Almost ten years ago I spoke of the biggest problem facing us psychiatrists.....

[vistaril]

And I was mostly shrugged off.

I'm speaking of course of psychiatric nurse practitioners.

The responses I got at the time were a mix of "but other fields use them too" to "they don't do the same thing".

Even then, however, I could see that other fields(apart from anesthesia of course) were and are using them *different*. They were following a true collaborative model. Not even that actually- the nps will usually serve as more of a helper for example, and were/are not driving treatment choices for their supervisors to just 'sign off' on.

The situation was troubling ten years ago. Now, it's become 10x worse.

As far as how bad it is, the state I am in(Alabama currently, but I've practiced in 3 other states over the last 4 years as well) is sort of in the middle. NPs don't have their own independent practice and they do need on paper a collaborating physician, but the 'on paper' part is key.

What I see going on in terms of day to day practice with psych nps:

1) they have pretty much their own total autonomy in clinic now. It's rare that in community health systems especially a pt will see a psychiatrist. Many of them think the psych np they are seeing is their psychiatrist. After all, how would they know any different? What you will typically see is a large community mental health system that may span several counties has one nominal director(which may be a part time position). The director is basically selling their collaborative slots so that the nps can actually see all the patients. You can have 5 psych np slots used I think, and those 5 psych nps can run the entire outpt MH system and see all the patients. There is no collaboration needed beyond some impractical 'chart review' which is meaningless.

2) psych nps are increasingly taking over inpatient roles. Unlike outpt(at least here), the patients do have to be technically be seen face to face by a psychiatrist. This could take the form of anything though- it could literally take the form of 'eyeballing' the patient. At one of my previous hospitals(an extremely large psych hospital that had about 95 inpatients), 2 to 3 psych nps(depending on whether they had any outpt responsibilities as well) would see all the patients there. This included the interview, notes, making out treatment plans, starting and changing meds, discharge decisions, etc and at the end of the day one of the psychiatrists who was assinged to 'sign off' on the patients that day after their clinic did so. I've discovered that this isn't unusual at all now in situations where the providers are not hospital employed. The hospitals save a ton of money of course but selling this off to a group as the group will often take far reduced stipends if it can be covered by psych nps.

In fact one of my previous positions involved working for a group that assigned me to cover about 40 inpatient geri beds. That was my whole day. I didnt have to do clinic or anything too. For it I got a pretty typical salary(almost 300k with benefits from the group). Well, this worked fine for awhile but after awhile I was told things were going to shift. now a psych np(paid around 100k Im sure) was going to do that geri inpatient and I would 'sign off' on it in the afternoon. I still had a job if I wanted, but I was going to do outpatient all day and then come by and sign off on those 40 geri notes. I decided not to, and so I left there and thats exactly how they are doing it now. And everyone is happy- the practice is happy because they are saving 200k because a psych np now does it rather than a psychiatrist. The hospital is happy because they dont have to hire a psychiatrist and the stipend can stay really low because the practice is covering it so cheaply. The np is happy because she has a job and gets a ton of autonomy. The only person who isnt happy(assuming he is an employee and not a partner/revenue sharer) is the psychiatrist who feels like he has to 'sign off' on 40 notes at the end of the day for no extra compensation to keep his job. Situations like the above have increased a lot in the last decade, and will only continue to become more common.

3) Hospitals and mental health systems are very much in on it. If they wanted to they could very much demand that for the stipend they are offering there has to be more hands on psychiatric involvement, but they would prefer to pretend not to see whats going on. Why? To get it covered for as little stipend cost on their end. They have already gone away from hospital employment in most cases to cover their psych units. Now by turning a blind eye to whats going on, they can get by paying as little possible stipend as possible on top of that and still some group will take the contract in the hopes of having their nps do it. So they really are to blame for how we've gotten where we are, because if they wanted to they could demand for psychs to see the patients and direct care. Of course they wouldn't find many takers under those terms with the stipend they want to
pay. And they never would allow that with their hospitalist service for example- that hospital I used to work at where psych nps saw everyone and a psych just 'signed off'? They employed a ton of salaried 7/7 hospitalists. Nps worked with them too but in a true collaborative model.

Sadly, I was 100% right about my prediction almost ten years ago with psych nps. It's too late to do anything. Hell it was probably too late to do anything then. For now certain practice settings(the VA and academic places) are still pretty safe from it....so thats a more appealing option than ever.

