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Jesse Bennett

TMS 10 Years Later

I’m always a fan of new treatment technologies. Each new treatment technology (whether a new medication, new clinical practice, new device, new app) represents more options for consumers and pushes competition (both in terms of outcomes and price).

But any new treatment approach has an uphill climb to get to widespread adoption. The reasons are many—and we’ve written about them before (see Going ‘Over The Rainbow’ To Tech Oz and The Snags In ‘Speed To Market’ For Health Care Innovations). Even for a treatment technology as basic as telehealth, only 18% of consumers have participated in an online treatment session. There is a large segment of consumers who are hesitant about using telehealth—Iand an under-investment in telehealth platforms by provider organizations (see Telehealth Gains Popularity, Telehealth Budgets Don’t).

An interesting case study of the evolutionary adoption of new treatment technology is transcranial magnetic stimulation (TMS)—the application of MRI strength magnetic field pulses to the left pre-frontal cortex (for a quick dive into this tech, check out Where Does TMS Fit In The New Landscape?). It has been ten years since the first TMS application, NeuroStar TMS Therapy, was approved by the Food and Drug Administration (FDA) for the treatment of depression (see FDA Approves NeuroStar TMS Therapy as Treatment for Depression).

So where are we? TMS has now gained coverage by 36 insurers, five Medicare Advantage plans, and one Medicaid plan in Vermont (see TMS Insurance Information); and this therapy is now part of the basic TRICARE benefit (see TRICARE Now Covers Transcranial Magnetic Stimulation For Major Depressive Disorder). NeuroStar TMS Therapy reports that 300 million consumers have insurance policies that cover their device (see Widespread Insurance Coverage For NeuroStar TMS Therapy) and consumers have received more than 1.7 million treatments NeuroStar Advanced Therapy Reaches Monumental Milestone Of 1.7 Million Treatments In The U.S.).

Since that time, the FDA has approved other applications of TMS for depression treatment. In 2013, the FDA approved Brainsway’s TMS device as a therapy for treatment-resistant depression (see FDA Approves Brainsway’s Deep TMS Depression Treatment Device), and just recently approved a new stimulator to be integrated into Brainsway’s device (see Acceptance Growing for BrainsWay’s Depression Therapy). Last November, Nextrim received FDA approval for its Navigated Brain Therapy TMS system (see Nexstim Launches NBT Major Depressive Disorder TMS Treatment Device In US), and is preparing to launch the system in the U.S. for major depressive disorder (MDD).

Over the past decade, there has been an increasing number of studies of additional applications for the technology, including improving refractory depression in consumers with borderline personality disorder (see Repetitive TMS Shows Promise for Treating Depression in BPD); improving the effectiveness of post traumatic stress disorder treatment (see Neuroscientists Use Magnetic Stimulation To Amplify PTSD Therapy); continued research into autism treatment and a decrease in autism symptoms (see TMS in Clinical Trials as Treatment for Autism and Magnetic Brain Stimulation Shown to Decrease Symptoms of Autism); the prevention of migraines (see Daily Use Of Handheld eNeura SpringTMS Device Prevents Migraine Attacks); the reduction of auditory hallucinations (see High-Intensity Transcranial Magnetic Stimulation Reduces Severity Of Auditory Hallucinations); and increased walking speed and improved fine motor movements during rehabilitation for stroke (see For Stroke Victims, Brain Magnetic Stimulation Leads To Improved Walking Speed).

So where are provider organizations with TMS? After a decade, it remains an exception rather than the rule in most clinical settings treating depression. In a panel discussion that I facilitated last fall, Victor Topo, MSW, Chief Executive Officer, Center For Life Management and an early adopter of TMS, spoke of the challenges (see Emerging Science Shaping Behavioral Health Service Delivery). He said there were certainly reimbursement issues—the Medicaid plan in his state (New Hampshire) does not cover TMS. But he spoke about getting more “ownership” of new treatment technologies across his clinical team; of the need for reengineering staff roles and responsibilities to accommodate offering TMS; and the need for a more robust business plan for the TMS service line. Culture, process reengineering, and feasibility analysis are common issues not just in launching TMS, but in launching any new treatment technology. I recently touched base with Mr. Topo, who noted:

Vic Topo

It seems strange that it’s the TMS 10-year anniversary. I would say challenges fall into three “C” buckets: Clinical, Culture, and Coverage. First, it’s tough getting clinicians to be open minded to a new approach, especially those who have been practicing for quite some time and are skeptical of neurotech as a new solution. Secondly, getting employees in traditional CMHC to adjust and accommodate a new solution is a cultural challenge. I guess that’s why they call it “disruptive.”

And finally, and this was the biggest customer impact challenge, coverage. Early on, in 2010, payers resisted paying for it. One insurer told me it was still considered “experimental.” A few companies out West covered it immediately and then slowly, one by one, virtually all fell in line within three years. Even Medicare came around. To this day, however, Medicaid is still a big barrier.

The ten-year trajectory of TMS has lessons for both executives of provider organizations and executives of organizations that want to introduce new treatment technology. Expect slow going (no matter how good the solution)—but also tend to the basics of best practice “proof of concept” to keep the process moving. The organizations that can accelerate that adoption process are organizations that will have the clear competitive advantage. Investments in technology takes rational decisionmaking, with a focus on strategy and ROI.

For more, join me on October 24 at The 2018 OPEN MINDS Technology & Informatics Institute for my plenary address, “Meeting The Innovation Challenge In Health & Human Services: Building A Nimble Management Team To Respond To Opportunities In A Value-Based Market.”