What hospitals pay locums compared

[Sushirolls]

I am an anesthesiologist. I make pretty decent per hour money. Between 2-300/hr.
I take all comers of course, Medicare and Medicaid. Currently I do locums but have done PP before.
I know insurance companies are a PIA, when trying to negotiate and sometimes get paid. I get it. But I feel like all people need access to basic healthcare. Even ones on Medicaid and Medicare.
So my questions to the Cash paying psychiatrists is this. Considering that the seriously ill people in psychiatry are most often not gonna have the steadiest jobs, the best insurance, do you feel at all bad for excluding these needy people from your care? Like the teacher who has a psychotic break at 30 and decompensates, takes a LOA, for a few weeks, then back to work but needs frequent close follow up for Bipolar 1. Let’s say she needs an OP psychiatrist or she moves cities. And that’s a good example of a working middle class person who can’t afford $300 a month on top of what she pays at her job for premiums.
Do you think that Cash only in a field like psychiatry where people are often poor is doing the most needy people a disservice? Let’s not even talk about the ones on Medicaid because they can go to the community clinics I have been told.
I hate insurance companies as much as the next person, but it’s what we have in this country. Do these people with proper insurance at work, and proper familial support, do they need to really pay on top of their regular insurance to see you guys?

I don't lose any sleep over not taking medicaid and future plans to drop medicare and insurance companies paying less than medicare. I am not a non-profit who gets tax breaks. I don't get to write off the charity care I have been doing, or the bad debt I can't collect on. Perhaps if I could get tax deductions for bad debt or charity care I'd take on more of such cases. But if I optimize my practice to make as much as possible, I can get tax deductions by donating money to non-profits - which is ultimately a more efficient way to do more community good.

Secondarily, society has safety nets of community mental health agencies, which are more suited for patients of lower functioning. They have ACT teams, they have Long Acting Injectable services, and they assist patients in the area they really need and that is social (worker) services, which private practices don't have (don't get reimbursed for). I've tried to take psychotic/schizophrenic patients, but when I don't have these service lines, I'm doing folks a disservice and they belong at the Community Mental Health Agencies (CMHA).

Thirdly, no one can be everything for everyone. Focusing on doing well for who a doc can, even if a higher paying population with a slight over representation in narcissism, is still servicing a population with a need. We advise people to not lose sleep over failing at being a savior.

Fourth, Big Box Shops and their poor admin, poor middle management, and Medical Directors who have checked out mentally contributed to burn out. For some, private practice control, is keeping them in the profession. The whole topic of burn out is simple, and the lip service Big Box shops preach to their Providers every so often, is a joke - when they are a major source of the problem. Independence, private practice is a real cornerstone to stopping burn out.

Fifth, so many patients that are financially struggling still manage to find the money to buy their cannabis, their alcohol, their cigarettes, their supplements/infusions/potions from their Natropathic Physician - but yet don't have the money to pay their copay?

Six, you need to understand that insurance companies have, do, and will likely continue to treat Psychiatry differently. For instance, in my local area one very high paying insurance, actually carved out their mental health/addiction services to be processed by another national insurance company that pays very close to medicaid rates. Another good company in my local area barely pays a bit more than medicare, but when I learned from 2 other sources their rates (different specialty), it was an RVU conversion factor well in excess of medicare - but another example of Psychiatry suffrage. In our field we try to encourage personal responsibility and self advocacy - who would we be if we rolled over and accepted this insult from insurance companies?

Seven, its not just the insurance companies that treat Psychiatry poorly its also the Hospitals, medical groups, health systems, etc. Typically, Psychiatry is located in the old building. The far building, the crumbling building. I have practiced in places where HVAC systems were broke and in the summer patients had sweat dribbling down their face, or in winter you could see your breath in the office, or elevators simply broke down every week, or homeless people attempt to live in vacant parts of the building, or rats found dead in toilets. I've had other colleagues describe how their often given the offices without windows. In my local area I just learned of one Big Box shop that might be eliminating the entire psych department. Never mind the issue of shutting down inpatient units, that's its own topic. Another large medical group in my local area didn't have psych for decades, and when they did bring on a few Psychiatrists they all filled in 3-6 months, but yet they haven't bothered to post positions for more despite their groups sending me referrals.

In grand summary I support my colleagues doing cash only, and further encourage any and all Psychiatrists - heck any physician - who opts for this. We are not the priestly class who must offer themselves up at the alter, no, we are merely widgets in the eyes of society - Providers, LIPs (licensed independent practitioners), Prescribers, etc. American society has long since broken the social contract with Physicians.

We owe society nothing. We have paid more than enough dues in sweat, sleep deprivation, time, research publications, etc, etc, etc.

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[chocomorsel]

How do you feel about interventional pain? Cash psychiatry occupies a similar niche, and is of higher value dollar by dollar.

There are many insurance taking psychiatrists, and the examples you cite the person would be able to find someone, but this person might be somewhat far out of the city, or perhaps affiliated with a hospital, which then has a longer wait. Or she could see an NP or primary care and if they don't solve her problem find a cash psychiatrist. Many different mechanisms to get care. Service price is determined by market supply and demand. Insurance companies refuse to pay a higher price to have a more inclusive network, causing further shortage of supply. OTOH they ARE willing to pay more for your services such that you'd be willing to be part fo the network. I don't think people should have any qualms about something that's not within their control. You know as well as I do that insurance reimbursement is not driven by value. If insurance company reimbursed your service wildly below market, many anesthesiologists would charge cash --- indeed, that's been happening with many cash based surgical centers in certain states, and most certainly anesthesiologists working for many elective procedures (i.e. cosmetic). Many patients prefer that system for a variety of reasons.

There's also something else you are not taking into consideration. Suppose a cash psychiatrist hire a physician on salary, this person would likely max out at $200-300 per hour. While you are getting $300 an hour, the hospital gets a lot more money. A lot of the value of cash psychiatry is the value and ease of business ownership, which doesn't exist in other specialties (except, something like interventional pain). The value of a business is to maximize profit, so if you have qualms about that, it's not the right path for you. There are many ways to practice psychiatry outside of private practice, including working at a nonprofit or government agency or conduct research--though often providers there see 3 patients a day and get on fixed salary, so I'm not sure who's really limiting the supply... You could also elect to give people sliding scale fees, if you find a particular case compelling. But at the end of the day your hours are limited, and you have make choices. I don't find that particularly unethical (at least, not compared to similar highly professions like corporate law or management consulting or dermatology)--plenty of people do, and you are free to choose a different career if you want.

I hate interventional pain and think it’s honestly a bunch of crock. Thanks for asking.

And the fact that you think that someone with a severe psychiatric illness should be managed by a mild level “provider” or a FP if they are unable to get to a psychiatrist makes me a little sad. This is not just run of the mill depression here from life stresses.

And while medicine is a business, there should be more to it than just “maximizing profits”. But I can see where that thinking comes from in a country like this.

Considering what you said about government insurance companies charging 20-30% less than cash paying means that you guys are getting good reimbursement compared to us in that aspect.

Like I said, I believe insurance companies are often terrible to deal with from our end. But being a cash taking psychiatrist only in a time when there is such a sick mentally ill population that needs help quickly rather that three months from now and literally has to wait months to see someone gives me qualms and pause. And there are lots of psychiatrist in my major city who are “not taking insurance” and for this family member it’s pretty good insurance. But what kind of people besides highly paid professionals can afford insurance premiums and also keep excess cash on the side for doctors that aren’t CoPays?

I like the sliding scale idea and that was my plan had I gone through and done psychiatry instead of being swayed into gas.

But yeah, rich people need help too.

 

[chocomorsel]

I don't lose any sleep over not taking medicaid and future plans to drop medicare and insurance companies paying less than medicare. I am not a non-profit who gets tax breaks. I don't get to write off the charity care I have been doing, or the bad debt I can't collect on. Perhaps if I could get tax deductions for bad debt or charity care I'd take on more of such cases. But if I optimize my practice to make as much as possible, I can get tax deductions by donating money to non-profits - which is ultimately a more efficient way to do more community good.

