A new national study of one million commercially insured patients found obsessive-compulsive disorder (OCD) as a primary diagnosis is dramatically under-represented in healthcare claims. The research shows this under-representation leads to inappropriate care that promotes healthcare system overutilization and, ultimately, extends the suffering of behavioral health patients.
The study, “Insights Into the Cost of Care for OCD,” compares the recognized one-year prevalence of OCD in the U.S. population1 to the one-year prevalence of OCD in the IBM MarketScan* commercial healthcare claims dataset. The study results were presented today at the Going Digital: Behavioral Health Tech conférence.
The study found 437 members per million identified as OCD patients in the sample. That’s merely 4% of 12,000 members expected to be identified as OCD patients in a one-million-person sample, based on the recognized one-year prevalence of 1.2% and lifetime prevalence of 2.3% in the U.S. population.2 This indicates 96% of the OCD population in the sample is not being treated for OCD as a primary diagnosis. They are hidden, or “submerged,” within the member population as a result of being unidentified or misdiagnosed.
The study found 437 members per million identified as OCD patients in the sample. That’s merely 4% of 12,000 members expected to be identified as OCD patients in a one-million-person sample, based on the recognized 1.2% U.S. population prevalence2. This indicates 96% of the OCD population in the sample is not being treated for OCD as a primary diagnosis. They are hidden, or “submerged,” within the member population as a result of being unidentified or misdiagnosed.
The likely reason: Patients with OCD are at high risk (up to 90%) of having comorbid conditions3, such as major depression and other anxiety disorders. These comorbidities then become the primary diagnosis and drive the levels of care that OCD patients transition through. The medical evidence, however, indicates that an accurate assessment of OCD and anxiety comorbidities is necessary to achieve a proper treatment.4
As a result, this gross under-representation becomes a revolving door of inappropriate, less effective care that can exceed 30 site-of-service transitions. These care transitions can increase the average annual behavioral health cost for high-acuity members to as much as $125,000 each, compared to $2,600 each for low-acuity members (i.e., indicating a correct diagnosis and level of care).
The study found the total behavioral healthcare cost for the 437 OCD members identified was approximately $12,276 per member, amounting to a behavioral health spend of $5.3 million annually. The total cost of care for the remaining OCD population (the hidden 96%) was roughly $8,6005 per member, amounting to $98.9 million in behavioral health spend, much of which paid for inappropriate or otherwise wasteful care.
Summing it up, the total OCD population, including identified and submerged (hidden) members, reveals that payers are spending about $104.2 million per year per one million members, or $8.69 PMPM6, to achieve unintended outcomes in many, if not most, of these behavioral health cases.
“When you consider the lifetime prevalence for OCD in the U.S. population is 2.3%7, and apply these findings to the entire commercially insured population, you discover payers are losing billions annually by not robustly identifying and effectively treating OCD sufferers in their member populations,” said Stephen Smith, chief executive officer of NOCD. “That’s because OCD often doesn’t hit the primary diagnosis that psychiatrists, psychologists, and clinical social workers use, and many don’t have a large patient roster of people that they perceive to have OCD. And when OCD is misdiagnosed or underdiagnosed, it won’t appear in the claims—so payers don’t know they have a problem, because they can’t see the problem.”
The research project, commissioned by NOCD and undertaken by Santa Barbara Actuaries Inc. (SBA), is based on a one-million-person sample of the IBM MarketScan* commercial healthcare claims dataset. The model has validity for predicting the likely prevalence, costs, and outcomes of a population that mirrors the average U.S. commercially insured distribution.
Analysts looked at millions of de-identified (anonymized) commercial healthcare claims, isolated confirmed OCD diagnoses of health plan members among the total population, and uncovered care utilization patterns and costs related to care transitions. The analysts also created statistically relevant criteria for identification of OCD patients as a submerged population, and a financial model that payers can use to examine outcomes of better screening to identify and treat OCD in co-morbid populations.
“We wanted to study a large population, around a million or so people, because that’s what payers need to see,” said Dr. Jamie Feusner, chief medical officer of NOCD. “That’s when you get to clinical validity—where the sample size is big enough to see variability in the utilization pattern—which is very good for understanding patient journeys or the episode of care, as well as measuring a condition’s prevalence in claims data, and the range of treatment costs. Payers will see that in the study, and can see how that might be affecting their own member population by using the financial modeling tool.”
Ian Duncan, Ph.D. FSA, president of Santa Barbara Actuaries agrees: “The data indicate that this is a missed opportunity for payers and employers to offer their members the right care at the right time. The cost of this identified population is $5.3 million annually, and the cost drivers are high levels of utilization, particularly transitions, through high-cost of care settings in, for example, the emergency room, residential treatment centers, and partial hospital programs.”
The full “Insights Into the Cost of Care for OCD” report is available free of charge to the public, and can be downloaded here. In addition, summary findings from the actuarial spreadsheet can be requested by payers and members of the press via the above link, and payers can also request access to the interactive financial modeling tool.
“This is eye-opening data that can help us change the conversation around mental health, and change how we deliver behavioral healthcare,” said Solome Tibebu, founder and host of the 2021 Going Digital: Behavioral Health Tech conference. “The report shows the potential impact we can have by taking a hard look at the data, and a fresh look at the practices and technologies we use to treat behavioral health conditions. We can advance our understanding of OCD in the population, and introduce better approaches to reduce the high cost of mental health conditions on people and society.”
About the Going Digital: Behavioral Health Tech Conference
The Going Digital: Behavioral Health Tech conference is the leading virtual behavioral health convening for health plans, employers, benefits professionals, health systems, providers, investors, and startups to share best practices for deploying effective, scalable behavioral health solutions to all individuals in light of COVID-19 and beyond. This virtual forum will showcase the changing technological, reimbursement, and policy landscape for telehealth and other virtual behavioral health solutions. Join us and thousands of other healthcare professionals working to make mental health and substance-use care more accessible for all. All proceeds of the event will support BEAM (Black Emotional Mental Health and Wellness Collective).
About Santa Barbara Actuaries Inc.
Santa Barbara Actuaries is an actuarial consulting firm that assists clients in developing economic models to demonstrate the financial efficacy of healthcare devices and intervention programs. Learn more at www.sbactuaries.com.
About NOCD Inc.
NOCD (https://www.nocd.com) is the #1 telehealth provider for the treatment of obsessive-compulsive disorder (OCD). We help people reclaim their lives with clinically proven OCD treatment, by removing barriers to OCD care, and by reducing the stigma associated with OCD. Our innovative telehealth platform lets members quickly access our national network of licensed therapists who specialize in Exposure and Response Prevention (ERP), the “gold standard” for OCD treatment. Working together with our therapists, patients, health plans, providers, and employers, we are improving the lives of people with OCD. Please visit our website for more information about NOCD.
* Certain data used in this study were supplied by International Business Machines Corporation (IBM). Any analysis, interpretation, or conclusion based on these data is solely that of the authors and not International Business Machines Corporation.
5 SBA’s analysis accounted for 70% of known costs of this population. The Inpatient spend accounts for the remaining 30% was not included, as it could be related to other mental and physical health comorbidities.
6 Per member, per month