What states are midlevels replacing psychiatrists?

[psyspy]

Are the states with restricted practice relatively immune to this?

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[Sushirolls]

No. All states are.
It matters more on Employer.
Most Big Box shops are in a race to the bottom to have a single MD/DO medical director around for whatever specialty, and then infill the void of labor needs with midlevels.

 

[psyspy]

If worst comes to worst, what would prevent cash only telehealth psychiatry practice?

 

[comp1]

Honestly...if you aren't getting five job offer emails or texts daily, you have done an amazingly good job hiding your contact info. The right answer is in no states are NPs replacing psychiatrists. There are more jobs and patients than either could handle. Salaries remain up.

 

[Sushirolls]

Before a tsunami, people historically would run into the mystery of the receding sea to marvel at the findings on the greatly extended beach. It isn't until the roar of the sea wall barreling at them people think oops.

The sea is receding, and things look pretty darn good right now in 2022 for psychiatry.

 

[dl2dp2]

Mid level wave seems to be plateauing as @Sushirolls is saying. They are already here. Fortunately, it’s now very apparent that MDs have [much] higher margins. Your mileage varies depending on the facility, payer mix etc

Think the next wave is PE takeover. Psychiatry roll-up is very hot right now. Thankfully, unlike things like EM/rad onc/derm, etc in psych you can easily say f u and set up your own competing shop. This will have some impact but less so than in other fields.

Another new thing is national telepsych chains. Again this was of major concern for a time but it seems that they are different products fundamentally vis-a-vis local brick and mortar, especially in the time of resumption of Ryan Haight etc. if anything inpatient telepsych is growing, very interesting.

 

[J ROD]

Replace is a strong word for me. Fill in the gaps of need for sure. With such high demand currently I do not see problems now. Now when supply is greater than demand I am sure some places will try and take it on the cheap.

 

[randomdoc1]

We will never be replaced. Physicians are physicians. Mid level infiltration is everywhere, but NPs are NPs and physicians are physicians. In my geographic area, there seems to be too many NPs. And guess what? Physicians are still sitting pretty. I can't speak for individual organizations. But I can speak for some things including economics. Despite the massive influx of psych NPs in this region, my colleagues and I constantly get bombarded with recruiting efforts while NPs are begging for a gig. We still get paid well. At least in private practice I can negotiate insurance rates. I'm potentially boarding on two more psychiatrists. Independent physicians unite indeed! NPs here can take what's left. Many of them end up inheriting my discharged patients (e.g. severe axis II, drug seeking, some sort of chronic difficulty). They can have it. And frankly, I'm grateful otherwise we're stuck with these hot potatoes.

 

[Sushirolls]

I'm in an area next to a ARNP university (factory) and they are saturating the local market. Are there still employed jobs in the area? Yes. But they are less desirable Big Box shop places with high turnover. The Insurance parity in the state also makes it more favorable for ARNPs, too. So they open their private practices and frequent form their own groups. They are also doing TMS heavily here, too. Many patients don't know alphabet soup differences. Its not until they've had a few years with ARNPs that some start realize things aren't right and then seek out the Psychiatrist level offices. My practice is growing, but slowly. It can be doable, and cash can, too. But the belief and assumption of turning on the lights and you will be full is not the case. Do these quick fill locales exist in the country? Yes, they still very much so do. But as the rate/ratio or ARNPs increase, and even a pinch of the burgeoning independent PA movement tosses into the ring, too... oh, and let's not forget the NDs who can do it all holistically! It makes a much more competitive market. Declining insurance rates (or most likely, already declined insurance rates in most locales) will make it difficult for people to start PP insurance without supplementing their income. Which forces the question, how hard do you want to work, and are the freedoms of PP worth the several year grind to break away from the Big Box shops? This calculus might not compute for some in years to come who are in the saturated markets.

One oddly positive bureacratic news of late, is the DEA and end of Covid. They will likely be hunting down telemedicien practices/firms that don't have a physical offices in the states they are practicing in. So assuming these practices close on constrict their service targets, these patients will flood back to their local docs. This regionality allows folks to self select to move to less saturated areas.

 

[psyspy]

Mid level wave seems to be plateauing as @Sushirolls is saying. They are already here. Fortunately, it’s now very apparent that MDs have [much] higher margins. Your mileage varies depending on the facility, payer mix etc

Think the next wave is PE takeover. Psychiatry roll-up is very hot right now. Thankfully, unlike things like EM/rad onc/derm, etc in psych you can easily say f u and set up your own competing shop. This will have some impact but less so than in other fields.

