April 26, 2023
Written by
Dr. Carlene MacMillan, MD
Esketamine (SPRAVATO®) offers a promising solution for treatment-resistant depression and acute suicidality, bringing hope to countless patients.
By incorporating SPRAVATO® as a service line in your practice, you can create a win/win situation that benefits both your bottom line and your patients' well-being.
However, integrating this treatment into your practice can pose unique challenges, such as navigating the REMS program and handling complex billing procedures.
Prefer audio? You can listen to Carlene MacMillan, M.D., and billing expert, Brittainy Wagner, LPC, here:
SPRAVATO® is an FDA-approved nasal spray that contains esketamine, a rapid-acting and powerful antidepressant. It is used to treat treatment-resistant depression and acute suicidality in adults. By incorporating SPRAVATO® into your practice, you can provide a life-saving treatment option for patients who have not responded to other antidepressants.
Before offering SPRAVATO® in your practice, it's essential to understand its indications and patient eligibility criteria. SPRAVATO® is designed for patients with treatment-resistant depression or acute suicidality who have not responded adequately to at least two different antidepressants. Patients are also expected to remain on an oral antidepressant during the course of their treatment, as was the case in the clinical trials that led to FDA approval.
The typical treatment protocol for esketamine involves an initial induction phase of twice-weekly sessions for four weeks, followed by a maintenance phase with sessions every two to four weeks. Patients receiving SPRAVATO® must be monitored for at least two hours after administration, during which they should not drive or operate heavy machinery and must remain in the office with a physician or nurse practitioner on site who is qualified to intervene in the case of an emergency.
Common side effects of esketamine treatment include dizziness, nausea, anxiety, and increased blood pressure. As with ketamine, there can also be dissociation although, this is typically fairly mild with intranasal esketamine compared with IV or IM ketamine. As a clinician, it's crucial to monitor patients for adverse reactions and manage side effects appropriately.
The Risk Evaluation and Mitigation Strategy (REMS) program is mandated by the FDA to ensure the safe use of esketamine (SPRAVATO®) by minimizing the risk of serious adverse outcomes resulting from sedation, dissociation, and abuse potential.
The REMS program can be time-consuming, requiring healthcare providers, patients, and pharmacies to enroll and comply with specific requirements to ensure the safe administration of the treatment. This includes submitting a form to the REMS program after each administration of esketamine.
Now you’ve determined if a patient is a good fit for SPRAVATO®, and what hurdles exist. Next, let’s explore how to set up your treatment space.
Once you have enrolled your outpatient location to offer esketamine, you will also need to purchase a safe to store the esketamine and train staff in how to manage its inventory to comply with all DEA regulations.
The next step is to set up the space to be comfortable and efficient. Creating a comfortable and welcoming environment is essential for providing effective esketamine treatment. Each option has its unique advantages and considerations, which we will delve into below.
Private Room:
When privacy is a top priority for your patients, a private room can be the ideal choice. This setup:
Shared Room with Screen
For practices looking to maximize space and resources, a shared room with a screen may be the best solution. This option:
Couch Setup
To create a more relaxed and home-like atmosphere, consider incorporating a couch setup in your treatment space.
Additional Considerations
In addition to the primary setup options, there are several other factors to consider when creating the ideal esketamine treatment environment. These include:
Selecting the right esketamine treatment setup is crucial for providing a comfortable and effective environment for your patients. Evaluate your practice's unique needs and resources to determine the best configuration for your space, keeping patient privacy, comfort, and preferences in mind.
Next, we'll cover Billing considerations.
Understanding the cost and reimbursement process is crucial for the successful integration of esketamine treatment into your practice. Here are some key points to consider:
Appropriate billing codes specific to SPRAVATO® (esketamine) treatment, not intravenous (IV) or intramuscular (IM) ketamine treatments, ensure proper reimbursement and avoid claim denials.
The method of billing depends on whether you're using the "buy and bill" approach, where you obtain the medication from a distributor, or prescribing it through a REMS-Certified specialty pharmacy and using the patient’s pharmacy benefit. The choice of method may depend on the patient's insurance and the nature of the payer (commercial or Medicare/Medicaid).
"Buy and bill" involves healthcare providers purchasing the medication directly from a distributor, then billing the medication's cost and its administration to third-party payers for reimbursement. In this scenario, providers also manage the drug inventory, collect copayments or coinsurance from the patients, prescribe, and administer the medication.
For SPRAVATO®, "buy and bill" often involves additional costs and restrictions. There's typically an administration fee separate from the drug's cost. Providers may use the S code or the G code for reimbursement, but if the purchase cost exceeds the insurance reimbursement, they might opt for prescribing Spravato from a pharmacy.
For Buy And bill:
Takeaway: Ultimately, the decision between "buy and bill" or using pharmacy benefits depends on the provider's fee schedule with the insurance company and which option is more financially advantageous.
If SPRAVATO® isn't covered under the patient's insurance pharmacy benefits, Janssen, the manufacturer, offers discounts or a savings plan to assist with the cost.
Successfully navigating billing and reimbursement for esketamine treatment requires a strategic approach to payer negotiations and being aware of potential challenges:
Payer Negotiations
Geographic Variability
Common Payer Issues
Esketamine (SPRAVATO®) is a breakthrough treatment option for patients with treatment-resistant depression and acute suicidality.
As a private practice psychiatrist, following this guide enables you to effectively integrate esketamine treatment into your practice, offering outpatient life-saving care to those who may struggle to afford other options while maintaining profitability—a win-win for both you and your patients.
Osmind EHR's seamless integration with the SPRAVATO® REMS program streamlines the process. You save hours of administrative burden, empowering you to concentrate on delivering the highest quality of care to your patients.
Learn how Osmind makes offering SPRAVATO® simple and profitable.
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If you, or someone you know, is in crisis or needs immediate assistance, please call 911 immediately. To talk to someone now, please call the National Suicide Prevention Lifeline at 1-800-273-8255.
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