Profile of an Anesthesia Ketamine Clinic

Michael Bronson, MD
Co-founder and Chief Executive Officer, Wellness Clinic of Orange County, Laguna Beach, CA

Jody Locke, MA
Vice President of Anesthesia and Pain Practice Management Services, Anesthesia Business Consultants, LLC, Jackson, MI

Ketamine as a Treatment Modality for Depression

Ketamine has been well known to anesthesia providers for years. As an anesthetic agent it has been used mainly for starting and maintaining anesthesia. It induces a trance-like state while providing pain relief, sedation and memory loss. The active ingredient is similar to that in LSD. More recently its value is coming to be appreciated as an effective treatment for depression.

While the treatment of depression has traditionally been the purview of psychiatry, the use of ketamine as a treatment modality has now attracted the attention of anesthesia providers who have become quite familiar with its pharmacological properties. The administration of drug infusions is a standard practice in the treatment of surgical patients. Given anesthesia provider experience in the administration of such powerful agents, the migration from the operating room to the clinic is a slight difference of degree, but not of kind.

The typical ketamine clinic patient receives an initial 60-minute infusion. They are placed into comfortable reclining chairs and may be given headphones and an eye mask. Vital signs are monitored as they would be for a surgical patient. About 15 minutes into the infusion, patients start to experience euphoria-heightened perceptions and a floating or dream-like state. Usually these symptoms resolve within 15 minutes after the completion of the infusion.

After a second session the patient should be experiencing significant mood elevation and pain relief. If the patient reports improvement, up to four subsequent sessions will be scheduled. If they are not responding, then they are considered a ”non-responder,” and they are referred back to the referring physician.

Following a successful treatment series of up to six sessions, they may return in two to four month intervals for a booster infusion. The advantages of ketamine infusion in the treatment of depression and mood disorders can be significant. Ketamine does not lead to addiction and most patients report positive results. A range of 70 to 80 percent of patients report significant improvement.

Should an Anesthesia Practice Consider a Ketamine Clinic?

The history of the Ketamine Wellness Clinic of Orange County (www.ketamineoc.com) provides an interesting and relevant case study. As is true in evaluating any new business ventures, there are many considerations. One thing is clear though: any new venture requires a champion with a clear vision and a supportive team of stakeholders. Mission Viejo Anesthesia Consultants in Mission Viejo, California has consistently distinguished itself as an organization open to exploring business options that are consistent with the mission and values of the practice.

The clinic was founded in 2016 after a thorough review of current scientific and clinical studies. During the 1990s, clinical research clearly suggested a role for N-methyl-D-aspartate receptor (NMDA) antagonists in the treatment of depression. In the early 2000s, the first double-blinded, placebo-controlled studies that gave patients ketamine and followed their results showed rapid and significant improvement in symptomology after a single dose of ketamine. Subsequent studies reproduced the same results and demonstrated that multiple infusions of ketamine lead to more long-term results. As the investigation of ketamine expanded, it was found to be an effective treatment for other mood disorders and chronic pain.

An initial team of group members carefully reviewed the research available to develop the basic elements necessary to start the clinic: flow charts, clinical protocols, clinic notes, consents referral forms and a website. The clinic remains a work in progress and all aspects of the operation are constantly being refined to optimize the patient experience and the consistency of positive outcomes. Since 2016, the clinic has provided services to over 500 patients who have received thousands of infusions. The current team of providers consists of anesthesiologists, behavioral health nurses and various support staff.

Initially the clinic was set up in a large room at the hospital with only a curtain to provide privacy to patients. That initial venue was staffed by a single physician and nurse. Since 2016, the clinic has grown significantly. The current location is a six-room office-based facility that is not affiliated with the hospital. This has required some investment on the part of shareholders, but this has allowed the clinic to realize its market potential.

How the Clinic Works

All patients must be referred by a treating physician to come to the Ketamine Wellness Clinic of Orange County. The referring physician provides comments on prior medications and/or interventions to ensure ketamine is an appropriate next step in therapy. The clinic also use this interaction to establish a relationship with the referring provider, as they consider themselves one part of a collaborative team to treat each patient. All potential patients are then screened by an anesthesiologist for medical appropriateness and any contraindications to ketamine therapy. Contraindications to ketamine therapy include uncontrolled blood pressure, unstable heart disease, intracranial mass or acute psychotic hallucinations.

Patients are given a scale to fill out prior to initiation of ketamine therapy to establish an objective baseline. They then complete the same scale at the end of the series to gauge response to treatment. Most patients are able to realize a 50 percent reduction in their baseline scale by the end of the treatment. These results are also communicated to their referring physician to “close the loop.” At this point, some patients are then able to work with their treating physician to decrease or eliminate some of the chronic medications they were taking before the ketamine therapy. The clinic also tracks these scales with a database which is used to run statistics to help fine-tune protocols. It is typical to fluctuate between a 70-80 percent response rate to infusions.

