The behavioral health industry is constantly seeking to bolster its clinician supply to meet raging levels of unmet mental health needs.
Access to care could improve significantly if more providers offered group therapy.
Group therapy is a rare behavioral health modality that promises benefits under both value-based care and fee-for-service reimbursement models, largely due to its efficient client-to-provider ratio.
“If you can get into these reimbursement models where you’re in some way incentivizing value, I think groups really shine, just because you’re able to deliver services so efficiently,” Ben Robbins, general partner at GV (Google Ventures), told BHB. “Groups is probably, if not the main tool, one of the key tools into unlocking value in behavioral health without getting into reimbursement models that may be very complicated.”
GV has investments in several group therapy providers, including Guidelight Health, which leverages community health workers, Firsthand, which utilizes peer support specialists, and Diverge Health which provides care through community health workers.
Research demonstrates that group therapy is effective, efficient and equivalent to individual therapy. Investors are already seizing the idea and pumping funding into organizations offering group therapy.
Industry insiders predict that group therapy will become increasingly utilized in the behavioral health industry. Still, several key issues, including lacking reimbursement rates, must be tamed before the modality can reach its full potential.
Why groups
People may have misconceptions about group therapy and believe groups are chaotic. Some are intimidated by the idea of sharing their stories with others.
In reality, group therapy can be validating for patients and allow group members to support each other and provide helpful suggestions for others with the same experience.
The social aspect of groups can also be beneficial, especially for young people.
“Kids and young adults, especially those in school, are around groups all day,” Dr. Monika Roots, president and co-founder at Bend Health, told Behavioral Health Business. “Only having individual therapy to learn techniques to then apply for things like depression and anxiety, without that socialization group piece is less effective. So as we think about things like severe depression, where you really need to practice those coping skills to come out of it, having that group interaction is probably the best thing that you can do for this age group.”
Madison, Wisconsin-based Bend Health is a virtual behavioral health services specializing in young people up to age 25.
Meeting with peers who have similar lived experiences or have similar demographics or backgrounds can also make it easier for certain minority groups to share their experiences or feel understood. Groups are effective for diverse populations, including racial and ethnic groups and LGBTQIA+ people.
Group therapy can help with physical as well as behavioral health conditions. Pain management groups can be used to prevent opioid misuse and smoking cessation groups can help prevent later health issues, for example.
Crucially, group therapy can mitigate the extensive workforce shortage besieging the behavioral health industry.
A study published in American Psychologist found that increasing group therapy by 10% would allow over 3.5 million more people to access therapy. Increasing group therapy would also reduce the need for almost 35,000 new therapists and save over $5.6 billion.
“More groups would mean that therapists would have more space in their schedule to enable them to match clients to the service that they need,” Dr. Martyn Whittingham, the study’s lead author, told BHB. “In some cases, this would be group therapy, but in other cases, it could free up space for individual, couples or family therapy. In other words, it allows the greater efficiency that groups provide allows clinicians to give people the services that they need, whether that is a group or something else. It streamlines scheduling considerably.”
Improved access to therapy would be especially meaningful for marginalized populations.
People from underserved backgrounds would find it easier to obtain mental health services, whether individual or group therapy. Marginalized populations have higher rates of behavioral health concerns, and quick access to care can prevent mental health conditions from worsening.
Group sessions should be kept brief, the study’s authors recommended, to make the best use of clinicians’ time while maintaining effective care.
The study’s authors also suggested increasing group therapy in locations where it is not currently offered, or offered in limited capacity: in private practices, in primary care doctors’ offices and virtually.
Virtual groups have the added benefit of making therapy accessible for people with transportation issues or busy schedules.
While researchers recommend increases in group therapy utilization, Robbins told BHB he is already seeing measurable increases in group therapy as part of a trend toward leveraging people with similar experiences to patients to provide care.
Investors are increasingly interested in groups, Robbins said, and they can be cost-effective for providers.
“Groups are really attractive because you can start to have in the course of an hour, you can have one clinician eight or 12 patients, instead of … usually it’s two or one,” Robbins said. “It’s really attractive in this ability to build something where you can serve a large number of people with the same number of clinicians.”
Barriers to wider adoption
While group therapy sessions can improve access to mental health services and offer clinical benefits, reimbursement processes and clinical differences from individual therapy can prove challenging.
“The current reimbursement model is completely wrong,” Whittingham said. “It was formed many years ago with an incomplete understanding of the behind-the-scenes work needed to make groups run.”
Individual therapy sessions are billed based on the time a clinician spends with a patient, according to Dr. Susan Sprich, clinical director of psychology at Massachusetts General Hospital. Group therapy sessions, however, are billed based on the number of participants. Clinicians need to have approximately seven group members in a session in order to get the same credit as they would for two individual 45-minute therapy sessions.
“If group members drop out or don’t attend regularly, the group leaders end up taking a financial loss,” Sprich told BHB.
Additionally, insurance reimbursement does not adequately cover relative value units (RVUs) and work and practice expenses, according to Whittingham. Clinicians may also pay more to rent a space big enough to accommodate a larger number of patients.
Payers are often less interested in reimbursing certain group therapy modalities. The COVID-19 pandemic pushed all group therapy services online, but since in-person options have returned, both payers and clinicians now believe virtual groups may not be as effective as in-person, Robbins said.
Other problems may keep therapists from leading group sessions.
Group leaders must write chart notes for each patient and contact each patient regarding attendance or other questions. This burden means that clinicians often prefer individual therapy over groups, Sprich said.
Leading group therapy in general requires a different skill set than individual therapy, Robbins said.
Whittingham recommends that practitioners receive specific training in leading groups, though this can represent an additional expense. He recommends that group therapy certification and ongoing training should be a requirement for clinicians to ensure consistent service delivery.
Mental health providers would do well to adopt stronger group programs, according to Whittingham, and third-party payers should be open to incentivizing group therapy to increase mental health access and outcomes.
“It is very clear to me that as a country, we are disincentivizing group therapy by incorrectly calculating its value,” Whittingham said. “A radical rethink is required.”
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