A new model for OCD treatment

Today we’re glad to share this article by Stephen Smith, Founder and CEO of nOCD.

Note: We’ve changed this person’s name to John to protect his privacy. 

It’s a story many of us can relate to.

After struggling with debilitating anxiety for years, and seeing a bunch of therapists in New York City who weren’t really sure how to help, John was finally diagnosed with obsessive-compulsive disorder: a moment of clarity that might’ve made John feel hopeful again.

But instead of enjoying any kind of transformation, he quickly learned that each hour-long appointment with an OCD specialist would cost him about $300 out of pocket. Getting appointments in would force him to take time away from work, or even miss a day, every single week. Worst of all, John knew that even once he’d found a suitable clinician it might take six to eight months before he could get off their waiting list and start making progress.

In essence, the mental health treatment system was preventing him from getting the help he really needed. Discouraged, feeling unable to deal with all these logistical burdens tacked onto his significant daily distress, John continued to struggle in silence.


It’s a story that sparks anger in many of us.

If John had been diagnosed with a different chronic condition, he most likely would’ve been able to get help faster– including a specialist to direct him, a care team to facilitate treatment compliance, and a community of others with OCD to offer him support.

Take the diabetes treatment industry, for example. People with diabetes can see an endocrinologist, use a service like Livongo through their employers or as individuals, participate in online support communities, and enjoy the support of their health plan in covering care.

Ideally we’d be saying the same thing about OCD, but the unfortunate truth is that the economics of OCD are especially daunting.

It’s a story that raises a whole bunch of questions.

What makes the OCD treatment industry different from that for other chronic conditions?

Why is OCD treatment so expensive for people like John?

Why won’t John’s OCD specialist accept insurance?

Why does John have to wait six months before he can schedule a consultation?

The questions are endless.


It’s a story that’s rooted in broken economics.

In the United States, where things are relatively good compared to almost any other country around the world, there are about 2,000 OCD specialists tasked with treating approximately 8.5 million people with OCD– about 2.5% of the adult population, and 1% of children.

Of course, the miseducation and stigma that keep many of these 8.5 million from recognizing their symptoms and seeking treatment don’t help. But millions do seek help in one way or another, revealing a major shortage of OCD specialists. This is especially disheartening given the fact that OCD is one of the top five most prevalent mental illnesses and was named by the World Health Organization as a top-ten most debilitating condition.

Given the specialized, time-intensive nature of Exposure and Response Prevention (ERP)– the gold standard for OCD treatment– and the lack of effective care coordination, most providers can only see about 40 patients per month, meaning only about 80,000 of the 8.5 million people with OCD in the US would even theoretically have access to the best care.

Further, because OCD specialists work alone in treating their patients and their degree takes years to earn, they charge at least $150-$250 per hour– consistent with other specialized healthcare providers. But payers will often reimburse them only $50 per hour for their services, which means OCD specialists have two options: charge their patients a massive copayment, or go cash-only.


That’s where the conversation shifts to payers. Why are payers reimbursing $50 or less per hour for mental health services? Many say it’s because of the stigma surrounding mental health, but that’s not the whole story. Payers are asked to treat a wide variety of populations, so in order to stay in business (remember that most are for-profit, publicly traded entities) they prioritize the management of populations that cost them the most to treat.

Because 60-90% of mental health-related data isn’t logged in an electronic health record (EHR) and 50% of OCD patients don’t get diagnosed or coded properly, payers today are mostly unaware of the huge clinical and economic impacts of untreated OCD. This makes it difficult for them to see, for example, that up to 40% of people with OCD end up developing severe and costly comorbidities like substance use disorders (SUDs).

Payers are heavily focused on improving the management of SUDs because they see the direct economic impact they have on their costs. So what might happen to their stance on OCD if they were to acknowledge that it’s the cause of millions of Americans’ SUDs, causing untreated people like John to become at-risk? Although public health research continues to make these correlations clearer, the industry needs to collect more population-level data so payers can see the long-term cost savings opportunity associated with reimbursing OCD treatment.


But it’s a story that can have a happy ending.

Is there really a way to align the economics of the OCD treatment system so the 2,000 OCD specialists in the U.S. can help the millions of untreated OCD patients like John get insurance-covered care without having to exert more time and effort?

With technology, the answer is yes, since it will allow the same number of providers to coordinate care more effectively and see a far greater number of patients. Imagine a world where anyone with OCD can see a specialist once a month, talk with a team of OCD teletherapists and peer support specialists every week, enjoy 24/7 access to a digital platform for CBT and ERP, and connect with others who understand their experiences in an online support community. With this tiered model, patients can effectively get care whenever they need it. And it makes sense financially for this treatment model to be covered by payers and promoted by providers.

In a tiered OCD treatment model, payers can save money on treatment both immediately and long-term, as the cost of treating each patient per visit will decrease. Patients would see their specialist provider about half as often, and would get quicker access to care, preventing them from developing severe and costly comorbidities.

In addition, OCD specialists can see more high-acuity patients each hour, as they can refer a larger percentage of their caseload to OCD coaches who manage the middle of the pyramid and help the specialists see six times as many patients per hour, on average. By allowing specialists to see more high-acuity patients, they can generate much more revenue, as a larger percentage of their patients will need more healthcare-related services.

The incentives are aligned in a tiered system, helping patients get better more quickly and more reliably, relieving the intense pressure providers feel today, and limiting costs for providers. 


Here’s an example of the impact that steps-based care could have for people with OCD, like John, in New York City alone.

In the New York City metropolitan area, there are roughly 20.3 million people. By the national average, about 500,000 of them are probably struggling with OCD. Public health research suggests that only about half of the OCD population seeks treatment– about 250,000 people in the NYC area.

Based on nOCD’s data, there are about 200 clinicians in this area who are trained to effectively treat OCD, which indicates that each provider would need to have the ability to see about 1,250 patients per month. That would be about thirty times as many patients as they see today, based on the national average. With a steps-based care model, the cohort of people with OCD whose symptoms are most severe– about 10%, or 50,000 people– would go to appointments weekly. At these visits, they’d see an OCD specialist for about 10 minutes and an “ERP administrator” for the rest of the time.

With this structure, an NYC OCD specialist would see the 250 most severe patients three out of five days each week. Then, the 200 providers would spend the remainder of their week seeing about 1000 patients whose symptoms are less severe– people who can go weeks or even months without seeing an expensive specialist while getting care from a combination of free technology, low-cost peer supporters, and teletherapy-based OCD coaches.

 

Given the need for more OCD-specific coaches, ERP administrators, peer supporters, and free technology, nOCD is committed to creating this “middle of the pyramid,” aligning the treatment system’s economics in a way that offers people with OCD like John access to care– no matter their age, location, or socioeconomic status. We’re training providers to specialize in OCD, creating innovative technology, and spreading awareness, so people with OCD everywhere can feel better. As 2018 progresses, be on the lookout for updates on nOCD’s work of bringing always-on care to everyone with OCD. Thank you for your support.

Thanks to Stephen for sharing this article with us today.

Patrick Carey

Author Patrick Carey

Patrick writes for our blog, app, and website. On weekends he drinks a ton of coffee and wishes he had his own dog.

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