Secondarily, society has safety nets of community mental health agencies, which are more suited for patients of lower functioning. They have ACT teams, they have Long Acting Injectable services, and they assist patients in the area they really need and that is social (worker) services, which private practices don't have (don't get reimbursed for). I've tried to take psychotic/schizophrenic patients, but when I don't have these service lines, I'm doing folks a disservice and they belong at the Community Mental Health Agencies (CMHA).

Thirdly, no one can be everything for everyone. Focusing on doing well for who a doc can, even if a higher paying population with a slight over representation in narcissism, is still servicing a population with a need. We advise people to not lose sleep over failing at being a savior.

Fourth, Big Box Shops and their poor admin, poor middle management, and Medical Directors who have checked out mentally contributed to burn out. For some, private practice control, is keeping them in the profession. The whole topic of burn out is simple, and the lip service Big Box shops preach to their Providers every so often, is a joke - when they are a major source of the problem. Independence, private practice is a real cornerstone to stopping burn out.

Fifth, so many patients that are financially struggling still manage to find the money to buy their cannabis, their alcohol, their cigarettes, their supplements/infusions/potions from their Natropathic Physician - but yet don't have the money to pay their copay?

Six, you need to understand that insurance companies have, do, and will likely continue to treat Psychiatry differently. For instance, in my local area one very high paying insurance, actually carved out their mental health/addiction services to be processed by another national insurance company that pays very close to medicaid rates. Another good company in my local area barely pays a bit more than medicare, but when I learned from 2 other sources their rates (different specialty), it was an RVU conversion factor well in excess of medicare - but another example of Psychiatry suffrage. In our field we try to encourage personal responsibility and self advocacy - who would we be if we rolled over and accepted this insult from insurance companies?

Seven, its not just the insurance companies that treat Psychiatry poorly its also the Hospitals, medical groups, health systems, etc. Typically, Psychiatry is located in the old building. The far building, the crumbling building. I have practiced in places where HVAC systems were broke and in the summer patients had sweat dribbling down their face, or in winter you could see your breath in the office, or elevators simply broke down every week, or homeless people attempt to live in vacant parts of the building, or rats found dead in toilets. I've had other colleagues describe how their often given the offices without windows. In my local area I just learned of one Big Box shop that might be eliminating the entire psych department. Never mind the issue of shutting down inpatient units, that's its own topic. Another large medical group in my local area didn't have psych for decades, and when they did bring on a few Psychiatrists they all filled in 3-6 months, but yet they haven't bothered to post positions for more despite their groups sending me referrals.

In grand summary I support my colleagues doing cash only, and further encourage any and all Psychiatrists - heck any physician - who opts for this. We are not the priestly class who must offer themselves up at the alter, no, we are merely widgets in the eyes of society - Providers, LIPs (licensed independent practitioners), Prescribers, etc. American society has long since broken the social contract with Physicians.

We owe society nothing. We have paid more than enough dues in sweat, sleep deprivation, time, research publications, etc, etc, etc.

I wasn’t talking about CoPays or even Medicaid in my example. I was talking of $300 to see a psychiatrist on top of premiums and Copays for let’s say BC/BS or Aetna or Teachers union insurance or whatever. Not government healthcare.

Didn’t know that psych got stuck in old buildings with non functioning toilets and heat and rats. That’s terrible but not surprising considering how mental health is treated all over the damn world as a second class health issue. Very sad.

I am not against PP at all. You clearly have me misunderstood me. Did I say anything like that in my post? I think physicians should be their own bosses and open their own shops. It seems though that the millennial population prefers to be employed for some reason.

I again, not even talking about charity care in the above scenario but thanks for jumping on your soapbox to let me know how you feel about it. Yeah I am aware of community programs many staffed by NPs that haven’t a clue. I don’t feel like that’s where our illest patients should be seen though.

What do you mean Big Box medicine?

Yes, plenty of people in this country misuse their money. Not just psychiatric patients. And the fact that you as a psychiatrist generalize such a population considering that they are not mentally well and therefore by virtue of their poor mental health make poor decisions about their money is quite sad actually. I would expect that notion to come from someone who’s not an expert on mental health.

Again, not talking about charity care here. Please let’s get that straight.

Thanks for your opinion though. Let’s engage without jumping to conclusions please.

I also hate “providers, LIPs” or any of those terms meant to muddy the waters and turn us into something we are not.

There’s a serious shortage of Psychiatrists out there and I am glad that your income is increasing even as employees as you guys really do a lot for the community.

 

[dl2dp2]

But being a cash taking psychiatrist only in a time when there is such a sick mentally ill population that needs help quickly rather that three months from now and literally has to wait months to see someone gives me qualms and pause.

I think you are confused. I don't blame you because you don't know much about this field and how it works, and rigidity in morality often is a byproduct of confusion--people are very quick to blame something as "unfair" when they don't know how something works.

There are two aspect of ethics, and you are mixing them. On a personal level, your responsibility is primarily reserved for yourself, your family and your community. The fact that insurance companies are not providing a mechanism for a style of practice that you find satisfactory is not something that you can fix. If I take insurance, I can't deliver the kind of service I want to deliver and make as much money as I do. This is simply consequence is not within your control, and one can't claim responsibility for something that's not within their control. Someone might pick a job that pays more and works less because of family responsibilities or work life balance. I don't see any of that as particularly ethically problematic.

On a macro level, what you really care about is the result of policy ("is the system resulting in efficient use of resources"), not what you imagine the policy might induce. For example, unlikely your field, mental health spending is highly elastic, and MOST of the service is not used by people who have bipolar 1 and currently tanking. If you expand insurance coverage, what ends up happening is that your practice is stuffed to the brim with people who barely need psychotherapy--but of course everyone who comes to me for psychotherapy and a tiny dose of SSRI *THINK* they really need it RIGHT NOW. Insurance companies are not dumb--OON exists because the total healthcare spending decreases when cost is elastic and co-pay is high. Basic econ 101. In the situation you describe when someone REALLY needs the service, it's likely that this person [eventually] will be able to get the service they need. So these macro level policy/collective behavior considerations can't be so simplistic as if I do X (am "ethically bound" to take insurance) I'll automatically get Y (rare severe pathology out of service person always gets the service when they need it). Your logic only considers supply without considering demand.

Indeed, there's pretty clear evidence suggesting most of the psychiatrist shortage in the last few decades is primarily due to increasing demand. Mental health is less stigmatized now, and more people seek treatment. For example, see this:

Source of Increased Health Care Spending in the United States

In 2015, five health conditions—heart disease, mental disorders, diabetes, osteoarthritis, and cancer—accounted for nearly one-third of all medical care spending in the United States. More than $100 billion was spent to treat heart disease alone. Expenditures associated with heart disease and...

jamanetwork.com

Cost of per capita treatment for mental health has not changed, but the total utilization increased dramatically.

 

[chocomorsel]

I think you are confused. I don't blame you because you don't know much about this field and how it works, and rigidity in morality often is a byproduct of confusion--people are very quick to blame something as "unfair" when they don't know how something works.

There are two aspect of ethics, and you are mixing them. On a personal level, your responsibility is primarily reserved for yourself, your family and your community. The fact that insurance companies are not providing a mechanism for a style of practice that you find satisfactory is not something that you can fix. If I take insurance, I can't deliver the kind of service I want to deliver and make as much money as I do. This is simply consequence is not within your control, and one can't claim responsibility for something that's not within their control.

On a macro level, what you really care about is the result of policy, not what you imagine the policy might induce. For example, unlikely your field, mental health spending is highly elastic, and MOST of the service is not used by people who have bipolar 1 and currently tanking. If you expand insurance coverage, what ends up happening is that your practice is stuffed to the brim with people who barely need psychotherapy--but of course everyone who comes to me for psychotherapy and a tiny dose of SSRI *THINK* they really need it RIGHT NOW. Insurance companies are not dumb--OON exists because the total healthcare spending decreases. In the situation you describe when someone REALLY needs the service, it's likely that this person [eventually] will be able to get the service they need. So these macro level policy/collective behavior considerations can't be so simplistic as if I do X (take insurance) I'll automatically get Y (rare severe pathology out of service person always gets the service they need).