The Economics of a Ketamine Clinic

While the management of an office-based practice providing infusion therapy is similar to the management of an anesthesia practice, in some ways it is quite different. In both cases the volume of services provided and the ability to get paid for those services are essential keys to success. Perhaps the biggest difference, however, is that the anesthesia practice is captive to the facilities it serves for surgical case volume and payer mix while the clinic-based practice has much greater potential to control and manage both volume and sources of payment. It should also be noted that physicians will typically manage up to six infusions concurrently, which is similar to the management of multiple labor patients in the OB suite.

It is the number of variables that have to be managed that can make a clinic practice riskier. The goal must be to manage the business as efficiently as possible. Management and financial reporting must be specifically tailored to the unique nature of the services being provided. Payer rules for infusion therapy are quite different than those pertaining to payment for surgical and obstetric anesthesia. Contracting with insurance is not necessarily the best strategy for a ketamine clinic. While it is true that patients are expected to pay at time of service, many can also submit claims to their insurance that may reimburse them for the monies they have paid.

One of the complicating factors is the coding of infusions. In the office setting (POS 11), there is a code for intravenous infusion: 96365. This applies to intravenous infusion, for therapy, prophylaxis or diagnosis; initial, up to 1 hour. Code 96366 should be added for each additional hour. These codes are not applicable in the facility setting (POS 22, 24, etc.) where a E/M visit code must be used. Based upon the face-to-face time documented, it is suggested to use 99354 for prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management or psychotherapy service).

Many insurance plans do pay for the infusion codes, excluding the VA, depending on the patient’s benefit level. The clinic has not seen an unusual percentage of denials for these services, although in some markets pre-authorization may be required. In the case of this clinic, the practice chooses to bill patients first as a matter of expediency.

The Value of a Ketamine Clinic

As anesthesia practices explore alternative lines of business, should they be investigating a ketamine clinic? The answer is yes, but there are a number of critical criteria that should be met first.

• Is there a market for infusion therapy in your area? Ideally, the practice should be providing a service that is not otherwise available in the immediate area. Some market research will be necessary to determine this.
• Is this a buy or make decision? In other words, does the practice wish to develop a clinic from scratch or become affiliated with an existing clinic practice? Affiliating with an existing and established practice minimizes some of the start-up challenges, but may diminish some of the potential returns.
• Are existing providers interested in providing such a service? Without willing and available providers such an enterprise cannot be undertaken.
• Is there a champion for the service? A member of the group or a small group of members needs to take ownership of the enterprise. This person needs to research the options and orchestrate the project. This could be an opportunity for a younger member of the group to exercise leadership.
• What is the practice’s tolerance for risk? Is it willing to make an investment and live with the consequences?
• What are the business objectives for the venture and how will they be measured? Any new venture should contribute to the value of the practice. This value is either financial or strategic. There needs to be accountability and transparency for the venture to be successful.

Anesthesia practices in the current environment need to be exploring ways to expand and diversify their practices. Options are limited, but they do exist. Although it is easy to get paid for ketamine infusions in the right market—patients simply scan their credit cards and start treatment—getting payment from insurance can be tricky. This is why it is so important to establish a fee schedule that is appropriate to the market and the patient population. Mission Viejo is a particularly affluent area; nevertheless, there is obviously a need for the service. A properly managed clinic should have great potential in almost any market.

Michael Bronson, MD is co-founder and Chief Executive Officer of Wellness Clinic of Orange County which operates the Ketamine Wellness Clinic of Orange County. Mr. Bronson joined Mission Viejo Anesthesia Consultants (MAC) in 2013 after completing residency at UC San Diego where he served as Chief Resident. Bronson currently sits on the MAC Board of Directors, Mission Hospital Medical Executive Committee and function as the OR Director of Orthopedic and Neurosurgical services. Current projects include designing the infrastructure for a hybrid physical and virtual preoperative clinic as well as developing software to automate the daily anesthesia assignments. He can be reached at michaelpbronson@gmail.com.

Jody Locke, MA serves as Vice President of Anesthesia and Pain Practice Management Services for Anesthesia Business Consultants. Mr. Locke is responsible for the scope and focus of services provided to ABC’s largest clients. He is also responsible for oversight and management of the company’s pain management billing team. He is a key executive contact for groups that enter into contracts with ABC. Mr. Locke can be reached at Jody.Locke@AnesthesiaLLC.com.