Independent Intakes for a Spravato/Ketamine Clinic

[Mad Jack]

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This is a bit of an odd one. I have someone that has offered me a job doing intakes for a Spravato and ketamine clinic for treatment-resistant depression. They are aware I'm not the kind of person that will simply rubber-stamp treatments, and it is not a private equity thing, so I will have full autonomy in deternining patient appropriateness for treatments. What I'm not sure about is how to assess something like this from a risk perspective and what adequate compensation would be for each eval. Kind of on the fence about something like this overall, but as long as the treatment protocols look good and they have adequate follow-up it seems reasonable?

If anyone has any advice for this one, it would be much appreciated

 

[lobstar]

I imagine they want you to be the psych/pseudo pre-op eval before they are "just the administrator". For example, BP runs wild, they get psychotic and it doesn't go away, they can point fingers at you.

It's also about who owns the patient. They get nausea from treatment who has to manage that? They get headaches who manages that? Patient starts getting an addiction, did you not screen correctly for pre existing addiction or did they not monitor for the development of one.

At the very least it might just be you getting the history and organizing the paperwork so insurance pays for it.

 

[psydocc]

That is is an odd one because the only specialty that should be treating treatment-resistant depression cases is psych, but a psych clinic wouldn't need to be outsourcing their intakes like this... I'd be very cautious about partnering with non-psychiatrists (usually anesthesia and EM docs) that operate spravato/ketamine/TMS clinics. They are only in it for the money and they are absolutely looking for a psychiatrist they can shift all the blame to when things go south. The standard of care for interventional psychiatry for treatment-resistant depression is not "I saw the patient once, confirmed TRD and then signed off to let non-psychiatrists deal with it." Just my 2 cents, if I'm getting involved in a TRD case then I want full ownership of the patient care, protocol, med regimen, and, of course, the reimbursement.

 

[Mad Jack]

I imagine they want you to be the psych/pseudo pre-op eval before they are "just the administrator". For example, BP runs wild, they get psychotic and it doesn't go away, they can point fingers at you.

It's also about who owns the patient. They get nausea from treatment who has to manage that? They get headaches who manages that? Patient starts getting an addiction, did you not screen correctly for pre existing addiction or did they not monitor for the development of one.

At the very least it might just be you getting the history and organizing the paperwork so insurance pays for it.

Yeah, essentially it is an EM doc who would be the actual prescriber and taking over care for the patients, but insurance will only cover services if they are provided in collaboration with a psychiatrist. Pretty much would be doing a history to ensure they meet insurance criteria and to screen out patients that would not be appropriate due to contraindications. I don't feel particularly good about the idea of it but figured I would solicit the thoughts of others to sort out whether that is just my inherent fear of the unknown and lack of entrepreneurial spirit or whether it seems objectively questionable

Thanks everyone!

 

[lobstar]

Would the DEA registration for the clinic administering it be through you or how would it even be set up? I think you can also acquire the whole thing by also being the dispensing location to make more money. Would be curious of those details.

Also both spravato and ketamine IV? They could be making a mountain of cash with enough volume and if you do you'd be the lynchpin so get some cash out of them.

 

[Mad Jack]

Would the DEA registration for the clinic administering it be through you or how would it even be set up? I think you can also acquire the whole thing by also being the dispensing location to make more money. Would be curious of those details.

Also both spravato and ketamine IV? They could be making a mountain of cash with enough volume and if you do you'd be the lynchpin so get some cash out of them.

Starting with Spravato but with possibility of expanding to IV ketamine down the line. The EM doc has the DEA and site DEA. It could be quite lucrative but also ehhhhhh. Maybe if I was running it myself and providing longitudinal care I would feel better about it as a treatment option, but I'm not really feeling the setup of being a collaborating psychiatrist on paper. I also prefer to not do business with friends, as it can create problems down the line, so that's another not so much in my book. He was offering 350 per eval 1099 or W2, full malpractice coverage with tail, but honestly that doesn't feel like nearly enough, I could make way more than that just doing cash intakes on my own if I wanted

 

[Stagg737]

Starting with Spravato but with possibility of expanding to IV ketamine down the line. The EM doc has the DEA and site DEA. It could be quite lucrative but also ehhhhhh. Maybe if I was running it myself and providing longitudinal care I would feel better about it as a treatment option, but I'm not really feeling the setup of being a collaborating psychiatrist on paper. I also prefer to not do business with friends, as it can create problems down the line, so that's another not so much in my book. He was offering 350 per eval 1099 or W2, full malpractice coverage with tail, but honestly that doesn't feel like nearly enough, I could make way more than that just doing cash intakes on my own if I wanted

Sounds awful. IMO this could be fair if you were basically just doing an initial consultation to assess for TRD and make sure they meet the criteria for insurance, but $350 per eval even them sounds way too low.

The thing that makes it a definitive no to me is that he wants you as a “collaborating psychiatrist” and is offering malpractice coverage. I assume that means he wants you to be the liability shield. So why would you only be getting a 1x low payment for ongoing collaboration?

 

[mistafab]

If you are truly collaborating, an intake fee and a % of profit (i.e. partnership) makes sense. Otherwise your liability grows exponentially but your payment remains linear.