Depends on what your definition of “really” needing psychiatric help entails. In the meantime we’ll keep letting the PCPs deal with the psychotics who may not be dangerous enough to require inpatient help but too severe to be seen and managed by a PCP.
This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.
Keep hope alive. I am rethinking hospitalization honestly. Make up some story about danger.

 

[dl2dp2]

Depends on what your definition of “really” needing psychiatric help entails. In the meantime we’ll keep letting the PCPs deal with the psychotics who may not be dangerous enough to require inpatient help but too severe to be seen and managed by a PCP.
This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.
Keep hope alive. I am rethinking hospitalization honestly. Make up some story about danger.

Or you can just help by paying out of pocket for private care. Is your time not worth money? People are paying much more than $300 a month for things they really don't need. I don't see the outrage there. Why is this different from paying for a private criminal justice lawyer, or a divorce attorney? Or paying for an accountant? Of course--you eventually will.

 

[chocomorsel]

Or you can just help by paying out of pocket for private care. Is your time not worth money? People are paying much more than $300 a month for things they really don't need. I don't see the outrage there. Why is this different from paying for a private criminal justice lawyer, or a divorce attorney? Or paying for an accountant? Of course--you eventually will.

What’s private care? You mean like a private caretaker?
Because people are already paying obscene amounts of money for healthcare insurance. To cover all the other physicians they have to see.
Is there such a thing accountant and attorney insurance? And then on top of that gotta pay out of pocket?
Seriously?
My time is worth money. But the insurance company pays me for my time. Even the crappy Medicare and Medicaid rates.

 

[michaelrack]

Is there such a thing accountant and attorney insurance? And then on top of that gotta pay out of pocket?
Seriously?
My time is worth money. But the insurance company pays me for my time. Even the crappy Medicare and Medicaid rates.

There is such a thing as legal insurance (Google it), but it works differently from health insurance.
And there are community mental health clinics that welcome Medicaid/Medicare.
A lot of psychiatrists with private clinics used to have side gigs in these clinics (independent contractors), but now nurse practitioners have mostly taken over these clinics

 

[chocomorsel]

There is such a thing as legal insurance (Google it), but it works differently from health insurance.
And there are community mental health clinics that welcome Medicaid/Medicare.
A lot of psychiatrists with private clinics used to have side gigs in these clinics (independent contractors), but now nurse practitioners have mostly taken over these clinics

What percentage of the public uses this legal insurance? In comparison to health insurance.
And in this scenario, again I am not even talking about Medicaid and Medicare. I am talking about private health insurance. For some reason you guys seem to keep getting confused.

 

[michaelrack]

What percentage of the public uses this legal insurance? In comparison to health insurance.
And in this scenario, again I am not even talking about Medicaid and Medicare. I am talking about private health insurance. For some reason you guys seem to keep getting confused.

Probably very little use legal insurance, but you asked if there was such a thing and I answered that question.
Forgive me if that was a rhetorical question that I wasn't supposed to answer

 

[dl2dp2]

What percentage of the public uses this legal insurance? In comparison to health insurance.
And in this scenario, again I am not even talking about Medicaid and Medicare. I am talking about private health insurance. For some reason you guys seem to keep getting confused.

You are blaming the wrong group of people. I tried to negotiate with major insurance companies to bring up their rates to market but they refused. How much people pay for insurance has little to do with how much that premium will eventually go to me. Insurance companies also variably cover many other essential healthcare services, and certainly lots of doctors are not automatically in every network. This is not just a psychiatry issue.

 

[chocomorsel]

Probably very little use legal insurance, but you asked if there was such a thing and I answered that question.
Forgive me if that was a rhetorical question that I wasn't supposed to answer

Oh, no. It was a real question and thanks for the education on that.
I am just saying that this is an additional incurred cost with already paying high premiums and deductibles to see a physician. Only to be told time and time again we’re trying to make an appointment “We don’t take insurance.
And our cash fee is $250-$400 an hour”
Since there are a lot less psychiatrists out there compared to Family med or Internal meds, meeting this roadblock makes it especially difficult to find someone who does take insurance.
I think if we all as physicians jumped on that bandwagon together we could sink insurance companies. But the cost of being hospitalized would be absurd as it is already.
Are people with children, paying for their children’s health insurance, and then also paying another $300 to $500 a session to see a PCP for care?

 

[dl2dp2]

Are people with children, paying for their children’s health insurance, and then also paying another $300 to $500 a session to see a PCP for care?

If you feel strongly about this issue you may consider advocating for legislative action to stipulate a minimum coverage for mental health networks. As is psychiatrists have a hard time bringing insurance companies to the negotiating table. We are seeing $0 of that expensive premium you are talking about.

 

[chocomorsel]

If you feel strongly about this issue you may consider advocating for legislative action to stipulate a minimum coverage for mental health networks. As is psychiatrists have a hard time bringing insurance companies to the negotiating table. We are seeing $0 of that expensive premium you are talking about.

If you are saying insurance companies don’t negotiate with you at all because you are psychiatrists then absolutely that is wrong. Is that the case? I would like to know as a potential consumer of said services. My insurance card has psychiatric services covered.

 

[dl2dp2]

If you are saying insurance companies don’t negotiate with you at all because you are psychiatrists then absolutely that is wrong. Is that the case? I would like to know as a potential consumer of said services. My insurance card has psychiatric services covered.

When you go in network there is a contract negotiation process. Insurance companies refuse to negotiate on their fees in good faith (i.e. FAIRHealth prevailing market rate data, etc.), resulting in very narrow networks. This is actually a rather psychiatry specific phenomenon that's partly historical: prior to the Parity Act, psychiatric services are often not covered at all, and until ACA mental health is not required to be covered even for in-network providers. The system devalues mental health. If insurance companies are more willing to negotiate, employed psychiatrists would also have a higher salary, which then would also broaden network. As is employed psychiatrists are on the lowest side of the totem pole w.r.t salary. Highly lucrative private psychiatrists who generate 1M in total revenue, while not exceptionally rare in some markets, is not common in general. It would not be logical to assign the blame of current market distortions to a tiny group.

 

[chocomorsel]

When you go in network there is a contract negotiation process. Insurance companies refuse to negotiate on their fees in good faith (i.e. FAIRHealth prevailing market rate data, etc.)

Would be nice to sink them. Until then it’s the best we got for people who can’t afford extra cash money for mental health.

 

[Ahamis]

Depends on what your definition of “really” needing psychiatric help entails. In the meantime we’ll keep letting the PCPs deal with the psychotics who may not be dangerous enough to require inpatient help but too severe to be seen and managed by a PCP.
This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.
Keep hope alive. I am rethinking hospitalization honestly. Make up some story about danger.

During my residency our major outpatient clinic was a community clinic in a metropolitan area. New patients were able to see psychiatrists at the same day (most of the time) or the day after. Despite that, the no show rate for follow-ups were high.

When I interviewed for jobs I found many positions in community mental health clinics throughout the country. The salaries are slightly lower than the market.
You might think that you would find community clinics only in big cities but that is not necessarily true. I live in a city with a population of 80k and there is a community mental health clinic here.

So, there are many community clinics around the country. There are resources available. However, a considerable percentage of severe mentally ill patients refuse to do follow-up with psychiatrists/mental health professionals. And most of the time, there is not much you can do to force them to adhere to treatment.

 

[chocomorsel]

During my residency our major outpatient clinic was a community clinic in a metropolitan area. New patients were able to see psychiatrists at the same day (most of the time) or the day after. Despite that, the no show rate for follow-ups were high.

When I interviewed for jobs I found many positions in community mental health clinics throughout the country. The salaries are slightly lower than the market.
You might think that you would find community clinics only in big cities but that is not necessarily true. I live in a city with a population of 80k and there is a community mental health clinic here.

