Why We Don’t Offer Spravato at Ember Health

At Ember Health, we specialize in intravenous (IV) ketamine care for people seeking relief from depression. Over eight years, we’ve treated more than 2,750 patients, 84% of whom have experienced meaningful improvement in their depression symptoms. After completing an initial course of treatment, our patients return once every six weeks on average for a single booster infusion to maintain their benefits over time.

There is, however, a persistent challenge with this model: medical insurance coverage has not caught up with the evidence.

IV ketamine for depression remains an off-label use of a generic medication. Most of our patients therefore pay Ember directly and submit claims to their insurers for out-of-network reimbursement. Approximately 75% of our patients receive reimbursement averaging 70% of the cost of care, but the process can be cumbersome and unpredictable. For many people, it puts treatment out of reach.

Meanwhile, another ketamine-based treatment, Spravato (esketamine), is widely covered by insurance. Spravato is esketamine, a patented derivative of ketamine developed by Janssen Pharmaceuticals, a Johnson & Johnson company. It is delivered as a patented nasal spray  and was FDA-approved for treatment-resistant depression in 2019.

Understandably, this raises a question we hear frequently:

If insurance covers Spravato, why doesn’t Ember offer it?

The answer comes down to something we think about constantly: value.

By value, we don’t simply mean what treatment costs, but what people and health systems receive in return: clinical outcomes, safety, quality of care, and the most efficient use of time and resources to sustain recovery.

1. IV ketamine is more studied and more effective for depression than Spravato

With over 7,000 published papers and 400 RCTs, IV ketamine has been the most extensively studied treatment for depression in the past 30 years (source, source). Originally patented in 1962 as an anesthetic medication, ketamine became generic in 2000, and has since been studied around the world for its antidepressant effect when administered intravenously (IV).  In the literature, IV ketamine has shown to help up to 75% of people with depression (source). In our own outcomes data, we have found that 84% of Ember patients experience meaningful improvement in depression symptoms. Ketamine is generic, and the FDA does not have a way to add a new indication to a generic medication label, meaning it remains “off-label” for depression, despite this volume of evidence (you can read more about what type of drug ketamine is in our blog post What Type of Drug Is Ketamine?).

Spravato has specifically been studied for treatment-resistant depression in 6 trials and 9 papers (source). Its FDA approval process relied heavily on data from previously published generic IV ketamine research.  J&J reported spending hundreds of millions of dollars to develop the patented derivative, with the FDA choosing to fast track its review and approval under the “Breakthrough Therapy designation” (source, source). The original Spravato trial data given to the FDA showed that it was “not-supperior” to oral antidepressants, which have a 30 - 40% efficacy for depression, and 2 of the 4 original Spravato studies failed to demonstrate benefit over placebo (source, source).

Since Spravato’s 2019 approval, the medical community has learned a lot about how the treatments compare. To date, research shows that IV ketamine provides greater relief from depression symptoms (the magnitude of benefit) with a 5 fold better “effect size” of IV ketamine vs Spravato (source). Furthermore, IVK appears to help more patients reach remission, meaning after IV treatment more people have few or no remaining depressive symptoms (source). Those improved response rates for IVK also happen faster, with fewer treatment sessions, compared with Spravato, and patients receiving IV ketamine are less likely to drop out of the initial treatments (source, source).

While Spravato has provided important relief to many, evidence suggests that it is not as effective as generic IV ketamine for depression. We therefore have not seen a clinical reason to replace a treatment model that leads to superior medical outcomes for the people we serve.

2. We want to minimize the treatment burden required to stay well

Treatment for depression doesn't happen in a vacuum. Every appointment means time away from work, childcare, transportation, and the rest of a person's life.

The FDA-required Spravato schedule begins with treatment twice weekly for four weeks, followed by weekly treatment for another four weeks. Beginning at week nine, treatment is generally administered either weekly or every other week to maintain response. Half of people still using Spravato at the end of their first year of treatment are going in for treatment every week. Each session also requires at least two hours of post-administration monitoring.

At Ember, after completing their initial course of four infusions over two weeks, our patients return for a booster once every four to six weeks on average. 

