Industry Insights
A candid conversation with a 30-year clinical veteran about the tension between clinical quality and business metrics — and how the best companies resolve it.
Paul Deger is a licensed professional counselor with over 30 years in mental health, spanning direct patient care to training hundreds of clinicians at digital health companies including Anthem and Bend Health. That dual vantage point — clinician and operator — makes his read on why digital health companies struggle unusually clear-eyed.
“This will be easy because there's so much demand for it. We just need to have the supply.”
Paul has heard variations of that line for a decade. The corrective, in his view, isn't swinging the pendulum toward "clinicians haven't figured this out, so we need a business eye on it" — it's putting clinicians in the room as full decision-makers, not token voices. "The only way this is going to work is having all the stakeholders in the room, all getting equal respect."
Where business and clinical perspectives clash most is numbers versus humans. Data matters — especially measurement-informed care — but it doesn't capture the toll of the caseloads clinicians are asked to carry. What keeps founders and clinicians aligned, in his experience, is usually a personal connection to the suffering the work addresses. "That's always where we can meet."
Utilization and NPS are easy metrics to reach for, Paul said, but they don't show impact. Standardized scales like the PHQ-9 and GAD-7 help, but he's built his own battery of 15 to 20 measures because clients often present as "mild" on standard scales despite an obvious clinical need in the interview. "Sometimes things are going to get worse before they get better … if you get too caught up in that data early on, you're going to think, okay, we got to pull the plug here."
“The truest measurement for me is presence … exposure to human suffering for 45 minutes versus 50 is not that much different. So even if you're doing a shorter number of sessions to get that higher number, there still is a toll.”
There's no universally right caseload number, Paul said — but he questions anyone claiming to sustain 30 sessions a week without cost to either quality or their own wellbeing.
Asked how he's kept clinical quality intact while scaling therapist teams quickly, Paul's answer was tech — but not the kind you'd expect. "We didn't hire you for your technical skills. If we did, you'd be joining the engineering team, not the therapy team." The technology has to be invisible: intuitive enough that a new clinician can focus entirely on the client in the room. The second half of the formula is culture — the kind where therapists tell their friends to apply. "I feel good when I'm doing good work. That's the culture you want to build."
Covid brought a cultural recognition that mental health has always been underserved, Paul said — but venture-backed timelines still pull against it. He recalled a founder under board pressure for next-quarter results who nonetheless held to a longer view. "I've got a long game here." Associates, in particular, get treated as cheap help rather than developed properly, which thins the pipeline of experienced clinicians the field will need later.
"Ultimately this is a business of empathy," Paul said. "Humans are the only beings capable of it. Tech needs to support that, not get in the way."
We're designing supervision and training around the realities in this article — structured feedback, outcome tracking, and a team invested in your growth as a clinician.
Explore Careers at Attune →