Toronto-based Greenbrook TMS Inc. (Nasdaq: GBNH) has been kicked off the Nasdaq Stock Market LLC.
On Friday, the transcranial magnetic stimulation (TMS) and Spravato clinic provider announced it had received a final delisting notice from the stock market. The suspension is effective as of the opening of trading on Feb. 26. It’s unclear when shares will be listed on other over-the-counter (OTC) securities markets, according to a press release.
“After careful consideration, the company determined that it was in the overall best interests of the company not to appeal the decision,” the release states.
Greenbrook TMS first received two violation notices in May 2023. One was for its share price falling below $1 and another for its total share value slipping under $35 million for 30 consecutive days. The company had until Nov. 13, 2023, to remedy the violations.
The company has not responded to a request for comment. Its stock price was 13 cents per share on Friday afternoon.
Public documents show a company that charted a grand course that suddenly ran aground. In May 2022, it acquired a competitor that added nearly 50 sites to its footprint. After five years of rapid expansion that led to the operation of 183 clinics and a workforce of about 850, the company instituted a restructuring plan to “fortify the company’s path to achieve sustainable profitability.” The plan was announced in March 2023.
Since then, Greenbrook TMS has been whittling away at itself, casting off less profitable clinics and streamlining the business. Since then, it has shrunk its headcount and clinic footprint by at least 18%.. As of Sept. 30, 2023, Greenbrook employed 699 people and operated 150 clinics across 18 states, according to its latest financial filings.
The company’s website lists 122 locations.
The company has taken on increasing amounts of debt for over a year to help make up for mounting losses. Greenbrook TMS lost $62.4 million in 2022, more than double its loss in 2020 at $30.4 million. Greenbrook posted a $34.2 million loss in the first nine months of 2023, the documents show.
Since the company only provides psychiatric interventions, it’s subject to several powerful market forces with nothing else to stabilize it. It also forces this business model to grapple with potentially unsustainable unit economics. Dr. Owen Muir, founder of the New York-based interventional psychiatry firm Fermata and an expert in TMS, told BHB that this constrains the profitability of clinics.
Greenbrook TMS relies heavily on referring clinicians, as it says in its documents. So, it doesn’t have a consistent tether to its patients or another service line with recurring revenue. Further, TMS is widely seen as effective, but payers have been hesitant to make it easily accessible through health benefits without difficult prior authorizations and utilization management.
“They have interventions, but they don’t have ongoing care: so it’s really hard to generate the kind of revenue per site that would make that business make sense,” Muir told BHB.
Further, Greenbrook TMS’ debt load partially complicates its revenue generation. The company secured loans from the TMS device maker Neuronetics Inc. (Nasdaq: STIM) to finance its equipment needs. However, Neuronetics charges about $70 per use of the equipment.
On the Sparvato side, clinics are very space- and time-constrained when using it. The care protocol for the drug calls for patients to remain in the clinic with a specially trained clinician for two hours, quickly limiting the number of patients a clinic can take on.
Muir called Greenbrook TMS a pioneer in the space. The company was founded in 2011. However, he also noted that the market’s demand for effective interventions doesn’t outweigh the economics of intervention-exclusive businesses. This was reflected in a handful of stumbles in the ketamine-assisted treatment market in 2023.
“The financials don’t work because the payers don’t want to pay for a thing like that because it’s either really expensive or not expensive enough, depending on the payer,” Muir said.
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