So can we talk money?

[Doctor Bagel]

I am being presented with an opportunity in a small town located within hour of major metro. They are offering employed but also an income guarantee - which I did not think was common in our field. If I were to be setup with an income guarantee, what should I look for/demand?

You'd want to know how long the income is guaranteed for, if there's any potential obligation to repay anything if your collections are too low, and when the contract gets re-evaluated. Also with guaranteed income, how much control do you have over your schedule? Are they going to expect 15 minute follow ups and 30 minute new evals? In this location, how likely are you to get up to a collections level where you would meet this guaranteed income? If it would be pretty fast, and you're stuck with guaranteed income for 3 years or so, it might not be a great deal. If it would take a while, the longer the guarantee, the better. My understanding from other people I've known with these deals (admittedly not in psychiatry) is that your income initially drops after the guaranteed income ends but usually meets/exceeds it later.

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[Doctor Bagel]

Same pay, if not higher in the Midwest compared to CA with lower taxes and COL. You make out better.

Maybe California is maybe a nicer place to live than OH or IL. I really don't want to live in the midwest. My plan if I really want to go for the bigger money stuff is go to the interior mountain states -- Montana, Wyoming -- from emails I get, those could be promising too.

 

[calvnandhobbs68]

24% are making less than 200K assuming they work full time? That kinda sucks.

 

[sunlioness]

I'm all about the Midwest. Salaries are high. Population density is low. You can live five minutes from work in a very nice, very affordable house. You still have money to take a 4 star vacation to all those places it would be obnoxious and expensive to actually live in.

Sign me up for the cornfield.


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[OldPsychDoc]

I'm all about the Midwest. Salaries are high. Population density is low. You can live five minutes from work in a very nice, very affordable house. You still have money to take a 4 star vacation to all those places it would be obnoxious and expensive to actually live in.

Sign me up for the cornfield.

The women are strong, the men are good-looking, and the children are all above average...or so I've been told.

 

[sunlioness]

That might be just Minnesota. ;-)


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[Shikima]

That might be just Minnesota. ;-)


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Or Pam from Archer.

 

[notdeadyet]

Or Pam from Archer.

Shame about the hands.

 

[vistaril]

I'm all about the Midwest. Salaries are high. Population density is low. You can live five minutes from work in a very nice, very affordable house. You still have money to take a 4 star vacation to all those places it would be obnoxious and expensive to actually live in.

Sign me up for the cornfield.


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I'm not neccessarily pro-midwest or anti-midwest, but one thing about it is that most of those states seem to have robust state income taxes. One can live in Nashville, Austin, Orlando, Tampo, Dallas, Chatanooga, etc and not pay any state income tax. And no, for many people it really doesn't 'all come out even in the end' regarding taxes. In some of those states property taxes are also higher than tn and fl.

 

[Information Underload]

I'm all about the Midwest. Salaries are high. Population density is low. You can live five minutes from work in a very nice, very affordable house. You still have money to take a 4 star vacation to all those places it would be obnoxious and expensive to actually live in.

Sign me up for the cornfield.


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Or you can live in the woods and right on a lake if you're choosing Minnesota, Wisconsin or Michigan.

 

[notdeadyet]

Like where you live. It may be expensive or it may be affordable, but you'll spend many multitudes more time in the community you live in than you will in these places you may (or may not) have the money to vacation in. And you'll have the potential for actually have a positive impact (beyond dropping the Tubmans) in the community you live and work in. Why not put roots somewhere you love, cool factor be damned?

 

[FlowRate]

Like where you live. It may be expensive or it may be affordable, but you'll spend many multitudes more time in the community you live in than you will in these places you may (or may not) have the money to vacation in. And you'll have the potential for actually have a positive impact (beyond dropping the Tubmans) in the community you live and work in. Why not put roots somewhere you love, cool factor be damned?

How else will I level up my bank account if I don't grind on mobs in the higher toughness areas?

 

[jettavr6]

From the number of phone calls that I'm getting from recruiters, I'd encourage every graduating resident to not accept anything less than $250-275k including bonuses and benefits. They are calling places like my practice, which is well established and thriving, looking for psychiatrists.

I get the sense that they are extremely desperate. Psychiatry is in extremely high demand right now. It helps to get the advice of an attorney before signing a contract.

 

[Shikima]

How else will I level up my bank account if I don't grind on mobs in the higher toughness areas?

