
Google’s search monopoly complicates a mental health crisis - woldemariam
https://www.bloombergquint.com/businessweek/google-s-search-monopoly-complicates-a-mental-health-crisis
======
drivebycomment
It looks like the main reason the ads price for therapy went up is the extra
competition - that COVID making the therapy market from in-person to virtual
creates the supply to be not constrained by distance, which means suppliers
have to compete across greater pool of suppliers, including therapists from
cheaper cost of living areas. This naturally creates a downward pressure for
the average price, and of course firms like BetterHelp show up to take
advantage of this price differential - i.e. they are doing an arbitrage.

So this comes down to therapists living in expensive areas complaining about
competition from therapists from cheaper areas. Given there are still people
who need/want local therapy, there will be a new price equilibrium but most
likely it will be lower than before. No amount of complaining about Google or
ads or arbitrage like BetterHelp will make the price stay as before. Nothing
much to see here - this looks mostly like a market adapting to a new changed
market condition.

~~~
tomgp
Also VC backed online therapy providers are mentioned. Are these sustainable
businesses (no one knows) and, crucially, if they fail will they do so before
they wipe out independent therapists having used their purchasing power to
raise ad prices beyond reach?

In the 90s part of the promise of the web was that it would disintermediate
service provision, these economics would seem to act against that possibility.
With large aggregator middle men best positioned to profit with large scale
small margin offerings.

~~~
Sangama34
It is not Google's job to ensure private practice of shrinks is sustainable.
Large scale small margin offerings clearly better serve the patients and if
Google does not help them they will be in a better position to seek other
alternatives like national TV. I do not think small shrinks can even enter
those spaces today.

One possibility I see is for many shrinks to come together form a co-operative
and compete with vc backed alternatives.

~~~
nip180
> Large scale small margin offerings clearly better serve the patients

This isn’t clear to me at all. I actually associate low-margin business with
worse outcomes for traditionally high-touch services.

------
munificent
As I understand it, the problem here has little to do with Google. The problem
is that the transition to telehealth means that therapists are now competing
directly with large national mental healthare providers like BetterHealth and
Talkspace mentioned in the article. Those big companies have deeper
advertising pockets.

If you want to break up companies to make it easier for independent
therapists, those are the ones to break up. Google is just the marketplace.

This is like blaming the sidewalk or the interstate highway system when Wal-
Mart causes your local mom and pop store to shut down. Google isn't driving
her prices up, _competition_ is.

~~~
shuntress
It is _a little bit_ like that.

It would probably be considered a problem if Wal-Mart paid the state/highway
department to ensure that major town roads "flow naturally" to Wal-Mart and
are better maintained than roads that lead elsewhere.

This is definitely similar to major companies in a specific domain buying the
top search result from google for any query within that domain.

~~~
wanderer2323
you analogy seems questionable to me.

The major telehealth bying google ads is Wal-Mart bying 10 large highway
billboards. The indie therapist not being able to afford the auction is the
mom-and-pop shop not being able to afford those buidboards.

now if the major telehealth would get a dedicated bandwidth and the indie
therapist's video calls were getting throttled we would be talking roads etc.

For now it's the 'walmart moving into a small town' scenario but the bloomberg
article blames the company that operates the billboards.

~~~
shuntress
No, your analogy is inaccurate.

A billboard ad is not an explicit and direct "physical" connection to the
product the way that a search result is.

Dedicated bandwidth and throttling, to extend my original analogy, would be
like the roads going _only_ to Wal-Mart or being difficult in some significant
way to take anywhere other than Wal-Mart. It is the same problem only more
pronounced.

The first search result you encounter when executing some search is much more
similar to the first store you encounter when searching for some store (by
taking the easiest or "most natural" path into the shopping district) than it
is to viewing a billboard.

Edit -- To clarify what I mean about billboard ads: A billboard ad is
something you see that is unrelated to whatever else you are doing. Yes, a
digital "billboard" ad is still a direct connection to the product being
advertised but it is also distinctly separate from whatever content or
activity it displays alongside.

A search result _is_ the content/activity you have sought out by searching.
There could definitely be a grey area if google's design made sponsored search
results stand out more or be distinct in some way that causes them to read as
some content other than a search result (either by position, border, size,
color, etc) but that is very clearly _not_ the case of their current design.

Sponsored search results look _exactly_ the same as non-sponsored search
results apart from the "Ad" text displayed with the URL. They are clearly
intended to look and function the same as the "normal" content of the page and
not intended to be an incidental "secondary" experience alongside your search.

------
Sangama34
The article is so wrong. This is part of the reason why I do not take main
stream journalists very seriously. I wish same issue was taken up by some hard
core economist.

What is wrong with the article :

\- So one small Psychiatrist is losing business to other Psychiatrists.

