Why don’t medical aids pay for TMS yet? When will funders pay for TMS in South Africa?
As a psychiatrist, I have seen the immense benefits of Transcranial Magnetic Stimulation (TMS) for patients suffering from depression and other mental health conditions. TMS is a non-invasive, safe, and effective treatment that uses magnetic fields to stimulate specific brain sites. Although it is a relatively new treatment modality in South Africa, it is well-established internationally.
I started engaging with the medical aids by motivating for TMS in individual patients. Quickly I realized that this was going nowhere. Medical Aids did not know what to do with those motivations. They did not know what TMS was and did not have processes like codes in place.
It has been an intriguing education for me. I learnt that the funders have a special team to review the evidence and evaluate costs. Discovery has the Centre for Clinical Excellence and Strategic Risk. Medscheme has a Health Policy Unit.
The first thing the funders wanted to know was, “What do psychiatrists think of this treatment?”
Most South African psychiatrists in the private and public sectors belong to SASOP (South African Society of Psychiatrists). SASOP is a guild that tries to maintain the standards of the profession. The last treatment guidelines for depression were released by SASOP in 2013. In 2013, TMS was just emerging on the world stage as a treatment possibility. Clearly, could not look to those guidelines for an opinion on TMS.
Fortunately, SASOP is very aware of the need for current treatment guidelines. 2022/2023 has seen the gathering of thought leaders reviewing evidence to form new treatment guidelines- so-called Treatment Pathways. A Special Interest Group (SIG) was formed to look into “Interventional Psychiatry” In Pathways, TMS is a clear treatment branch, particularly for treatment-resistant depression.
With that validation in place, funders were now willing to collaboratively engage in evaluating TMS.
They wanted to look at several steps:
- Side effects and risks
- The patient population- inclusion and exclusion criteria
- The machinery
- The special training needed
- The costs involved
For each step, evidence was collated, and meetings were called. I have been forced to look deep into the evidence. I think that I could write a PhD on the subject!
We are now a year into the process. The funders have approved of TMS treatment in concept but are unsure what the process should look like. So, we are not there yet.
I am alternately frustrated and impressed.
Frustrated because I am a clinician daily seeing patients who would benefit but can’t afford TMS.
Impressed because the process is very thorough. If your medical aid pays for a particular treatment, you can be satisfied that there is good evidence for that treatment.
Ultimately, I feel honoured to be part of a process with the ultimate goal of providing better patient care