So, there are many community clinics around the country. There are resources available. However, a considerable percentage of severe mentally ill patients refuse to do follow-up with psychiatrists/mental health professionals. And most of the time, there is not much you can do to force them to adhere to treatment.

Very unfortunate about your last paragraph. It is quite difficult to get a mentally ill person with no insight to get the help they need. It often has to be life or death before one gets help which is unfortunate.
I was specifically focusing on a doctor’s office as I know a lot of these mental health clinics are staffed by NPs. But will reach out.
Thank you.

 

[Candidate2017]

In the meantime we’ll keep letting the PCPs deal with the psychotics who may not be dangerous enough to require inpatient help but too severe to be seen and managed by a PCP.
This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.
Keep hope alive. I am rethinking hospitalization honestly. Make up some story about danger.

In my experience, psych patients whose parents are physicians tend not to fare well. Lots of familial negative transference issues toward psychiatry and mental illness, some of which are actively fostered during med training, as well as their own biases and feelings of powerlessness to "fix" people. Physicians actively dismiss people who carry a psychiatric illness. I see this in the ED and med floors, like uncaught/untreated A-fib, STEMI, hypertensive urgencies etc. In anesthesiology, the big appeal is not having to listen to patients. Think about that.

Perhaps you are losing objectivity, due to having a psychotic family member, and buying into public vitriol against "greedy doctors". As a physician, you know we all are sacrificial foot soldiers in a rigged system run by powerful politicians and insurance, hospital and pharma CEOs.

Psychotic patients are not suitable for most PP psychiatrists because they need more than meds. They need family therapy, social workers, case workers, employment rehab, PCP coordination, compliance monitoring, $3000 monthly injections etc. This costs way more than an insurance 99213/214/215 visit or even a $700/hr Manhattan psychotherapy visit. The PP psychiatrists who work with psychotic patients have the above resources because they are subsidized by public grants, academia, and/or charge $1000/hr. Public CMH clinics also have such resources. Private insurance does not support resources for psychotic patients because they are not profitable. You probably need to pay out of pocket or seek out advocacy groups like NAMI for local resources. Even psychiatry residents can find a way to pay out of pocket for their own psychotherapy.

Another thing to consider is that psychiatrists are similar to surgeons in that we screen for patients who are most likely to benefit from our interventions. Unlike surgeons though, we don't "fix" people. We provide meds. education, sometimes therapy. But it is up to the patient and their families to do the actual work.

You can always do a psych residency if you feel psych patients are underserved and to get a taste of what we have to go through: told how to practice by social workers/RN managers/insurance utilization, working in 3rd world decrepit psych facilities, yelled/cursed at/spit/threatened with violence and rape by ungrateful patients and families.

 

[Candidate2017]

This is not very unusual of a rate in major markets ($300x2 for psychopharm, or $500+ for combined). Actually kind of on the lower side.

FYI, Medicare rate for 99214+90833 = ~130+~80 = $210, so Medicare rates are only ~ 20-30% lower than cash rates, which is a fairly small disparity in all of medicine. Something like hip replacement Medicare rates are often 100% below cash/commercial rates.

FAIRHealth OON data shows (average) 99213 = $290 90833=$140 for Manhattan (as an example). This is typically the "reasonable and customary" rates for reimbursement used by insurance company for OON service.

Do you have a link to the FAIRHealth data on average locality rates? I can't find it on their website. Thanks.

 

[dl2dp2]

Welcome to FAIR Health

Welcome to FAIR Health

www.fairhealthconsumer.org

Big green button in the middle of their home page.

 

[Ironspy]

Depends on what your definition of “really” needing psychiatric help entails. In the meantime we’ll keep letting the PCPs deal with the psychotics who may not be dangerous enough to require inpatient help but too severe to be seen and managed by a PCP.
This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.
Keep hope alive. I am rethinking hospitalization honestly. Make up some story about danger.

Sorry your family is dealing with this. If insurance is good they should look into out of network benefits. You could help them with the paperwork. If they have no OON benefits you could consider helping with the cash fee. I have 2 family members with SMI and bad insurance who see cash psych. They are both now stable and seen q6-8 weeks so it’s actually affordable since they are healthy enough to work bc of good care

 

[chocomorsel]

Sorry your family is dealing with this. If insurance is good they should look into out of network benefits. You could help them with the paperwork. If they have no OON benefits you could consider helping with the cash fee. I have 2 family members with SMI and bad insurance who see cash psych. They are both now stable and seen q6-8 weeks so it’s actually affordable since they are healthy enough to work bc of good care

Thank you. Will look into it. My situation is an older relative who will never work again. But the OON sounds promising.

 

[calvnandhobbs68]

I am an anesthesiologist. I make pretty decent per hour money. Between 2-300/hr.
I take all comers of course, Medicare and Medicaid. Currently I do locums but have done PP before.
I know insurance companies are a PIA, when trying to negotiate and sometimes get paid. I get it. But I feel like all people need access to basic healthcare. Even ones on Medicaid and Medicare.
So my questions to the Cash paying psychiatrists is this. Considering that the seriously ill people in psychiatry are most often not gonna have the steadiest jobs, the best insurance, do you feel at all bad for excluding these needy people from your care? Like the teacher who has a psychotic break at 30 and decompensates, takes a LOA, for a few weeks, then back to work but needs frequent close follow up for Bipolar 1. Let’s say she needs an OP psychiatrist or she moves cities. And that’s a good example of a working middle class person who can’t afford $300 a month on top of what she pays at her job for premiums.
Do you think that Cash only in a field like psychiatry where people are often poor is doing the most needy people a disservice? Let’s not even talk about the ones on Medicaid because they can go to the community clinics I have been told.
I hate insurance companies as much as the next person, but it’s what we have in this country. Do these people with proper insurance at work, and proper familial support, do they need to really pay on top of their regular insurance to see you guys?

You "take all comers" because your hospital gets to bill buttloads of money for their facility fee on top of your personal fee. Additionally, the hospital gets to charge insurance for every med you administer and for the OR time. You're on the good end of the insurance reimbursement game in this country. Median salary for anesthesiology is regularly over 100K more than psychiatry and often more than gen surg, OB/Gyn, Crit Care, EM, etc. So yeah sorry if your "take all comers" stuff doesn't hold much water. You take all comers because your hospital takes all comers and pays you a lot of money to do it.

If you believe all people deserve access to basic healthcare, I'm assuming you're in favor of a universal insurance system in this country?

Additionally, Inpatient and outpatient medicine are also completely different stories. If this was someone in family medicine telling me about how they take Medicaid and Medicare patients, I'd take this a bit more seriously, but even family med has people doing "concierge care" with annual fees and per visit pays because they're sick of having to do 10 minute sick visits in order to hit their RVUs or support their salary. There was also a recent article about how FM actually gets paid more right now for mental health visits than psychiatry....due to the mental health carveouts mentioned above.

I'm sorry your family member can't seem to find someone in their insurance network nearby for psychiatry but maybe you could donate 1 hour of your time for them to get an intake somewhere since it seems to be that important to you. Rather than "making up something" about them being dangerous to try to get them admitted inpatient.

 

[Stagg737]

Locums telepsychiatry...is this a thing? Anyone have experience with it?

Also, I know this has been discussed at times but for those with locums experience, what companies have you found to be the best to work with?

It is a thing. No personal experience but there is a psychiatrist at our VA who has a "locums" contract for 6 months of telepsych because a position was unfilled for so long.

 

[Stagg737]

I wasn’t talking about CoPays or even Medicaid in my example. I was talking of $300 to see a psychiatrist on top of premiums and Copays for let’s say BC/BS or Aetna or Teachers union insurance or whatever. Not government healthcare.

I did a rotation with a cash only outpt psychiatrist who charged $200/hr and was surprised by how many patients were from lower economic classes even though they had medicaid/care. A couple said the $200 every 2-3 months was worth the mental stability. Also, cash only psych is much more affordable if you also do DPC + cheapest plan possible for catastrophic care. If they already qualify for Medicare, even better.

