Tue, 08/10/2021 - 15:22
By: Dr. Mark Xuereb, MD, MRCPsych (UK), MRCEM (UK), MMCFD, Director of The TMS Neuromodulator Clinic, Birkirkara, Malta, EU
At least this is the situation in Malta! The major insurance representatives on this sunny and tiny island in the middle of the Mediterranean Sea make it very difficult for patients to get TMS despite fulfilling the required criteria. With a minimum monthly wage of only $950, you can see why Malta’s first and only Neuromodulation Clinic gets angry when the insurance companies turn down any application for standard TMS treatment packages. And, forget about the FDA endorsed 4-6 weeks of treatment for treatment resistant depression. Migraine, OCD and smoking cessation? Don’t even go there! The companies have to ‘check with experts abroad’. Being an ex-British colony, these are presumably British experts and perhaps some local anonymous professionals who never saw or touched a TMS machine.
We are not allowed even to talk to these untouchable ‘experts’ to make a case. There is no locally qualified ‘expert’ who has the equipment, contacts, or experience in the field other than those working in our clinic. The so called ‘experts’ are presumably doctors (who may not even be qualified mental health professionals) whose sole knowledge on TMS is Wikipedia based. Having been exposed to TMS since 2010, and living in Malta, I challenge anyone on the planet to prove me otherwise. The problem is we are the only CTMSS trained TMS team and CTMSS members on the land. It is not the first time that colleagues who have no training, qualifications, or hands-on exposure pontificate against TMS to patients. This is an ongoing challenge which we take with gusto. We have been addressing the issue through education for the past 5 years through media campaigns, education etc. We’re not giving up!
Yet when people suffer, don’t get better, or even commit suicide, interacting with insurance companies becomes frustrating, hair pulling, mindboggling and timewasting, to put it mildly. It is tantamount to one claiming to be an expert in US maritime law simply because ‘I read the research’ and claiming to be as adept in the field as a seasoned LL.M. New Orleans Tulane University maritime law graduate.
This is presumptuousness at its best. Never mind the many meetings, phone calls and emails to show the efficacy and evidence-base guidelines to ‘win them over’ with charm, professionalism, and all other powers of persuasion full on. Been there, done that and bought the T shirt. Most importantly, never mind the patient.
You are asked to fill in pages of insurance papers for nothing. With our wages, most people cannot afford the full 40-60 sessions. Charging them to fill in the forms is akin to blasphemy. In general, insurance companies allow a ceiling of – wait for it - $350 per annum per patient for mental health illnesses and you can’t even get insurance coverage for anxiety as stipulated in the guidelines. All insurance companies have – wonder of wonders – the same criteria. I wonder why? So if you think insurance gives you a hard time in your clinic, think again.
This is why we had to get creative and offer a sliding scale of prices. Most patients can only afford a twice weekly treatment package spanning 5 weeks. We even try to bundle in Stanford-type variant protocols to treat those in need. Needless to say (and without blowing our trumpet) we get good results and hope to make time to publish our data since we pioneered this revolutionary technology in 2016. And yes, we do pro bono (about a third of our sessions are free) because we are not just a commercial enterprise.
You can therefore imagine what happens. The good thing is that we get patients from all over the globe due to our appealing rates ($120 per session for those who can afford it). We even had someone coming all the way from Fresno, California (!) for a holiday which doubled up as a treatment package. The not so good thing is that many patients end up losing faith in TMS ‘ghax il-kalamita ta’ Dr. Mark ma hadmitx fuqi’ (because Dr. Mark’s magnet did not work on me). It is then a challenge for our team members: Rachel, Erica, Michela, Simone, and myself to remind patients that they consented to a sub-optimal, ‘off licence’ package- against our advice - which they and their insurance company could afford.
We need to make TMS affordable to the needy and the masses. We need a concerted global drive to address insurance issues and address the stigma inherent in these insurance policies.
Does the state help? No. The government purchased a cracked neuromodulator which gathered dust for 2 years before it was fired up by non-trained personnel, but that is another story which I might write about. Let’s sort out the insurance pandemic first as one CTMS body on the frontline. We owe it to our patients!
Dr. Mark Xuereb with TMS Administrator Erica Grech and TMS Clinic Manager Rachel Portelli at the TMS Clinic in Malta, EU.