 

[TexasPhysician]

I’m not understanding why EM is entering the space, and why they think they can handle this. Spravato isn’t exactly lucrative. It also requires psych follow-up and managing complications/dosing.

You are being hired to clear patients for treatment done by someone not prepared to handle it. I’d think about it like this: An ortho surgeon hires a general surgeon to clear patients for ortho to do appendectomies. It doesn’t make sense financially or from a liability perspective.

Best to just walk away.

 

[calvnandhobbs68]

I’m not understanding why EM is entering the space, and why they think they can handle this. Spravato isn’t exactly lucrative. It also requires psych follow-up and managing complications/dosing.

You are being hired to clear patients for treatment done by someone not prepared to handle it. I’d think about it like this: An ortho surgeon hires a general surgeon to clear patients for ortho to do appendectomies. It doesn’t make sense financially or from a liability perspective.

Best to just walk away.

I don't disagree but I mean EM is perfectly capable of handling the physiologic aspect of administering IV ketamine better than psychiatry. Spravato is weird but yeah I've also seen some nonpsych people trying to setup Spravato clinics (I know one neurologist doing that + TMS for "depression"). I think there are people making it work financially by basically setting up Spravato days where they just schedule a bunch of patients to get "monitored" in the same room afterwards at the same time to meet REMS requirements.

What they likely aren't capable of handling is what happens when someone starts self harming or becoming more suicidal during or after the treatment course or whatever other psychiatric complication/complaint comes up...lol what are they gonna do say send them to the ER.

 

[lobstar]

It's funny because if EM does it and there's SI/SH oops go to ER or call 911.

And if psych does it and there's hypertension or respiratory issues oops go to ER or call 911.

 

[sloh]

I’m not understanding why EM is entering the space, and why they think they can handle this.

Emergency medicine is such a dumpster fire specialty right now, niches that most other specialties wouldn't touch with a ten-foot pole are attractive to them. Whatever it takes for them to escape the pit.

 

[Stagg737]

What they likely aren't capable of handling is what happens when someone starts self harming or becoming more suicidal during or after the treatment course or whatever other psychiatric complication/complaint comes up...lol what are they gonna do say send them to the ER.

I mean, yes? That's basically what our academic center does in our Spravato clinic if a patient develops SI in treatment or if there is concerning SI for a patient who calls clinic.

The problem isn't that though. It's the rest of the psychiatric care/depression management that needs to take place that makes an ER doc doing this problematic. After all, Spravato is approved for TRD which requires multiple previous trials of antidepressants. So having ER docs chronically assessing and managing depression when their specialty is a triage/crisis management field is a bit problematic. If being used for acute SI or behaviors, it is required that the patient be on an antidepressant and monotherapy in that situation is not approved, so again needs a psychiatrist involved even if they would say the exact same thing the ER doc would (go to the ER).

 

[TexasPhysician]

I don't disagree but I mean EM is perfectly capable of handling the physiologic aspect of administering IV ketamine better than psychiatry. Spravato is weird but yeah I've also seen some nonpsych people trying to setup Spravato clinics (I know one neurologist doing that + TMS for "depression"). I think there are people making it work financially by basically setting up Spravato days where they just schedule a bunch of patients to get "monitored" in the same room afterwards at the same time to meet REMS requirements.

What they likely aren't capable of handling is what happens when someone starts self harming or becoming more suicidal during or after the treatment course or whatever other psychiatric complication/complaint comes up...lol what are they gonna do say send them to the ER.

Any physician is capable of managing the vast majority of physiologic complications of Spravato. If that were the baseline, ophtho could have Spravato monitoring days. The complications that occur are almost always psychiatric. EM is underprepared thus should let this go.

You could argue that EM is best to manage the complications of almost any medication in any field. That doesn’t mean EM is good for managing all other specialties treatments.

 

[calvnandhobbs68]

Any physician is capable of managing the vast majority of physiologic complications of Spravato. If that were the baseline, ophtho could have Spravato monitoring days. The complications that occur are almost always psychiatric. EM is underprepared thus should let this go.

You could argue that EM is best to manage the complications of almost any medication in any field. That doesn’t mean EM is good for managing all other specialties treatments.

Right which is why I said IV ketamine and that the Spravato part was kind of weird. Sounds like the clinic is trying to do both at some point.

 

[FatherPsychiatry]

Emergency medicine is such a dumpster fire specialty right now, niches that most other specialties wouldn't touch with a ten-foot pole are attractive to them. Whatever it takes for them to escape the pit.

Agreed

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Rumor is out that Hodge Conjecture is almost/is solved by OpenAI and that they or Anthropic are also close to Birch-Swinnerton-Dyer.

3 Millennium problems solved in a few months?

Crazy times. I guess AI is proving to be a little bit more than a 2023 chat bot. Wall Street still wants proof that these accomplishments can be translated into ROI. It's one thing to burn Capex and solve math but we need more evidence that this tech translates to corporate profits.

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That's the top and most active thread in the Emergency Med subforum now 🤑

 

[comp1]

Just don't do this. There are better jobs.