Medicare Esketamine Spravato Access: 24-State Treatment Desert Analysis
Medicare esketamine (Spravato) clinic billing appears in only 26 states in 2023 data, creating treatment deserts across half the country despite 60% growth.
What This Study Found
Analysis of 2023 Medicare claims reveals stark geographic disparities in esketamine access. Only 26 states show any clinic-billed esketamine use while 24 states report zero clinic-billed services. Despite this widespread absence, clinic-billed volume surged 60% year-over-year from 14,290 to 22,917 services, with approximately $20.8 million paid.
Per-capita leaders include New Jersey and Massachusetts at roughly 120+ services per 100,000 Medicare beneficiaries, while California reaches ~70 per 100,000. About half of all states remain at or near zero even after population adjustment.
Medicare Administrative Contractor (MAC) analysis reveals dramatic 10-fold variation in per-capita rates—WPS J5 averaging ~88 per 100,000 versus CGS J15 at ~8.5 per 100,000. National Part B totals reached 25,532 services in 2023 and 38,240 in 2024, with hospital outpatient settings accounting for only ~10% of volume—insufficient to explain the widespread state-level zeros.
Here’s how this impacts Medicare enrollees.
Why It Matters
For Medicare Fee-for-Service beneficiaries seeking esketamine, geography determines access. In roughly half the country, patients face longer travel distances, referrals to hospital outpatient departments, self-pay arrangements, or no treatment pathway at all. The clinic-billed lane—typically more accessible and predictable for patients—is effectively missing across 24 states.
This represents a de facto treatment desert for an FDA-approved therapy targeting treatment-resistant depression. Patients in high-access states like New Jersey have fundamentally different care experiences than those in zero-access regions. The 10-fold MAC variation suggests administrative factors, not clinical demand or coverage policy, drive these disparities. As esketamine use accelerates nationally, access inequality widens between served and underserved regions.
Methods in Brief
This analysis examined Medicare Fee-for-Service claims data from CMS’s Medicare Physician & Other Practitioners datasets (2022-2023) for HCPCS codes G2082 and G2083 representing supervised esketamine administration. State-level clinic-billed services were normalized using December 2023 Medicare enrollment data and aggregated by Medicare Administrative Contractor jurisdictions.
The study reconciled clinic-only state totals against national Part B summaries (2023-2024) to quantify hospital outpatient volume. Absent states were cross-verified using provider-level files. Analysis covered Fee-for-Service beneficiaries only; Medicare Advantage claims are excluded from public datasets. Data processing followed CMS small-cell suppression rules and standard aggregation methods for public use files.
Limitations & How to Interpret
Findings reflect clinic-billed Fee-for-Service activity only—Medicare Advantage claims and hospital outpatient state-level data are unavailable in public files. CMS suppresses very small beneficiary counts, potentially hiding micro-volumes in some states. Results show associations between administrative jurisdictions and billing patterns but cannot establish causation.
The analysis captures Medicare billing visibility, not total esketamine use across all payers and settings. Some patients in “zero” states may access treatment through hospital outpatient departments or private-pay arrangements not reflected in clinic-billed FFS data.
Data & Materials
White paper DOI: http://dx.doi.org/10.2139/ssrn.5470886
Dataset DOIs: 10.5281/zenodo.17049243, 10.5281/zenodo.17049285
Wikidata items: https://www.wikidata.org/wiki/Q136093706 , https://www.wikidata.org/wiki/Q136093624
License: Creative Commons Attribution 4.0 International
Last verified: September 12, 2025
Dataset download: https://ketaminetherapyfordepression.org/datasets/medicare-and-medicare-advantage-coverage-policies/
How to Cite
Alvear, M. (2025). Geographic Disparities in Medicare Esketamine (Spravato) Access: A Claims-Based Analysis Documenting a 24-State Treatment Desert. http://dx.doi.org/10.2139/ssrn.5470886
FAQ
Q: Does “zero clinic-billed services” mean no esketamine access at all in those states?
Not necessarily. The 24 states showing zero clinic-billed services may still provide esketamine through hospital outpatient departments (not visible in state-level public data), Medicare Advantage plans (excluded from Fee-for-Service files), or private-pay arrangements. However, for traditional Medicare patients seeking the most accessible clinic-based pathway, these states effectively function as treatment deserts. The clinic lane typically offers more predictable scheduling, clearer cost estimates, and easier care coordination compared to hospital outpatient settings.
Q: Why do some Medicare Administrative Contractors show 10 times higher usage rates?
MAC-level variation likely reflects differences in billing education, documentation requirements, and administrative support for esketamine claims processing. Some contractors may provide clearer guidance to clinics about proper coding, prior authorization workflows, and REMS compliance documentation. This creates jurisdictional disparities where patients’ access depends partly on which MAC serves their region. The variation suggests administrative rather than clinical factors drive much of the geographic inequality.
Q: How much does Medicare actually pay for esketamine treatments?
In 2023, Medicare paid approximately $22.37 million for esketamine across all Part B settings, with clinic-billed payments totaling ~$20.8 million. Individual session costs vary by dose and setting, but the allowed amounts and patient coinsurance depend on Medicare’s fee schedule and the beneficiary’s supplemental coverage. Patients should verify both the Medicare-allowed amount and their expected out-of-pocket costs before starting treatment, as coinsurance can represent a significant expense.
Q: Is this access problem getting better or worse over time?
The data shows mixed trends. Total volume is growing rapidly—clinic-billed services increased 60% from 2022 to 2023, and national totals rose again in 2024. However, geographic concentration persists. Some states “turned on” in 2023 (Arizona, Iowa, Maryland, Montana, Ohio, Wisconsin) while others “turned off” (Louisiana, Minnesota, Nebraska). The core pattern of roughly half the states showing zero clinic-billed activity remained stable, suggesting that while overall access expands, geographic disparities are not self-correcting.
Q: What should patients do if they live in a “zero access” state?
Patients should first ask potential providers specifically whether they bill traditional Medicare for Spravato, as some clinics offer the treatment but don’t participate in Medicare billing. If no Medicare-billing clinics exist locally, explore hospital outpatient departments, which may provide the service but aren’t visible in state-level public data. Contact Medicare Administrative Contractor beneficiary services to identify participating providers. Consider travel to nearby higher-access states if feasible. Advocacy through state medical societies and patient organizations can help highlight access gaps to policymakers.
Q: How reliable is this data given CMS privacy suppression rules?
The findings are robust despite small-cell suppression. CMS hides counts with fewer than 11 beneficiaries to protect privacy, which could mask tiny volumes in some states. However, sensitivity analyses excluding very small states, alternative denominators, and cross-verification with provider-level files all confirm the core pattern. The 10-fold MAC variation and dramatic state-level differences are too large to be explained by suppression artifacts. While some micro-volumes may be hidden, the fundamental geographic disparities represent real access differences.
Author: Michael Alvear
Contact: [email protected]
ORCID: https://orcid.org/0009-0003-3845-418X
Last reviewed: September 12, 2025