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Monday, September 26, 2022

Local players strategize to increase access to psychedelic therapy

Ketamine is the only psychedelic substance that has an approval from the Food and Drug Administration—albeit not for use in the treatment of psychiatric conditions. In its label, ketamine is approved as an anesthetic in surgical procedures only.

Using ketamine for psychiatric conditions would be considered “off-label,” Itzkoff said.”But off-label use means insurers have the liberty of not covering it should they choose not to, because the FDA has not backed it.”

Ketamine will almost certainly never receive “on-label” status because it has been a generic drug for decades, and no drug company will want to undertake the expense of putting the drug through trials for that approval when there is no exclusivity to be enjoyed, Itzkoff added.

Self-pay is common for ketamine infusions, and price tags in the city can range between about $500 to $1,000 per session, according to rates posted by local clinics.

As ketamine infusions for psychiatric conditions require multiple sessions—typically six or more—the cost is prohibitive for those who are lower income, said Richard Meloff, co-founder of Nushama, which offers ketamine and wellness services.

It can be an uphill battle to get insurance to cover ketamine treatments. “We worked really hard on our relationships with payers to ensure we’re delivering evidence-based care, and they’re finally coming around,” Itzkoff said. Curated, with four clinics, including its flagship in Chelsea, is in-network with Cigna, Aetna and UnitedHealthcare.

“The burden falls on the provider to supply the evidence to the payer to cover the treatment off-label, and that requires a lot of staff and infrastructure to compile that evidence,” Itzkoff said. Curated has a team of 30 people solely dedicated to collecting such data to persuade payers to cover the cost.

Medical literature includes clinical trials that have shown ketamine’s benefit in depression, anxiety and post-traumatic stress disorder.

“The requirements to put together such evidence is a huge barrier for small offices, that’s why many don’t bother with being in-network,” Itzkoff said.

Pursuing insurance coverage also means additional cost needed to ensure each facility that delivers the infusions and its staff are properly credentialed by the payer, Meloff said. Nushama, which has four locations, including its flagship in Midtown, uses only its Upper East Side location for patients accessing ketamine services through insurance, he said.

Even if it is covered by insurance, negotiated payment rates for using ketamine can be lower than if the provider had used other treatments instead, making being in-network even less attractive, Itzkoff noted.

“We’re not looking to make a killing,” she said. “We’re looking to deliver this service for people who need it and keep our doors open.”

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