Ginger, Real, and mental health in a post-COVID world
What does the future of in-person therapy look like?
I got the vaccine yesterday, which is why this is coming out a day late. I spent the 15 minute waiting period reading about nanolipids. Science! 💉
Prompted by Chrissy Farr’s excellent newsletter last week, I’ve been thinking a lot about how and if telehealth-first companies will transition to physical space post-pandemic. While Farr was talking about virtual and in-person obstetrics appointments, I started to think about mental health. It seems to me that there is no area of medicine better suited to staying largely remote.
Patients may feel less stigmatized video-conferencing in, and our limited pool of mental health professionals can more easily reach patients if they don’t have to meet in-person. Further, while it seems that therapists might gain some additional clinical information by meeting patients in-person, mental health care (in my decidedly non-clinically-trained opinion) is the specialty that least requires that additional information. A gastroenterology appointment may end with the doctor palpating the patient’s abdomen, but there’s no equivalent exam in mental health.
Below, I talk about how mental health in general has received an infusion of funding over the last year, and then I talk about two types of telehealth-first mental health companies and how I expect them to adapt to a post-COVID world.
2020 has seen a boom in health tech funding across all categories, and mental health is no exception.
This post from Rock Health has some detailed, interesting information, and I’m reposting one of their visuals below.
Which companies are garnering the most excitement? Sebastian Caliri, an investor at 8VC, is quoted by Rock Health as saying (emphasis mine):
“We are going to start seeing more and more funding going toward specialized providers. In 2020 we saw the emergence of companies that pull out a discrete service line and become best in class in a specific indication or population, like Eleanor Health and Ophelia Health in SUD, and Brightline, Little Otter, and Sprout Therapy in pediatrics. I am excited about investing in companies that can pick a specific indication or patient demographic and deliver better health outcomes and reduce spend in their focus areas.”
Conversely, the companies that seem like they’ll fall by the wayside* are those that provide a straightforward telehealth platform on which providers can practice.
*By wayside, of course, I mean they’ll likely be bought up by large insurers and will become integrated into the fabric of how most people seek care. So not a bad outcome for the companies, just not a particularly innovative one.
Within telehealth-forward mental health companies, there seem to be two main categories: one-on-one visits via telehealth and group therapy.** I talk about how each may adapt to a post-COVID world below.
**There are obviously other ways to segment mental health companies. Some, as mentioned above, focus on specific conditions. The payment models also differ—some, like Lyra, prioritize selling to employers for inclusion in employee benefit packages, while others, like Real, are more direct-to-consumer with a subscription model. Sarah Du did amazing work segmenting 70+ mental health startups here.
Ginger is a full-stack model for most mental health conditions. They offer chats with licensed therapists, video telehealth calls with therapists and psychiatrists, and skill-building exercises. They also have a prescription partnership with Capsule, allowing direct delivery of mental health medications. All of Ginger’s services are online and are likely to remain online.
It’s interesting to watch Ginger move into prescriptions and skill-building exercises, because the full-stack, meet-with-a-therapist model may have a growth ceiling.
In a Business Casual podcast episode from November, Real founder Ariela Safira (more on her company below) noted that traditional, one-on-one therapy can only scale so much. For one, there’s a dearth of licensed providers. But two, the model can only be so cheap. In the end, each patient is receiving services from a highly trained, expensive professional—there’s only so many ways to cap or otherwise distribute that cost.
In a post-COVID world, Ginger likely remains as it is. Its users can access therapy for cheaper than traditional therapy, and with greater geographic freedom. Ginger may build out physical spaces to provide its users with somewhere to congregate and seek care in person, but it will likely ramp up its sales to employers instead.
Given the constraints on mental health businesses, Safira has spoken publicly about her goal for Real to be a more scalable, accessible therapy model. Rather than meeting one-on-one with therapists, patients using Real access different courses on common life challenges (think: relationships, career, anxiety) that each patient can work through at their own pace. There are also roundtables that meld panels with group therapy.
Real is constrained by one obvious limitation: the company doesn’t do one-on-one therapy. For those who are wrestling with a topic not covered by a Real pathway, or who want/need deeper personal engagement, Real is not the right service.
Part of the reason I want to highlight this company, though, is that Safira has been very open about her plans to open physical locations. Originally, she told the Business Casual podcast, Real was going to be primarily in-person. When the pandemic began, the company instead doubled-down on telehealth provision. It remains to be seen if Real will open physical spaces as life slowly returns to normal, and it’s unclear what these spaces would look like, but I suspect they will be popular as people make up for lost social time, and as people seek to process what the last year or more meant to them and their peers.
Traditional therapy, performed in-person, will certainly come back—but I think it will segment into being primarily for (1) those with severe mental illness and (2) those with money.
Severe mental illness will probably always be best served with in-person treatment. It’s hard to imagine long-term psychiatric medication and condition management being best-delivered through telehealth—although I’m very willing to be wrong on this.
But for those without severe mental illness, in-person therapy might become a luxury good. As middle-income people seek therapy through apps like Ginger and Real, in-person therapy might become a wellness activity similar to regular facials. Therapists could build out the comfort of their offices and charge more to provide a relaxing and tranquil space for others to unburden themselves away from the possibility of their family overhearing them, or the frustrations of a spotty wifi connection.
Mental health care is one of the most obvious potential spaces for telehealth to continue to grow post-pandemic. The entrenched model, with its reliance on in-person visits, its general lack of insurance coverage, and its dearth of providers, is no longer working for most people.
As Ginger, Real, and other similar startups continue to grow and take on patients, the transition back to an in-person world will be an interesting one. I expect therapy models like those of Real and traditional therapy to benefit from physical spaces, while Ginger likely doubles down on employer sales. Regardless—and I don’t mean this flippantly—they’ll likely have many, many customers as we process this traumatic year.
Agree these are growing in volume as demand and acceptance increases... what will be important is for them to show efficacy for either automated or tele-care - there is not a lot of great evidence on that yet. It might just be for the milder cases, but that is still great as it will open up more access in the offices for more complex cases. Will be interesting if successful for adjuvant for complex cases too!
I run a large group mental health practice in NYC specializing in moderate to severe mental illness -- we have qualitative and quantitative data from our patients and our clinicians a month into the pandemic and then a year later on attitudes towards telehealth vs in-person for therapy and psychiatry. I was planning to do a blog post about but if interested in collaborating in something more or doing a followup to the above, DM me on Twitter (@CarleneMac). I think you are largely right although it is nuanced and many of the telehealth only plays really are not going to be able to address a full continuum. Virtually no practice will go back to 100% brick and mortar either though.