By late summer of 2024 I couldn’t ignore that something was wrong. More than a “summer slump” or a particularly busy vacation season, it was clear that my practice had changed while I wasn’t looking. The ground had shifted beneath my feet. Or beneath my couch (obligatory therapist joke).

It had been changing for at least a year at that point but I told myself things would pick up. They always did. This time I had to admit I wasn’t getting the steady flow of referrals I had taken for granted for years, and my practice was shrinking for the first time in over a decade as a solo therapist in private practice. Reaching out to other clinicians in my network, I heard the same concern: there are no referrals. Therapists are a steady, resilient sort, however, so we banded together to form groups, trade ideas about marketing and diversification, and share alternative referral sources. One of those ideas was joining a telehealth platform that promised to do all of the heavy lifting needed to manage a successful practice. 

An incredible pitch: I could take insurance without any of the headache of clawbacks or credentialing; they’d manage billing, flood my inbox with referrals, and pay me more than I could get if I joined an insurance panel myself. So I dipped my toe into the world of tech start-up style telehealth and practice management platforms. Over a year later I’m trying to get out.

At first, I was more permissive about the information they wanted in order to use the platform: sharing access to my account on CAQH (now freshly for-profit acquired DataSpring), using their EHR and templates to “guarantee” clawback protection, and providing my schedule and availability to increase my chances of referrals. The referrals never really came, in fact, I actually brought clients onto the platform. The platform started to encroach more and more on my practice and client privacy. AI tools were integrated throughout the platform, at first requiring therapists to opt in, and later implemented without requiring therapist or client consent. Human support disappeared as AI bots and widgets took over to perpetually misunderstand and misdirect pleas for help in conducting accurate insurance verifications. More and more dings and push notifications and reminders erupted, halting how I document, code, and bill to accommodate the platform’s demands for conducting my practice in the way they saw fit. Then reimbursement rates started to drop, while audits and clawbacks increased. It became clear the platform was optimizing for insurance companies, and not for therapists or clients. We are a product to be mined for data and time.

In the course of learning about what I had joined, I found that in the rise of telemedicine, middlemen have descended on our field to extract as much wealth as possible. Insurance companies invested in these platforms, with each insurer picking a platform they can funnel therapists into to boost stock prices and reduce reimbursement rates. Companies began to materialize that provide preferred therapist lists for insurers, ranking therapists on how much money they save insurance companies based on claims data. Third-party start-ups offered AI services to listen in to therapy sessions and audit medical records, with vague promises about confidentiality while we’ve seen data breaches and the erosion of trust and professionalism in our field. And just like Lyft and Uber before us, once a critical mass of therapists have converted to hitching their practice to the platforms, those once high reimbursement rates drop without any negotiation or engagement with the providers. Count me out.

I’m transitioning out of the platform. Between opening myself up to breaches of confidentiality and the loss of clinical autonomy, I can’t justify letting this middleman into the therapeutic relationship. It’s a little tricky to get out. I’m having to weigh seeing clients pro bono or at reduced rates if we want to continue, which is important to me to uphold our profession’s ethical standard of continuity of care and prioritizing patient well-being over profit.

Things have picked up. I learned to move with these shifts in our industry and seemingly insurmountable market forces by leaning more into relationships. I’ve found steadier ground to plant my feet: real relationships. I’ve focused on building more connections with other therapists and community partners, and to just do good work. As independent providers, we can’t compete with the resources that venture capital and private equity can throw at SEO optimization and preferential insurance referral lists. Just do good work and connect to other therapists. Be generous with referrals, and be a source of support for others. We can lift each other up as therapists, and more importantly, as human beings experiencing seismic changes to our field and livelihoods.

As Fred Rogers said, “look for the helpers” in times of crisis. So look for the helpers, and maybe be one of the helpers for someone else.

Jamie Carruth, LMFT, serves as a Steering Committee Leader for BHAM and as the California state lead and national coordinator for the Mental Health Insurance Reform Task Force. She is a psychotherapist and organizational assessment consultant in private practice in Los Angeles, focusing on the treatment of trauma and life transitions. Learn more or get in touch at jamiecarruth.com.