Geographic Disparities in Medicare Esketamine (Spravato) Access: A Claims-Based Analysis Documenting a 24-State Treatment Desert (September 2025)

In 2023, Medicare Fee-for-Service (FFS) clinic-billed esketamine (Spravato) appears in only 26 states; 24 states report zero clinic-billed use. Despite this geographic void, clinic-billed volume rose ~60% year-over-year (14,290 → 22,917 services; ≈$20.8M paid). National Part B totals— which also include hospital-outpatient settings that CMS does not publish by state—are 25,532 services and ≈$22.37M paid in 2023 (rising to 38,240 and ≈$34.18M in 2024), a ~10% uplift over the clinic-only state sum.

Per-capita leaders are New Jersey and Massachusetts (≈120+ services per 100,000 Medicare beneficiaries), while roughly half of states remain at or near zero even after normalization. Grouping states by Medicare Administrative Contractor (MAC) shows ~10× variation in per-capita clinic-billed use (e.g., WPS J5 ≈ 88 vs CGS J15 ≈ 8.5 per 100,000).

Consequences. For FFS beneficiaries, this is a de facto access desert across about half the country: patients are far less likely to find a clinic that bills Medicare for Spravato, face longer travel or referral to hospital outpatient settings, and encounter higher friction and uncertainty about out-of-pocket costs.

Implications. The pattern is consistent with limited Medicare billing by clinics, suppression of very small state-level counts in public files, and administrative differences across MACs; hospital-outpatient accounts for only a minority (~10%) of national volume and does not explain the widespread state-level zeros. Policy actions follow directly: expand Medicare-participating clinic capacity and REMS sites; issue MAC-level billing/education guidance; and require state-level reporting for hospital-outpatient esketamine to close the visibility gap. Scope: FFS only (Medicare Advantage excluded); CMS does not publish hospital-outpatient esketamine by state.