So can we talk money?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

How much money are you making (or would make assuming you worked full-time)

  • $400k/year or more

    Votes: 26 16.4%
  • $300,000 to $399,000

    Votes: 27 17.0%
  • $250,000 to $299,000

    Votes: 27 17.0%
  • $200,000 to $249,000

    Votes: 44 27.7%
  • $150,000 to $199,000

    Votes: 20 12.6%
  • Less than $150k/year

    Votes: 15 9.4%

  • Total voters
    159
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.
It's takes a year to fill out the online application

Members don't see this ad.
 
  • Like
Reactions: 4 users
I think this is an incredible thread, offering lots of insight. I'm about to start 3rd year rotations and Psych has always been high on my list. I particularly like hearing about peoples practice setup, business model, etc.. so if anybody else would like to share what they do, how they do it, their practice setup, I'm all ears!!

My plan is to go into cash PP someday. Always been entrepreneurial and I think that patients deserve better care not hindered by insurance companies
 
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.

It shouldn't. I do cash only, charge market value rates, but offer big discounts to Medicare patients and people who can't afford it. I can do this because I charge market rates. I have a few folks only paying $50 an hour for meds plus therapy. I would rather be able to provide excellent, non-third-party-involved care to some rather than be limited in by ability to do that for many. Also, my goal is for people to actually not need me any more so they can be discharged and I can see new people.
 
  • Like
Reactions: 2 users
Members don't see this ad :)
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 not mean to imply that the sole motivation in accepting the physician employee model is poor business acumen. I am personally moved by similar ethical considerations. I ran a successful private practice as well, yet I am currently an employed physician. I made this decision largely out of a desire to care for the sick and vulnerable. However, that motivation is not an indictment of the private pay model or those who pursue it. People who pay cash for their healthcare have as much right to it as those who do not. Likewise, physicians who lack the moral imperative to provide care for those who cannot pay have a right to decline the provision of service. The voluntary, contractual nature of the physician-patient relationship is fundamental to the profession of medicine. While it is unfortunate that such a relationship breeds the occasional "mercenary" physician, such free agency ennobles the profession of medicine at large- whose practitioners by and large provide care to those most in need despite economic disincentives.
 
I'd like to know how a patient, particularly ones seeking the care of the Psychiatrist, respond to the notion that one only accepts cash. Despite healthcare (arguably) being the most important thing one could pay for, it seems the norm of insurance has created a polarizing indifference towards a willingness to pay out of pocket for services. How did you guys find opening a (mostly) cash practice in terms of getting patients who consistently, and willingly, pay? And how fast do these patient bases fill up?

I imagine a patient who pays for insurance would be less likely to pay cash, because well, they have to pay for insurance anyway, so why not just find a Psychiatrist who accepts insurance?
 
so why not just find a Psychiatrist who accepts insurance?

"A new American Psychiatric Association study confirms what patients with mental illness in the Washington, DC, area already know ― that it is almost impossible to get a new patient appointment with a psychiatrist for needed care.

The research shows that the majority of network psychiatrists in the three largest carriers in the DC Health Link Health Insurance Exchange Network were either not reachable or were not able to schedule a new patient visit."

-American Psychiatric Association (APA) 2016 Annual Meeting: Forum, presented May 16, 2016.
 
  • Like
Reactions: 2 users
Thanks for clarifying, Guyton. I figured you meant as much, but I didn't want to let it slide that public psychiatry was the refuge of folks without business sense.
People who pay cash for their healthcare have as much right to it as those who do not.
Agreed, both have as much right to healthcare. But whereas folks who can pay cash have little problems getting healthcare needs met, folks who can not do. It's a justice thing. Seeing only folks who can pay cash (including the sliding scale) limits one's practice to a population that has better access.
The voluntary, contractual nature of the physician-patient relationship is fundamental to the profession of medicine. While it is unfortunate that such a relationship breeds the occasional "mercenary" physician, such free agency ennobles the profession of medicine at large- whose practitioners by and large provide care to those most in need despite economic disincentives.
I'd quibble over that one. This non-socialized medicine set-up does not lead to practitioners by and large providing services at economic disincentives. Quite the opposite, I'd argue. But it's a discussion for another thread and at the end of the day it's an issue of ethics of the individual, not the profession.
 
