The Middlemen Problem

by Dr. Corey Jentry

The Referral Economy

One of the stranger features of American behavioral healthcare is that some of its most influential decision-makers are also the least accountable or qualified.

They can’t diagnose and shouldn’t treat. Yet they have an unusual amount of influence on who gets admitted, where patients are sent, how quickly those decisions are made, and how long someone stays in care. Clinicians feel their influence regularly. Families rarely see it clearly. Regulators tend to arrive long after the damage has already been done.

These are the intermediaries. The business development representatives and their affiliated titles. The people tasked not with care, but with filling beds.

Authority Without Accountability

At the 2026 National Association of Therapeutic Schools and Programs (NATSAP) conference, I said something in my keynote that clearly unsettled the room: that business development, as it currently operates in behavioral healthcare, is not just inefficient or expensive, but is more often than not useless and sometimes actively harmful.

The reaction was instructive. A number of people took it personally. Others rushed to defend themselves as “good actors.” A surprising number of members quietly agreed with me offstage. This reaction says less about the individual’s intent than it does about how normalized and entrenched the system has become.

How Admissions Became a Sales Function

In most areas of medicine, referrals come from doctors. That’s it.

Sure, some people may walk into a cardiologist’s office and request a special workup and preventative testing because of family history, out of pocket.

But for the most part, a patient is evaluated, a diagnosis is made, and a medical doctor recommends care. And, as in most healthcare, a practice’s growth is determined by its outcomes, reputation, additional medical specialists, research innovation, and insurance acceptance.

Behavioral healthcare has inverted that logic.

In large portions of the industry, growth is driven by whoever controls the referral stream. Programs don’t really compete through demonstrating superior clinical outcomes, but by investing heavily in sales and marketing infrastructure. Established, well-networked business development representatives are paid higher base salaries than most seasoned therapists and social workers I know. And are even further compensated through hefty bonuses that are, more often than not, tied directly to the admissions volume they produce.

None of this is some big industry secret either. It is widely understood within the industry but rarely discussed publicly.

So let’s discuss it in public, shall we?

Incentives at Work

At one particularly horrible private equity-backed treatment program, where I worked in business development, all our representatives were given monthly quotas. Especially me and the other directors. It didn’t matter the circumstances; miss those numbers, and you were written up. Miss them again, and you’re fired.

So I know all of this not as some passive observer but as an active participant.

I’ve watched and experienced dozens of friends losing their jobs, sometimes within the first few months of starting work, for missing a single admissions target. And I have been told by corporate executives more times than I can count that I had to fire those people who didn’t “produce.” It doesn’t matter if you are a newly single mother about to be evicted from your apartment. If you missed or were behind on your admission goals: too bad, so sad…. no job for you. Because – God forbid – you ever get labelled as someone who doesn’t produce patients in the mental healthcare industry.

If you can’t ensure heads in beds, then your career in mental health is dead. And this company was hardly an outlier. Variations of this model exist nationwide across the industry, especially in cash-pay programs and the troubled-teens sector. The only real difference is how openly it is acknowledged.

The ethical conundrum here is not subtle.

Many of these programs accept private insurance. And tying employee compensation to admissions targets in an insurance-based healthcare setting is, at minimum, deeply questionable. At worst, it drifts into territory regulators have historically viewed as improper or illegal.

Even when technically permissible, the incentive structure alone should give anyone pause. The behavioral economics of this is not complicated. When someone’s livelihood depends on hitting a monthly admissions target, the system quietly but very potently reshapes human behavior. Low-acuity cases suddenly become “good fits.”

Those complex presentations that have no business being outside a psychiatric hospital and are far beyond the skill set of the licensed professionals, who aren’t even there to begin with, but the patient has a stellar insurance policy that reimburses at 100% of what is billed… BRING THEM IN!!!

When the program census is low and the business development numbers are lacking, the urgency to fill those empty beds replaces almost any deliberation.

Intentions Versus Structures

It is worth noting that all this doesn’t happen because business development professionals are immoral people. I mean, some are… but for the most part, they aren’t. It is mainly because the system asks and puts pressure on them to behave in ways that would compromise even the most principled individual.

People trying to pay rent or keep their kids in clothing do not have the luxury of philosophical reflection when their job is on the line. The overwhelming majority of these business development reps are just trying to do their job in the best way they know how in very challenging circumstances and under immense pressure from their supervisors and business owners.

So this is a systemic and leadership problem.

The leaders of this industry respond to this critique by pointing to their intentions. Most program owners genuinely believe they are helping people and can’t fathom how you could have business development representatives without admissions expectations. I remember bringing up this very issue with the Chief Marketing Officer at the P.E.-backed programs I worked for once, noting that the company might rethink some of its KPIs and reassess how it evaluates and reviews business development activity. Both because of massive staff turnover and the moral and legal questionability of certain practices. She looked at me like I had just insulted her mother, then told me my job was to get people into the program and leave the rest to them.

Many business development representatives care deeply about the families they speak with. I assume many of the business owners and CEO’s do as well. That may all be true. It is also beside the point. Good intentions do not neutralize bad incentive structures. In fact, when the rubber meets the road, they are more often than not overwhelmed by them.

The Family’s View From the Outside

From the family’s perspective, this system is extraordinarily bewildering. They are told – frequently and with passionate conviction – that a particular program is exactly right for their child or loved one. Rarely are they told why.

Families are rarely shown anything that could be legitimately considered comparative outcome data that differentiates the efficacy of one program or approach from another. Second opinions or waiting are sometimes subtly, sometimes adamantly discouraged, given the “urgency of the moment.” Things like waiting a few weeks, trying an outpatient option, or counselling combined with therapy, are often construed as dangerous. Thus, sending the person to residential care is presented as the compassionate choice.

