Launch HN: Legion Health (YC S21) – Smarter Staffing for Mental Health
Hi HN! We’re Yash, Arthur, and Daniel, the founders of Legion Health (https://legion.health). We're an online marketplace for health care professionals, starting in mental health. Basically, we sell psychiatrists' and therapists’ time to telehealth companies by the hour. Professionals sign up for shifts that fit their schedule, and telehealth companies can scale more quickly by not needing to hire them full time.
Telehealth companies and other health care organizations (hospitals, medical groups, home health, etc.) face huge problems around recruiting, managing, and scheduling clinicians to meet patient demand. This is getting worse because of a large (230,000+) shortage of mental health professionals in the US. Staffing companies exist, but they solve only one piece of that problem, are expensive, and don’t mitigate risk for their customers.
We heard how bad things were during a 2-hour call with the Director of Business Operations at a large telehealth company last December. She told us in amazing detail how difficult it is to recruit doctors to her platform and how much gets spent on that sole task. In addition, she talked about the weekly fluctuation in patient demand and the pain felt when scaling her physician workforce up and down. Independently, over the next week, Arthur started thinking about "Uber for doctors" and Daniel conceived "AWS for doctor time," and then we realized they were two sides of the same marketplace.
While honing our idea, we found that it is most applicable to mental health. In the US, mental health has undergone a boom in demand in recent years (whether at hospitals or telehealth companies, like Modern Health, Daybreak, and Ophelia—all funded by YC). However, supply has not kept up—there just aren’t enough professionals. Mental health is also a field that is quite suited to care delivery via telehealth. So we started there.
Our product solves problems on both sides of the market. On the supply side, many mental health professionals are looking for additional work to supplement their existing part- or full-time jobs at a hospital, the VA, etc. On the demand side, health care organizations are looking for a more affordable and flexible solution for their staffing problem. We find out what time is available from our network of clinicians, divide it into hour-long chunks, then sell those hours to our customers (the health care organizations) who only pay for the time that they use—that is, the hours when the clinicians are actually working with their patients.
Unlike staffing companies and in-house recruiters, we turn health care companies' fixed costs into variable costs, significantly reduce hiring risk, and have no upfront fees. Compared to other telepsychiatry solutions, we are much less expensive because our network consists mostly of psychiatric nurse practitioners and social workers who, in many states, do almost everything that psychiatrists do but (for historical reasons) charge lower rates. Unlike other telehealth staffing solutions, we are obsessed with quality (in regard to both clinician performance and building our product to facilitate long-term clinician-patient relationships), ease of integration, and not having minimum usage amounts.
Our product doesn’t exist in a public form. Rather, health companies white-label our network to better meet their patient demand. We currently have a network of 131 mental health professionals whom we match with our customers manually (“do things that don’t scale”). We are building software for scheduling, clinician-customer-patient matching, clinician onboarding, notifications, etc.
COVID-19 has made telehealth normal for patients, clinicians, and institutions, so the opportunity here is huge. Even traditional institutions (hospitals, rural clinics, home health, assisted living, hospice, etc.) need a smarter staffing solution because hiring health care professionals is incredibly hard for them as well. At present, we are figuring out where to show traction first as we scale. So far, we’re seeing that the organizations with the shortest sales cycles tend to be smaller, more agile, more tech-friendly companies.
If I could end on a personal note: although all this marketplace talk sounds cold and fungible, all three of us first encountered this problem from the patient side. My father had brain cancer last year, and getting ahold of his hospice nurses to do simple tasks like refilling his meds was a pain. The nurses wanted to help; there just weren't enough of them. For Arthur, when he was a child in rural Colorado, his brother had a nasty string of epileptic seizures brought on by inadvertent exposure to chemicals from a meth dealer down the street. It took 2 months (after over 150 seizures) for his brother to see a specialist in Denver who could treat him. For Daniel, it was when a close friend in crisis tried to schedule an appointment with her psychiatrist and found that the earliest she could see him was in 3 months. The latter experience hits closest to what we’re tackling first at Legion Health, but the fact that we all know how desperate it feels when care is needed, but not available, gives us motivation to keep going, even when running into the notorious intractability of the US health care system.
