Ketamine use is surging as veterans and people with persistent depression look for alternative treatments. But the industry that's sprung up around that demand is showing signs of buckling, leaving some patients stranded without support, Axios' Sabrina Moreno writes.

The big picture: The shutdown of some brick-and-mortar ketamine clinics has injected more uncertainty into an industry fueled by the broader psychedelics boom that has no oversight or standardized treatment protocols.

• And there aren't enough clinicians to fill the resulting gaps in care, stoking fears that vulnerable patients could seek unvetted telehealth-only options without waitlists, said Jeffrey Zabinski, a psychiatrist at Columbia University who provides both IV and intranasal ketamine therapy.

State of play: Ketamine is an old anesthetic with fast-acting antidepressant effects that is administered through IV infusions, nasal sprays and lozenges.

• Social media, academic research and word-of-mouth testimony has helped drive interest in ketamine and chipped away at perceptions of it as a club drug.
• The loosening of telehealth regulations during the pandemic boosted awareness as more startups began marketing at-home oral ketamine.
• Venture capital investors took note of the hype in 2021 and poured more than $700 million into the psychedelics space, Fast Company reported.

Yes, but: By March of this year, one of the biggest ketamine clinic chains, Ketamine Wellness Centers closed.

• Field Trip Health & Wellness, another major provider, shuttered its centers in major U.S. markets and Canada amid financial struggles soon after.

What they're saying: "I don't think these get-rich-quick venture capitalist-backed ketamine companies are going to be able to survive, because I don't think doctors will refer patients to that," said Scott Smith, a South Carolina-based family doctor who is licensed in 48 states to dispense low-dose sublingual ketamine.

What we're watching: How ketamine therapy might be affected by the Drug Enforcement Administration’s crackdown on telehealth prescribing, which would limit prescriptions for off-label use.

• Meanwhile, investor interest is shifting to companies that provide back-end support for ketamine therapy and track outcomes.

Go deeper.

More than 1 in 5 U.S adults without access to a vehicle or public transportation missed or skipped a medical appointment in the previous year, according to a new study that sheds light on a key social factor in health equity, Axios' Adriel Bettelheim reports.

Why it matters: While telehealth may have reduced transportation barriers, it's not accessible to all and can't substitute for in-person care for some medical needs, the Urban Institute researchers wrote.

• The findings point to gaps that could be filled by Medicaid coverage of nonemergency medical transportation or expanded access to telehealth.

What they found: 21% of adults without access to a vehicle or public transit went without needed medical care last year.

• Though 91% of adults said they had access to a vehicle, the figure was substantially lower among Black adults (81%), those with low family incomes (78%) or a disability (83%) and individuals with public health insurance (79%) or no coverage (83%).

Go deeper: Research suggests as much as 40% of a person's health can be attributed to socioeconomic factors like education, employment and the availability of transportation.

CMS on Thursday proposed new reporting rules for Medicaid and the Children's Health Insurance Programs health plans, that would, among other things, set national standards for appointment wait times and require disclosure of provider payment rates, Axios' Arielle Dreher writes.

Why it matters: The moves add transparency and accountability requirements for Medicaid managed care plans that serve the majority of program beneficiaries. They come as states begin a sweeping redetermination of Medicaid eligibility accompanying the end of the COVID public health emergency.

Details: The rules would set maximum national standards on wait times for certain appointments and require states to conduct "secret shopper" surveys to ensure compliance by health plans.

• They would ensure that at least 80% of Medicaid payments for home health care be spent on compensation for those direct care workers, instead of on overhead or taken as profits.
• They would require states to publish wait lists for home care services, putting numbers to long wait times residents looking for services experience.

CMS plans to beef up enforcing price transparency rules for hospitals, the agency announced this week.

Why it matters: A Trump-era cost transparency rule requires hospitals to post the prices for common goods and services in both consumer-friendly and machine-readable formats online.

• But multiple studies have found few hospitals are in full compliance and Congress has expressed interest in stepping in, Axios' Caitlin Owens reported earlier this year.

By the numbers: As of April 2023, CMS has issued more than 730 warning notices and 269 requests for corrective action plans from hospitals. It has issued fines to four hospitals.

The details: Under the new enforcement guidelines, CMS will standardize how long hospitals have to complete each step of the transparency process and start automatically issuing fines to those who miss deadlines.

• CMS will also no longer issue warnings to hospitals that make no attempt to post prices but instead immediately request the hospital submit a corrective action plan.
• The average time to complete a case cycle is 195 to 220 days. Under the updated enforcement, CMS officials said the average time should be cut to not more than 180 days.

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Meet Orla, a 3-year-old pup showing "pure joy" at Crissy Field in San Francisco a few months ago.

• Orla "loves to leap in the air to catch (and eat) flying clumps of wet sand," writes her human Kathy Coffey.

🐕 Do you have a dog in your life you'd like to share with the Vitals world? Hit reply to this email with a picture and some details about your pup, and they might be featured in a future edition!