On NOCD Therapy’s third birthday, here’s a candid summary of what we’ve seen, what we’ve learned, and what we are doing to transform the virtual behavioral health industry.
During a time when society has never had a greater need for high-quality mental healthcare services, some virtual behavioral health companies have garnered a negative reputation for being clinically ineffective, adopting a “growth-at-all-costs” mindset, and lacking transparency. The problem was recently highlighted by John Oliver, the popular Last Week Tonight host, who shared his unfiltered take on the US mental health crisis, as well as the boom of teletherapy, telepsychiatry, and mental healthcare apps. He communicated his frustration during the HBO segment, specifically noting: “There is nothing inherently wrong with teletherapy… In theory, teletherapy can help fill in some of the very real gaps in access, but the reality of these services has often been deeply underwhelming.”
As the Cofounder and CEO of NOCD and a person with obsessive-compulsive disorder (OCD), a serious mental illness (SMI) that is widely misunderstood and affects 2.3% of the population, I can personally understand Mr. Oliver’s dissatisfaction with the US mental healthcare system. Often, Americans who need high-quality services for mental health issues the most are not able to get them. A shortage of licensed mental health professionals is certainly fueling the crisis, but what is most to blame—yet rarely specified—is the healthcare system’s failure to properly channel people with the most severe psychiatric conditions to specialists who are qualified to treat the root cause of their suffering.
The problem has occurred due to two systematic gaps. The first is diagnostic: many licensed mental health professionals do not properly offer evidence-based diagnostic assessments at the start of care. This causes people with severe behavioral health issues to get misdiagnosed based on the symptoms of their suffering, rather than the root cause, and then mistreated by providers who lack the specialty training needed to effectively help them. Imagine suffering with a severe heart condition, getting misdiagnosed due to pain in your arm from it, and then being referred to a hand specialist for treatment. The situation could be life-threatening.
This leads to the second systematic gap. Imagine if hand specialists purposely solicited vulnerable people with severe heart issues by running marketing campaigns online for “life-changing care,” knowing they lack the specialty training needed to treat them. It would be dangerous, irresponsible, and likely illegal. It’s shocking that similar unethical practices have been regularly occurring within the behavioral health system for decades without repercussions. This is a problem I have experienced firsthand.
When I finally discovered that the suffering I was experiencing had a name—OCD—I turned to Google to find a therapist near me who could treat OCD. I searched “OCD specialists in my area” and discovered a large list of providers on various websites, each one of whom claimed they could effectively treat OCD, among dozens of other conditions. When I investigated further, I’d estimate that less than 10% of the providers who were marketing to me actually had specialty training in Exposure and Response Prevention (ERP) therapy, the evidence-based behavioral therapy for OCD.
Let’s think about that for a second. I was severely depressed at the time, a common occurrence for people with OCD and other SMIs. In fact, research suggests people with OCD are ten times more likely to die by suicide than the general population when they’re untreated. Despite my severity and risk level, many of the providers marketing to me were offering “talk therapy” services, which are proven to be ineffective for people with OCD, and can actually be harmful. If I hadn’t found an article from the International OCD Foundation that educated me about the questions to ask licensed mental health professionals before seeking help, I might have gotten worse, and the results could have been catastrophic.
The boom of virtual behavioral health solutions over the past three years has only exacerbated the problem. Many companies under pressure from their investors to scale rapidly have taken the same “shortcut-to-growth” approach as the group practices that predated them. They have specifically failed to comprehensively diagnose people, and they have inaccurately marketed themselves as “one-stop-shops” for treatment, because there are no clear regulations in place against it. The only difference between many virtual behavioral health companies today and behavioral health providers of the past is the aggressiveness of their marketing towards at-risk populations that they do not have the training to treat.
Society has been susceptible to these overly-aggressive campaigns, due to the widespread perception of mental health issues and treatments as homogeneous, a result of lingering stigma and a lack of education surrounding the complexity of the mental healthcare crisis. Companies with sleek brands promise hope, and millions of Americans want to believe that they can deliver. However, their lack of specialization often leaves at-risk people who muster the strength and courage to start their treatment not only with a terrible experience that makes them worse, but also with a deep sense of distrust in future treatments that potentially could transform their lives. Sadly, we are only beginning to see the devastating consequences of these unethical campaigns.
Change is needed, and that’s why we created NOCD. As opposed to building technology designed to profit from the mental healthcare system’s inadequacies and our society’s limited understanding of quality mental health treatment, we started NOCD to improve identification and treatment services for communities suffering with severe mental health conditions, starting with OCD. Our focus on delivering a highly personalized treatment experience has allowed us to serve tens of thousands of members each quarter and has brought considerable positive change to the OCD community, supported by peer-reviewed outcomes, widespread payer reimbursement, and a national network of ERP specialists.
We have also taken a radically transparent approach to running our company, giving our community members the ability to anonymously post unfiltered NOCD Therapy reviews on our website. It is easy to imagine the fear our team had when launching this page, but it is clear to see the long-term value that receiving quality feedback about NOCD Therapy will have on our ability to maintain excellent clinical outcomes and keep members safe as we continue to serve the OCD community. Further, we know candid feedback about NOCD Therapy will have an immediate, positive impact on people with OCD and their families in the community when they decide to seek treatment. Since time is of the essence, they will be able to understand what has and has not worked with NOCD Therapy in a matter of seconds. Here’s a quick summary of what our team has observed.
