OCD AND MANAGED CARE: ONE SIZE DOES NOT FIT ALL

By Richard S. Schloss, M.D., copyright 1999

As a psychiatrist who treats a large number of OCD patients, I have witnessed the increasing intrusion of managed care into the field of mental health over the past few years, and the resulting erosion of the availability of quality care to anyone with basic health coverage. Sufferers of Obsessive-Compulsive Disorder are, in my opinion, especially vulnerable to the kinds of restrictions to appropriate care that most managed mental health plans impose. OCD may be known as "The Doubting Disease," but when it comes to managed care, we should all have some serious doubts.

First and foremost must be the lack of confidentiality that is the cornerstone of managed care. Many of my patients initially sought help reluctantly, waiting until their anguish became intolerable after suffering in silence for years, because of fear of embarrassment at being thought of as crazy or bizarre. Some had even successfully kept their OCD secret from their spouses for twenty years or more! Yet the very first demand that the managed care plan imposes is full access to the psychiatrist's confidential patient records, as well as the submission of frequent treatment update reports which are subjected to scrutiny by nameless, faceless "reviewers." Many patients who have turned their lives around while under my care would never have presented themselves in my office in the first place if they had thought that their most intimate thoughts would be dutifully relayed to some managed care reviewer in another state.

Secondly, and no less important, is the narrow choice of psychiatrists and therapists imposed by the managed care plans. Although the situation is slowly improving, there are still, sadly, large numbers of psychiatrists, psychologists, and social workers who have little more than a passing acquaintance with OCD. Yet these are the very practitioners to whom managed care plans refer when patients call their toll-free numbers seeking help. None of the many managed care organizations that have unsuccessfully solicited me to join their "panels" have ever asked in their applications, "What is your experience in treating OCD and related disorders?" Would anyone submit himself to treatment of, say, skin cancer by a dermatologist who admitted that he was unfamiliar with the particular kind of malignancy being seen? Yet that is precisely the situation in which managed care plans tend to place their patients with OCD.

I have heard too many reports from patients of therapists in these plans attempting to treat OCD with psychoanalytically-based psychotherapy, which has been shown repeatedly to be ineffective for reducing obsessions or compulsions. Patients with unwanted, intrusive thoughts of violence are told that they secretly harbor unconscious wishes to harm their loved ones, which is counter to our current understanding of OCD, and which may actually have a counter-therapeutic effect and make symptoms worse. Other patients have been told flatly that "CBT (Cognitive-Behavioral Therapy) does not work for obsessions," even though the therapists in our office have successfully used CBT to reduce or eliminate obsessions as well as compulsions in many patients. Similarly, psychiatrists who have little experience in treating obsessions and compulsions will prescribe one of the current FDA-approved medications for OCD, but may not know how long to wait before increasing the dose, or how to manage common side-effects without having to stop the medication entirely. They may also be unaware of effective schemes for combining medications to improve results, which is frequently required in the treatment of OCD.

This brings me to the third and final way in which managed care plans negatively interfere with the treatment of OCD: through the use of formulary restrictions, which limit the psychiatrist's choice of therapeutic agents to prescribe. Although there are now five medications on the market with FDA-approved indications for OCD, they are pharmacologically distinct from each other, and patients wilt typically have different responses to different agents, in terms of both therapeutic results and side-effects. Yet managed care formulary rules will limit the psychiatrist to only one or two of these medications, and will refuse to pay for "non-formulary drugs." They may also balk at combinations of agents with similar indications, citing "duplication." I have personally run into these roadblocks with patients already seeing me outside of their plans who are seeking reimbursement for their prescriptions; those patients who could afford it have elected to pay out-of-pocket for the medications that helped them, but others have had to compromise their treatment.

It is for these reasons that I made the decision last year to not accept any managed care plans in my practice. Although it has reduced my income somewhat, I can treat all of my patients secure in the knowledge that I am not allowing my best judgment to be swayed by "what the plan will allow." OCD sufferers, too, should stand up and demand access to optimal treatment without arbitrary restrictions imposed solely to maximize the profits of the big insurers. Your mental health is too important to allow the decisions that will determine whether you get well--or stay incapacitated--to be made by an insurance company employee who has never met you, and who has no understanding of what it's like to live with OCD.