This means that in someone’s first year of treatment, Spravato requires 68–112+ hours in a medical office, compared with the 18–24 hours for IV ketamine at Ember, excluding travel time.

We’re also mindful that the body has to process any medication it receives, including through the liver and kidneys. With IV ketamine, 100% of the administered medication reaches the bloodstream, allowing it to achieve the intended clinical effect with a lower total dose. Intranasal ketamine has lower bioavailability, so achieving a therapeutic effect requires a larger administered dose (source). Together, the higher administered dose and greater frequency can result in substantially more cumulative medication exposure over time.

Our goal isn't to provide as much ketamine as possible, but rather to help patients achieve relief and then maintain that relief with the fewest treatments necessary.

3. We aren't willing to compromise the 1:1 care around the medicine

The medication itself is only one component of ketamine treatment.

At Ember, every patient receives one-to-one clinical care from a clinician trained in IV administration, medical monitoring, and psychological support..

Spravato is also medically supervised. The FDA mandates administration in a certified healthcare setting with monitoring for at least two hours because of risks including sedation, dissociation and respiratory depression. Psychological support is not a routine part of Spravato treatments, though many clinicians argue it should be, given that the altered state is fundamentally the same between the treatments. 

Spravato’s requirements don’t mandate Ember's level of one-to-one clinical care, however. Further, the reimbursement rates insurance pays for Spravato treatment do not allow for the cost of 1:1 care with clinically qualified individuals, meaning Spravato treatment centers often have a single clinician overseeing multiple patients simultaneously.

Ketamine can create an unusually vulnerable psychological state. We believe patients deserve a clinician who is immediately available to monitor their vital signs, and also help them feel safe, supported, and cared for throughout the experience.

We designed our staffing model around what we believe constitutes excellent ketamine care that keeps our patients safe both clinically and psychologically, not around what an insurer will reimburse.

4. We are putting our resources where it will lead to gold standard outcomes

There is another important distinction between these treatments: the economics of the medication itself.

Generic IV ketamine is inexpensive. A single medication dose at Ember Health costs a couple of dollars. The majority of Ember’s fees are not due to the medication, but the care we provide: clinician time, care planning and coordination, individualized dosing, medical monitoring, psychological support, facilities, and outcomes tracking.

Spravato reverses that equation. Because esketamine is a patented branded pharmaceutical, the medication itself represents a substantial portion of the total cost of treatment. The reimbursement rates put the cost of a single dose of Spravato between $900-$1,200 (source).

This creates a strange paradox often present in American healthcare: Insurers may pay substantially more for a patented drug while declining to cover a less expensive generic medication used within a more resource-intensive clinical care model.

We could redesign Ember around what insurance reimburses, but we’ve chosen to place our time, effort and energy in a different direction instead - making high-quality IV ketamine care accessible, by getting insurance to cover it in-network.

There are encouraging signs that healthcare systems are beginning to take action. Ember Health has signed a contract with the Department of Veterans Affairs (VA), who will soon be covering the cost of care at Ember for qualifying veterans. We are in the process of signing similar contracts with employer benefits programs, who care deeply about value for their employees.

The logic is compelling: If a treatment can help patients get better, while requiring fewer treatment visits, and costing less, it deserves serious consideration from the institutions paying for care.

The bottom line

Our position isn't that Spravato is a bad treatment. For some patients, particularly those whose insurance currently makes Spravato accessible, it may be a meaningful and appropriate option. We are glad that people with depression have more choices than they did a decade ago.

But Ember was built around a specific question: What would care look like if we designed it around the best possible experience, outcomes, and value for patients?

For eight years, our answer has been medically monitored IV ketamine, individualized dosing, one-to-one clinical care, thoughtful psychological support, rigorous measurement, and ongoing collaboration with patients' mental health providers. We don't believe we should lower that standard simply because healthcare reimbursement hasn’t yet caught up to the evidence and outcomes. Instead, we're working to make the gold standard of care accessible to everyone who needs it.

We believe that patients shouldn't have to choose the treatment their insurance happens to prefer. They should be able to access the treatment that they and their clinicians believe offers the best path toward getting, and staying well.

‍