Takeaways From What Has Been Working
1) Our focus on OCD has led us to offering a strong clinical experience.
People generally love their NOCD Therapist and see positive results: out of 1,076 member ratings over the past twelve months, 96.5% of therapists have an average rating of five stars. Also, in a peer-reviewed study of over 3,500 NOCD Therapy members, people were shown to get significantly better within an average of 14 hours of clinical time, about 50% less time than through standard, outpatient ERP therapy.
A member-first focus on satisfaction and quality outcomes requires commitment and investment. Before NOCD Therapists start treating OCD community members, they spend a considerable amount of time in training to treat OCD with ERP. Moreover, once they are in our network and have begun seeing members, each NOCD Therapist goes through extensive clinical supervision with our clinical leadership team, with continued, data-driven monitoring. Additionally, we are invested in finding the right therapist match for NOCD Therapy members, both by providing in-depth information in our therapist directory and through our personal, white-glove matching process. We ensure each member receives the personalized experience they deserve.
2) Partnering with payers has helped us increase access to affordable OCD treatment.
We contracted with health insurance companies nationally to make specialized OCD treatment in-network for as many people as possible, in hopes that our members only have to pay a copay. The average copay per 60-minute session of NOCD Therapy is less than $50. Additionally, members who are paying out-of-pocket and need financial assistance can elect to pay for their sessions using a payment plan. Our team is proud of this accomplishment, considering most people have paid over $300 per session out-of-pocket to see an ERP specialist therapist for OCD in the past.
3) We’ve built a care model that better fits a chronic condition like OCD.
In addition to offering live, face-to-face sessions, we offer support between sessions inside the NOCD platform from peer community feeds, self-help tools, support groups, and in-app messaging with NOCD Therapists, among other offerings. We realized from experience that we had to build a treatment model that fit the sporadic and persistent nature of OCD, a chronic condition, so people and their families could find support outside of therapy sessions.
Takeaways From What Needs Improvement
1) We underestimated the complexity and continuous need to optimize billing.
When starting a healthcare company, do not underestimate the complexity of managing the revenue cycle. About 15% of our poor member reviews are from challenges surrounding our billing processes. In hindsight, a mistake we made was not investing enough resources into our billing infrastructure while we were trying to keep up with high member demand in 2020 and 2021. As a result, our revenue cycle processes became backed up and did not deliver timely invoices to our members. There is nothing worse than receiving an unexpected and late bill, and we’d like to sincerely apologize again to all of our members who had such an experience.
To address this issue, we developed our own in-house revenue cycle management system and processes, which were finalized earlier this year. Our data shows that the infrastructure in place should improve the billing experience going forward, but if there is a concern, we hope you will reach out to us directly (you can email me personally at firstname.lastname@example.org—I try to respond promptly—or contact email@example.com). We are committed to continually improving in this area.
2) Continuously improving wait times in high-demand states is a must.
We strive to see members within 7 days nationally, but sometimes we miss the mark. Last month, 60% of our members were seen within 7 days, with longer wait times occurring mainly in California and Massachusetts.
To fix this issue, we are staffing more in specific regions of the country, since licensure for mental health professionals is regulated state-by-state. We have also become an NCQA accredited network, which should allow our team to onboard new NOCD Therapists into insurance plans much faster. Finally, we’ve developed new technology to help people who have scheduled their first session more than 7 days in the future move their appointment to an earlier date, should a slot open. Developing an in-house electronic medical record and data pipeline has helped us more easily manage our network capacity.
3) Our therapist transfer processes need to be more effective and efficient.
About 42% of negative reviews involved either a poor transfer experience or a slow transfer process. Transfers are situations when a member needs to switch therapists, often due to their therapist going on extended leave or leaving the NOCD network, or due to other considerations. We strive to make this process as seamless and efficient as possible. However, that isn’t always the case. Moving forward, we will fix this issue by consistently optimizing the NOCD Therapist experience, better predicting our therapist supply and member demand in specific regions of the country, and ensuring our capacity management processes maintain their efficacy.
Join Us In Making a Difference
It is important for the second generation of virtual behavioral health companies to take a strong stance with regard to clinical quality and radical transparency. We hope our actions play a large role in propelling healthcare into the future, as positive mental health is often the foundation of strong physical health. Any company can work to become a second-generation virtual behavioral health company, even if revenue growth was mistakenly prioritized above patient outcomes, needs, and experiences in the past. It is certainly not too late to make positive changes!
To catalyze the next step, on the same day NOCD Therapy launched three years ago, my team and I are announcing the formation of the Virtual Behavioral Health Alliance (VBHA). Any virtual-first behavioral health company that joins the VBHA must prove its commitment to radical transparency and demonstrate consistent, excellent clinical outcomes. Please feel free to learn more about joining the VBHA by emailing us at firstname.lastname@example.org.
Finally, if my team and I can support you in the process as a sounding board or formal referral partner, please don’t hesitate to reach out. There is a lot we have learned from scaling NOCD Therapy. Like most industries, virtual behavioral healthcare was first built with dominos. We have seen some of them fall. Now, it is time to pick up the pieces, learn where need be, and rebuild the system with legos.