Aetna recently cut its pay rates for therapists and psychiatrists using the Alma practice management service, and said it would launch a service for insured people to get “Mental Health On Demand” in a single-session model, setting off an uproar among therapists and psychiatrists.
Aetna’s decision to cut pay rates to therapists and psychiatrists practicing through Alma, a membership-based billing platform with more than 24,000 licensed mental health clinicians, came in late May, and was followed almost immediately by Aetna’s announcement that it would provide “mental health on demand” and that its therapists are trained in a “single session intervention model.”
Therapists responded with anger. First, those who practice via the Alma management platform got notice of a sudden pay cut on May 20 — and Alma said it objected to the move, and was helping to facilitate a petition objecting to the rate cut. Second, the announcement by Aetna on May 28 that it would launch its own service caused outrage among therapists, as it said “Aetna clinicians are trained on a clinically-proven single session intervention model, which is designed to provide members with both immediate impact – including crisis management – and a personalized plan.” Further complicating the picture is the Aetna statement that the contact would be through chat, phone or video, then adding “AI-powered tools embedded within this dynamic platform streamline note-taking and administrative tasks, allowing clinicians to remain fully focused on each member and their immediate needs.”
The pay changes were to have taken place July 15. But on July 8, Alma sent an email announcing that Aetna had rolled back some of the planned cuts, and also said it would push back implementation of the remaining rate cuts to Aug. 15, from the original July 15. Little explanation was given, and specifics were murky. The Alma July 8 email is detailed in this Reddit post.
Rate cuts
After the first announcement, strong objections were raised. On June 8, the American Psychiatric Association and its APA Services professional organization sent a letter to Aetna objecting to the cuts. Those cuts, according to the letter, included:
- “Reimbursing CPT code 90837 (psychotherapy, 53+ minutes) at the same rate as CPT code 90834 (psychotherapy, 37–52 minutes); [these are standard therapy codes; the difference is the length of the session]
- “Eliminating reimbursement differentials between master’s level providers and psychologists for these services; [this means that the pay differences for higher credentials would be erased]
- “Reimbursing CPT code 99215 at the same rate as CPT code 99214; [these are medical visits, with the lower number being paid less, for presumably less severity] and
- “Eliminating reimbursement differentials between nurse practitioners and physicians/psychiatrists for these services [again eliminating pay differences for higher credentials].”
The letter pointed to potential harm to patients, noting that length of sessions and distinctions between emergency codes like 99215 and 99214 reflect meaningful decisions and distinctions.
“Flattening reimbursement across these codes effectively devalues higher-acuity and longer-duration services that are often medically necessary for patients with serious mental illness, trauma-related disorders, substance use disorders, suicidality, and other
complex psychiatric conditions,” the letter said, adding that erasing distinctions between physician-level training and lower-level training might well harm the sustainability of the workforce “and the ability of patients to access medically necessary specialty care.”
“We are particularly concerned that reimbursement policies of this kind may create incentives inconsistent with clinically appropriate care, including pressure to shorten visits or reduce availability of in-network behavioral health services,” the letter said. “Over time, these effects could worsen existing access barriers for patients seeking behavioral health treatment.”
It also said if Aetna applied these cuts only to mental health treatment and not to medical-surgical treatment, the move is potentially a violation of the Mental Health Parity and Addiction Equity Act.
Alma also wrote to its therapists that it did not agree with the cuts, and it posted a link to an anonymous survey for its clinicians to document their objections. The Alma CEO, Harry Ritter, posted online that there had been thousands of responses that he planned to use to file an objection to Aetna.
Rollback of changes
Alma said in its July 8 post about Aetna’s rollback of the rate cuts that it had made some gains. (I did not get Alma’s email, so am quoting from this Reddit post replaying the email.)
“Our negotiations with Aetna have concluded. While we were able to partially reverse the proposed changes, we did not achieve a full reversal to the current rates.
“Here’s what we successfully changed from Aetna’s original proposal:
“CPT codes 90837 and 90834 reimbursement rates will not be consolidated into a single rate
“E&M codes 99214 and 99215 reimbursement rates will not be consolidated into a single rate
“Reimbursement will continue to reflect degree type and training, rather than being paid at one flat rate
“However, Aetna’s final rates still reduce overall reimbursement for mental health services through Alma. We know that is disappointing and that these changes affect your practice.” There was no detail about this last point.
We asked Alma for specifics, because there was a lot unsaid in this note, but they did not respond by deadline; if they do respond, we will update.
On Reddit, one therapist said their rates were being cut by 30 percent. Another wrote “So it’s gone from massively cutting 60 minute sessions, but cutting nothing else, to cutting all sessions some.”
Online objections
Reddit message boards erupted in flames over the announcements. Among the common responses were clinicians bemoaning the hit to their bottom lines, and re-stating that the practice management companies like Alma, along with Grow, Rula, Octave and others that are funded by venture capital, private equity and often insurance companies’ venture funds, are serving to dismantle the mental healthcare system and harm therapists and their clients.