What families don’t see is the machinery behind these recommendations. They don’t know who is paid, how, or based on what metric. They have no idea that the person urging immediate admission is essentially a salesperson who may lose their job if they don’t close the deal by the end of the month. The result is a system that rewards action rather than accuracy.

Reputation as a Defense Mechanism

This also helps explain the industry’s sensitivity around public criticism. When speaking about abuse, many rush to discredit people like Paris Hilton and the work of survivor communities like hers, calling them outright liars or polemics, rather than examining the greater environments that allowed harm to occur.

At NATSAP, far more energy was spent by the people there defending their own reputations or trying to trash Paris Hilton’s, or mine for that matter, than on examining incentives or reflecting on the industry’s (or their individual) part in this process. The irony of this is hardly lost on me, as programs like these are the first to tell their patients that they need to learn accountability, how to take criticism, and to own up to “their part” in a situation.

The defense line seemed to be: but we really care, and we are good people. I don’t doubt that most of the people in that room were good people who cared. But the reality is that good people routinely participate in poorly designed systems that cause harm. As Karl Marx famously said:

“Men make their own history, but they do not make it as they please; they do not make it under self-selected circumstances, but under circumstances existing already, given and transmitted from the past.”

What Many Leaders Privately Admit

What makes this particularly corrosive is that the same leaders who privately acknowledge that business development is expensive, annoying, and distorting continue to justify it as “necessary.” They describe it as the cost of doing business, as though mental healthcare services are simple commodities rather than a public trust. The irony is that many of these same leaders would never tolerate similar incentive structures for their clinicians. Anyone would be rightly horrified if psychiatrists were paid bonuses for prescribing certain medications or admitting a certain number of patients per month to the local psychiatric hospital.

In this situation, we recognize immediately how such incentives would corrupt judgment and lead us to question the intent behind the prescribing or placement. Yet in the mental healthcare industry, we tolerate them one step removed, where potentially much more damage can be done with far less oversight.

How Medicine Actually Handles This

There is a straightforward alternative. Why shouldn’t treatment referrals work the same way medical referrals do?

I argue that placement decisions about level of care and placement should be made by licensed psychiatrists, social workers, or doctoral-level psychologists. These individuals already operate within a clearly defined scope of practice, are accountable to regulatory bodies through their licensing and credentialing, and are easily insulated from financial incentives tied to admissions volume by clear-cut laws.

None of this would eliminate error; nothing does. But I argue it would dramatically reduce the likelihood that financial pressure masquerades as clinical urgency and help ensure that the people making treatment recommendations have the knowledge and qualifications to do so.

Business development, as it is currently practiced, is not an individual practice problem. It is a leadership problem. It is an ecosystem problem. It is the predictable outcome of designing a system where short-term revenue generation is structurally privileged over everything else.

What Reform Would Require

If the industry is serious about reform, this is where the conversation has to move. Not toward better messaging or reputation management, but toward changing the incentive structures that ultimately govern behavior. Families are not asking for perfection; they just want honesty and help. They want to know who is responsible, what actually works, and what the hell you are going to do to help them with their child. The comedic tragedy of this is that the most effective programs already operate closer to this model. The best practices, programs, and practitioners are often the least popular in the field precisely because they refuse to play the referral game.

They are run by professionals who care more and invest more in their clinical staff and patient outcomes over their marketing and optics. They are cast as “difficult to work with” or “don’t play well with others” because they regularly say no to taking on patient cases (or referral nonsense, for that matter) that they deem are not appropriate. And they don’t “collaborate” with admission referents or unlicensed “case managers” on the direction that a patient’s care should take.

These practices thrive simply because of the results they produce. For example, there are practices and programs like the Boston Child Study Center and River Stones, who don’t bother with business development, don’t mind if they upset a “referral,” and don’t look at treatment placement based on “who owes me one” but on who is the best specialist with the skills to address this patients needs and challenges.

They invest in what counts, and it shows in their results, their staff, and the fact that they don’t have publicized groups organized to destroy them for ruining lives.

The Choice the Industry Keeps Avoiding

The industry is at an inflection point and now faces a choice. It can continue to defend an incentive structure that quietly undermines its credibility, or it can begin the harder work of dismantling it and building something new. That is, before city, state, and federal regulators start doing it for them, and without their input. Which, fyi, is what is supposed to happen when business ecosystems cause harm.

What unsettles people is not the accusation that harm is done or exists, but that they are somehow participating in it. The suggestion that much of what the industry has normalized may be unnecessary, or worse, incompatible with ethical care, shouldn’t be taken as a threat but as a extrodinary opportunity. That is what they would tell their patients.

To paraphrase Migos, the industry needs to start “walking it as they talk it” to their patients.

About The Author

Dr. Corey Jentry

Dr. Corey Jentry is a survivor of the troubled-teen industry and the author of Selling Sanity: The Troubled-Teen Industry, the Insane Profits, and the Kids Who Pay the Price. As a teen, Corey was drawn into a program that promised healing but instead delivered manipulation, control, and emotional abuse. Those years left scars but also sparked a lifelong mission: to expose what really happens behind closed doors and to fight for kids who don’t have a voice.

Corey holds a Ph.D. in Political Science from the London School of Economics, where he focused on power structures, systemic violence, and conflict resolution. Today, he combines personal experience and academic expertise to expose harmful systems and to help families and organizations find safer and ethical paths forward.

Through writing, speaking, and consulting, Corey’s mission is simple: to protect kids, empower families, and push for change in an industry that too often profits from pain.