I again, not even talking about charity care in the above scenario but thanks for jumping on your soapbox to let me know how you feel about it. Yeah I am aware of community programs many staffed by NPs that haven’t a clue. I don’t feel like that’s where our illest patients should be seen though.

It actually probably is for the reasons Candidate gave. The most severe cases require far more than just medication and therapy and often have social problems as bad or much worse than their psychiatric issues. I don't think any field (other than maybe FM) deals with the social work aspect of patients care as much as we do, and most private clinics and even some major hospitals just don't have the resources to treat these patients chronically.

This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.

Best of luck with your family member. If it's that severe, you could always try and go to a cash only psychiatrist for eval and initial care until you can get into a clinic that takes insurance and ask the case office to send records. Not the best choice, but likely a far better one than having them go inpatient unless they truly need it.

 

[chocomorsel]

You "take all comers" because your hospital gets to bill buttloads of money for their facility fee on top of your personal fee. Additionally, the hospital gets to charge insurance for every med you administer and for the OR time. You're on the good end of the insurance reimbursement game in this country. Median salary for anesthesiology is regularly over 100K more than psychiatry and often more than gen surg, OB/Gyn, Crit Care, EM, etc. So yeah sorry if your "take all comers" stuff doesn't hold much water. You take all comers because your hospital takes all comers and pays you a lot of money to do it.

If you believe all people deserve access to basic healthcare, I'm assuming you're in favor of a universal insurance system in this country?

Additionally, Inpatient and outpatient medicine are also completely different stories. If this was someone in family medicine telling me about how they take Medicaid and Medicare patients, I'd take this a bit more seriously, but even family med has people doing "concierge care" with annual fees and per visit pays because they're sick of having to do 10 minute sick visits in order to hit their RVUs or support their salary. There was also a recent article about how FM actually gets paid more right now for mental health visits than psychiatry....due to the mental health carveouts mentioned above.

I'm sorry your family member can't seem to find someone in their insurance network nearby for psychiatry but maybe you could donate 1 hour of your time for them to get an intake somewhere since it seems to be that important to you. Rather than "making up something" about them being dangerous to try to get them admitted inpatient.

“Donate 1 hour of your time to do intake somewhere means?”
I don’t speak psychiatry.

And yes, I believe in universal healthcare and am willing to pay more taxes for it.

 

[chocomorsel]

I did a rotation with a cash only outpt psychiatrist who charged $200/hr and was surprised by how many patients were from lower economic classes even though they had medicaid/care. A couple said the $200 every 2-3 months was worth the mental stability. Also, cash only psych is much more affordable if you also do DPC + cheapest plan possible for catastrophic care. If they already qualify for Medicare, even better.



It actually probably is for the reasons Candidate gave. The most severe cases require far more than just medication and therapy and often have social problems as bad or much worse than their psychiatric issues. I don't think any field (other than maybe FM) deals with the social work aspect of patients care as much as we do, and most private clinics and even some major hospitals just don't have the resources to treat these patients chronically.



Best of luck with your family member. If it's that severe, you could always try and go to a cash only psychiatrist for eval and initial care until you can get into a clinic that takes insurance and ask the case office to send records. Not the best choice, but likely a far better one than having them go inpatient unless they truly need it.

I disagree that our illest patients should be seeing NPs. However if I find a community clinic staffed by a doc, I am all for it.
As far as my family member having lots of social problems, that’s not the case. However if you are saying, and it’s not just you, that many docs in PP are not equipped to handle the severely ill patients, I find that sad for your profession. What are you guys equipped to handle then in PP? The easy and mildly ill? Why are you not able to handle the severely ill but stable outside of the social work aspect? If the answer is social work, I will buy it because that is draining.
Increasing my search and willing to drive farther. I suspect my family is going to require more than 200-300 every three months though. We have only been looking less than a month total off and on. Was just surprised at how all the ones the PCP referred us to said “cash only.”

 

[calvnandhobbs68]

“Donate 1 hour of your time to do intake somewhere means?”
I don’t speak psychiatry.

And yes, I believe in universal healthcare and am willing to pay more taxes for it.

Is "I don't speak psychiatry" supposed to be insulting? After you come onto a psychiatry forum to bitch about cash-only psych but are apparently unwilling to donate a few hundred bucks of your 300K+ salary for this family member you're so concerned about?

I'll break it down for you. If you make 200-300 an hour locums, donating the monetary equivalent of 1-2 hours worth of your time ($300-600) to your family member that you're so concerned about shouldn't be too much of an issue. The amount of time you've spent complaining about cash pay psychiatry on this forum is probably the same amount you'd pay for a followup appointment in dollars per minute....

You just seem to have a tenuous grasp of any aspect of healthcare outside of anesthesia based on your comments so far. Outpatient private practice is similar to many outpatient setups in that you're limited in what you can handle. There are pediatrics offices that don't stock vaccines because they're so expensive or need government subsidies because they barely break even on this. Most outpatient PCPs don't do their own labs and are pretty limited in the procedures they can do. Call around and explain the situation to the private practice psychiatrists in the area and see what they say. If you're talking about a family member who is not violent, has good social support, the ability to get to/from appointments, no housing problems, no substance abuse problems then that might be a totally different story. Unfortunately, that doesn't describe the vast majority of our severely mentally ill population who often require case workers just to help them get to/from appointments and pick up medications for them.

You're also not going to find things like neuropsychiatry or geriatric psychiatry or neuropsych testing outside of academic medical centers or specific offices specializing in these types of things. Just like you can't find many other medical specialities outside of larger centers or have to pay out of pocket to see them.

 

[Ironspy]

I disagree that our illest patients should be seeing NPs. However if I find a community clinic staffed by a doc, I am all for it.
As far as my family member having lots of social problems, that’s not the case. However if you are saying, and it’s not just you, that many docs in PP are not equipped to handle the severely ill patients, I find that sad for your profession. What are you guys equipped to handle then in PP? The easy and mildly ill? Why are you not able to handle the severely ill but stable outside of the social work aspect? If the answer is social work, I will buy it because that is draining.
Increasing my search and willing to drive farther. I suspect my family is going to require more than 200-300 every three months though. We have only been looking less than a month total off and on. Was just surprised at how all the ones the PCP referred us to said “cash only.”

I don't disagree with you philosophically but can offer you the following perspective--

I work at a community mental health site part time and have a cash only solo micro practice. I see sick patients in both settings. However, I cannot easily order EKGs and imaging studies in private practice and cannot see patients who are affected by homelessness, severe substance use, severe personality disorders etc because I would need case managers, after hours phone back up, social workers which I do not have access to in my private setting. I do order labs but it takes some time coordinating to get the results. The handful of very ill lower functioning patients I see privately have family members who are helping with fees. Severly ill patients often have medicaid and I would need to hire a biller who would keep a percentage of the insultingly low rates that medicaid pays. Clinics get block grants in addition to these fees but I would only get the fee which is low. Medicare rates are better but the admin hassle is not. I do enjoy seeing sicker patients in our clinic and think they deserve good care but we are expected to see a high volume of these patients for relatively little money (<200k for full-time compared to $3-500/hour for private practice). A better comparison for you would be the following--would you take a >150K pay cut to "see all comers" as an anesthesiologist? Oh, and the lower paying job also has longer hours, higher volume and more administrative hassles. I am currently willing to deal with this but don't blame psychiatrists who aren't.

 

[chocomorsel]

I don't disagree with you philosophically but can offer you the following perspective--

I work at a community mental health site part time and have a cash only solo micro practice. I see sick patients in both settings. However, I cannot easily order EKGs and imaging studies in private practice and cannot see patients who are affected by homelessness, severe substance use, severe personality disorders etc because I would need case managers, after hours phone back up, social workers which I do not have access to in my private setting. I do order labs but it takes some time coordinating to get the results. The handful of very ill lower functioning patients I see privately have family members who are helping with fees. Severly ill patients often have medicaid and I would need to hire a biller who would keep a percentage of the insultingly low rates that medicaid pays. Clinics get block grants in addition to these fees but I would only get the fee which is low. Medicare rates are better but the admin hassle is not. I do enjoy seeing sicker patients in our clinic and think they deserve good care but we are expected to see a high volume of these patients for relatively little money (<200k for full-time compared to $3-500/hour for private practice). A better comparison for you would be the following--would you take a >150K pay cut to "see all comers" as an anesthesiologist? Oh, and the lower paying job also has longer hours, higher volume and more administrative hassles. I am currently willing to deal with this but don't blame psychiatrists who aren't.

