Good rate for PHP evals?

[Celexa]

I am in discussions with a PHP to do their psychiatric intakes as a secondary gig. 1099, 1-4 evals per week, flexible schedule. 60 min appts. They have NPs to handle follow ups while the pts are in the PHP (I need to clarify this, but fairly certain no obligations vis a vi being the NPs official collaborating physician. For the purposes of my question here can assume they would not be working under my license). The patient population is complex but one I enjoy working with.


What's a good rate for work like this? I assume not as high as I could set for myself in true private practice, but somewhere close?

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[Merovinge]

I don't actually know what a contracted rate would be, but I do think it's worth determining if you want to be a part of a PHP that has an initial psychiatric eval by a psychiatrist who then has no follow-up with the patients throughout the rest of their care while they are managed by NPs. This seems like a terrible setup for actually providing quality care to patients, but a great way for a therapist or MBA to own a PHP and maximize their bottom line while meeting accreditation standards.

I would want to know who the medical director of the PHP is and have a conversation with them about how they envision the program going. I think it would be hard to structure this in a way that does not open you to liability down the road when something bad happens (which sounds like is more a when not an if given the complexity of the pt population). This is a lot different than providing occasional 1-off second opinions as you are the first opinion in this case.

 

[claypigeon]

I used to do this for $200 an eval (W2) but then would do follow ups at $100 each which was more lucrative. Then the PHP switched to a similar model and hired an APC so the physician saw patients only for the eval and the APC managed them the rest of the way.

I didn’t like the liability there and would rather do more outpatient work for that pay so stopped the PhP gig.

If doing this, I’d ask for at least $250 an eval as an independent contractor but think $300 + is more appropriate.

 

[Bartelby]

PHP patients are higher risk, not following them up personally I would feel iffy about, and follow ups are frankly a lot easier and reimburse better than intakes. I would be hesitant to take this role but would probably ask for double my usual hourly rate if I did consider it.

 

[Celexa]

I don't actually know what a contracted rate would be, but I do think it's worth determining if you want to be a part of a PHP that has an initial psychiatric eval by a psychiatrist who then has no follow-up with the patients throughout the rest of their care while they are managed by NPs. This seems like a terrible setup for actually providing quality care to patients, but a great way for a therapist or MBA to own a PHP and maximize their bottom line while meeting accreditation standards.

I would want to know who the medical director of the PHP is and have a conversation with them about how they envision the program going. I think it would be hard to structure this in a way that does not open you to liability down the road when something bad happens (which sounds like is more a when not an if given the complexity of the pt population). This is a lot different than providing occasional 1-off second opinions as you are the first opinion in this case.

It's a well established PHP so I'll definitely be getting more of a sense of how it runs before accepting.

PHP population being high risk overall, I definitely agree with. But I'm surprised to see so much concern for liability over the NP issue. Given the duration of the PHP, this didn't strike me as particualrly problematic--there aren't that many med changes it makes sense to make in that time period, and I'm used to writing one time consult notes in which I lay out the next two or three steps for non-psychiatrists. Team meetings are built into the workflow. The pts are closely monitored while in the PHP and then the treatment relationship ends and I would think with it the vast majority of the liability. Am I missing something? This actually seems to me one of the places where using NPs as physician extenders is very reasonable.

 

[Stagg737]

It's a well established PHP so I'll definitely be getting more of a sense of how it runs before accepting.

PHP population being high risk overall, I definitely agree with. But I'm surprised to see so much concern for liability over the NP issue. Given the duration of the PHP, this didn't strike me as particualrly problematic--there aren't that many med changes it makes sense to make in that time period, and I'm used to writing one time consult notes in which I lay out the next two or three steps for non-psychiatrists. Team meetings are built into the workflow. The pts are closely monitored while in the PHP and then the treatment relationship ends and I would think with it the vast majority of the liability. Am I missing something? This actually seems to me one of the places where using NPs as physician extenders is very reasonable.

If this were a 1x "consultation" it could be different as you are just offering an opinion without placing orders or being directly involved in care. Another prescriber is the one responsible for prescribing medications and actual clinical decisions, so you'd have some protection there.

