Outpatient mental health providers are looking for options to improve patient outcomes and add a new service line to their business.
Transcranial magnetic stimulation (TMS) has come to the fore among a handful of alternative options that may help providers deliver additional value to patients and health plan partners. TMS is growing in popularity as a service line among providers as some national platform companies have added the services to their offerings.
“TMS is effective at getting people into remission,” Dr. Owen Muir, founder of Fermata, told Behavioral Health Business. “That means no more depression. That’s the endpoint we look at.
“If what you want is for your depression to be over, not 50% less miserable, then TMS is a really great choice because it does that reliably with extremely limited adverse effects.”
Fermata is an interventional psychiatric center based in Brooklyn, New York.
Muir said most antidepressants and other medications have limited benefits for most patients but come with serious side effects. While often not considered a first treatment, TMS has more benefits for more people.
The latest science continues to throw cold water on the efficacy of the most common antidepressants. Selective serotonin reuptake inhibitors (SSRIs) don’t work in the way they were originally designed, if they work at all, in people with depression.
One study found that high-dose TMS led to an 87% reduction in depression assessment scores, with 90% of study participants considered to be in remission with their depression. Another study from 2015 found that TMS demonstrates “both a statistical and clinically meaningful durability of acute benefit over 12 months.”
However, TMS fundamentally changes the character of offices and businesses that seek to add this service line, Muir said. It requires practices to be more dedicated to the business aspect of outpatient mental health and health care interventions.
TMS in practice
While TMS is an FDA-cleared intervention for depression and other mental illnesses, health plans often treat it skeptically. This requires behavioral health providers to be ready to engage more staff to handle prior authorizations and other reimbursement issues while working with health plans.
“It’s a lot better now. But even up until a year ago, there was a significant level of things you had to do to get patients qualified for TMS,” Dr. Priyanka, chief medical officer for the Denver-based outpatient mental health provider Mindpath Health, told BHB. Priyanka does not use a last name.
Mindpath Health operates in seven states. It offers psychiatry, therapy, TMS, on-demand services in North Carolina, and esketamine treatments in North and South Carolina.
Several years ago, the company’s top leader wanted to bring in new treatment options. The company saw TMS as an opportunity to engage with providers by offering new training and development options and an alternative for treating patients. It also allowed the company to add to its service line.
But, Priyanka said, TMS is not a panacea from either the clinical or business aspects. It may not be appropriate for all patients in the first place. Additionally, many health plans require patients to try other treatments before giving clearance for TMS.
Mindpath Health had an advantage in rolling out TMS. The company has had offices in California for over 20 years, its original state market. In turn, it had an existing patient base to whom it could introduce the new line of treatment. The company looks for offices in its footprint where clinicians are interested in establishing TMS and have a patient base that may need the treatment.
“It comes with significant investment in making sure that infrastructure is in place,” Priyanka said.
Muir also said that significant overhead comes with offering TMS. The service line fundamentally requires an office, a device and clinicians that are specifically trained and certified to provide treatments.
“You can’t avoid insurance. You can’t avoid having a staff,” Muir said. “You need to have a lease. You need to have a device. You need to have a lease on the device. You need to have technicians. … It’s not a cash cow.”
Adding TMS is not a “casual decision” and shifts the experience from running a therapy practice to running a business, Muir said. Other medical specialties made similar decisions about using medical devices and other major technologies a long time ago. However, outpatient mental health has historically lagged behind other specialties in technology adoption.
“If you’re thinking about doing … TMS, you’re thinking about being a different kind of doctor who’s going to be involved in business decision-making or thinking very seriously about those businesses,” Muir said. “The trade-off for that is that you get vastly better outcomes for your patients.
“This is a life-saving treatment that I frankly could not practice without.”
TMS’ intensity
TMS requires an intensity in both treatment and study that some may find surprising.
A course of treatment described by the U.S. Department of Veterans Affairs requires patients to come in for 3 to 40 minutes a day, for anywhere from a week to 8 weeks.
More intensive courses of treatment, or accelerated pattern of treatment, do 10 treatments a day across five days. More common treatment courses are 36 once-daily treatments for a few minutes or until the patient is in remission. Treatment can last between 4 and 6 weeks, Muir said.
In an accelerated treatment course, which is what Muir provides in his practice, the patient is in the office for 10 hours and gets 8.5 minutes of treatment by the TMS device per hour.
“The remission rate in that course is 79%,” Muir said. “It’s also rapid-acting, which matters if you’re cripplingly depressed.”
TMS is cleared to treat depression, obsessive-compulsive disorder, smoking cessation and anxious depression.
There are many types of devices and companies that offer TMS devices. Anthony Barker, the inventor of the figure-eight magnetic coil used in most TMS devices, did not file a patent, leading several companies to develop their own versions. Muir said there are near-infinite potential variations in the type and intensity of TMS.
Some well-known device manufacturers include BrainsWay Ltd. (Nasdaq: BWAY), MagVenture, CloudTMS and Neuronetics Inc.
Offering more value
The wider behavioral health industry is seeing a slow but continuous movement toward value-based care. While widely varied in conception, most arrangements between payers and providers account for some accountability in care outcomes or processes. Adding TMS may help providers engage in value-based care practices better.
Mindful Health Solutions steps patients through different levels of treatment rather than taking them straight to intensive treatments, the company’s CEO John Minahan previously told BHB. Specifically, its providers encourage patients to try TMS before opting for ketamine treatment because its impact is more durable.
“We’ve found something that helps them (patients) go enjoy their lives without having to continue to be on a drug,” Minahan said. “Not everyone is going to get TMS first, … but we look at what the patients need first.”
Mindful Health Solutions and Mindpath Health focus on operating on an in-network basis, making partnerships with health plans vital to their businesses. However, access to TMS even, for patients using in-network coverage, is still challenging.
“Outcomes in TMS are very important to push on the clinical and patient sides, but also the payer side of it all,” Priyanka said. “If patients are seeing the benefit, then why not make access easier.”
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