For most specialty referrals, distance is a detail. A patient drives forty minutes to see a cardiologist once, maybe twice a year, and nobody thinks much of it. Esketamine is different. The way the treatment is delivered turns distance from a detail into one of the main reasons a referral succeeds or stalls.
Written for referring clinicians across the Midwest, this explainer links the structure of esketamine treatment to what 443 adults of working age told our ten-state summer poll. All figures are whole-sample and final.
What patients said about distance
Asked to pick two must-haves in a clinic offering ketamine or esketamine, respondents put insurance first at 85 percent and a nearby site second at 43 percent. Approval from the FDA registered 27 percent, results that come quickly 24 percent. Privacy got 11 percent of picks; service-member and first responder expertise got 10.
Nearness, in other words, was no tiebreaker. For a large share of respondents, it was one of only two things they chose to prioritize.
Why esketamine makes distance structural
Several features of the treatment compound the effect of every mile.
Certified sites only. Spravato, the esketamine spray, holds approval for adults whose depression outlasted other care, and a REMS program governs every dose. It is self-administered under direct observation at a certified healthcare setting. There is no take-home option.
Observation after every dose. Patients stay a couple of hours or longer after every dose while staff watch for sedation, dissociation, and changes in blood pressure.
No driving until the next day. Patients should not drive or operate machinery until the day after treatment, following restful sleep. Every visit requires a companion or arranged transport.
A demanding early schedule. Under the prescribing information, induction typically involves sessions twice a week for the first four weeks, followed by weekly sessions, and then weekly or every-other-week maintenance depending on response.
Put those together and a site thirty minutes away means, for each visit, an hour of round-trip driving for someone else, plus a session of two hours or more, twice a week, for a month. A site ninety minutes away can make that schedule unworkable for a patient without flexible support.
The Midwest dimension
The ten states in our survey include dense metros and long stretches of rural territory. A patient in Chicago, Minneapolis, or St. Louis may have several certified sites within reach. A patient in western Kansas, rural Iowa, or southern Indiana may not. Where a site exists, it may not take the patient's plan, and a closer site across a state line may not accept the patient's state Medicaid.
Coverage and distance therefore interact. A referrer who checks only one will sometimes find the patient stuck on the other.
How distance intersects with coverage
Coverage is the dominant factor, and it narrows the field before distance is even considered. For 65 percent of respondents, insurance would heavily shape or settle whether they try it, and half would accept insurance steps over simpler self-pay, with the rest split between paying and uncertainty. A good companion to the referral is the Brain Recovery Centers guide on esketamine costs and coverage.
For patients whose coverage limits them to a few in-network sites, the nearest covered site may be much farther than the nearest site overall. That is when transportation benefits matter. Many Medicaid plans cover non-emergency medical transportation, and in our poll Medicaid ran close behind commercial coverage, 37 percent to 39. Patients frequently do not know the benefit exists.
What patients want from the care model
We also asked how respondents would prefer to receive this kind of care. Among our respondents, 44 percent favored a clinic in person, 22 percent video care from home, 23 percent a clinic start that shifts home, and 11 percent had no preference.
Adding the clinic and hybrid groups gives 67 percent, two thirds, who want a clinic in the picture, which fits esketamine's in-clinic requirement. But the 22 percent drawn to at-home telehealth deserve a careful conversation. At-home ketamine programs are off-label for depression and involve less direct supervision. They are not a substitute for esketamine, and patients may not realize the difference unless you draw it.
Hybrid arrangements can still reduce the travel burden in legitimate ways. Psychiatric evaluation and follow-up may be possible by telehealth, depending on the practice and state rules, even though each esketamine dose must be given on site.
Practical implications for referrers
- Ask about travel as a clinical question. "How would you get to appointments twice a week for a month, and who would drive?" belongs in the referral conversation.
- Know drive times, not just addresses. Keep approximate travel times from your practice area to each certified site you refer to.
- Check coverage and distance together. The closest site and the closest covered site may be different places.
- Raise transportation benefits with patients on Medicaid and Medicare Advantage plans that offer them.
- Explain the schedule up front. Patients who understand the induction phase can arrange support before they start, rather than dropping out partway.
- Clarify esketamine versus at-home ketamine for patients drawn to home-based care.
Why your guidance carries weight
Patients look to you for direction. Physicians were the most persuasive voice for 74 percent of respondents, and 56 percent planned to take the question to their family doctor before anyone else. A referral that has already accounted for distance arrives with that trust intact.
Limits
These are whole-sample results; this explainer reports no regional or payer breakdowns. As market research, they are not clinical evidence. Whether esketamine is appropriate for a particular patient is your clinical judgment.
Please print 988 in patient materials. Calls and texts to that number reach Suicide and Crisis Lifeline counselors at every hour, which matters most for patients facing long waits or long drives.
Methodology
Our data come from Pollfish survey 395586438, which consumer panelists could take until June 23, 2026; it ended at 443 completes, all ages 18 to 64, across Minnesota, Ohio, Kansas, Illinois, Wisconsin, Iowa, Missouri, Oklahoma, Indiana and Nebraska. Provider factors were choose-two; coverage was multi-select. These overall figures have passed validation. The publisher behind this guide paid for the survey and commissioned it.