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[hebel]

And I was mostly shrugged off.

I'm speaking of course of psychiatric nurse practitioners.

The responses I got at the time were a mix of "but other fields use them too" to "they don't do the same thing".

Even then, however, I could see that other fields(apart from anesthesia of course) were and are using them *different*. They were following a true collaborative model. Not even that actually- the nps will usually serve as more of a helper for example, and were/are not driving treatment choices for their supervisors to just 'sign off' on.

The situation was troubling ten years ago. Now, it's become 10x worse.

As far as how bad it is, the state I am in(Alabama currently, but I've practiced in 3 other states over the last 4 years as well) is sort of in the middle. NPs don't have their own independent practice and they do need on paper a collaborating physician, but the 'on paper' part is key.

What I see going on in terms of day to day practice with psych nps:

1) they have pretty much their own total autonomy in clinic now. It's rare that in community health systems especially a pt will see a psychiatrist. Many of them think the psych np they are seeing is their psychiatrist. After all, how would they know any different? What you will typically see is a large community mental health system that may span several counties has one nominal director(which may be a part time position). The director is basically selling their collaborative slots so that the nps can actually see all the patients. You can have 5 psych np slots used I think, and those 5 psych nps can run the entire outpt MH system and see all the patients. There is no collaboration needed beyond some impractical 'chart review' which is meaningless.

2) psych nps are increasingly taking over inpatient roles. Unlike outpt(at least here), the patients do have to be technically be seen face to face by a psychiatrist. This could take the form of anything though- it could literally take the form of 'eyeballing' the patient. At one of my previous hospitals(an extremely large psych hospital that had about 95 inpatients), 2 to 3 psych nps(depending on whether they had any outpt responsibilities as well) would see all the patients there. This included the interview, notes, making out treatment plans, starting and changing meds, discharge decisions, etc and at the end of the day one of the psychiatrists who was assinged to 'sign off' on the patients that day after their clinic did so. I've discovered that this isn't unusual at all now in situations where the providers are not hospital employed. The hospitals save a ton of money of course but selling this off to a group as the group will often take far reduced stipends if it can be covered by psych nps.

In fact one of my previous positions involved working for a group that assigned me to cover about 40 inpatient geri beds. That was my whole day. I didnt have to do clinic or anything too. For it I got a pretty typical salary(almost 300k with benefits from the group). Well, this worked fine for awhile but after awhile I was told things were going to shift. now a psych np(paid around 100k Im sure) was going to do that geri inpatient and I would 'sign off' on it in the afternoon. I still had a job if I wanted, but I was going to do outpatient all day and then come by and sign off on those 40 geri notes. I decided not to, and so I left there and thats exactly how they are doing it now. And everyone is happy- the practice is happy because they are saving 200k because a psych np now does it rather than a psychiatrist. The hospital is happy because they dont have to hire a psychiatrist and the stipend can stay really low because the practice is covering it so cheaply. The np is happy because she has a job and gets a ton of autonomy. The only person who isnt happy(assuming he is an employee and not a partner/revenue sharer) is the psychiatrist who feels like he has to 'sign off' on 40 notes at the end of the day for no extra compensation to keep his job. Situations like the above have increased a lot in the last decade, and will only continue to become more common.

3) Hospitals and mental health systems are very much in on it. If they wanted to they could very much demand that for the stipend they are offering there has to be more hands on psychiatric involvement, but they would prefer to pretend not to see whats going on. Why? To get it covered for as little stipend cost on their end. They have already gone away from hospital employment in most cases to cover their psych units. Now by turning a blind eye to whats going on, they can get by paying as little possible stipend as possible on top of that and still some group will take the contract in the hopes of having their nps do it. So they really are to blame for how we've gotten where we are, because if they wanted to they could demand for psychs to see the patients and direct care. Of course they wouldn't find many takers under those terms with the stipend they want to
pay. And they never would allow that with their hospitalist service for example- that hospital I used to work at where psych nps saw everyone and a psych just 'signed off'? They employed a ton of salaried 7/7 hospitalists. Nps worked with them too but in a true collaborative model.