Another new thing is national telepsych chains. Again this was of major concern for a time but it seems that they are different products fundamentally vis-a-vis local brick and mortar, especially in the time of resumption of Ryan Haight etc. if anything inpatient telepsych is growing, very interesting.

Do you know if Ryan Haight act applies to inpatient telepsych?

 

[comp1]

Inpatient facilities are DEA registered. The Ryan Haight issue primarily relates to care to the home.

 

[PikminOC]

If worst comes to worst, what would prevent cash only telehealth psychiatry practice?

There are many already

 

[PikminOC]

I'm in an area next to a ARNP university (factory) and they are saturating the local market. Are there still employed jobs in the area? Yes. But they are less desirable Big Box shop places with high turnover. The Insurance parity in the state also makes it more favorable for ARNPs, too. So they open their private practices and frequent form their own groups. They are also doing TMS heavily here, too. Many patients don't know alphabet soup differences. Its not until they've had a few years with ARNPs that some start realize things aren't right and then seek out the Psychiatrist level offices. My practice is growing, but slowly. It can be doable, and cash can, too. But the belief and assumption of turning on the lights and you will be full is not the case. Do these quick fill locales exist in the country? Yes, they still very much so do. But as the rate/ratio or ARNPs increase, and even a pinch of the burgeoning independent PA movement tosses into the ring, too... oh, and let's not forget the NDs who can do it all holistically! It makes a much more competitive market. Declining insurance rates (or most likely, already declined insurance rates in most locales) will make it difficult for people to start PP insurance without supplementing their income. Which forces the question, how hard do you want to work, and are the freedoms of PP worth the several year grind to break away from the Big Box shops? This calculus might not compute for some in years to come who are in the saturated markets.

One oddly positive bureacratic news of late, is the DEA and end of Covid. They will likely be hunting down telemedicien practices/firms that don't have a physical offices in the states they are practicing in. So assuming these practices close on constrict their service targets, these patients will flood back to their local docs. This regionality allows folks to self select to move to less saturated areas.

Don't forget prescribing psychologist

 

[calvnandhobbs68]

Don't forget prescribing psychologist

Meh the prescribing psychologist movement is like nothing compared to NPs. There are thousands more psych NPs pumped out every year than there would even be psychologists interested in prescribing medication. Doesn't mean I think it should happen (the concept itself is bizarre...kind of like saying physical therapists should be allowed to prescribe any "orthopedic" related medications) but it's not the same level of threat that NPs are.

 

[Stagg737]

Honestly...if you aren't getting five job offer emails or texts daily, you have done an amazingly good job hiding your contact info. The right answer is in no states are NPs replacing psychiatrists. There are more jobs and patients than either could handle. Salaries remain up.

Eh, I've heard of plenty of psychiatrists being replaced by NPs within some systems. That being said, I agree that job opportunities for psychiatrists are plentiful for anyone who can use Google. Also, with the movement to increase MH awareness and care there won't be a shortage any time soon. I also get e-mails from job postings daily and have started getting e-mails from actual hospital recruiters in other states who found my name. I agree that demand is still high and will likely remain that way for a while.

Meh the prescribing psychologist movement is like nothing compared to NPs. There are thousands more psych NPs pumped out every year than there would even be psychologists interested in prescribing medication. Doesn't mean I think it should happen (the concept itself is bizarre...kind of like saying physical therapists should be allowed to prescribe any "orthopedic" related medications) but it's not the same level of threat that NPs are.

I know very few psychologists who want to be able to prescribe medications, and most of those actually are in or went to residency and became psychiatrists. Frankly, I wish the movement was for psychologists to be able to fast track to prescribing meds instead of NPs, at least most psychologists perform good evals and give a good differential/formulation.

 

[comp1]

All of the psychiatrist positions we are converting to MD or NP are positions that we have not been able to fill in over a year of active recruitment. I'm sure there's somewhere in the country that had some weird idea to replace currently employed MDs with NPs, but it is in no way common or becoming some sort of trend.

 

[deleted456421]

All of the psychiatrist positions we are converting to MD or NP are positions that we have not been able to fill in over a year of active recruitment. I'm sure there's somewhere in the country that had some weird idea to replace currently employed MDs with NPs, but it is in no way common or becoming some sort of trend.

Typical replacement by attrition. I’ve seen it at several places. It’s amazing how NPs and MDs suddenly become equivalent after a few months of lost billing.