  • Like
Reactions: 1 users
I'd like to know how a patient, particularly ones seeking the care of the Psychiatrist, respond to the notion that one only accepts cash. Despite healthcare (arguably) being the most important thing one could pay for, it seems the norm of insurance has created a polarizing indifference towards a willingness to pay out of pocket for services. How did you guys find opening a (mostly) cash practice in terms of getting patients who consistently, and willingly, pay? And how fast do these patient bases fill up?

I imagine a patient who pays for insurance would be less likely to pay cash, because well, they have to pay for insurance anyway, so why not just find a Psychiatrist who accepts insurance?


http://www.medscape.com/viewarticle/863386

  • Only 14% of the psychiatrists listed in the network directories were available to schedule new outpatient appointments; 86% of the psychiatrists listed were either unreachable or were not taking new patients.

  • Nearly a quarter (23%) of the telephone numbers listed for network psychiatrists were nonworking numbers.

  • Nearly half (49%) of the psychiatrists were no longer at the number listed.

  • Callers often had to call several times to get a response.

  • Only 7% of listed psychiatrists were able to schedule a new appointment within 2 weeks; 3% were able to do so within 15 to 28 days; and 4% had wait times longer than 4 weeks.

  • The average wait time for a new appointment was nearly 3 weeks (19.1 days).
If you have quick availability and are reachable, you'd fill fairly quickly.
 
  • Like
Reactions: 1 user
I'd like to know how a patient, particularly ones seeking the care of the Psychiatrist, respond to the notion that one only accepts cash. Despite healthcare (arguably) being the most important thing one could pay for, it seems the norm of insurance has created a polarizing indifference towards a willingness to pay out of pocket for services. How did you guys find opening a (mostly) cash practice in terms of getting patients who consistently, and willingly, pay? And how fast do these patient bases fill up?

I imagine a patient who pays for insurance would be less likely to pay cash, because well, they have to pay for insurance anyway, so why not just find a Psychiatrist who accepts insurance?

My prospective patients get a clue when I actually answer the phone when they call. "YOU'RE the doctor?" They are amazed they got me directly and it sets them up for the kind of care they are paying for. They can usually get in within two weeks. They pay for access in between appointments. They pay for me to prepare for their appointments with research / reading / homework tailored to their individual case. I always remind them that they are paying for superior customer service...even the candies in reception are not free, they are paying for them! Most are happy to do so.

I am at the point that I am considering paying concierge for primary care myself. The service is just so much better. Customer service in general in society is in the toilet and I really feel there is going to be more of a market for those offering more to those willing to pay a little more - a few hourlong customer service phone calls with Comcast or the like will do that to you.
 
  • Like
Reactions: 4 users
Beautiful. I appreciate the responses -- this gets me very excited to hopefully enter the field of Psychiatry
 
My prospective patients get a clue when I actually answer the phone when they call. "YOU'RE the doctor?" They are amazed they got me directly and it sets them up for the kind of care they are paying for. They can usually get in within two weeks. They pay for access in between appointments. They pay for me to prepare for their appointments with research / reading / homework tailored to their individual case. I always remind them that they are paying for superior customer service...even the candies in reception are not free, they are paying for them! Most are happy to do so.

I am at the point that I am considering paying concierge for primary care myself. The service is just so much better. Customer service in general in society is in the toilet and I really feel there is going to be more of a market for those offering more to those willing to pay a little more - a few hourlong customer service phone calls with Comcast or the like will do that to you.

Very cool. How do you answer calls and see patients at the same time, though? I'd imagine you're pretty booked, so wouldn't you need some sort of front desk person answering calls, or do you see so few patients that you can call back yourself? What's your office set up like, i.e. do you share an office with other cash-pay psychiatrists and/or psychologists or do you work out of your own home or your own office?
 
I see patients pretty early in the morning when I am not usually getting calls - the joys of being a morning lark and working with insomniacs. I work half time in a pretty small office, solo. I made a decision to see fewer patients and provide them a high level of service rather than spread myself too thin and compromise care (or retire early). Just a personal decision that has worked out well for me.

I don't think I have done a 30 minute med check since I've been in private practice.

Very cool. How do you answer calls and see patients at the same time, though? I'd imagine you're pretty booked, so wouldn't you need some sort of front desk person answering calls, or do you see so few patients that you can call back yourself? What's your office set up like, i.e. do you share an office with other cash-pay psychiatrists and/or psychologists or do you work out of your own home or your own office?
 