 

[vistaril]

From the number of phone calls that I'm getting from recruiters, I'd encourage every graduating resident to not accept anything less than $250-275k including bonuses and benefits.

thats true if you are geographically flexible. For some people, thats not an option.

Also, as I've said before, the salary/job opportunities in psychiatry depending on the locale don't often correlate to supply/demand that closely. You could have an area with theoretically high demand and low supply and still either be crap paying or not have any decent job opportunities. A lot of other factors beyond a single individuals control can overshadow 5th grade econ analysis.

 

[nexus73]

Through an informal conversation with someone in the area, I heard the Phoenix VA is down 8 psychiatrists from ideal staffing. That's concerning considering there are 3 psychiatry residencies in close proximity and Phoenix is a fairly sight after location (maybe that's debatable).

 

[keifernny2]

so I wish that every place just paid based on RVUs, it'd make it a heck of a lot easier to compare.

 

[prominence]

Through an informal conversation with someone in the area, I heard the Phoenix VA is down 8 psychiatrists from ideal staffing. That's concerning considering there are 3 psychiatry residencies in close proximity and Phoenix is a fairly sight after location (maybe that's debatable).

What does this have to do with answering the question posed by the title of this thread?

 

[Doctor Bagel]

Through an informal conversation with someone in the area, I heard the Phoenix VA is down 8 psychiatrists from ideal staffing. That's concerning considering there are 3 psychiatry residencies in close proximity and Phoenix is a fairly sight after location (maybe that's debatable).

Hiring is an issue for the VA because it's such a bureaucratic process. I think the time between getting approved for a position, posting it, leaving it open for the required period, etc, means it takes about a year to fill a position.

 

[nexus73]

I'm commenting on the shortage of psychiatrists, even in a large metro area like Phoenix, and asking what does this mean for supply and ultimately salary for psychiatrists in general, and especially in smaller places without the draw of Phoenix or nearby psych residencies. I know in my neck of the woods it took a year to get the last inpatient psychiatrist, and he may not be sticking around past his contract end date. The lack of psychiatrists definitely raises my salary as an employed doctor. I don't know if insurance pays the private practice psychiatrists more because of the lack of supply.

 

[prominence]

I'm commenting on the shortage of psychiatrists, even in a large metro area like Phoenix, and asking what does this mean for supply and ultimately salary for psychiatrists in general, and especially in smaller places without the draw of Phoenix or nearby psych residencies. I know in my neck of the woods it took a year to get the last inpatient psychiatrist, and he may not be sticking around past his contract end date. The lack of psychiatrists definitely raises my salary as an employed doctor. I don't know if insurance pays the private practice psychiatrists more because of the lack of supply.

Ok, fair point then.

 

[Extralong]

I would like to see who voted in the above poll. I think there is some ballet stuffing going on.

 

[Leo Aquarius]

The poll doesn't tease out psychiatrists working one vs. two jobs. I suspect those making over $300K are doing extra work somewhere.

 

[Doctor Bagel]

The poll doesn't tease out psychiatrists working one vs. two jobs. I suspect those making over $300K are doing extra work somewhere.

It's not a particularly sophisticated poll. I was trying to get a rough feel when I created it. I'm still hoping all those people who answered that they're making less than $150k were reading it wrong and are only making that little working less than full-time. It's hard to separate out different streams of income -- personally I earn in one category for my base pay, but my on call pay puts me into the next bracket. I answered in the lower bracket because that's my 40 hour/week type of pay. On call pay is variable, too, though. For example, I'm on pager call right now. I do this one night a week, and it bumps my income a bit -- it accounts for maybe 1 to 2 hours of work, but it also means I get woken up throughout the night, which is its own cost. My current pay for just one job is a combination of base pay + pager call on weeknights + weekend calls (actually working + pager call overnight) + student loan benefit.

 

[oldanddone]

I would like to see who voted in the above poll. I think there is some ballet stuffing going on.

Is that when you endow with a sock?

 

[Extralong]

The poll doesn't tease out psychiatrists working one vs. two jobs. I suspect those making over $300K are doing extra work somewhere.