 

[PikminOC]

Eh, I've heard of plenty of psychiatrists being replaced by NPs within some systems. That being said, I agree that job opportunities for psychiatrists are plentiful for anyone who can use Google. Also, with the movement to increase MH awareness and care there won't be a shortage any time soon. I also get e-mails from job postings daily and have started getting e-mails from actual hospital recruiters in other states who found my name. I agree that demand is still high and will likely remain that way for a while.



I know very few psychologists who want to be able to prescribe medications, and most of those actually are in or went to residency and became psychiatrists. Frankly, I wish the movement was for psychologists to be able to fast track to prescribing meds instead of NPs, at least most psychologists perform good evals and give a good differential/formulation.

It's not about the Psychologists you know. It's about the diploma mills who are trying to get lots of money for the psyds they are admitting at high rate.

 

[PikminOC]

Meh the prescribing psychologist movement is like nothing compared to NPs. There are thousands more psych NPs pumped out every year than there would even be psychologists interested in prescribing medication. Doesn't mean I think it should happen (the concept itself is bizarre...kind of like saying physical therapists should be allowed to prescribe any "orthopedic" related medications) but it's not the same level of threat that NPs are.

But it's still something more. And certain states have them.

 

[G Sheb]

Much ado about nothing.
Rates for psychiatrists have gone up considerably over the past year.

 

[WisNeuro]

But it's still something more. And certain states have them.

5 as of now, though I believe that there are always bills floating around a handful of state legislatures at any given point, so it will slowly grow. Though, most of these essentially require going through an NP/PA program anyway, so it still circles back around to NP/PA training type programs. Comparatively, though, the number going through the RxP route is a drop in the bucket compared to the number of psych NPs graduating. So, while RxP is a territory in your current turf wars, it's currently Liechtenstein.

 

[Monocles]

Anecdotal evidence from Massachusetts:

I work on an academic child inpt unit and in trying to get collateral, I've found the distribution of outpatient prescribers seem to be 50% pediatricians, 25% psych NPs, and 25% psych MD/DOs. Surprisingly there doesn't seem to be any correlation between SEC and having access to a psychiatrist... families with significant means (8 figure net worth+) sometimes have midlevel providers that they are itching to replace...

We have been trying to fill our own inpt role for months without any luck. Not even NPs will bite lmao (as I'm sure there's better money in private practice)

 

[nexus73]

Anecdotal evidence from Massachusetts:

I work on an academic child inpt unit and in trying to get collateral, I've found the distribution of outpatient prescribers seem to be 50% pediatricians, 25% psych NPs, and 25% psych MD/DOs. Surprisingly there doesn't seem to be any correlation between SEC and having access to a psychiatrist... families with significant means (8 figure net worth+) sometimes have midlevel providers that they are itching to replace...

We have been trying to fill our own inpt role for months without any luck. Not even NPs will bite lmao (as I'm sure there's better money in private practice)

Nps get paid way less as employees.

 

[Stagg737]

It's not about the Psychologists you know. It's about the diploma mills who are trying to get lots of money for the psyds they are admitting at high rate.

As others said, it’s still nothing compared to NP encroachment. And a PsyD is a psychologist…

 

[calvnandhobbs68]

As others said, it’s still nothing compared to NP encroachment. And a PsyD is a psychologist…

Yeah I'd argue that most of the psychologist programs are more of a "doctorate" type program than the "DNP" programs. Still doesn't mean I think they should be able to do medical treatment (same way I don't think my friend whose a PhD cell biologist should be prescribing medications even if he took some classes in it and I probably shouldn't being manning an electron microscope).

 

[PikminOC]

5 as of now, though I believe that there are always bills floating around a handful of state legislatures at any given point, so it will slowly grow. Though, most of these essentially require going through an NP/PA program anyway, so it still circles back around to NP/PA training type programs. Comparatively, though, the number going through the RxP route is a drop in the bucket compared to the number of psych NPs graduating. So, while RxP is a territory in your current turf wars, it's currently Liechtenstein.

Everyone calls it turf wars until it happens to them.

 

[PikminOC]

Much ado about nothing.
Rates for psychiatrists have gone up considerably over the past year.

And how about for np?

 

[G Sheb]

And how about for np?

I do not know and it doesn't matter.
The market for psychiatrists is even better than it was pre-pandemic. Jobs are plentiful. Rates have considerably increased even if you account for inflation. I contract with several hospitals, and they all had a pay raise between 10-30%.
There have been lots of doom voices predicting that the sky is going to fall. All bs.