Ok, understand your points completely. Medicaid and Medicare rates for anesthesia are also insultingly low FYI. They don’t pay us like they pay surgeons. They pay us about 20% of what surgeons and other subspecialists pay.
It’s the private insurance that makes up for the difference.

But I am talking about a clinic/pp
where you don’t even have to take all comers. Take the insurances that pay you well and take cash as well if you want. But to put a blanket “no insurance policy” on all insurances where some are much better than others, well I honestly don’t understand. And I have been in PP solo. I was given the lowest rates. But I didn’t consider them insulting. Obviously I can’t compare across specialties.

Anyway, you do you. Glad you enjoy the mix of sicker patients. Thanks for explaining about the different studies and such. I didn’t know.

I don’t want to be employed and take a “pay cut” no. I prefer PP or locums. The whole mentality of wanting to be employed in medicine beats me. Seems to me like in psychiatry it would be so much easier to start a business compared to other medical specialists as you don’t need much equipment. But so many people want to be employed.

 

[brazilianpsych]

“Donate 1 hour of your time to do intake somewhere means?”
I don’t speak psychiatry.

And yes, I believe in universal healthcare and am willing to pay more taxes for it.

then why dont you pay the psychiatrist with your cash and pretend its a tax?

I dont get it

 

[chocomorsel]

Is "I don't speak psychiatry" supposed to be insulting? After you come onto a psychiatry forum to bitch about cash-only psych but are apparently unwilling to donate a few hundred bucks of your 300K+ salary for this family member you're so concerned about?

I'll break it down for you. If you make 200-300 an hour locums, donating the monetary equivalent of 1-2 hours worth of your time ($300-600) to your family member that you're so concerned about shouldn't be too much of an issue. The amount of time you've spent complaining about cash pay psychiatry on this forum is probably the same amount you'd pay for a followup appointment in dollars per minute....

You just seem to have a tenuous grasp of any aspect of healthcare outside of anesthesia based on your comments so far. Outpatient private practice is similar to many outpatient setups in that you're limited in what you can handle. There are pediatrics offices that don't stock vaccines because they're so expensive or need government subsidies because they barely break even on this. Most outpatient PCPs don't do their own labs and are pretty limited in the procedures they can do. Call around and explain the situation to the private practice psychiatrists in the area and see what they say. If you're talking about a family member who is not violent, has good social support, the ability to get to/from appointments, no housing problems, no substance abuse problems then that might be a totally different story. Unfortunately, that doesn't describe the vast majority of our severely mentally ill population who often require case workers just to help them get to/from appointments and pick up medications for them.

You're also not going to find things like neuropsychiatry or geriatric psychiatry or neuropsych testing outside of academic medical centers or specific offices specializing in these types of things. Just like you can't find many other medical specialities outside of larger centers or have to pay out of pocket to see them.

You are barking up the wrong tree if you want to pick a fight.
I simply don’t understand the language you use as I work in the OR. I am asking you to explain but you seem to want to pick a fight. And yes, obviously I don’t have a grasp on other fields and how they practice and that is why I am asking. To learn. Why do you feel the need to answer so aggressively and jump to conclusions about me when you don’t know me?

You have no idea where I am coming from or how much money and time and money I am already donating and what my other responsibilities and “donations” are in life. But you are jumping to conclusions after being insulted. By a simple question as we all speak specialty specific language.

It was a simple question. From someone deeply tied to the field of psychiatry.

Whatever.

 

[brazilianpsych]

You are barking up the wrong tree if you want to pick a fight.
I simply don’t understand the language you use as I work in the OR. I am asking you to explain but you seem to want to pick a fight.
But good luck.
You have no idea where I am coming from or how much money and time and money I am “donating” to said family member but you are jumping to conclusions and being insulted.

You got issues. It was a simple question.

To be honest it also sounded aggressive to me, glad to know it wasn't

 

[chocomorsel]

To be honest it also sounded aggressive to me, glad to know it wasn't

Every field has its language. There is language that I use to other OR docs that you wouldn’t understand. That is all.
People are really looking to pick a fight.
Yes, I find it unfair for many people in need to not get access to care and have to pay extra on top of their premiums and CoPays. And yes, I am bitching about it. And I am asking as to why it’s done. And taking it in. And thinking if it were me, I would feel really bad. And realizing that psych is dumped oh even more than I thought and maybe that’s their way of fighting back.

Why are people so pissed about it? And jumping to conclusions about my role and telling me “donate” when they don’t have a clue as to what I “donate” and trying to make me out to be a selfish person who doesn’t want to help a family member when they have no idea the extent of my involvement?

Seriously? I am in a profession that gets insulted all the time. Is that where this is stemming from?

I don’t go getting pissed off and attack people when they ask about my practice and the why?

For the folks who’ve answered and tried to explain without trying to pick a damn fight, Thank you. For the ones who feel annoyed about my bitching about cash practice not being fair, I understand.

But for the ones who look to pick and fight and somehow feel “insulted” about asking for an explanation of specialty specific language, I got nothing for you. There is no “intake” in my field. Hence the question.

 

[Ironspy]

Ok, understand your points completely. Medicaid and Medicare rates for anesthesia are also insultingly low FYI. They don’t pay us like they pay surgeons. They pay us about 20% of what surgeons and other subspecialists pay.
It’s the private insurance that makes up for the difference

In psychiatry many private insurances pay Medicare rates or worse so it’s harder to “make up the difference “ It takes time and $ to get credentialed and they don’t share their rates until the process is complete. I could get credentialed with 10-15 plans and only keep the ones that pay well but that’s a ton of time and I would rather help patients utilize their out of network benefits which many plans expect them to do for psych bc the networks are narrow to nonexistent. Glad that’s not true in anesthesiology. Your frustration is shared by many psychiatrists and is better directed at insurance companies which created a system designed to discourage utilization

 

[chocomorsel]

In psychiatry many private insurances pay Medicare rates or worse so it’s harder to “make up the difference “ It takes time and $ to get credentialed and they don’t share their rates until the process is complete. I could get credentialed with 10-15 plans and only keep the ones that pay well but that’s a ton of time and I would rather help patients utilize their out of network benefits which many plans expect them to do for psych bc the networks are narrow to nonexistent. Glad that’s not true in anesthesiology. Your frustration is shared by many psychiatrists and is better directed at insurance companies which created a system designed to discourage utilization

Thank you for explaining this. I hate insurance companies too. Would love to take them down.

 

[chocomorsel]

then why dont you pay the psychiatrist with your cash and pretend its a tax?

I dont get it

At the crazy rates I am paying for the insurance per month, and the deductibles and copays the tax is already included. If I hear directly about a good one, then maybe.
We already in this country pay crazy high fees for insurance that are probably comparable to the "taxes" already being charged in other countries. The difference is, much of this cost is paid by people's employers and the employees only pay a fraction. For the ones who have to pay out of pocket for those insurance premiums, this can easily reach the 15-30 k a year on premiums alone. Most people don't see that, since they are employed, although we do in our fields since many of us are in PP and pay for our own insurance or the "group" pays for it. I bet if individuals had to bear the full brunt of insurance, then they would be more inclined to pay for universal healthcare.
I pay thousands per month for this family member in insurance premiums, co-pays, medical bills and other expenses. The person is severe but stable enough on the meds they are already on. Just wanted to see if there was a possibility for improvement is all.

 

[calvnandhobbs68]

You are barking up the wrong tree if you want to pick a fight.
I simply don’t understand the language you use as I work in the OR. I am asking you to explain but you seem to want to pick a fight. And yes, obviously I don’t have a grasp on other fields and how they practice and that is why I am asking. To learn. Why do you feel the need to answer so aggressively and jump to conclusions about me when you don’t know me?