For you guys who take cash only, do you collect your fees up front before the session with your patients?
 
Members don't see this ad :)
For you guys who take cash only, do you collect your fees up front before the session with your patients?
I take payment at the end as we are scheduling their next appointment. "Do you usually do credit card or check?" is my stock cue for payment. No one has ever "therapized and dashed" on me, I guess.
 
My office manager collects payment at the time of service. She asks each patient if they would like to pay when they check in or at the end when they schedule their next appointment.

The majority of my patients pay at the time of service and the remainder prefer to be billed monthly. Many elect to keep a credit card on file. For those who are billed, I make sure they understand they must pay the balance in full within 30 days or they will not be able to reschedule and, of course, no refills on their medication until they've scheduled an appointment. This has not been a problem.

I also see the majority of patients for an hour but I do offer 30 minute appointments for those who prefer that option and are not psychotherapy patients.
 
And I assume you'd charge a fee for no shows to the CC on file? Seems like the fear of not getting a refill would be strong enough to keep everybody paying
 
For those who are billed, I make sure they understand they must pay the balance in full within 30 days or they will not be able to reschedule and, of course, no refills on their medication until they've scheduled an appointment.
If something bad happens because the patient didn't get a refill because they didn't pay for over 1 month, are you liable? What do you do to address this risk?
 
Man i am so damn excited to finish residency. I am ready to work my ass off in PP. I have goals to reach the higher pay scales listed above to help pay loans off asap like in 3-4 years then i can cut back a bit. Im hoping that 60 ish hour work weeks gets me there and weekend office hrs and if i need to cover an inpatient unit for a weekend 1x-2x a month... not sure if 40 ish hours equates to roughly 250k for PP or employed position but I wont make that much in my first year even working 60hrs in PP but maybe by 2nd year there are some chances. I was doing close to 80 in first year as we do 4 months medicine and i was ok with that .. just hated being there at 6am and from years 2-3 60 ish hours was the norm with call included so this is doable i feel.
 
Last edited:
My prospective patients get a clue when I actually answer the phone when they call. "YOU'RE the doctor?" They are amazed they got me directly and it sets them up for the kind of care they are paying for. They can usually get in within two weeks. They pay for access in between appointments. They pay for me to prepare for their appointments with research / reading / homework tailored to their individual case. I always remind them that they are paying for superior customer service...even the candies in reception are not free, they are paying for them! Most are happy to do so.

I am at the point that I am considering paying concierge for primary care myself. The service is just so much better. Customer service in general in society is in the toilet and I really feel there is going to be more of a market for those offering more to those willing to pay a little more - a few hourlong customer service phone calls with Comcast or the like will do that to you.
As a concierge-type family doc (DPC but close enough), this has been my exact experience as well. Are there patients who will never want to pay cash for medical care? Sure. Are there patients who love the idea of paying out of pocket to get superior customer service and care? Absolutely.

My rates (like most DPC doctors) are low enough that almost anyone can afford them. Seriously, who honestly would have trouble with $50/month for unlimited primary care?
 
It shouldn't. I do cash only, charge market value rates, but offer big discounts to Medicare patients and people who can't afford it. I can do this because I charge market rates. I have a few folks only paying $50 an hour for meds plus therapy. I would rather be able to provide excellent, non-third-party-involved care to some rather than be limited in by ability to do that for many. Also, my goal is for people to actually not need me any more so they can be discharged and I can see new people.
This is the most understated part about owning your own practice - you can offer free/discounted care when you want to. I had a patient who paid her bill then had to buy 4 new tires and couldn't afford it so I refunded half of her bill so she could afford those tires. I didn't have to go to an office manager or administrator to get that approved: I just did it. I saw her back today, she paid the rest of her balance and was so thankful that I worked with her.
 
  • Like
Reactions: 1 user
This is the most understated part about owning your own practice - you can offer free/discounted care when you want to. I had a patient who paid her bill then had to buy 4 new tires and couldn't afford it so I refunded half of her bill so she could afford those tires. I didn't have to go to an office manager or administrator to get that approved: I just did it. I saw her back today, she paid the rest of her balance and was so thankful that I worked with her.

+1
It's the best part of being an owner and not an employee.
 