 

[WisNeuro]

Everyone calls it turf wars until it happens to them.

Nah, psychologists fight their own turf wars. We all think we deliver better care than midlevels, it's just that none of us have the data to back that claim up. At this point in my career, it's all the same to me, it'll be some time before midlevels encroach in my high paying forensic space.

 

[PikminOC]

Nah, psychologists fight their own turf wars. We all think we deliver better care than midlevels, it's just that none of us have the data to back that claim up. At this point in my career, it's all the same to me, it'll be some time before midlevels encroach in my high paying forensic space.

Glad you're not concerned about your colleagues.

 

[PikminOC]

I do not know and it doesn't matter.
The market for psychiatrists is even better than it was pre-pandemic. Jobs are plentiful. Rates have considerably increased even if you account for inflation. I contract with several hospitals, and they all had a pay raise between 10-30%.
There have been lots of doom voices predicting that the sky is going to fall. All bs.

It's different out in outpt private practice.

 

[WisNeuro]

Glad you're not concerned about your colleagues.

My colleagues are capable of taking care of themselves. I don't feel the need to infantalize them. I also support advocacy efforts through my national and state level orgs and regularly speak with my representatives. When it's all said and done, doctoral level professionals in healthcare need to put money where their mouths are and do some meaningful outcome studies.

 

[clausewitz2]

My colleagues are capable of taking care of themselves. I don't feel the need to infantalize them. I also support advocacy efforts through my national and state level orgs and regularly speak with my representatives. When it's all said and done, doctoral level professionals in healthcare need to put money where their mouths are and do some meaningful outcome studies.

And failing that use that superior education and supposed clinical acumen to distinguish what they have to offer in a way that makes them a more compelling option than the latest newly-minted LCSW to hang out a shingle down the road. This should be fairly easy if the quality difference is as pronounced as we like to think it is. And yes I think the same applies to MDs v. NPs.

 

[voxveritatisetlucis]

MGH/BWH use NPs in psych

Pretty sure BIDMC, BMC, Tufts do as well

 

[WisNeuro]

And failing that use that superior education and supposed clinical acumen to distinguish what they have to offer in a way that makes them a more compelling option than the latest newly-minted LCSW to hang out a shingle down the road. This should be fairly easy if the quality difference is as pronounced as we like to think it is. And yes I think the same applies to MDs v. NPs.

Exactly, if you have a good product and reputation, you'll find work. I'm booking into the holidays at the end of the year, and frequently have to turn down legal work due to lack of time. Looks like it's time for another increase in my fee schedule rates heading into 2023.

But really, our healthcare system would greatly benefit from a multidisciplinary effort to look at education, clinical practices, and outcomes in a comprehensive and meaningful way.

 

[PikminOC]

And failing that use that superior education and supposed clinical acumen to distinguish what they have to offer in a way that makes them a more compelling option than the latest newly-minted LCSW to hang out a shingle down the road. This should be fairly easy if the quality difference is as pronounced as we like to think it is. And yes I think the same applies to MDs v. NPs.

Patients really don't care or know the difference when it comes to MD and midlevels

 

[clausewitz2]

Patients really don't care or know the difference when it comes to MD and midlevels

'Kay. I'll have to remember to tell the patients of mine who came to me because they are unhappy to be seeing Naps.

 

[PikminOC]

'Kay. I'll have to remember to tell the patients of mine who came to me because they are unhappy to be seeing Naps.

I'm talking about the majority.

 

[WisNeuro]

I'm talking about the majority.

Who are we to take away their choice if they neither know nor care what the difference is?

 

[comp1]

Exactly, if you have a good product and reputation, you'll find work. I'm booking into the holidays at the end of the year, and frequently have to turn down legal work due to lack of time. Looks like it's time for another increase in my fee schedule rates heading into 2023.

But really, our healthcare system would greatly benefit from a multidisciplinary effort to look at education, clinical practices, and outcomes in a comprehensive and meaningful way.

If you have a BAD practice and reputation you'll find work. There's no shortage of work...

 

[calvnandhobbs68]

If you have a BAD practice and reputation you'll find work. There's no shortage of work...

I mean and lets be real. If you call yourself an "ADHD clinic" and diagnose everyone with ADHD and give everyone 30mg Adderall BID who comes in complaining that they can't concentrate you'll find work. We can't be blind to the fact that "busy" doesn't necessarily equal "quality" in medicine.