We'd love to hear what you think, even if it’s constructive criticism on our approach. If you or a friend hires health care professionals (especially in mental health), we'd love to talk to you to figure out what parts of our tech product you find most valuable, so we can figure out where to build next. If you or a friend is a mental health professional, thank you for doing such important and necessary work during these difficult times. Excited to answer any questions and hear your ideas, feedback, and experiences in the comments! On first look it seems like a scary way of commoditizing one of the most personal connection requiring forms of care there is. How do you ensure quality and aligned goals with the patients if it's literally just selling hours? Great question, and I really appreciate you bringing that up. This is one that we get from many of our customers. First, we have consulted with experts from across health care to implement the most rigorous quality standards for the professionals in our network. Not only do our clinicians have to pass tests of baseline quality (background check, licensure check, etc.), but they are also directly assessed based on their level of clinical expertise, years of experience, education level, etc. We even speak with all of our clinicians to do a basic sanity check and determine how they will present over video. On the back end, we are currently creating processes to assess post-visit performance in a number of ways, including timeliness, patient satisfaction, etc. That will allow us to weed out lower-quality professionals and reward our higher-quality professionals. Lastly, a key part of quality in mental health is continuity of care (a longitudinal patient-clinician relationship). Features in our product allow for our customers (health care organizations) to view our clinicians' availability and directly schedule their patients to match that availability, such that the relationship is maintained. Then, we have a number of ways (one of them being highly favorable compensation) to ensure that our mental health professionals stay with us. I hope this helps, and happy to explain further. I don't know about this. Most psychiatrists I've known have always recommended to meet in person rather than holding something over call. Always set up extra appointments and made time for them at no expense. The ones who would do anything lower than that would come off to me as sub par (and I've had online psychiatrists too, and all of them were subpar). Interesting observation, and this very much was likely the case for private practice psychiatrists pre-COVID. Now, we are seeing that more mental health practitioners (high-quality included) have become comfortable providing care over video because care quality is actually the same (several studies show this), no-shows are reduced for the psychiatrist (equals more revenue), and patients really prefer it. Furthermore, psychiatrists who take insurance or who are affiliated with a hospital/telehealth/other health care institution (i.e. not in private practice, plus these are the health care companies that are our customers) are more likely to bill for extra appointments because rates are lower than in private practice (although equal regardless of in-person or over video due to government mandates) and because the customer is less price-sensitive anyway as insurance is footing some of the bill. Therefore, these (still high-quality) folks just have different behavior patterns based on payment and based on response to COVID. I hope that helps. Very true observation there is a lot of unpaid work that happens for patients in crisis Do you have a triage system in place where you have a phd level provider that diagnoses and funnels to the appropriate level person to do ongoing treatment? Also why would Good provide join your team what are you offering that makes you competitive to a provider. I actually really like that idea because it fits into one of our longer-term visions of providing an off-the-shelf turnkey "care team" solution, whereby a cadre of professionals work together to provide care for our customers' patients. Currently, we don't have such as system in place, but our customer might! In that case, a customer might use a PhD or mD from us to provider higher levels of care and then a social worker or nurse to provide ongoing higher-touch treatment. We are simply providing the health care professionals (and their time) to augment a health care organization's existing staff. Per your second question, that's actually one of our competitive advantages! Right now, we are finding that many awesome providers who are already reputably employed at a hospital, at the VA, etc are looking to make more money (by the way, the fact that they are already reputably employed is a good screen for quality too). They would like to work an additional 10-40 hours on top of their main job in the mornings, evenings, days off, and weekends. That is a large source of potential supply that is going unused and that could help so many people! Simply put, we offer these providers a chance to make more money by using their expertise to see more patients whenever they want. We provide the patient volume and the competitive rate. All providers have to do is show up and provide the excellent care that they already do. There are a couple issues I see with this model. 1) Credentialing is super slow in medicine and probably quite expensive. It will take your provider months to come online. 2) If you aren’t paying high at 65-70% of billable rates you will have trouble finding providers that want to go through all that hassle when they can just work more hours at their regular job. 3) It’s not clear to me that you are doing anything different than what a regular private practice would do. Everyone is full online now post pandemic so they are mostly limited by availability of clinicians. They could hire parts time folks and offer the same deal I think many just choose not to. You would get stuck with all the compliance costs and little actual revenue. Thanks for highlighting these issues. 1. Credentialing is definitely super slow. We want to get to the point where we can handle billing for our customers as well, so we'll have to create relationships with payers to speed the process up. Right now, many of our customers and clinicians are already used to this long process, so nothing is really different here. 2+3. We are providing the patient volume at 0 cost to the clinician. This is all just extra income for the clinician at the cost of their time, regardless of whether the clinician is in private practice or working for a hospital with a fixed salary. Opportunity cost requires for the private practice to do marketing, etc to drive patient volume to them. Also, the private practice, again, has the same problems around recruiting and scheduling that a hospital would have. What you describe is not 0 cost. You take some sort of cut for services provided, that’s what a private practice does. In exchange for patient flow computing scheduling compliance and billing they charge 30-40% of the patient bill.