You have no idea where I am coming from or how much money and time and money I am already donating and what my other responsibilities and “donations” are in life. But you are jumping to conclusions after being insulted. By a simple questing as we all speak specialty specific language.

It was a simple question. From someone deeply tied into the field of psychiatry.

Whatever.

I mean conceptually it's the difference between a history and physical and a progress note. I find it hard to believe that you've never heard of a new patient intake but suppose it's not impossible....

Typically when someone says "I don't speak xxx" it's designed to sound insulting towards whoever they're saying that to. So you may want to avoid doing that in the future if that's not what you're intending.

It sounds like your problem may just be with the idea of cash only speciality practices in general. If you pay full price for market insurance (not through an employer) then your best recourse is to talk to the insurance plan about your dissatisfaction and let the money talk by looking for a new insurance plan with better "mental health" coverage (cause as you've now learned we're often carved out into that) and buying that next year. Or just buying a cheaper insurance product with less coverage that makes you eligible for an HSA and recognizing that you'll be paying few hundred bucks every few months for whatever specialty care you're needing. We all seem to agree the insurance system sucks in this country and many psychiatrists find it much much easier to not participate in this system at all.

Depends on what your definition of “really” needing psychiatric help entails. In the meantime we’ll keep letting the PCPs deal with the psychotics who may not be dangerous enough to require inpatient help but too severe to be seen and managed by a PCP.
This is an issue that is affecting a family member with good insurance in a big city whom we’ve tried to make an appointment for to no avail. Will eventually find someone hopefully.
Keep hope alive. I am rethinking hospitalization honestly. Make up some story about danger.

The person is severe but stable enough on the meds they are already on. Just wanted to see if there was a possibility for improvement is all.

So then why are you talking earlier in this thread about lying and saying they're dangerous so they could get admitted to a psychiatric facility? This is one of the things that's annoying me about this whole back and forth. There's quite a big gulf between "this person needs to be in an inpatient psychiatric facility" and "they're stable but I wanted to see if we could adjust medication for some improvement".

 

[chocomorsel]

I mean conceptually it's the difference between a history and physical and a progress note. I find it hard to believe that you've never heard of a new patient intake but suppose it's not impossible....

Typically when someone says "I don't speak xxx" it's designed to sound insulting towards whoever they're saying that to. So you may want to avoid doing that in the future if that's not what you're intending.

It sounds like your problem may just be with the idea of cash only speciality practices in general. If you pay full price for market insurance (not through an employer) then your best recourse is to talk to the insurance plan about your dissatisfaction and let the money talk by looking for a new insurance plan with better "mental health" coverage (cause as you've now learned we're often carved out into that) and buying that next year. Or just buying a cheaper insurance product with less coverage that makes you eligible for an HSA and recognizing that you'll be paying few hundred bucks every few months for whatever specialty care you're needing. We all seem to agree the insurance system sucks in this country and many psychiatrists find it much much easier to not participate in this system at all.





So then why are you talking earlier in this thread about lying and saying they're dangerous so they could get admitted to a psychiatric facility? This is one of the things that's annoying me about this whole back and forth. There's quite a big gulf between "this person needs to be in an inpatient psychiatric facility" and "they're stable but I wanted to see if we could adjust medication for some improvement".

Because they are severely psychotic but not a danger to themselves nor anyone else. They can sometimes be aggressive when it comes to ADLs. I was having a bit of a difficult time transitioning and running into cash only road blocks.

I don’t know what intake is. But I know what an H and P is. Donating my time to sit with a psychiatrist for an H and P is something that I have no problem doing if I can find a psychiatrist.

If I am running into practices that refuse to take “all” insurances how can I tell that it’s specifically my family’s insurance that’s the problem? No one told us “we don’t take X and X insurance.” I specifically looked for a health plan with Mental health insurance and paying for a Gold plan. This family member has much better insurance than my cheap one. But I am much healthier.

I suppose I should have said “I don’t speak the language” but clearly didn’t know it was insulting.

Thank you.

 

[Stagg737]

I disagree that our illest patients should be seeing NPs. However if I find a community clinic staffed by a doc, I am all for it.
As far as my family member having lots of social problems, that’s not the case. However if you are saying, and it’s not just you, that many docs in PP are not equipped to handle the severely ill patients, I find that sad for your profession. What are you guys equipped to handle then in PP? The easy and mildly ill? Why are you not able to handle the severely ill but stable outside of the social work aspect? If the answer is social work, I will buy it because that is draining.
Increasing my search and willing to drive farther. I suspect my family is going to require more than 200-300 every three months though. We have only been looking less than a month total off and on. Was just surprised at how all the ones the PCP referred us to said “cash only.”

A lot of this was already addressed, but I do not think they should be seeing NPs. Most PP's don't have the necessary ancillary services to take care of the most severely ill whose biggest problems are more often social issues than psychiatric ones, which is why they should be seen (hopefully by physicians) at CMH programs that can provide those services.

To give you an extreme example, I had a patient on an inpatient unit who was acutely manic who we were trying to transfer to another facility d/t her not being a veteran admitted to a VA. Both our social workers were on vacation/sick that day so I had to do most of the work myself. It took ~10 hours to get all the transfer paperwork together then send/fax it, ensure the legal aspects were taken care of, communicate with the other facility, arrange transportation, and discuss with the patient. This was for a single patient for a simple transfer. Imagine having to do this for the majority of patients on an outpatient basis, making sure they're showing up for their appointments, paying bills to maintain housing, taking medications, etc. This is not something which is reasonable to expect a physician to do but a very common need among the most severely ill patients.

If it were simply about the managing the meds or even emergencies it wouldn't be an issue at all. But that's not the only aspect which is something most other fields just don't understand about psych. I've honestly never encountered an outpatient PP that was equipped to the extent that they could handle those with SPMI who didn't have solid family or social support. The logistics just aren't realistic in a large portion of situations, even less so in cash only private practices which can't receive grants or aid from government programs.

It's strange that everyone your PCP referred you to is cash only and I'd be very surprised if there were no physicians in your area who accept insurance. You may have to just call the insurance company and obtain a list of covered prescribers.

 

[chocomorsel]

A lot of this was already addressed, but I do not think they should be seeing NPs. Most PP's don't have the necessary ancillary services to take care of the most severely ill whose biggest problems are more often social issues than psychiatric ones, which is why they should be seen (hopefully by physicians) at CMH programs that can provide those services.

To give you an extreme example, I had a patient on an inpatient unit who was acutely manic who we were trying to transfer to another facility d/t her not being a veteran admitted to a VA. Both our social workers were on vacation/sick that day so I had to do most of the work myself. It took ~10 hours to get all the transfer paperwork together then send/fax it, ensure the legal aspects were taken care of, communicate with the other facility, arrange transportation, and discuss with the patient. This was for a single patient for a simple transfer. Imagine having to do this for the majority of patients on an outpatient basis, making sure they're showing up for their appointments, paying bills to maintain housing, taking medications, etc. This is not something which is reasonable to expect a physician to do but a very common need among the most severely ill patients.

If it were simply about the managing the meds or even emergencies it wouldn't be an issue at all. But that's not the only aspect which is something most other fields just don't understand about psych. I've honestly never encountered an outpatient PP that was equipped to the extent that they could handle those with SPMI who didn't have solid family or social support. The logistics just aren't realistic in a large portion of situations, even less so in cash only private practices which can't receive grants or aid from government programs.

It's strange that everyone your PCP referred you to is cash only and I'd be very surprised if there were no physicians in your area who accept insurance. You may have to just call the insurance company and obtain a list of covered prescribers.

Totally understand.

