the LSH fee question keeps coming up and the answer everyone gives is the dollar amount, which is the least interesting part of it. the more useful frame imo is: what is that consult actually purchasing on the clinical side, and does the answer change how you should think about the value. hypothesis I’ve been turning over: for most people, the telehealth consult fee is functionally an access toll, not a clinical service, because the decision tree it walks through is narrow enough that you could write it on an index card. eligibility screen, contraindication screen, starting dose (almost always 2.5), titration script (4-week intervals, step up if tolerated). the pharmacy-routed model collapses the consult into a gate rather than a longitudinal relationship. that isn’t a complaint. it’s accurate to the product. but it changes what you should expect the fee to buy you, and it explains why the “is it applied to meds or on top” question keeps surfacing without a clean answer: because the consult is priced as a service line, not a med-bundled component, even though clinically it functions closer to the latter. where I’d push back on my own hypothesis: there are two things the consult could be doing that aren’t captured in the index-card version, and whether you’re getting them is the actual variable. one is the titration decision at each step, which is not the same question as the titration default. the registration trials give you a 4-week floor between steps, not a clinical schedule, and the real decision variable at each step is the tolerability-to-incremental-benefit ratio for that specific patient. a consult that engages with that variable is doing something. a consult that just rubber-stamps the next step on the calendar is not. you can usually tell which one you’re getting by the second or third interaction, not the first. two is the taper question, which almost nobody discusses up front and which is the corollary to step-up titration that gets handled worst across this whole category. the step-down curve is not the step-up curve in reverse, and a clinic that has a coherent answer to “what does coming off look like” is differentiating itself from one that doesn’t, regardless of what the upfront fee is. so the better question than “how much is the fee” is probably: at the second or third touchpoint, is anyone actually engaging with my tolerability-to-benefit ratio at the current dose, or is the cadence purely calendar-driven. if the answer is the latter, you’re paying for access. fine, just price it accordingly in your head. fwiw I don’t have a current LSH data point on the fee specifically, so I’m deliberately not answering that part. the framing is what I’d contribute.