It is perfectly possible that Ross is an inefficient Psychiatrist here and
patients are better served by other Psychiatrists. This is a loss for Ross but
barely a "complication". Also it is not clear to me if the market was divided
50-50 between say Google and Bing why would it be any difference. From over 10
years of experience in ad industry I have realized that it is a ruthlessly
free market system where the inefficient player will get punished very
quickly.

What Google has done here is that opened up a lager pool of customers for the
suppliers and that has resulted into fierce competition among suppliers. The
customers invariably will benefit here as they have more options.

\- The rant about smart campaigns

This is one of the real bad arguments. A couple's councilor is upset that
Google is unable to differentiate between a PTSD councilor and couple's
Councillor. Will the world be better served if a couple's councilor has to
compete with a florist or a nanny ? [That it what yellow pages were].

The article laments that customers have more choice and it is not easy for the
suppliers to rely on information asymmetry to make profit. They take some
fictional futuristic scenario and compare google against it and blame those
problems on Google. But in reality it is a good problem to have.

PS. This is by no means to claim that Google's ad algorithms are perfect, but
it is without dispute that they are better than all available alternatives.

~~~
reaperducer
_\- So one small Psychiatrist is losing business to other Psychiatrists._

Perhaps you're approaching this from a technical standpoint because you're a
computer person. He's not supposed to represent the entirety of the problem.
He's there to illustrate the problem. Journalists do this to "humanize" the
story, to make it more understandable by the audience. This is done all the
time. If there's space available, several people are added. Or there may have
been several examples in the reporter's original writing, but they were cut
for various reasons like lack of space.

As an HN reader, you're probably not the audience.

------
thatfrenchguy
In France, they fixed this by not allowing doctors or drugs to advertise. One
of the best decisions ever, for a lot of reasons: you cut care cost, and you
avoid that kind of third party profiteering.

~~~
KKKKkkkk1
Advertising is how a free-market economy disseminates information about new
products and services. How does France solve this?

~~~
irrational
I presume the information is disseminated to medical professionals (presumably
by official means and not from advertisements) and then the medical
professionals determine if the new products or services are appropriate for
you.

It’s like my non-technical boss coming into the office and telling me that we
should start using technology X that he saw in an advertisement. Typically,
with my boss, he sees something at a trade show or a trade magazine or in an
email, and becomes convinced that it is the best thing ever for us and will
solve all of our problems. Then we have to put forth a lot of effort
convincing him that he is wrong (he has never brought us anything remotely
useful) without making him feel dumb.

How about he lets us technical people recommend to him the appropriate
technologies instead of the other way around?

~~~
kube-system
Awareness can also be an issue -- the experts can't help you if you don't tell
them about your problem. And a layperson can't get help from an expert unless
they know they have a problem. This can especially be a concern with medical
issues that carry social stigma.

~~~
kevincox
Then maybe the government should put up ads that say "Talk to your doctor
every once and a while."

------
MattGaiser
> he didn’t even check to see how they did. “I mean, it’s Bing, right?” he
> says.

Bing and Yahoo are still about 20% of the American market. It is not
inconsequential.

I suspect that prices have soared there as well though, simply because the
pandemic severely disrupts therapists. In a world of video calls, there is no
local market.

There are as many places seeking to sell you therapy as sell you gasoline now.

~~~
rietta
> pandemic severely disrupts therapists. In a world of video calls, there is
> no local market.

This is absolutely not true in the United States. Therapists are licensed in
each state and it can cause severe professional problems and ethics situation.
A counselor cannot technically even see a client telehealth if they are on
vacation out of state that week unless the counselor is also licensed in the
State the client is vacationing in.

Source: My wife is a licensed practical counselor and regularly studies for
her mandatory continuing education credits in the evening. I hear her watching
the lectures and answering questions on those exams.

~~~
marcinzm
Covid has lead to a changing of guidelines around telehealth both at a state
and a federal level. And even if it's not technically allowed it's unlikely
that any state will prosecute medical professionals due to the ongoing crisis
as it's really bad PR.

~~~
rietta
Yes, that change came down pretty quick with Georgia Department of Behavioral
Health and Developmental Disabilities after the Federal requirements changed.
My wife was working from home telehealth for the first time ever for months.
Her agency has since shifted back into the clinical environment. But
telehealth in this setting went from not allowed for counselors to done for
safety of clients and staff.

Private practice may be somewhat different in that State and Federal insurance
rules are not at play for private pay, but most sensible counselors will not
want to risk their license. You don't have to be prosecuted criminally to lose
your ability to practice.

------
changoplatanero
Not clear to me how breaking up the google search monopoly would lead to a
lower cost per click for valuable keywords.

~~~
tyingq
Yes, this just seems to be more providers bidding on "online therapy"
keywords, since the in-person kind isn't so practical right now.

