Internal Talkspace memo illustrates challenge of delivering virtual mental health services in 50 states

Talkspace, an online therapy provider, is seeing unprecedented demand for its service as the coronavirus pandemic drags on, affecting the mental health of millions of Americans. But it faces a big challenge ahead: Hiring enough therapists licensed in all 50 states to treat growing pool of patients.

Its solution? To ask its providers to continue seeing patients out-of-state — even after emergency measures expire — and offer to pay certain legal fees if they get in trouble for doing so. But working across state lines without certification may put providers in a risky spot, legal experts say. 

Earlier this year, the government passed emergency waivers that lifted restrictions on mental health professionals, allowing them to to treat patients online and in states where they’re not licensed. These measures, however, are designed to expire at some unknown date — the precise expiration date will vary by location, based on when local officials believe the pandemic has receded enough.

To get around this uncertainty, Talkspace in May began sending a memo to therapists asking if they wanted to join a group willing to “work in many states, depending on only demand and need versus the mutable timing of the actual executive orders.”

The memo does not explicitly ask providers to work across state lines where they’re not licensed. But it does offer help for therapists who run afoul of insurance companies or state regulators.

“Please know that Talkspace will provide indemnification for any claim your insurance company denies due to state border issues or client state of origin,” it reads. “We will also fund any legal appearances before state regulatory boards.” 

By implication, Talkspace is also offering to help its providers get licensed in Florida. The letter refers specifically to the “Florida model,” a program that existed before the pandemic that offers a relatively quick and easy registration process for providers to deliver care in Florida without being licensed. But Talkspace does not say whether it will help providers get licensed in most other states, a process that could take months and cost thousands of dollars. 

“Talkspace will always follow federal, state and local regulations as required,” said CEO Oren Frank in a statement. Frank said the pandemic has driven demand higher while also making it harder to get in-person appointments.

“I feel strongly that CMS [Centers for Medicare & Medicaid Services] should reexamine limitations around tele-mental health that can prevent people from getting the help they want and need.”

Talkspace got its start in 2012 after Oren and his wife Roni had an experience with couples’ therapy that transformed their marriage, and they looked for a way to bring this kind of insight to a broader audience. The company has since received more than $100 million in venture funding from investors such as Norwest, Revolution and Spark Capital.

Talkspace users create an account and get matched with therapists, who work for the company as  contractors. For $260 a month, a user can send a therapist a message at any time, and full video sessions are also available.

The service has seen new demand during the pandemic, as millions of Americans struggle with extended lockdowns and other major life disruptions. A Kaiser Family Foundation poll found that over 30 percent of adults are now reporting symptoms consistent with an anxiety or depressive disorder, up from 11 percent in 2019. 

SensorTower, a company that tracks mobile app usage, says that Talkspace saw 38,000 installs in September from the U.S. versions of Apple’s App Store and Google Play. That’s an increase of 23% year-over-year and up 46% from February, the month before the pandemic started.

Many of these users are moving between states thanks to flexible work policies during the pandemic. Now, Talkspace is on the hook to figure out how to keep up with rising demand and this increasingly mobile userbase.

Nathaniel Lacktman, a partner at Foley & Lardner focused on health technology, warns that therapists who take up Talkspace’s offer could end up in trouble. “They could get something on their record that follows them across the various state medical boards, and worse, unlicensed practice is a crime in a number of states.”

“This is an enterprise-wide aggressive growth play in lieu of getting licensure.” He added, “When a company uses the waivers to blitzscale its patient base, it needs a plan for what to do when those waivers end.”

Making matters more difficult, there’s a widespread shortage of mental health professionals. The U.S. Department of Health and Human Services is estimating that mental health and substance use social workers will have shortages of more than 10,000 workers.

Other companies in the space, such as Ginger, which is backed with $120 million from investors, have approached the problem by bringing on whole teams solely dedicated to helping therapists and psychiatrists apply for and maintain licenses in other states. Russell Glass, the company’s CEO, described it as “a giant pain.”

Therapist Sara Feldman, who is based in California, says she uses use Talkspace because of the convenience, and the access to patients who might not otherwise seek care in person. Feldman was not one of the providers who received the memo, so did not comment on it. 

But Feldman notes that the licensing rules can make life particularly challenging during Covid-19. Some of her clients have gone on vacation or moved out of state, and it takes time and research to determine if she can still provide care. 

“There are so many therapists who are starting to embrace technology, but it’s a steep learning curve in understanding the rules and laws around it,” she said.