March 2021, Amazon Health is expanding nationwide after rolling out telehealth services to employees in January 2021. Retail giant Kroger Co., one of America’s leading retail healthcare organizations, with over 2,300 pharmacies, 11 specialty pharmacies, and 200 clinics nationwide, also has been growing its own empire through Kroger Health, its healthcare arm.

Making Mental Health Care Affordable?

The rate for a CVS Heath session is $59, well below the national average, which is between $100 to $200 in the United States. CVS plans to make the sessions coverable by insurance and EAP plans, or clients can choose to pay cash or pay by credit card.

It may also be of note that Aetna, which CVS Health purchased in 2018, plans to cover the cost of these services for their insureds. By making care more affordable and accessible, CVS Health hopes that treating people suffering from depression, anxiety and stress will help prevent other serious health conditions.

TBHI’s Perspective

That’s the CVS Health news, but the much larger issue regarding the viability of ethical, evidence-based behavioral health remains unanswered. As we watch multiple retailers enter offer large-scale employment to our behavioral colleagues, what are the ramifications for our practices and incomes? Most of us had to bite the financial bullet when managed care waged war on clinician paychecks in the ’80s. Practitioner reimbursement rates were drastically reduced, and obtaining approval for needed coverage was made unconscionably difficult. Some of that is still felt by clinicians; today, who still are routinely required to request authorizations for needed services.

Who’s Protecting Clinicians and Consumers from Telehealth Fraud?

Without ethical oversight into dealing with retail giants venturing into behavioral healthcare, most clinicians are unaware of the dangers they face. As we’ve seen with some of the larger behavioral health employers online, following the evidence-based can easily be sacrificed to the profit motive. The standard of care is eroding. Practitioner and consumer deception by online employers is the norm, much like other Internet giants. False claims by online employers are rampant. See the Clinical Social Work Association’s LCSWs and the Use of Texting in Mental Health Treatment for commentary on some text-messaging companies.

What’s the Problem?

The heart of the problem is that regulatory boards and professional associations are powerless to protect clinicians from online employers whose mission differs from the legal and ethical mandates for clinical care. The situation is perfect for the telehealth employer, who absolves itself from liability by hiring licensed professionals. More specifically, most online behavioral health employers require that clinicians sign documentation that asks if they are licensed. What most eager clinicians don’t know is that if they indicate that they are licensed, their signatures place all clinical care responsibility squarely on the shoulder of the licensed clinician. By signing these documents, unwitting clinicians accept all legal and ethical liability for understanding the nuances and repercussions of telehealth practice – and the company happily washes their hands of it (see references below).

Meanwhile, the clinician is given digital tools and in-house training that normalize practicing differently than what they were taught in their prior professional training. Without realizing it, most providers working for these companies have accepted all ensuing responsibility for competence without obtaining the needed competencies for digital care.

The problem is even more complex. With their limited budgets, the behavioral regulatory boards are also powerless to disseminate proper information to the public beyond posting a few vague notices on their websites, such as those published by the California Board of Behavioral Science. (See accordion file in the middle of the page, labeled “Telehealth.”) Most state licensing boards don’t have anything posted, and if they do, it also is buried in the state licensing board’s website. While this information may seem helpful initially, a distraught consumer seeking professional care is likely to miss it when searching for an online therapist.

Follow the Money?

Consumers then are left to the influences of advertising budgets, which will soon stem from the large retailers… The operating budgets for many retail giants are far more than that of our regulatory boards and professional associations combined. Most of our regulatory boards operate on very thin budgets, and it is no secret that our regulatory system is in serious disarray. Boards often cannot agree on fundamental issues across professions within our states, and much less across states, for the same profession. This issue is the very one that has prevented licensure portability for decades, even though geographic boundaries to healthcare practice have been rendered obsolete by the Internet for decades.

In telehealth alone, despite the availability of training such as How to Practice Over State Lines Legally, most clinicians are simply overwhelmed with trying to get the information they need to manage inter-state service delivery. The most frequent problem is that they don’t know where or how to go to get clear, actionable, and reasonable solutions from the regulatory boards. Many are afraid to make their issues known to the boards and rather prefer to stay off their board’s “radar.” The strained relations between some regulatory boards and their licensees have only complicated matters. One simply has to read comments made by many clinicians who have written to the TBHI blog in response to previous posts to see that rather than being considered a resource, they often are experienced by licensees to be irrational and punitive. Behind the scenes, many professionals have sent TBHI private messages thanking us for our information and clearly stating that approaching their boards for clarification is the last thing they care to do.

Where Is This Going?

Who will rule our field in the years to come? If you are a Netflix subscriber, you may want to watch the recently released documentary entitled, The Social Dilemma, which features guests such as Tristan Harris, founder of Center for Humane Technology. This remarkable view of what’s happening at the highest levels of technology development clearly shows how behavioral populations are at serious risk from big Internet tech giants. In the words of the Center’s website, As long as social media companies profit from addiction, depression, and division, our society will continue to be at risk.

The problem, of course, is that there is no end in sight. Brought down to the individual practitioner level, how will each of us, our employers, boards, and professional associations deal with what is already happening all around us, and which very few of us take the time to see or address? Unfortunately, these issues don’t seem to be discussed at many national associations or private training facilities. Here at TBHI, on the other hand, we have made it our business to inform our colleagues, their employers, and the national and state associations of both the pros and cons of using technology for behavioral care. Those who don’t know our focus is legal and ethical compliance, clinical competencies, and social awareness.

What Can You Do?

We urge you to speak to your colleagues, obtain the needed training to be more aware of the technological forces such as the retail movement into our community, and consider its impact in 20, 50, and 100 years. Simply returning to in-person care is not the answer. What will happen to our paychecks in the long run? How will our national associations prepare us? Who is protecting us, our clients and patients, and consumers at large? While professional associations have traditionally been practitioners and client/patient advocates, many clinicians today don’t bother joining their state or national associations. Even if clinicians did join associations, are the association talking about these issues? More importantly, what are they doing to prepare us for the inevitable? (For decades, we at TBHI have been alerting them to these issues, but very little progress has been made. Meanwhile, the march of technology waits for no one.)

Through our training and newsletters, we at TBHI are trying to keep you informed so that you can see what’s happening under our very noses. While we are not saying that any specific retailer or online behavioral health company is at fault, we are asking you to consider our concern — and please, comment below.

References

  1. Maheu, M. M., Drude, K. P., Hertlein, K. M., & Hilty, D. M. (2018). A Framework of Interprofessional Telebehavioral Health Competencies: Implementation and Challenges Moving Forward. Academic Psychiatry42(6), 825–833. https://doi.org/10.1007/s40596-018-0988-1
  2. Callan, J. E., Maheu, M. M., & Bucky, S. F. (2017). Crisis in the behavioral health classroom: enhancing knowledge, skills, and attitudes in telehealth training. In Career paths in telemental health (pp. 63-80). Springer. https://doi.org/10.1007/978-3-319-23736-7_5
  3. Glueckauf, R. L., Maheu, M. M., Drude, K. P., Wells, B. A., Wang, Y., Gustafson, D. J., & Nelson, E.-L. (2018). Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, 49(3), 205–219. https://doi.org/10.1037/pro0000188
  4. Luxton, D. D., Nelson, E.-L., & Maheu, M. M. (2016). A practitioner’s guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. American Psychological Association.

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