~~~
stingraycharles
And if I’m not mistaken, the audience is now also a lot bigger, right? Would
this not imply that this evens each other out? The therapist of the article
could just maintain her bid price, not?

~~~
tyingq
It's a weird market since there's only so many room for ads. Normally, you
would add shelf space, Google doesn't do that.

~~~
CydeWeys
Yeah but clearly the ads being bid up are worth it to someone, no? Is the
issue that the limited supply is now being taken up by therapists charging
more than her, i.e. those who can bear higher costs of advertising?

And if so ... what exactly is the workable alternative? This is all just
market forces. The cost of advertising and acquiring new business has been
around for much longer than Google.

~~~
tssva
They aren't even being taken up by therapists charging more than her. They are
being taken up by corporations providing online access to therapists for
substantially less than she charges. The consumer is actually benefiting.

She charges $250 a session. Lets say she sees 6 patients per day generating
$1500 gross revenue a day. She spends $20 a day in ads which works out to
around 1.3% of gross revenues spent on advertising. That is an extremely low
amount spent on advertising. The US Small Business Administration
recommendation for businesses with revenues less than $5 million per year is
to spend 7-8% of gross revenues on marketing.

~~~
CydeWeys
That's a good point and thanks for doing the numbers. Maybe she just has
unrealistic expectations of how much is normal to spend on advertising? It
sounds like it. She should definitely be able to afford to spend more than a
platform like BetterHelp, which is making a lot less per consultation than she
is.

------
ineedasername
I don't see the direct connection to out mental health crisis in this issue.
None of this addresses the mental health care crisis in terms of patient
outcomes and patient well being.

Instead, the article talks about how individual therapists are losing out as
ad prices rise and newer tech-mediated therapy platforms are gaining attention
& market share. (and working for those platforms doesn't pay nearly as well)
Also google has a near-monopoly for online advertising, so these therapists
have few options if they aren't born natural marketers, and Google customer
support is bad. In short, it's bad for therapists.

Nothing much said about this being bad for patients though. It's possible
patients have greater access to care with these new platforms.

------
Isinlor
The article completely failed to convince me on it's main point.

No regulation will fix the fact that people have limited attention, besides
banning ads altogether.

Google does a lot of bad stuff, but auctioning ads is not one of them.

Also somebody dares to bill people ONLY 50$ per hour! How dare they to not
bill 250$?! ...

~~~
mrtranscendence
Paying a skilled therapist with a master's degree $15 an hour is robbery. And
they're probably taking folks on as contractors, which means no insurance.
That $30 - $50 for a session is a race to the bottom.

~~~
tux1968
How is the market failing to set the appropriate price? A therapist should be
able to charge whatever they want, up to the point they can't find anyone
willing to pay it.

------
WarOnPrivacy
A question from the millions of folks who don't have $50-250/hr (x hr/mo) -
could this possibly lead to a genuine chance at therapy?

[a] Five therapists offering 2/hrs per week to the community isn't nothing -
it is a drop in an ocean of need, however.

[b] No. Trying to launch an insurance debate won't help answer this question
in a helpful way. Thanks for asking tho.

------
gowld
Isn't Google Maps search free for users and providers?

Doesn't high ad pricing mean there is a glut of supply for the service in
question?

The article subject seems upset that someone else gets the customers, but
that's not a problem for anyone. If the subject got the customers, that
wouldn't be "fair" to their competitors.

~~~
ss2003
A higher priced ad means that the provider is charging extra for the service.
Those charges are passed directly to the consumer. If you have a business that
is small niche of larger area you will be priced out of ads by larger, higher
charging competitors. This squeezes out small and creative organizations and
leaves the overall market with a few cookie cutter services that charge much
more than the value of the product or service. Consumers without a lot of
discretionary income can't find a service to use. Small businesses cease to
exist.

~~~
pradn
Competition for a limited resource (ad space, land, wireless spectrum) selects
for companies with higher margin. In one understanding, higher profits mean
the business is providing higher value. In another, it means the business is
sucking up excess value that could be had by upstream consumers.

Ad space can be seen as land rented out a user request at a time.

Having more competitors to Google will help only a little bit. There's only so
many user request x ad space x keyword units to be split among the companies.
So the total amount of "land" advertisers bid for remains constant, so prices
will be roughly similar. The only difference will be that Google will command
a smaller cut of the auctioned price. I doubt that will make as much of a
difference as an influx of entrants to the bidding market. Some Google
keywords are 10s or 100s of dollars; the Google cut isn't driving hat, but the
value of a new customer acquisition.

Disclaimer: I work at Google but not on ads.

~~~
ss2003
When there was more competition for Google, and when ads and links for other
Google products didn't take up half the page of search results, there was
much, much more eye ball space, even though there were many fewer eyeballs.
I'm not going to make the case for causation vs. correlation here, but this is
part of the often mentioned general deterioration of the Internet.

------
techntoke
Anytime I see a service that pays for ranking then I intentionally avoid them.

