Larissa Golloub had just onboarded a new patient to her therapy practice when she had the sense that something wasn’t right. Her client had videoed in from a location with a lot of trees. “I said, ‘Where are you?’ And she says, ‘I’m in Connecticut,’ and my heart sank,” Golloub says. The problem? Golloub isn’t licensed in Connecticut and she can be disbarred for practicing without authorization.
The COVD-19 pandemic has caused everyone’s plans to change—including therapists, who’ve been forced to take their practices online. Alma, a therapy community and platform that used to offer shared offices for individual clinicians, pivoted entirely online. Meanwhile, therapists have been reeling from the changes Americans are making to their living situations. A fifth of Americans either moved or know someone who moved because of the virus, according to a Pew Research survey. That has thrown therapy practices into chaos as they try to keep track of where their clients are living and whether they can legally counsel them. In some cases, therapists, afraid of breaking the law, have stopped seeing some of their patients.
Different states have different laws, but typically therapists must practice and see clients in the state where they are licensed. Under COVID-19, some states have loosened restrictions on practicing across state lines; others have created expedited licensing processes to help therapists come under compliance. But what was meant to make getting care easier during a complicated pandemic has actually made the landscape more confusing. Therapists have been forced to keep up with local ordinances or stop seeing their patients.
In Connecticut, where Golloub’s patient was staying, licensure requirements have been suspended until January 2021. Even still, Golloub says she isn’t comfortable seeing her client across state lines. “Things can change suddenly,” she says. “Then where are we?”
The push for a national license
The change in telehealth regulations during the pandemic has revived a conversation about national licensing for therapists and doctors at large. “Mental health needs are going to skyrocket in the aftermath of the pandemic. Creating an agile, responsive, national force of mental health workers that can respond to mental health crisis ‘hot spots’ will be important,” wrote therapist Elizabeth Brokamp in a MoveOn.org petition that has garnered 37,000 signatures. Not only would a national license allow for health professionals to see their patients across states, it would also open up more mental healthcare options for people who live in remote areas or states with low numbers of therapists.
The biggest barrier to a national license is that there’s no existing body at the federal level to oversee the process. Licensing is typically handled at the state level. Some states offer an expedited licensing process for social workers and psychologists who have already been licensed in another state. But the process is still cumbersome and expensive.
Even larger players in the teletherapy space are feeling the pressure to practice across state lines despite the unsteady regulations. An internal memo from text-based therapy company Talkspace highlights the challenges that even national companies face as people have moved around and increasingly sought out services. In May, the company started asking its therapists if they would be willing to work in states according to client demand regardless of whether rules around licensure remain relaxed, according to CNBC. The company offered to help therapists with any related legal costs they might incur from seeing clients in a state where they are not licensed. However, the costs are more than financial. Such infractions could become a stain on a therapist’s record, or worse, forfeit their ability to get licensed in the future.
Some therapists are considering getting licensed in multiple states in order to continue caring for their roving patients. Andrew Schwehm, a therapist who is part of Alma’s therapy community, has tried to accommodate his patients as they’ve had to shift where they live. He practices in New York City, though many of his patients grew up in Connecticut, Washington, D.C., and New Jersey and have moved home during the pandemic to be with family.
“With most of my clients it’s just going to be virtual indefinitely,” he says. “I don’t even have an office right now.” His plan is to work within the pandemic guidelines, and when they end get licensed in all the states his patients have moved to. “To transfer care in the middle of a pandemic—it wouldn’t be professional or ethical. I have to look out for the patients’ best interest,” he says.
The insurance problem
Schwehm has seen the petition advocating for a national standard in licensing for mental health professionals, the vast majority of whom are social workers. Certainly, he thinks it would make treating patients easier and more continuous, especially for patients who either have to travel frequently or can’t get away from the house. However, he’s nervous about the implications of national licensing.
A national license may allow insurance companies to lower the rates they pay therapists. Instead of basing their reimbursement rates around local price averages for sessions, they could use a national average, which is likely to be lower, to determine how much they will pay therapists. Another problem he foresees is if care can be delivered from anywhere, then it’s possible insurance providers might put pressure on members to get their care from a cheaper source. Mental healthcare is expensive and insurance companies often refuse to pay providers their actual rates.
Insurers are also looking for ways to make mental healthcare even more affordable. Earlier this year, UnitedHealth Group’s venture arm made a “significant investment” in online therapy startup AbleTo. In April, CNBC reported that United Health may be in the process of purchasing AbleTo for $470 million. UnitedHealth has previously gotten in trouble for restricting access to mental health services and addiction care because of financial incentives. The company now must reprocess some tens of thousands of claims that it failed to reimburse appropriately.
In addition, there is a concern that a national license would make it easier for insurance companies to work only with providers in areas where there’s a lower cost of living and where they could ostensibly pay a lower price for mental healthcare. Schwehm says he’s worried that a bigger company, like UnitedHealth, might use a national license to create a service with only cheap and poorly trained practitioners in a more cost-effective part of the country and restrict mental health benefits to that single telehealth service, therefore reducing patients’ access to quality care.
For now, a national license seems like a far-off possibility. Some states have already extended the original end date for their rolled-back licensing rules. Vermont will keep its relaxed licensing rules for telehealth in place until March 2021, while Delaware has pushed its back until July 2021. Though the federal government has embraced the rise of online healthcare, these softened licensing requirements are not likely to last. For patients on the move, you may find your therapist has to break up with you.
Correction: The article has been updated to accurately reflect the relationship between AbleTo and United Healthcare Group.