If you're doing the eval and starting meds then you're part of the clinical team and fair game for lawyers. If the NP misses something (SJS, worsening of SI after initiating SSRI, etc) and there's a significant adverse outcome lawyers may go after everyone. You might be fine if the event occurs after they've seen the NP multiple times and the NP has been making changes, but if it happens early what protection do you have? Not really different from outpatient, but given that PHP patients will be much higher acuity than a lot of outpatients there's naturally more risk of an adverse event there.

 

[Celexa]

If this were a 1x "consultation" it could be different as you are just offering an opinion without placing orders or being directly involved in care. Another prescriber is the one responsible for prescribing medications and actual clinical decisions, so you'd have some protection there.

If you're doing the eval and starting meds then you're part of the clinical team and fair game for lawyers. If the NP misses something (SJS, worsening of SI after initiating SSRI, etc) and there's a significant adverse outcome lawyers may go after everyone. You might be fine if the event occurs after they've seen the NP multiple times and the NP has been making changes, but if it happens early what protection do you have? Not really different from outpatient, but given that PHP patients will be much higher acuity than a lot of outpatients there's naturally more risk of an adverse event there.

More risk but also more eyes on the patient unlike outpatient where they could go weeks and if they aren't answering the phone you're SOL outside of maybe asking for a welfare check. The PHP is in person. On balance it seems to land pretty squarely within standard risk levels to me, if the compensation is fair and I get along with the team. I find it interesting that people post here all the time about inpatient locums and weekend jobs and the idea of doing that and being on the hook for so much of what happens inpatient while having such a minor role seems awful to me.

I guess we just all have different tolerances and sensitivities to different types of risk. There are definitely still a lot of details I'll need to pin down before accepting.

 

[Stagg737]

More risk but also more eyes on the patient unlike outpatient where they could go weeks and if they aren't answering the phone you're SOL outside of maybe asking for a welfare check. The PHP is in person. On balance it seems to land pretty squarely within standard risk levels to me, if the compensation is fair and I get along with the team. I find it interesting that people post here all the time about inpatient locums and weekend jobs and the idea of doing that and being on the hook for so much of what happens inpatient while having such a minor role seems awful to me.

I guess we just all have different tolerances and sensitivities to different types of risk. There are definitely still a lot of details I'll need to pin down before accepting.

More eyes doesn't change the patient acuity though and it doesn't really matter if those eyes don't know what they're looking for. You're also C/L and I'm sure you see patients where you walk into a room and know what's going on in a couple of minutes when other docs had no idea what was going on. Now imagine those docs being counselors and techs with no medical training and no idea what they're actually looking for. What if a patient lies about their alcohol use and starts withdrawing and staff and NP they call think it's just anxiety attacks (something I've seen before at a PHP)? We do all have different tolerances of liability, but PHP is a higher acuity population and the idea of doing an initial eval and treatment then handing off to someone who may be terrible without any follow up seems like a perfect set up to get screwed over.

 

[mistafab]

I’m not sure about risk level - but seems this could be a great gig to provide excellent care to folks in the php setting. You as an initial “consult” paid a fee, perhaps 350-400 for a 1 hour, then they are followed by the php. You are not supervising after that point but perhaps available for informal consult. You do not order meds nor dictate care. You do not write orders.

Not that different from collaborative practice models. So long as you aren’t “supervising” the NP and are actually an “Intake only” 1099 the risk is actually pretty low. If you are actually going to php meeting, coordinating care, treatment planning, etc - your risk would be higher.

 

[Merovinge]

I’m not sure about risk level - but seems this could be a great gig to provide excellent care to folks in the php setting. You as an initial “consult” paid a fee, perhaps 350-400 for a 1 hour, then they are followed by the php. You are not supervising after that point but perhaps available for informal consult. You do not order meds nor dictate care. You do not write orders.

Not that different from collaborative practice models. So long as you aren’t “supervising” the NP and are actually an “Intake only” 1099 the risk is actually pretty low. If you are actually going to php meeting, coordinating care, treatment planning, etc - your risk would be higher.

