From our survey

Referral assumptions about payer mix our poll did not support

Every referral habit rests on a few assumptions about the patient on the other end. For esketamine, several of those assumptions deserve a second look. We tested five of them against what 443 adults in ten Midwest states told our summer poll. Some held up. Most did not.

The audience here is referring clinicians. Our figures are final whole-sample totals. We do not report any breakdown by payer or other group here.

Assumption one: "Esketamine candidates are mostly commercially insured."

What we found: The coverage respondents reported was split almost evenly between public and private. Commercial insurance was named by 39 percent, Medicaid by 37 percent. Medicare followed at 23 percent, with 9 percent uninsured and 5 percent on TRICARE. Respondents could list more than one.

The two-point gap between commercial and Medicaid is not meaningful. The parity is. A referral process designed around the commercially insured patient is designed around, at best, half the picture. Practices that only know which sites take commercial plans are missing the other half.

Assumption two: "Patients who rely on insurance will balk at authorization."

What we found: Friction is widely accepted when coverage is at the end of it. Given insured care with extra steps or simpler self-pay, a slim majority of all respondents, 51 percent, took insurance, 23 percent took self-pay, and 26 percent were unsure.

That does not mean paperwork is harmless. It means patients are generally willing to wait if someone tells them the wait is normal and who is handling it. What they absorb badly is a dead end, like a referral to a clinic outside their network.

Assumption three: "Advertising will bring patients to the right site, so the referrer's role is small."

What we found: This is the assumption the data rejects most firmly. The recommendation that would move respondents to try ketamine or esketamine came from their own doctor for 74 percent, friends and family for 18 percent, an online veteran or first responder for 4 percent, advertising for 2 percent and podcast hosts for 1 percent.

Where would they begin? Most, 56 percent, would go to their own primary doctor; 23 percent would go to psychiatry; just 12 percent would start by searching alone. The referrer is not a minor node in this process. For most patients, the referrer is the process.

Assumption four: "Patients will find the treatment themselves once they hear about it."

What we found: Most have not heard about it. Spravato was a blank for 73 percent of respondents and a name without meaning for 21 percent, leaving 6 percent who could describe it.

The words patients use also make self-discovery unlikely. When 319 respondents wrote out their likely search terms, they typed symptoms and pleas, such as "ptsd treatments," "how to overcome depression," and "depressed." They did not type drug names. A patient who leaves your office without the name written down may never connect their search to the treatment you mentioned.

For the 5 percent of respondents with no starting point, your referral is the only map.

Assumption five: "Distance is secondary once coverage is sorted."

What we found: Coverage came first by a wide margin, on 85 percent of respondents' two-item lists. Nearness came a clear second at 43 percent, ahead of FDA approval (27 percent), fast results (24 percent), privacy (11 percent), and a veteran or first responder specialty (10 percent).

For esketamine, distance is not an abstraction. Every session happens at a certified site with a two-hour-plus observation, and the patient needs a driver. A covered site an hour away means a two-hour round trip plus the visit, repeated. Medicaid ride benefits can close the gap, though patients often do not know to ask.

What these add up to

Taken together, the findings describe a patient who:

• Is nearly as likely to carry Medicaid as a commercial plan.
• Filters every option through coverage first and proximity second.
• Will tolerate paperwork but not a wrong turn.
• Has probably never heard of the treatment by name.
• Is waiting for your recommendation more than anyone else's.

The practical responses follow directly. Keep a current list of certified sites sorted by accepted plans, Medicaid managed care plans included. Ask about coverage before naming a site, and send the medication history authorization reviewers want. Brain Recovery Centers publishes a patient-facing explainer on esketamine costs and insurance that you can hand out. Write down the treatment's name for the patient. Mention transportation benefits.

A clinical reminder

Spravato, the esketamine brand, is approved for treatment-resistant depression and reaches patients only through certified sites in a REMS program. IV and home-use ketamine are used off-label for depression, a distinct option with different regulatory footing and usually different coverage. Patients often confuse the two. Which, if any, fits a patient is your call. This survey is market research and says nothing about efficacy.

Crisis resources

The interval between a referral and a first session can be long. Patients should leave with 988 written down (the Suicide and Crisis Lifeline, open to calls and texts day and night) alongside the name of the site and the treatment.

Methodology

Referrers can verify the source, Pollfish survey 395586438, fielded to its consumer panel and ended on June 23, 2026, with 443 completes from adults 18 through 64 living across Nebraska, Ohio, Illinois, Oklahoma, Wisconsin, Missouri, Minnesota, Indiana, Kansas and Iowa, with 319 answers to the open-text question. Coverage and provider-factor items were multi-select. Results are whole-sample and validated. The publisher asked for the study and footed its cost.