In a modern work from home environment a provider could contract with a local urban private practice and offer part the hours for the same arrangement. The only real difference is they would have to interview and provide stable ability, the work can be fully remote otherwise. Also typically the practice takes a higher cut if you work fewer hours. I think that's precisely why we're needed. With the scale that we plan to have, we can actually provide stable patient volume and deal with all the pains of recruiting and onboarding. Every smaller organization otherwise will have too much difficulty piecemealing different clinician availabilities together to create FTE(s) Well, I don't quite get it, but anything is welcome in this part of healthcare. I'm looking for a psychiatrist and am being told they're not taking on new patients or that I need to wait 3 months for an appointment. I just need a prescription for a medication that I had before. While being forced to pay for health insurance, being told that this country has great healthcare, losing my voice (literally), and trying hard to get myself to jump off a bridge, I can't help but find the whole thing a bit ridiculous. Best of luck to you, and try looking into an European expansion. Things aren't as good as they might seem. Hey, if you have suicidal ideation or self harm tendencies and can't find help, please go to the emergency room. They can help you there. Also, here's the link for the Suicide Prevention Lifeline: https://suicidepreventionlifeline.org/ Please find help and take care of yourself. Thank you for providing this resource here :) I cannot say that I understand what you are going through right now, but I truly wish you all the best. We are really trying to help with the issue of access just as you reference here. Wait times are too high to see a psychiatrist so 1) how can we unlock a latent supply of these professionals (by way of their excess time) and 2) in what cases can we substitute these professionals with others whose supply is greater and who can provide similar functions. Depending on the state that you live in, a psychiatric NP can get you that prescription at a lower cost to you and, more importantly, quicker. We want to allow other organizations to do that for their patients using our providers. Hang in there? Maybe you can find a primary care doc who can write you a prescription to hold you over for 3 months… Hopefully a psychiatrist will have a cancellation you could grab sooner. You need to go to your pcp and talk to them about suicidal tendencies. They can priority schedule you. PCP to provider schedules going will give higher priority to high risk patients Hey Yash & team, just wanted to say looking forward to what you guys accomplish! This is great to see. Legion Health's business model is interesting & cool to see because the current company I work for, the business is basically the same but we're just in the manufacturing & logistics industries. Supply side: Operators aka independent contractors who are looking for flexible work in the manufacturing & logistics space.
Demand side: Businesses in the industries that face labor shortage & don't want to hire full time employees & want to only meet demand depending on the marketplace. So, really cool to see this! I love how you guys are focusing on mental health because that's something really important to me & I value because I've been through it in the past year. Had all the mental health illness symptoms including anxiety, loss of appetite, depression, loss of sleep, no social interaction, etc. Looking forward to seeing the big things you guys accomplish! Thank you! Very cool to hear it's a business model you've seen work well in other industries. What we saw is that this is supply-constrained space – where many folks such as yourself need convenient access to behavioral health services – so anything we can do to increase the liquidity of the labor market (while maintaining quality) will be beneficial to patients. Thank you for the well wishes! I may be a customer if the price is right -- but I'm wondering how this actually fits as a standalone product. My customer cost and your profit are hard to mentally balance in my mind. And maybe I've been wrong in evaluating these markets, but recruiting for a Telehealth offering is tablestakes, and a core competitive advantage to this space. Also to echo Jommi's comment, these aren't plug-n-play relationships from what I've seen. Especially from the Apps that try the text based therapy route to get around the 1:1 relationship This also sounds like its about to run into the classic problem with hair stylists in the US. You're going to end up having clients want to see their therapist on their schedule - making the load balancing a super tough problem, because you can't just hot swap a new therapist in. You're going to have to run predictive modeling on the demand side to know when to have your supplier free. Thank you for the interest. You're right that there are many providers interested in telehealth, but filtering for quality folks and keeping them from churning is a non-trivial problem. In addition, it is a very supply-constrained vertical in medicine, so these problems are especially pressing. Part of the reason our current partners use our solution is because we do the upfront filtering, and we de-risk churn to a large extent. If you only want to use 20 hours a month from a great provider in NM, you don't have to worry that they're going to run off for a better offer, because we use their other time with other partners – and they remain satisfied. Regarding continuity of care: these providers mostly have recurring availability, which makes it very easy to schedule them in advance for CBT or other types of recurring visits. We lean into continuity, rather than trying to avoid it with async approaches. Regarding folks going around our platform to see our providers: frankly, that would more a liability to our customers than it would be to us, because they are the ones trying to maintain patient stickiness. Oftentimes, these services are employee benefits, so there's less problem here with patients trying to go around the platform. But the long term answer is we want to make it SO much easier for providers to see patients via our channels that they don't have any reason to go around us (and have to deal with malpractice insurance, payments, scheduling, and video infrastructure on their own). Very