Another issue is the cost of medications. Abilify, the medication used for treatment-resistant major depression, is very expensive, said Mumma. “The health plan might be paying more than $1,000 per month” for Abilify, he said. “Add to that the costs of Celexa or other medications, plus the medication management.”
Tracking medical costs
TMS is non-medication based treatment, so there are no drug-drug interactions. But it is expensive, and by itself it can unbalance what is supposed to be a cost-saving device. So at Lancaster, officials are looking at the population health impact in various ways – for example, they will be conducting a 12-month lookback to see if costs were reduced for these patients. However, the unfortunate reality is that much of this data is impossible to get to, said Mumma. The best way to find out would be to track medical costs for Lancaster’s own employees, to see if those who use TMS have lower costs. (Like most hospitals, Lancaster General is self-insured.)
Mumma also has scrutinized the literature, finding that one study showed that the most costly expense to employers was depression, at a cost of more than $350,000 per thousand employees. That isn’t only medical costs, of course, but aggregated costs of medical treatment, pharmacy, absenteeism, and “presenteeism” – in which employees are still at work but unable to function. “If we were to do depression care differently, that’s a huge savings,” said Mumma.
Proving it works by billing insurance
At Lancaster, TMS is only used as indicated – for TRMD – but some physicans are using it off-label for various conditions, said Mumma. Providers can’t bill insurance for off–label uses, but many providers do cash-pay only. Mumma thinks this could be a mistake. “The challenge is that this treatment is so effective, with anecdotal as well as statistical reports, but we won’t see the real benefit until major medical and psychiatric insurance companies realize that by spending a little more on TMS, we are going to reduce the overall costs.”
Mumma wants to differentiate the TMS provided by Lancaster from the “boutique” plans. “We don’t take cash, we put everything through insurance,” he said.
Asked how much Lancaster paid for its TMS equipment, which is made by Neuronetics (the owner of the technology), Mumma demurred. He also was not able to say how much Lancaster charges for the treatment, although he did say it is not a being used as a profit center, but rather as a way to decreases cost for these patients.
Lancaster started offering TMS at the end of August. In mid-November when we interviewed Mumma, there were six patients in active treatment – at 37 minutes a day per patient, not including checking in and checking out, that’s about the most they can have. So far, four patients have graduated into the maintenance phase. An additional 16 are in various stages of the preauthorization process with insurance.
Once insurance companies recognize that TMS can help them save money they would spend elsewhere on these patients, they will be even more supportive of it, said Mumma.
Some researchers are looking at TMS for other conditions, and patients are sometimes so desperate for improvement that they are putting their own money into it, said Mumma. “Shame on the system for making that happen,” he said, adding that there are positive anecdotal results from patients with autism, PTSD, and other conditions.
In clinical trials, suicidality was four times higher in the placebo group than the TMS group, said Mumma. (In the clinical trials, TMS was compared to sham TMS, not compared to medication.)
Major depression is a devastating disease for people who don’t get better, and 40 percent of the patients experience remission, said Mumma, who is not compensated by Neuronetics.
The big question is whether TMS is going to be as effective as electroconvulsive therapy (ECT), said Mumma. Clearly TMS is much more appealing to patients. “ECT is scary as hell, and it has ugly side effects like memory loss,” he said. ECT is effective, but many studies are showing comparable results for people with TMS, said Mumma.
“Nobody’s using the word, ‘cure,’” said Mumma. But TMS is different from medications, he said. “It’s difficult to get off of antidepressants once you get on, and antidepressants are basically a band-aid for a problem – just symptom improvement, not managing the illness.” TMS does allow patients to return to functionality with fewer side effects than medication, said Mumma.