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I need to understand the current payment processes for rTMS treatment (for MDD patients) by the different stakeholders (national health systems / public and private payers / insurance ect.) in Germany. I need to deeply understand the rTMS ecosystem in these countries including the current annual market size.
Germany has a reputation for having one of the best healthcare systems in the world. The two main stakeholders in its healthcare industry are the Government Health Insurance System (GKV) and Private Health Insurance (PKV) companies.
Most German residents (approximately 70 million people out of a population of around 80 million) are members of the government health system: this equates to around 85% of the population. Those with a gross salary of less than 57,600 Euros per year or 4,800 Euros per month must be members of the GKV. However, those with enough expendable income can seek to be covered either partially or fully by PKV. PKV users make up the remaining 15% of the population.
PKV covers a wider choice of medical and dental treatment than the government-run system. The cost of full private medical insurance is based on the level of benefits chosen; the entry age of the user; and any preexisting medical conditions.
The number of German patients with Major Depressive Disorder (MDD) who have sought rTMS treatment has steadily risen over the past decade. While there is no clear evidence for the exact market size of the industry, it is clearly becoming a more popular method of treatment among the German population.
THE Government Health Insurance System (GKV) and rtms
Unfortunately, the German Government Health Insurance System does not usually cover rTMS treatment at the present time. Numerous providers of the treatment state that this is the case: for example, the company NeuroCare claims that their rTMS program is not normally covered by the GKV. However, they recommend that each patient undergoes an individual GKV assessment to confirm this, just in case an exception can be made. Similarly, rTMS provider PlusPatient states that the treatment is not currently a regular benefit of GKV. Thus, it is safe to assume that the treatment coverage of rTMS by this particular stakeholder is practically non-existent.
Private Health Insurance (PKV) and rtms
Private health insurance is a huge business in Germany; in 2016, the industry was worth 25542.7 million euros. Generally, private health insurance policies cover more forms of treatment than the GKV - this often includes coverage of rTMS.
Numerous rTMS providers state on their official websites that private health insurance usually covers their treatment. According to the company Magnetstimulation, nearly all private insurance policies cover their range of services. NeuroCare and PlusPatient are both vague regarding this, stating that while many private insurance providers do cover rTMS (it is always best to clarify this before embarking upon treatment). Likewise, the extent to which rTMS is covered can depend on the individual's policy details.
Private healthcare insurers themselves do not readily specify in the public domain whether they cover rTMS treatment or not. Many policies do include treatment for mental health conditions, including any "additional technique" that a patient needs aside from medication or therapy to treat their condition. rTMS could well fall under the "additional" category. There is no way of confirming this with the information available; however, the information from Magnetstimulation suggests that this is the case with at least some providers.
It is, however, key to note that the unique contract made between the patient and the insurance company will greatly affect which exact treatments are covered.
If rTMS is covered as an "additional" mental health treatment in private health insurance policies, between 80% and 100% of the treatment's cost will be covered by the insurance company (depending on the individual patient's policy). To translate this into real monetary terms, we can use the pricing information given by the website rTMS Neuromodulation. This particular doctor charges 70.52 euros per rTMS session for patients using private insurance, or 1500 euros for a bulk purchase of 20 sessions. If a patient were to have the minimum policy of 80% of the cost being covered by insurance, 56.41 euros per session or 1200 Euros for the bulk-bought sessions would be paid by their insurance company. Of course, the exact amount covered would constantly change on a case-by-case basis.
There are no figures that reveal exactly how much rTMS treatment is covered by private insurance. However, since government insurance very rarely pays for rTMS, we can safely conclude that the private insurance sector covers most of the costs. While some rTMS providers' websites suggest that the individual can pay up front for the treatment without using insurance, there is no publicly published data that outlines how common this practice is.
Conclusion
Two major stakeholders exist in the German healthcare insurance industry: the GKV and PKV companies. It has been firmly established that the GKV covers rTMS treatment for patients with MDD only very rarely, if at all. This logically leads to the conclusion that PKV must cover this treatment. However, the extent to which this occurs in reality is unclear. Whether a private insurance policy covers rTMS is down to both the approach of the company to mental health treatments, and the specific policy held by the patient. It is highly advisable that any German patient hoping to undertake rTMS should contact their health insurance company for a case-by-case examination, since that is the only way to know if the treatment can or will be covered.