Sure but why the heck does someone who needs PHP level of care not deserve to have ongoing psychiatric follow-up? Collaborative practice models are patients at the lowest risk level, this is basically the exact opposite. Maybe if you never write orders and only list it as a consult you shield yourself from a good chunk of liability, but I still don't understand what incentive you have to participate in treatment like this.

If people at a PHP or IP LoC don't need regular psychiatric follow-up, I am not sure what the argument would be for having more than say 25% of our current force of psychiatrists and almost everything driven by mid levels.

 

[Merovinge]

It's a well established PHP so I'll definitely be getting more of a sense of how it runs before accepting.

PHP population being high risk overall, I definitely agree with. But I'm surprised to see so much concern for liability over the NP issue. Given the duration of the PHP, this didn't strike me as particualrly problematic--there aren't that many med changes it makes sense to make in that time period, and I'm used to writing one time consult notes in which I lay out the next two or three steps for non-psychiatrists. Team meetings are built into the workflow. The pts are closely monitored while in the PHP and then the treatment relationship ends and I would think with it the vast majority of the liability. Am I missing something? This actually seems to me one of the places where using NPs as physician extenders is very reasonable.

We have plenty of "well established" PHPs in my local that are still nonsense and absolutely don't provide the best care to their patients. Interestingly, the large majority are run by physicians but there are certainly notable ones that are not. Your conversation with the CMO/medical director will be the most revealing. Given that I do this all day, every day, I have a bit more conviction to my opinion but I just cannot imagine how things would go with patients if I saw them once and then passed the care off to an NP never to be seen again by a physician.

 

[Celexa]

I really appreciate this discussion. I can't say I'm on the same page regarding the risk question, but I definitely appreciate the perspectives. My primary gig is academic CL. It can't exactly be called the lowest risk enterprise--patients are sick by every definition of the word, and while it's not emergency room, we of course have a hefty proportion of medically clear post-suicide folks that we evaluate. Many get sent home without inpatient admission (some, to PHPs of course!). I don't think there's much dispute that discharging suicidal or recently suicidal pt's is probanly the highest risk work in psychiatry. And it being a faculty job, I get paid a relative pittance. I love the work but I'm clear eyed about my reasons for staying in academia and recognize money ain't it.

There multiple questions to be answered by the PHP before I would accept this offer. But I certainly wouldnt accept it if I'm not paid a substantial multiplier of my academic hourly rate, and it doesn't seem any higher risk than my primary gig. Maybe that makes me a twice a fool, lol. But high risk psych is still low risk for most other fields. If I'm satisfied with the level of care the PHP provides and the structure in place for me to do evaluations, I don't see risk being a reason to decline.

 

[SmallBird]

It's a well established PHP so I'll definitely be getting more of a sense of how it runs before accepting.

PHP population being high risk overall, I definitely agree with. But I'm surprised to see so much concern for liability over the NP issue. Given the duration of the PHP, this didn't strike me as particualrly problematic--there aren't that many med changes it makes sense to make in that time period, and I'm used to writing one time consult notes in which I lay out the next two or three steps for non-psychiatrists. Team meetings are built into the workflow. The pts are closely monitored while in the PHP and then the treatment relationship ends and I would think with it the vast majority of the liability. Am I missing something? This actually seems to me one of the places where using NPs as physician extenders is very reasonable.

I’ve used this model in IOP, which has the benefit of then ensuring that every patient is formulated by a psychiatrist, even if ongoing biological interventions are done by an NP.

The trouble in PHP is that it’s not just a med check but more of an assessment regarding disposition and progress just like on an inpatient unit. I would have found it very jarring to handoff all my PHP patients after just the intake and even if to a physician colleague would have imagined multiple instances where I disagreed with the length of stay and extent of changes.

In terms of $ - if this was paid simply on RVU at mean rates it would be about $300. However if your evaluation is also the one being used to authorize the PHP stay you could argue that some of the facility fee should contribute to your pay. In the PHPs I’ve opened the model was that 50% of physician comp was from billing and 50% from the facility fee.

 

[Merovinge]

I’ve used this model in IOP, which has the benefit of then ensuring that every patient is formulated by a psychiatrist, even if ongoing biological interventions are done by an NP.