California doesn't look bad either even though they have a high COL. They don't have independent NP practice, and I wonder if that helps with either pay. I'm suspecting the high pay locums spots are in undesirable places, too.

Do not come to California! At least not LA or the Bay Area. The cake is a lie! You might make slightly more money but your COL is through the ROOF. I am trying to leave. It's BS, like running on a treadmill that keeps getting faster and faster. Midwest FTW, should have never left Ohio after med school! If you don't mind the area, Sacramento is not so bad though.

The funny thing about doctors is that our salaries don't vary as much as other fields no matter what part of the country we're in. Thus, most other fields get paid substantially more in high COL areas whereas doctors are only paid slightly more in those areas, or even less due to competition. Thus, if you go to low COL area you will do substantially better than everyone else in that town. If you have lots of money around other people with lots of money, your money will be worth less. If you have lots of money and everyone else has little, you will have a lot of purchasing power. Simple economics.
 
  • Like
Reactions: 1 users
Do not come to California! At least not LA or the Bay Area. The cake is a lie! You might make slightly more money but your COL is through the ROOF. I am trying to leave. It's BS, like running on a treadmill that keeps getting faster and faster. Midwest FTW, should have never left Ohio after med school! If you don't mind the area, Sacramento is not so bad though.

The funny thing about doctors is that our salaries don't vary as much as other fields no matter what part of the country we're in. Thus, most other fields get paid substantially more in high COL areas whereas doctors are only paid slightly more in those areas, or even less due to competition. Thus, if you go to low COL area you will do substantially better than everyone else in that town. If you have lots of money around other people with lots of money, your money will be worth less. If you have lots of money and everyone else has little, you will have a lot of purchasing power. Simple economics.

Physician salaries are actually lower in some of the really high cost of living areas like cities on the east coast.

I'm guessing a lot of my California job emails are really for places like Fresno, Bakersfield, Riverside, Redding or insert other similarly non-super desirable place in California.
 
Do not come to California! At least not LA or the Bay Area. The cake is a lie! You might make slightly more money but your COL is through the ROOF. I am trying to leave. It's BS, like running on a treadmill that keeps getting faster and faster. Midwest FTW, should have never left Ohio after med school! If you don't mind the area, Sacramento is not so bad though.

The funny thing about doctors is that our salaries don't vary as much as other fields no matter what part of the country we're in. Thus, most other fields get paid substantially more in high COL areas whereas doctors are only paid slightly more in those areas, or even less due to competition. Thus, if you go to low COL area you will do substantially better than everyone else in that town. If you have lots of money around other people with lots of money, your money will be worth less. If you have lots of money and everyone else has little, you will have a lot of purchasing power. Simple economics.

I have some contacts near Chico if you're interested in relocating....
 
Do not come to California! At least not LA or the Bay Area. The cake is a lie! You might make slightly more money but your COL is through the ROOF. I am trying to leave. It's BS, like running on a treadmill that keeps getting faster and faster. Midwest FTW, should have never left Ohio after med school! If you don't mind the area, Sacramento is not so bad though...
"You can check out any time you like..."
 
  • Like
Reactions: 1 users
Physician salaries are actually lower in some of the really high cost of living areas like cities on the east coast.

I'm guessing a lot of my California job emails are really for places like Fresno, Bakersfield, Riverside, Redding or insert other similarly non-super desirable place in California.
I'm sure of it. I did a locums gig in central California, and while it paid well, and would have paid even more had I joined permanently (which the hospital admin strongly urged me to do,) it was a miserable place and I couldn't wait to get out of there. The locums agency tried to sell me on a $200 per hour assignment in Fresno after that, but I already had 1 foot out the door (or over the Sierra Nevadas, as the case may be.)

I agree that Sacramento would be doable.
 
Do not come to California! At least not LA or the Bay Area. The cake is a lie! You might make slightly more money but your COL is through the ROOF. I am trying to leave. It's BS, like running on a treadmill that keeps getting faster and faster. Midwest FTW, should have never left Ohio after med school! If you don't mind the area, Sacramento is not so bad though.

The funny thing about doctors is that our salaries don't vary as much as other fields no matter what part of the country we're in. Thus, most other fields get paid substantially more in high COL areas whereas doctors are only paid slightly more in those areas, or even less due to competition. Thus, if you go to low COL area you will do substantially better than everyone else in that town. If you have lots of money around other people with lots of money, your money will be worth less. If you have lots of money and everyone else has little, you will have a lot of purchasing power. Simple economics.