But by screening out all insured severely ill patients, you are also screening out any one of them who has solid social support and doesn't require all of this. Which is actually being taken care of by her PCP who referred me to these psychiatrists. A screening questionnaire or I guess "intake" may help. The PCP is part of a large health system. We have already been to the large university system's psych department and they were of little help in management. Talked to a psychiatrist in one of my locums jobs about 2k miles away who gave me hope, but he's 2k miles away so was hopeful I could find someone close to family member's home. Eventually I may have to take this person up there and park myself there working for a few months and see if this psychiatrist can help. He's interested and takes her insurance.

I understand about people wanting to make their money if the insurance company fees are "abysmal". There is someone on here earlier who said that their insurance fees are only 20-30% less than cash only, and another said they are worse than Medicare. Obviously it's location and practice specific.
Maybe in my town they are extremely bad.

 

[Ironspy]

Totally understand.

But by screening out all insured severely ill patients, you are also screening out any one of them who has solid social support and doesn't require all of this. Which is actually being taken care of by her PCP who referred me to these psychiatrists. A screening questionnaire or I guess "intake" may help. The PCP is part of a large health system. We have already been to the large university system's psych department and they were of little help in management. Talked to a psychiatrist in one of my locums jobs about 2k miles away who gave me hope, but he's 2k miles away so was hopeful I could find someone close to family member's home. Eventually I may have to take this person up there and park myself there working for a few months and see if this psychiatrist can help. He's interested and takes her insurance.

I understand about people wanting to make their money if the insurance company fees are "abysmal". There is someone on here earlier who said that their insurance fees are only 20-30% less than cash only, and another said they are worse than Medicare. Obviously it's location and practice specific.
Maybe in my town they are extremely bad.

An intake is an initial outpatient visit--a term you don't likely see as an anesthesiologist

The "cash only" psychiatrists allow patients to utilize their insurance if the insurance has out of network benefits and 80-90% of my private patients do. Typical coverage is that the patient pays the first $x,000 and the insurance reimburses 60-100% of costs after that. I provide the documentation needed for reimbursement and am happy to fax it directly to their insurance company as well. I get paid cash at time of visit and am able to spend all of my time and energy practicing psychiatry. Paying cash is often the quickest way to get high quality care.

 

[calvnandhobbs68]

Just to put this all in perspective too, I just opened my mail and got my bill from my most recent PCP visit. $154 was the billed charge for about a 20 minute virtual appointment. Insurance adjustment was down to $144. Haven't hit anywhere near my deductible yet (and probably won't this year since I'm in a high deductible plan), so I'll be paying all of that from my HSA. Which I absolutely do not complain about at all...but then I find it quite a bit ridiculous that people complain about a $300 60 minute initial appointment and $175 30 minute followups to see a specialist.

 

[chocomorsel]

An intake is an initial outpatient visit--a term you don't likely see as an anesthesiologist

The "cash only" psychiatrists allow patients to utilize their insurance if the insurance has out of network benefits and 80-90% of my private patients do. Typical coverage is that the patient pays the first $x,000 and the insurance reimburses 60-100% of costs after that. I provide the documentation needed for reimbursement and am happy to fax it directly to their insurance company as well. I get paid cash at time of visit and am able to spend all of my time and energy practicing psychiatry. Paying cash is often the quickest way to get high quality care.

Works for me. Thanks!

 

[nexus73]

Insurance doesn’t pay for case management. If insurance paid me adequately to pay social workers (plural) to be on staff in my clinic this would be more reasonable. Really they would also need to pay me more for these patients to offset losses related to increased time coordinating care and no shows, which they don’t.

But a problem with severely mentally ill patients is chronic poor insight, poor medication compliance, and lots of no shows. Psychiatry appointments (if it’s a good physician) are 30-45 minute follow ups, 60-90 minute initial evaluation. 10-16 patients per day. Not 25-30+ per day a pcp might see for 10-15 minute visits. You can’t really double book 30-45 minute appointments to offset no shows. Then 1 or 2 no shows destroys income for the day (or 5-6 no shows might not be uncommon in community mental health). And then we’re already getting paid less than PCP even though we’re specialists.

This is the reason psychiatry services for severe mental illness are at community mental health clinics. Insurance will pay those clinics for case management. And they get special insurance rates and grants to offset costs associated treating this population of patients that a private practice psychiatrist has no access to.

Best bet is get family member on Medicare/Medicaid, find the community mental health clinic or FQHC in town and seek care there. Psychiatrists do work in these settings as employed doctors. Or find a psychiatrist taking commercial insurance or cash, willing to coordinate with a cash pay case management/therapist to provide adequate ancillary support; but this is likely a harder route.

There was recently an article about this exact issue in California. The private insurers lie about paying for these services, making it sound like their insured can access services at regular psych practices, but family members find out the unfortunate reality that commercial insurance stinks for mental health care if you have severe mental illness like schizophrenia.

'Go On Medi-Cal To Get That': Why Californians With Mental Illness Are Dropping Private Insurance To Get Taxpayer-Funded Treatment

In dozens of interviews, families, attorneys, judges, therapists and public officials agree: People with serious mental illnesses often do better dropping private insurance and qualifying for taxpayer-funded treatment.

www.capradio.org

 

[Ironspy]

Works for me. Thanks!

psychology today is a good place to find private practice psychiatrists and therapists. You can filter by insurance as well.

 

[chocomorsel]

Insurance doesn’t pay for case management. If insurance paid me adequately to pay social workers (plural) to be on staff in my clinic this would be more reasonable. Really they would also need to pay me more for these patients to offset losses related to increased time coordinating care and no shows, which they don’t.

But a problem with severely mentally ill patients is chronic poor insight, poor medication compliance, and lots of no shows. Psychiatry appointments (if it’s a good physician) are 30-45 minute follow ups, 60-90 minute initial evaluation. 10-16 patients per day. Not 25-30+ per day a pcp might see for 10-15 minute visits. You can’t really double book 30-45 minute appointments to offset no shows. Then 1 or 2 no shows destroys income for the day (or 5-6 no shows might not be uncommon in community mental health). And then we’re already getting paid less than PCP even though we’re specialists.

This is the reason psychiatry services for severe mental illness are at community mental health clinics. Insurance will pay those clinics for case management. And they get special insurance rates and grants to offset costs associated treating this population of patients that a private practice psychiatrist has no access to.

Best bet is get family member on Medicare/Medicaid, find the community mental health clinic or FQHC in town and seek care there. Psychiatrists do work in these settings as employed doctors. Or find a psychiatrist taking commercial insurance or cash, willing to coordinate with a cash pay case management/therapist to provide adequate ancillary support; but this is likely a harder route.

There was recently an article about this exact issue in California. The private insurers lie about paying for these services so their insured can access services at regular psych practices, but family members find out the unfortunate reality that commercial insurance stinks for mental health care if you have severe mental illness like schizophrenia.

'Go On Medi-Cal To Get That': Why Californians With Mental Illness Are Dropping Private Insurance To Get Taxpayer-Funded Treatment

In dozens of interviews, families, attorneys, judges, therapists and public officials agree: People with serious mental illnesses often do better dropping private insurance and qualifying for taxpayer-funded treatment.

www.capradio.org

She has Commercial insurance already. The SW aspect is hardly needed and already been taken care of from a long time ago.
Thanks
Thank you.

 

[nexus73]

She has Commercial insurance already. The SW aspect is hardly needed and already been taken care of from a long time ago.
Thanks
Thank you.

Best of luck finding what you’re looking for.

 

[Candidate2017]

However if you are saying, and it’s not just you, that many docs in PP are not equipped to handle the severely ill patients, I find that sad for your profession. What are you guys equipped to handle then in PP? The easy and mildly ill?

Whoa, hold on.

If a surgeon says he or she is not equipped to handle an appendectomy in their PP outpt clinic, would you be disappointed in the surgical profession? Not equipped isn't the same as can't handle. They need a hospital's OR with a surgical team composed of anesthesiologist, scrub nurse, techs, clean up crew & extensive hospital post-op care from IM, ICU etc if anything goes wrong. Actually, the hospital and entire team needs the surgeon, for the $$$$$.

Psychiatrists can handle psychotic disorders, however insurance won't pay for our version of an OR and surgical team.