It's not a particularly sophisticated poll. I was trying to get a rough feel when I created it. I'm still hoping all those people who answered that they're making less than $150k were reading it wrong and are only making that little working less than full-time. It's hard to separate out different streams of income -- personally I earn in one category for my base pay, but my on call pay puts me into the next bracket. I answered in the lower bracket because that's my 40 hour/week type of pay. On call pay is variable, too, though. For example, I'm on pager call right now. I do this one night a week, and it bumps my income a bit -- it accounts for maybe 1 to 2 hours of work, but it also means I get woken up throughout the night, which is its own cost. My current pay for just one job is a combination of base pay + pager call on weeknights + weekend calls (actually working + pager call overnight) + student loan benefit.

I can see what you two are saying. I figure usually when there is a bimodal curve with non-scientific ballots, I tend to think stuffing the ballot. But I can see that there can be other reasons for this.

Is that when you endow with a sock?

Hahaha

 

[sean1]

Interesting thread..I appreciate reading others experiences...

Just wanted to give my experience...
I have an exclusively outpatient private practice in a midsized city. I see approx. 22-27 patients daily (9 hours a day - no weekends). Call is by phone for emergencies.
About 60 % of these are 15 min. med checks (reimbursement averages $70-75 each)
About 25-30% of these are 30 min. (med check with some therapy - average $110 each)
About 10-15% of these are 45 min. (new patient appts - average $160 each)
There tends to be a slight amount of overbooking for urgent appts. but usu. no shows offset this.
There is a minimal charge for no shows.
There is also a minimal charge for paperwork that patients need filled out (like LTD paperwork etc)

My collections average about $2100-2400 per day based on this model. This comes to about $45000 per month (assuming 20 working days).
My monthly overhead is about $4000-5000 per month incl malpractice, emr, phones, office staff, internet, space, etc.

So I clear 400k with this model.

 

[TexasPhysician]

My monthly overhead is about $4000-5000 per month incl malpractice, emr, phones, office staff, internet, space, etc.

So I clear 400k with this model.

Full time support staff, billing, malpractice, and rent is under 5k total per month? Please let me know how you do this.

 

[sean1]

Full time support staff, billing, malpractice, and rent is under 5k total per month? Please let me know how you do this.

so malpractice is about 1k per month
emr is about 1.5k per year
the rest of overhead as I listed incl. in-house biller are shared cost between multiple providers.

 

[TexasPhysician]

the rest of overhead as I listed incl. in-house biller are shared cost between multiple providers.

Gotcha. Groups are certainly leaner. Thanks.

 

[medium rare]

Interesting thread..I appreciate reading others experiences...

Just wanted to give my experience...
I have an exclusively outpatient private practice in a midsized city. I see approx. 22-27 patients daily (9 hours a day - no weekends). Call is by phone for emergencies.
About 60 % of these are 15 min. med checks (reimbursement averages $70-75 each)
About 25-30% of these are 30 min. (med check with some therapy - average $110 each)
About 10-15% of these are 45 min. (new patient appts - average $160 each)
There tends to be a slight amount of overbooking for urgent appts. but usu. no shows offset this.
There is a minimal charge for no shows.
There is also a minimal charge for paperwork that patients need filled out (like LTD paperwork etc)

My collections average about $2100-2400 per day based on this model. This comes to about $45000 per month (assuming 20 working days).
My monthly overhead is about $4000-5000 per month incl malpractice, emr, phones, office staff, internet, space, etc.

So I clear 400k with this model.

My experience is similar. I'm full-time private practice (cash only, no insurance) but only see between 10-16 patients/day. My practice as a clinical psychologist and psych NP is focused on the integration of psychotherapy and medication so I either see patients for 30 minutes or 60 min after a 90-minute initial eval - primarily meds for 30 min and meds/psychotherapy or psychotherapy alone for 60 min.

My collections are between $1600 - $2100/day. My monthly overhead is approximately $2500 for everything including malpractice (I share an office suite with 3 other docs and we split expenses by 4 including one full-time office manager who does everything from scheduling, answering calls, billing, PAs, etc). I charge my full fee for no-shows and late cancellations. I generally work 46 weeks/year.

I cleared $365k last year.

 

[Extralong]

My experience is similar. I'm full-time private practice (cash only, no insurance) but only see between 10-16 patients/day. My practice as a clinical psychologist and psych NP is focused on the integration of psychotherapy and medication so I either see patients for 30 minutes or 60 min after a 90-minute initial eval - primarily meds for 30 min and meds/psychotherapy or psychotherapy alone for 60 min.