Clinicians pay these companies — either in upfront fees or a percentage of their paycheck or both — to supply services like quick credentialing with insurance companies (a process that can take months for an individual), negotiating insurance rates that the companies commonly describe as higher than what individuals can get, scheduling, billing, rapid payouts for sessions, and an array of other services.
The companies all have slight variations on the theme, but most of them consider the therapists on their administrative rolls as 1099 employees, who work for a rate that the company has negotiated with insurers. The mental health field has seen a lot of controversy over them, and over the topic of how much control over a practice a therapist cedes to the company.
To be sure, these companies — and other online services like Betterhelp and Talkspace — have served to make therapy available easily. The Zoomification of therapy at the onset of the pandemic lockdown fueled these companies’ growth.
The rate cut is not the first imposed by an insurance company on a practice management company. In 2024, the UnitedHealthcare wing Optum Health imposed a rate cut on clinicians across a number of states practicing with Alma and Headway. The cuts, announced in late October, ranged in size from a few dollars, to $7 a visit, to $43 a visit, or a cut of 30 percent, therapists said.
As we were writing about those rate cuts, and about the UnitedHealth-Optum policy of requiring a pre-payment review for a number of sessions, we heard a lot from clinicians who were questioning the value of the practice management companies.
Effects of cuts
Barbara Griswold, author of the blog “Navigating the Insurance Maze,” and the book of the same name, is a therapist who helps other therapists with various aspects of the business of a practice, especially insurance. She posted about the Aetna cuts: “The sadder reality may be that when an insurance plan throws its clinicians under the bus like this, it pushes more therapists to leave insurance networks. And because Aetna is one of the largest health plans in the country, that means therapy becomes even less accessible to the public. Or if therapists switch from 60-minute to 45-minute sessions, many clients will not get the level of treatment that may be clinically necessary, driving up symptoms to a higher level of overall severity.”
She also posted a chart showing the effects on a therapist’s bottom line of the initially announced cuts (see at right).
Alma was recently sold to Spring Health, an employee assistance program company. This is the earliest big exit of one of the practice management companies, from independent to acquisition.
Susan Frager at Psychbillingcoach mentioned that when she wrote about the Aetna-Alma announcements.
She referred to “a so-called ‘therapist shortage’ combined with a wildly inflationary economy,” adding that Spring could be thinking of future contract negotiations. She added: “It’s been well-documented that there IS a therapist shortage on most insurance panels, despite the increasing prevalence of the platforms. It isn’t just a therapist shortage, though. Medical professionals of all disciplines — not just in behavioral health — are leaving for cash-based practices, for the same reasons mental health clinicians do.
“IF the upcoming midterm elections result in a progressive majority, and result in meaningful healthcare reform in 2027 and beyond, then who knows?
“As long as I’m fantasizing, I’ll mention that the abuses of payers and venture-capital entities largely persist because of a dangerously unequal balance of power, which has contributed over time to create the current ‘therapist shortage.’ Collective bargaining, which could restore some balance, is an illegal act for most self-employed healthcare professionals. However, Texas has a modified legal form of collective bargaining with insurance companies, which occurs under the supervision of the Texas state Department of Insurance. This is a model I’d love to see adopted nationwide.”
On demand: A 13-second response
Aetna, a CVS Health business, said the new “on-demand” service would be available to Aetna members 13 and older as of Jan. 1, 2027. Aetna added: “During the initial launch, Aetna clinicians engaged in hundreds of chats and demonstrated the immediate impact of Aetna Mental Health On Demand by answering members in just 13 seconds.
“Aetna has also enhanced its clinician-led care management program with advanced predictive tools that identify members at risk of future inpatient admissions, as well as those with immediate, acute needs, in near real time. Through proactive outreach, care managers connect members to individualized resources and provide ongoing support throughout their treatment – helping to improve outcomes and reduce avoidable hospitalizations.”
The development caused one therapy practice advisor to refer to a mid-1990’s cartoon of a therapist slapping a client, shouting “Get Over It!” with a caption reading: SINGLE-SESSION THERAPY IN THE AGE OF MANAGED CARE.” The Reddit forums were in flames over this topic. One Redditor referred to a skit by the comedian Bob Newhart titled “Stop It.”
Zynnyme, a practice management advisory group, wrote in a newsletter about the developments:
“Imagine your entire job is responding inside a thirteen-second window. One session per person with AI drafting your notes while you go. That is not a therapy practice, that is a queue, or an assembly line.
“Now look at those two events in order. If you wanted to make experienced, relationship-based therapy too expensive to deliver, and then offer a faster, cheaper, AI-supported substitute, this is exactly the order you’d do it in. Cut what you pay the experienced therapists and then announce the replacement.
“We’re not claiming they sat in a room and drew this on a whiteboard. We’re saying think about every roll out in terms of increase profits for shareholders and everything starts to click.”