 

[texanpsychdoc]

5 as of now, though I believe that there are always bills floating around a handful of state legislatures at any given point, so it will slowly grow. Though, most of these essentially require going through an NP/PA program anyway, so it still circles back around to NP/PA training type programs. Comparatively, though, the number going through the RxP route is a drop in the bucket compared to the number of psych NPs graduating. So, while RxP is a territory in your current turf wars, it's currently Liechtenstein.

Indeed - PA may be onto something in the near future. On a side note, I will be starting my post-doc M.S. in Clinical Psychopharmacology in a month so that I can work towards Rx abilities. I've heard from numerous sources lately that the VA is looking to pilot a program for RxP in the next 2-3 years. That would be great so I don't have to leave my job!

 

[FlowRate]

MGH/BWH use NPs in psych

Pretty sure BIDMC, BMC, Tufts do as well

Not sure about MGH but unless BWH has changed a lot in the past two years, I think they had hired 1 who was starting as I was leaving and in part because it was hard to get clinical attendings in.

BI used to have some old school NP's on CL and, while I'd classify them as relatively good NP's, they weren't replaced when they retired and weren't nearly as useful as residents/attendings.

 

[comp1]

The VA has very limited need for prescribing psychologists because it already has prescribing clinical pharmacists. There's also very limited interest from psychologists. It certainly won't pay more.

 

[WisNeuro]

If you have a BAD practice and reputation you'll find work. There's no shortage of work...

Clinically, certainly, though in my area, you may lose some repeat patients. In the forensic/IME world you will lose work if you do a poor job. That area is all about repeat business.

The VA has very limited need for prescribing psychologists because it already has prescribing clinical pharmacists. There's also very limited interest from psychologists. It certainly won't pay more.

Yeah, no worries over here about me going this route, I'm not about to take a massive pay cut.

 

[voxveritatisetlucis]

If you have a BAD practice and reputation you'll find work. There's no shortage of work...

In some cases, it might even be the opposite especially in the cash pay type practices. Meaning that I’m sure some patients will stop seeing a psychiatrist if he or she doesn’t prescribe benzos/amphetamines

 

[texanpsychdoc]

The VA has very limited need for prescribing psychologists because it already has prescribing clinical pharmacists. There's also very limited interest from psychologists. It certainly won't pay more.

Perhaps, but each VA is different with respect to the ratio of prescribers they have, and even with them filling roles with clinical pharmacists, PAs, and NPs, there is still a substantial gap with significant wait times, especially at my VA. Also, even if there might be limited interests from some psychologists, they do not speak for those who are interested and poised to serve in those roles. One could argue that the supposed "limited interests" of some psychologists may be attributed to a lack of available jobs that would justify and incentivize prospective RxP psychologists to get the training and education for prescribing roles.

 

[smalltownpsych]

I live in a state with RxP, briefly looked into it as I know that I could make some extra money and provide better treatment than the Psych NPs in town and I don’t think the sole outpatient psychiatrist is a bit busy. Didn’t seem worth it at all and like many psychologists, I decided I could make more money and be more effective going a different route. Also, my experience so far with Psych NPs, I don’t think that the typical psychiatrist has to worry much.

I have found that apparently I don’t even have to worry that much about encroachment from the literally hundreds of midlevel counselors I am competing with locally. Five months after opening my doors, and next week I’ve got 22 hours booked for a cash only practice. I worried about it before I opened my doors, of course, but it seems that people figure out who helps and who is worth it and are willing to pay for the quality. Then again, I tend to work with very severe cases so the stakes are pretty high. Some of my patients were referred by therapists who didn’t feel comfortable with level of pathology. I also have good connections with a local private pay residential treatment program so that helps too.

 

[G Sheb]

It's different out in outpt private practice.

Is it? What's the evidence behind this? I haven't met any graduating psychiatrists with no red flags who had trouble find a job wherever they wanted. PP should be an even easier market for psychiatrists.

I get that some are dissatisfied with their careers, but projecting their dissatisfaction onto unfounded projections or baseless claims isn't helpful for prospective psychiatrists.

 

[MedMan80]

In my rural area, we have a glut of NP looking to work for our organization that pays them more than other organizations. Incredibly hard to recruit MD's however and we need them to run the inpatient unit/run the CL service and teach med students. Mid levels here are really only comfortable working under an MD for inpatient or do outpatient only.