Transcranial Magnetic Stimulation (TMS) may be the best way to help patients with treatment-resistant major depression (TRMD) – people who have tried antidepressants at least once for the appropriate amount of time on the appropriate dose, according to Pete Mumma, Administrative Director of the Behavioral Health Service Line in the Department of Psychiatry at Lancaster General Health in Lancaster, Pennsylvania. But that doesn’t mean it’s easy to “sell” the TMS device to financial people in your institution.
Here’s how Mumma did it: 9.1 percent of the population has depression, and .05 percent has TRMD. These people are “superutilizers,” who consume 18 percent of a health system’s uncompensated or undercompensated spending. “It’s unsustainable,” he said. “We expect people who have extreme needs to be treated in pathway models that don’t meet their needs – what will we do with these patients, not just from a mental health perspective, but from a total medical perspective?”
For example, an individual with TRMD who also has cardiac disease or cancer is going to be very complicated to treat. “Any medical provider who is helping patients with TRMD is going to bump up against some or all of their issues,” said Mumma. Symptoms such as lack of energy, lack of concentration, and sleep problems create further distractions for the patient, he said. The recommendations of the cardiologist or oncologist won’t go as far as they would if the patient didn’t have depression.
The impact of mental health problems on physical treatment is more relevant now than it was in the past because of the way health systems are being reimbursed, said Mumma, citing in particular the penalty for readmissions within 30 days. If a patient fails cardiac treatment – perhaps because he didn’t exercise, something that is notably difficult for people with depression – and needs to be readmitted, that’s a ding to the hospital’s bottom line. “So cardiologists and every other doctor wants to make sure they eliminate barriers to good outcomes,” he said. Mental problems that make it difficult to follow through with physician recommendations are suddenly seen as very important – a good thing for both patients and the health care system.
“We can spend a little money up front to treat the depression, and the patient’s cardiac care goes farther, faster,” said Mumma.
Typically, patients start with a daily course of treatment, which takes about 37 minutes. This would go on for four to six weeks. The treatment is painless and requires no sedation. Once the initial course is done, some patients may come back every three months, said Mumma.
While Mumma can’t give Lancaster cost data, he did share information about the average cost of a session – $300 to $350 per session for a cash patient, five days a week for four to six weeks. That totals a minimum of $6,000 and a maximum of $10,500. What insurance companies and Medicare pay may be less. Providers who look at TMS as a profit center usually don’t deal with insurance, but just cash patients, said Mumma.
What really excited the Lancaster board was the prospect of saving money on the superutilizers who have TRMD by using TMS, said Mumma. Treating the really sick who are typically covered by Medicare – not the best payer as it is – is challenging. “If Medicare doesn’t cover the costs, how can we support TMS for that population?” asked Mumma. “The obvious answer to me is to ask how much we can save Medicare if we were to treat the sickest of the sick. Could we invite them to be more compliant or alliant with treatment through the lifting of major depression? Could we reduce obesity, diabetes, the silent killers?”
Many of these patients use the emergency room two to three times a week because they don’t live near a primary care center, or because their primary care provider doesn’t take Medicare, he said. They tend to call 911 because they can’t drive themselves.
But TMS as being used by Lancaster is not a money-maker – it’s a money-saver. Medicare now does have TMS on the fee schedule in many regions, said Mumma. “Frankly, the fee schedule is neutral to the cost,” he said. “We’re not making money on TMS at the Medicare rate.”
The first line of treatment for depression is medication, but people with TRMD are patients for whom medication isn’t working. On the system side, the clinical benefit is important, but on the patient side, it’s crucial. “The tragic thing is these patients aren’t getting better,” said Mumma of TRMD.
Doing depression care differently – what Mumma is suggesting is avoiding the “shotgun approach” that most depression patients who have tried one medication after another have experienced. At Lancaster, before selecting a medication, the psychiatry department does “pharmacogenetic” testing via a cheek swab to at least narrow down the type of medication to try in the first place. “But many patients get agent after agent, and have had no other options over their lifetime.” Now, at least patients who have failed one course of medication with an appropriate dose and duration have another option.
“Through medications, we’re trying to light up some parts of the brain and quiet others,” said Mumma. That’s the same thing that TMS does – the magnet near the head “reaches deep into the amygdala, which scientists think is responsible for mood,” he said. “Instead of washing the brain with chemicals, this seems to isolate the problem.” Many patients continue to take medications while getting TMS but find they can reduce their medications over time, he added.