Green Hills doctor’s efforts get Medicare nod for new therapy

Move could open door to private insurers

A Green Hills doctor’s impassioned but unlikely lobbying effort has paid off with the nation’s largest public health insurer: Medicare.

As a result, Middle Tennessee psychiatrists, as of Dec. 1, are among the first in the nation to receive Medicare reimbursement for an expensive new treatment for depression, the only FDA-approved therapy of its kind.

Dr. Scott West, who pioneered Neurostar TMS (transcranial magnetic stimulation) Therapy® in Nashville in 2010, began advocating for extended coverage of the treatment last year after finding success with several patients.

Now Tennessee, Georgia and Alabama are one of two Medicare regions (New England is the other) where TMS therapy is covered. West and other advocates hope commercial insurers will follow, which could lead to a significant new revenue stream for area doctors.

“I sent several letters to every insurer that works in Tennessee,” West said. “I believe in this treatment and explained the benefits,” which, he said, include keeping patients out of the hospital — a central goal in health care reform.

The health insurance industry has been wary of the treatment, which uses MRI-strength magnetic pulses to non-invasively stimulate the part of the brain that regulates mood, and very few plans cover the pricey therapy. A full treatment of 20 to 40 sessions can cost patients $8,000 to $12,000 in out-of-pocket costs.

When West began his campaign, Tennessee’s Medicare Benefit Administrator, a Birmingham-based unit called Cahaba GBA, was reviewing fee structures, and the treatment was on its radar. West’s letters heightened the group’s interest, and the review board arranged a conference call to allow West and other regional psychiatrists to make the case for TMS.

The board’s decision to cover the therapy guarantees Medicare coverage for 80 percent of a patient’s cost.

The entrance of private payers would make the therapy available to more patients, but also would help cover physicians’ costs. The high-tech chair, where the treatment is administered, can alone cost $70,000 to $100,000.

West treats about seven patients a day with the therapy. One 40-minute session costs a privately insured patient about $400 but, as of Dec. 1, will cost a Medicare patient $164.33, of which all but $32.87 will be reimbursed by the government. The 2013 reimbursement rate for the treatment has not yet been set.

Several of the seven physicians in Greater Nashville who offer the therapy don’t foresee changes to their business plans just yet. Dr. Kent Colburn of Heritage Medical Associates has 32 Neurostar TMS Therapy patients. He stressed his enthusiasm for TMS, but he doesn’t expect to expand his services yet, given the rate that Medicare is paying.

BlueCross BlueShield of Tennessee spokeswoman Kelly Allen said the Medicare decision does not guarantee private insurers will follow suit, but it may help.

“Our review board is always looking at treatments like this,” she said. “It may mean that our review board may pull it up again sooner rather than later, but as of right now no decision has been made.”

Source: Nashville Business Journal