cool and good luck! I poorly rephrased the continuity of care in the third paragraph... I highly doubt someone is going to circumvent an EMR/scheduling platform to go see the provider direct, but I've been wrong about worse things. The comment was just to say I believe you'll want to invest in those predictive analytics down the road to make sure continuity is paramount. What is more interesting in what I'm seeing you guys write is maybe you're going for acute and crisis care... which is smart. Totally agree about having to get good at demand forecasting. Good thing we have Daniel; his college thesis involved creating revenue forecasting model for BMW North America that they still use! Disclosure: I'm an MD who specializes in psychiatry. The idea that Nurse Practitioners and Social Workers "do almost everything that psychiatrists do but (for historical reasons) charge lower rates" doesn't feel like a fair characterization. I have worked with many excellent NPs and Social Workers, and have a tremendous regard for their work, but the level of training is - objectively - much different. Here's an infographic comparing training, which is more or less accurate, but there's some variation between programs: https://i.redd.it/ixgg0l7v6lv51.jpg This is a very good point, and thank you for sending this information. However, the infographic is quite misleading because it doesn't stack up nursing school vs. medical school (i.e. it doesn't show the type of courses and training taught in a 4-year nursing program at all). A undergraduate bachelor's degree even in biology is not comparable to the clinical training in nursing school. That being said, I see your point. There some types of complex care that only MDs/PhDs should be providing, and we will have psychiatrists and doctorate-level psychologists for that care. However, many of the services that our customers provide can be done by other clinicians in our network under the supervision of an excellent MD or PhD. Part of our goal is to really figure out the "matching" problem so that we can triage care to the clinician type with the right amount of training for the patient situation. By doing that, we feel like we can really increase access the way that we hope. The matching thing is a solved problem in hospitals. The patient meets a doctor level provider for the first visit then is assigned proper care based on the diagnosis with a lower level provider. The problem you will have is that you have a lot of low level provider with varying skills and a high level provider will have a hard time matching patient to the correct provider capable of administering the correct treatment protocols. I think this is a very valid point and something that we will need to consider. Thank you for bringing it up. The variation in quality is certainly not easy to solve, especially when pairing it with a clinical decision-making hierarchy. I don’t understand why anyone won’t want to get cut rate mental health treatment when they don’t pay for it. In the us folks are not price conscious for health care so why pick the minimum qualified person to provide care? You're totally right - no one wants cut rate mental health treatment. If you see my response to Jonni, I explain what our quality process is. Hopefully that convinces you that these aren't cut rate folks and rather very high quality professionals. And you have good intuition about most of the US health care system, but mental health has some nuances that should be shared. First, many mental health practitioners do not take insurance (only 56% of psychiatrists, for example, take insurance). That makes patients more price sensitive. It's hard to pay $350/hour for help. Secondly, and more importantly, there is a massive shortage of these clinicians relative to demand. Wait times to see a psychiatrist in rural areas can be up to 6 months. That's a big part of the issue that we want to solve: i.e. how can we use our solution to really expand access to the services people need? You are going after the wrong market. The bottom of mental health is not a money maker. Even if your somehow get more efficiency your margins will suck. Instead go for the best and charge like the best. Like you described above it’s a 6 month wait to get care from someone decent, so why not charge folks for the opportunity to get care now from the same qualified folks they would have waited months to see? Your mom need psychiatry meds? Fine we will get someone today or tomorrow no wait but it’s 600$. I’d pay it if it was my mom. Daughter suicidal and needs to start with someone now? We can do that but there is additional costs. Want access to that doctor that never has an opening at the regular practice. Well for $300/ 15 min he can see you next week. Better yet apply sliding airline style pricing and you got a recipe for serious returns I think you have a valid point here, but we are really trying to be a B2B company because the problems around staffing for other health care organizations are real and they are willing to pay a lot for a more flexible and lower risk solution. What you are describing is B2C and, quite frankly, lower volume. There are other companies that are doing a great job delivering that kind of care, and they are our customers. At CareDash, we’ve witnessed the issues for providers, patients, and partners that Yash has noted here. This is no small problem, but the overall issues are very systemic in nature for the US healthcare system but interim gap measure like this are helpful for everyone. Thank you so much for this comment! Would love to talk to you based on your experience at CareDash here! I see that you have a large network of therapists and have built a pretty impressive B2B directory. How are you going to handle billing, stark law, and anti-kickback? Great question. At the moment, we don't. Our customers can bill using the providers' NPIs. We stay out of that part and just facilitate the relationship. Because we aren't routing patients to specific providers, we also aren't violating anti-kickback. Is this what BetterHealth does? I haven't used it, but I hear a ton of ads for it on podcasts. Thanks for your question. BetterHelp is a direct-to-patient telehealth company that allows the therapists on their platform to see patients. We are B2B and are trying to provide a better staffing solution for those companies that want to scale or better manage patient demand. TLDR: BetterHelp is a potential customer!