My collections are between $1600 - $2100/day. My monthly overhead is approximately $2500 for everything including malpractice (I share an office suite with 3 other docs and we split expenses by 4 including one full-time office manager who does everything from scheduling, answering calls, billing, PAs, etc). I charge my full fee for no-shows and late cancellations. I generally work 46 weeks/year.

I cleared $365k last year.

Hmmm. It's hard for me to believe that your collections are $1600-2100/day only from seeing patients as an NP and/or psychologist/psychotherapist. Something doesn't smell right, or something shady is going on.

 

[Doctor Bagel]

Hmmm. It's hard for me to believe that your collections are $1600-2100/day only from seeing patients as an NP and/or psychologist/psychotherapist. Something doesn't smell right, or something shady is going on.

Cash only so you can charge what you like -- if people are willing to pay, I'm not sure anything shady needs to go on. No room for things like fraudulent billing without things like insurance companies.

 

[prominence]

Hmmm. It's hard for me to believe that your collections are $1600-2100/day only from seeing patients as an NP and/or psychologist/psychotherapist. Something doesn't smell right, or something shady is going on.

Cash only, provides quality psychotherapy plus ability to prescribe at the same visit... if the provider can generate enough pt flow, doesn't seem shady in the least. There's more than enough pts seeking mental health services and that demand isn't going away anytime soon. Non-psychiatrists help fill that void. Medium rare, congratulations on your successful business model

 

[Extralong]

I guess thats what sdn is for; for the rare .001% NPs posting numbers in this thread that many physicians barely can attain. Maybe its true, but I have an extremely hard time believing it. Thats all.

 

[medium rare]

My point in posting was to demonstrate the demand that exists in the market. Not dealing with insurance makes it much easier to do business and cuts down on overhead considerably. Most of my patients pay with a credit card, maybe 20% pay with check and less than 5% pay in cash. And, there is no shortage of patients. If I took insurance, my phone would never quit ringing.

There is strong demand for practitioners who do integrated psychotherapy and med management and, as you know, we are rare birds. IMO, any psychiatrist interested in and trained to provide psychotherapy in conjunction with medication should consider this option - patients will pay for it. I like to think this will be an emerging, 'new' trend to have psychiatrists start providing psychotherapy again. Patient quality of care would certainly increase.

 

[Extralong]

Cash only, provides quality psychotherapy plus ability to prescribe at the same visit... if the provider can generate enough pt flow, doesn't seem shady in the least. There's more than enough mental pts for non-psychiatrists and that demand isn't going away anytime soon. Medium rare, congratulations on your successful business model

Cash only does not equate to quality care. If you give out C2-5s all day long, you can have a great flowing private practice.

 

[Doctor Bagel]

My point in posting was to demonstrate the demand that exists in the market. Not dealing with insurance makes it much easier to do business and cuts down on overhead considerably. Most of my patients pay with a credit card, maybe 20% pay with check and less than 5% pay in cash. And, there is no shortage of patients. If I took insurance, my phone would never quit ringing.

There is strong demand for practitioners who do integrated psychotherapy and med management and, as you know, we are rare birds. IMO, any psychiatrist interested in and trained to provide psychotherapy in conjunction with medication should consider this option - patients will pay for it. I like to think this will be an emerging, 'new' trend to have psychiatrists start providing psychotherapy again. Patient quality of care would certainly increase.

Are you in a location where cash pay is normal? It's not the norm in my market although I think if enough psychiatrists started only accepting cash (and sure, letting patients bill for out of network coverage), that could change.

Theoretically all psychiatrists should be trained in providing psychotherapy in conjunction with medication management. That's like our thing. Although yes, some ongoing therapy supervision would probably be a good thing for most of us.

 

[prominence]

Cash only does not equate to quality care.

I meant that the annual income Medium Rare cited via a cash only practice in combination with such a provider offering both quality psychotherapy plus psychiatric medication management at the same office visit does not seem far-fetched to me.

 

[scudiera]

How else will I level up my bank account if I don't grind on mobs in the higher toughness areas?

Dying! Like you I'm just starting out in residency... really curious to see how the landscape will have shifted in 4-5 years (and I don't mean in typical SDN sky is falling fashion, legitimately, I'm wondering where the job market will take me if I'm flexible on location at that time).

 

[medium rare]

Are you in a location where cash pay is normal?

Somewhat. I'm in the southwest in an area that was heavily penetrated by managed care in the late 80's and early 90's. More and more providers are getting off panels, limiting their participation to one or two panels or not participating at all.