The trouble in PHP is that it’s not just a med check but more of an assessment regarding disposition and progress just like on an inpatient unit. I would have found it very jarring to handoff all my PHP patients after just the intake and even if to a physician colleague would have imagined multiple instances where I disagreed with the length of stay and extent of changes.

In terms of $ - if this was paid simply on RVU at mean rates it would be about $300. However if your evaluation is also the one being used to authorize the PHP stay you could argue that some of the facility fee should contribute to your pay. In the PHPs I’ve opened the model was that 50% of physician comp was from billing and 50% from the facility fee.

Right and lets be honest, the real money is in PHP facility/group fees. Physician reimbursement is no different than OP except the patients take longer, require more records review/collaboration (as they are sicker and more tx refractory), and as always we shunt all the money for that to facility fees to make sure doctors have as little control/power in the space as possible.

 

[Merovinge]

I really appreciate this discussion. I can't say I'm on the same page regarding the risk question, but I definitely appreciate the perspectives. My primary gig is academic CL. It can't exactly be called the lowest risk enterprise--patients are sick by every definition of the word, and while it's not emergency room, we of course have a hefty proportion of medically clear post-suicide folks that we evaluate. Many get sent home without inpatient admission (some, to PHPs of course!). I don't think there's much dispute that discharging suicidal or recently suicidal pt's is probanly the highest risk work in psychiatry. And it being a faculty job, I get paid a relative pittance. I love the work but I'm clear eyed about my reasons for staying in academia and recognize money ain't it.

There multiple questions to be answered by the PHP before I would accept this offer. But I certainly wouldnt accept it if I'm not paid a substantial multiplier of my academic hourly rate, and it doesn't seem any higher risk than my primary gig. Maybe that makes me a twice a fool, lol. But high risk psych is still low risk for most other fields. If I'm satisfied with the level of care the PHP provides and the structure in place for me to do evaluations, I don't see risk being a reason to decline.

My question is how many of your CL patient's do you see once and then hand off to an NP to never be seen again by you but you possibly being responsible for the outcome of their care? Catatonic? Do some benzos and hope for the best Mr/Mrs NP, I'm sure they will look over the labs and vitals to make sure nothing bad happens right? The equivalent in PHP is suicidial with some plans, some preparatory actions, but denying intent to do it now? Okay follow-up with NP for your next 8 visits. That's not even counting if your PHP works with eating disorders and the lab work needed to track some of those patients or substance use disorders and drilling into what usage is actually happening and risks of death from either intoxication or withdrawal.

 

[clausewitz2]

My question is how many of your CL patient's do you see once and then hand off to an NP to never be seen again by you but you possibly being responsible for the outcome of their care? Catatonic? Do some benzos and hope for the best Mr/Mrs NP, I'm sure they will look over the labs and vitals to make sure nothing bad happens right? The equivalent in PHP is suicidial with some plans, some preparatory actions, but denying intent to do it now? Okay follow-up with NP for your next 8 visits. That's not even counting if your PHP works with eating disorders and the lab work needed to track some of those patients or substance use disorders and drilling into what usage is actually happening and risks of death from either intoxication or withdrawal.

The agency I work with part-time appears to use NPs to staff their PHPs and IOPs. It shows.

 

[Celexa]

Update: although the intakes are specifically when they require a psychiatrist, the PHP actually is really happy to have me in a more involved role. I am negotiating for a set number of hours per week with additional compensation if the number of patient- facing hours is above a certain amount. The NP will do most of the follow ups but I have discretion to see follow ups myself if I consider it necessary. Time to directly supervise the NP is factored in and I interviewed them, observed them with patients, and checked references. I'm going to get it in writing that I have absolute veto power over any new NP hires who would be working with me. I also observed some of the therapy groups and asked around locally regarding the reputation of the program and was satisfied with the answers I got.

I had been planning to have a side private practice, but this gig tumbled into my lap and makes more sense on several levels, while still accomplishing the goal of supplementing my academic salary. I appreciate everyone's perspectives here.

 

[Merovinge]

Did you speak to the medical director? Who was doing the work before you are stepping in?

 

[Celexa]

Did you speak to the medical director? Who was doing the work before you are stepping in?

I spoke with the outgoing psychiatrist as well as the non physician staff.