Is it really this bad? You're still in the upper 5% with a 240k income in LA.
 
Is it really this bad? You're still in the upper 5% with a 240k income in LA.

Where do you live now, and how aware are you of the difference in the cost of living (really it is the cost of housing that drives the discussion) in different markets around the country?

Where I live now in flyover country, I could make as an attending virtually the same income I could make in, say, Los Angeles; even if I could make slightly more in LA, the high marginal income tax rates would eat into it, as well as other higher costs in CA (gasoline, etc). The house I rent where I am in residency now, a single family home in a great neighborhood, etc., is worth maybe $250k; in Los Angeles, it would cost at least 3x, and maybe 4x as much or more. In the San Francisco Bay area, the same house could cost 10x as much...
 
Last edited:
Where do you live now, and how aware are you of the difference in the cost of living (really it is the cost of housing that drives the discussion) in different markets around the country?

Where I live now in flyover country, I could make as an attending virtually the same income I could make in, say, Los Angeles; even if I could make slightly more in LA, the high marginal income tax rates would eat into it, as well as other higher costs in CA (gasoline, etc). The house I rent where I am in residency now, a single family home in a great neighborhood, etc., is worth maybe $250k; in Los Angeles, it would cost at least 3x, and maybe 4x as much or more. In the San Francisco Bay area, the same house could cost 10x as much...

Exactly. The median house price in SF is over 1 million. Not worth it.
https://www.redfin.com/blog/2016/04/march-national-housing-market-tracker.html
 
I agree that Sacramento would be doable.

Does anybody have a feel for how many of the UCD psych program grads stay in the Sacramento area? My guess is not very many of them, but I wonder. Davis, about 20 miles away, is a really nice town, but the cost of housing is literally double that of Sacto, for understandable reasons if you have visited both places.
 
Does anybody have a feel for how many of the UCD psych program grads stay in the Sacramento area? My guess is not very many of them, but I wonder. Davis, about 20 miles away, is a really nice town, but the cost of housing is literally double that of Sacto, for understandable reasons if you have visited both places.

I knew someone who was an attending with the UCD program. While she worked there, it felt like a cattle call to her and wasn't being allowed to explore the areas of interest to her. No real quality of work. Again, because she was new to staff perhaps was having a lot of the junk jobs dumped onto her. Never the less she has moved on to other pastures.
 
Is it really this bad? You're still in the upper 5% with a 240k income in LA.
Someone living on welfare in the United States is in the top 20% of global earners, but that doesn't make them any less hungry.
 
  • Like
Reactions: 1 user
Physician salaries are actually lower in some of the really high cost of living areas like cities on the east coast.

I'm guessing a lot of my California job emails are really for places like Fresno, Bakersfield, Riverside, Redding or insert other similarly non-super desirable place in California.

These are places that have severe shortages of psychiatrists then? Are you able to negotiate higher wages or is it a done deal?
 
These are places that have severe shortages of psychiatrists then? Are you able to negotiate higher wages or is it a done deal?
I've been seeing offer of about $50-70K higher for comparable jobs in less desirable areas to live in California.

But keep in mind that California is a bigger state than most. A lot of these places are 2 hours from a city with a decent Thai place, woods consistent of actual trees, and much of anything other than industrial farming. On the upside, you'll pay next to nothing for cost of living.
 
Everything is negotiable. If you're desired deeply enough, they will negotiate.

For the newly graduated resident, how do you become "desirable?" Name of your program? Recommendations? Personality?

It's not like you have any experience as an attending to wow them over with.
 
just got this in mail...
IMG_1138.JPG
 
  • Like
Reactions: 1 users
Everyone is complaining about Cali COL. What about NYC?

The COL here is just as high as SF/LA, but at least in Cali you get palm trees, warm weather, nice ocean, surfing....

What do we get in NYC? Dirty subway? Snowstorms? Rude people? High stress?

I'm jealous of all you Californians!
 
  • Like
Reactions: 1 user
Colorado has state income tax right? I mean 450k in Denver sounds too good to be true!

Sent from my SM-N910V using Tapatalk
 
It's about 2 hours north of Denver.
 
Top