It's actually becoming harder for insurances to fill their panels in psych and many have provider lists that are not at all accurate with listed providers who are not taking patients, are retired, not actually contracted with them or even deceased.

I'd guess at least 50% of psychiatrists in my city do not take insurance and more have very limited involvement (1-2 panels).

 

[Guyton]

The recent upward trend in physician employment is a function of increasing regulation, legislation, and bureaucracy, not poor financial viability of the independent or small group practice. Running any small business is becoming increasingly complicated. This is especially the case in the more regulated industries, like healthcare. Thus, those without a strong entrepreneurial spirit increasingly settle for the physician employee model rather than struggle against a system engineered to benefit big business. However, the private pay model is alive and well, as it circumvents many of the obstacles intrinsic to third party payer models.

 

[Extralong]

The recent upward trend in physican employment is a function of increasing regulation, legislation, and beurocracy, not poor financial viability of the independent or small group practice. Running any small business is becoming increasingly complicated. This is especially the case in the more regulated industries, like healthcare. Thus, those without a strong entrepreneurial spirit increasingly settle for the physician employee model rather than struggle against a system engineered to benefit big business. However, the private pay model is alive in well as it circumvents many of the obstacles intrinsic to third party payer models.

I would argue that the private pay model is trending down for physicians. I am in full support of it, but its becoming much more difficult, as you pointed out.

 

[VA Hopeful Dr]

I would argue that the private pay model is trending down for physicians. I am in full support of it, but its becoming much more difficult, as you pointed out.

For physicians in general, I think you're right. Psychiatry is different though as private practice (cash-only or insurance) seems to be in a much better place compared to the rest of us.

 

[notdeadyet]

Thus, those without a strong entrepreneurial spirit increasingly settle for the physician employee model rather than struggle against a system engineered to benefit big business. However, the private pay model is alive and well, as it circumvents many of the obstacles intrinsic to third party payer models.

What keeps some of us from running cash only practices is not a lack of "entrepreneurial spirit" but personal ethical considerations about limiting our care to those who can afford to pay cash for their healthcare.

I did quite well working for myself for a number of years pre-medicine. I don't pine to work for county, federal, and state employers because I love bureaucracy and can't run a business. I do so because this is the only real way to work with the poor, underserved, and people most in need of healthcare services. Aside from the healthcare equivalent of taking the vows (running an exclusively Medicaid private practice clinic), and I ain't that noble.

 

[FlowRate]

Hmmm. It's hard for me to believe that your collections are $1600-2100/day only from seeing patients as an NP and/or psychologist/psychotherapist. Something doesn't smell right, or something shady is going on.

$300/hr isn't that outrageous (I've seen people in my area advertise $250) for $$ only MD's, not sure why a NP/PsyD would be too different.

 

[Igor4sugry]

Private practice is worthwhile for some people. But you have 24/7 call, that is something I'm not willing to do.

I would want to hear above persons list their expenses such as (cost of health insurance for entire family; malpractice; cost of finding someone to cover when you are on vacation).

 

[medium rare]

Private practice is worthwhile for some people. But you have 24/7 call, that is something I'm not willing to do.

I would want to hear above persons list their expenses such as (cost of health insurance for entire family; malpractice; cost of finding someone to cover when you are on vacation).

I'm not married and no children so I only have to worry about myself for health insurance - $253/month for a $5000 deductible that pays 100% after deductible is met. My malpractice insurance is $1300/year for NP and & $1250/year for psychologist. I cover for a private practice psychiatrist and she covers for me when I'm on vacation or out of town- no charge for either of us.

 

[PikminOC]

So getting back to the original question, what is your conceptualization of a fair full-time salary (assuming 40 hours a week and no call) and/or an hourly wage for a general psychiatrist? What is it in your area? How much should extra experience or the completion of a fellowship change this?

And please tell me those 9 people who indicated they're making less than $150k are not working full-time? If so, why?

I have seen full time academics pay less than that. But they get tons of benefits

 

[PikminOC]

I'm not married and no children so I only have to worry about myself for health insurance - $253/month for a $5000 deductible that pays 100% after deductible is met. My malpractice insurance is $1300/year for NP and & $1250/year for psychologist. I cover for a private practice psychiatrist and she covers for me when I'm on vacation or out of town- no charge for either of us.

In my state, it's 13000 per year for psychiatric malpractice Part time. No ect, no inpatients, no mp cases.