Sadly, I was 100% right about my prediction almost ten years ago with psych nps. It's too late to do anything. Hell it was probably too late to do anything then. For now certain practice settings(the VA and academic places) are still pretty safe from it....so thats a more appealing option than ever.

I think this is a fair take on the situation. It's a bummer overall, and I would have viewed it as a deal breaker for choosing psychiatry if the private practice market didn't exist.

I'd say we're lagging behind what's happened to anesthesiology by over a decade, but will probably catch up pretty fast. Looking at how things panned out for them, I'd expect psychiatrists to feel the pressure of caving into these supervisory roles in the employee setting. But, during this time we will probably continue to see salaries rise for the foreseeable future similar to anesthesia as they transitioned into the ACT model (ignoring the COVID effect on the overall economy).

It will be interesting to see how the extremely high demand for psychiatry slows down some of the above. We're also in a better position than EM or anesthesia in regards to midlevels because we are specialists that patients can choose, rather than a specialty that provides a service to people who show up to the ED or are getting surgery by a surgeon. Antcedotely, I've also found that most NPs cannot manage complex cases appropriately. Unfortunately, I don't think this matters to administrators because the patients are still being "seen" on paper.

Selfishly, I feel optimistic about my personal future in this changing environment. I truly do think I've targeted my training to provide services an NP usually cannot, and without sounding like a tool think I have the personality to attract and retain patients even in a competitive market.

 

[wolfvgang22]

You are mistaken that this is not also happening in the VA. VA Psychiatric NPs are able to get full independent practice authority now in the VA, and are even able to get X waivers to prescribe suboxone without physician supervision. The three things preventing NPs from taking over entirely are 1.State laws requiring NP supervision still exist in many states, 2. The shortage of psychiatrists is such that there is not even enough NPs to fill all of the often unpalatable positions, and 3. NPs frequently get out of their depth with complex patients.

I expect these barriers to NP independent practice lessen over time and as NP professional organizations become increasingly bold (or arrogant, if you prefer), and schools crank out more and more NPs.

I am not sure what it means for the future of psychiatrists. It is a real concern psychiatrists could be left with big student loans and few jobs. Hopefully the process doesn't accelerate and gives us time to figure out what to do.

 

[vistaril]

You are mistaken that this is not also happening in the VA. VA Psychiatric NPs are able to get full independent practice authority now in the VA, and are even able to get X waivers to prescribe suboxone without physician supervision.

I didn't make myself clear- yes I know VA NPs are doing all sorts of things. But the reality of the matter is even while that is still going on, VA psychiatrists are still keeping their cushy jobs that pay low physician level salaries(almost 300k considering benefits/bonuses usually) even with this. In other words, current VA psychs arent being pushed out of their good positions now due to what nps are doing. That's *not* the same in the private world

 

[LukaDoncicLuk]

I'm a medical student who is very interested and passionate about psychiatry, but from my perspective, the writing is on the wall for this specialty. Psych NPs can and do provide horrendous care without immediately obvious dire consequences and the public and admins are more than happy with this because they "save money" and "increase access".

It's really sad because if psych NPs weren't such an issue I would immediately choose psychiatry as my specialty but I am now seriously considering neurology because there is less of an ability for a midlevel to roleplay as a neurologist- they would cause immediate, obvious and considerable harm to patients if they were practicing independently.

I refuse to enter a specialty where I will be forced into a managerial position where I will be signing off on substandard care. I would love to hear some contrasting points of view because I really do want to pursue psychiatry but do not think it is a smart decision considering what the future landscape of the specialty will look like.

 

[vistaril]

I think this is a fair take on the situation. It's a bummer overall, and I would have viewed it as a deal breaker for choosing psychiatry if the private practice market didn't exist.

I'd say we're lagging behind what's happened to anesthesiology by over a decade, but will probably catch up pretty fast. Looking at how things panned out for them, I'd expect psychiatrists to feel the pressure of caving into these supervisory roles in the employee setting. But, during this time we will probably continue to see salaries rise for the foreseeable future similar to anesthesia as they transitioned into the ACT model (ignoring the COVID effect on the overall economy).

It will be interesting to see how the extremely high demand for psychiatry slows down some of the above. We're also in a better position than EM or anesthesia in regards to midlevels because we are specialists that patients can choose, rather than a specialty that provides a service to people who show up to the ED or are getting surgery by a surgeon. Antcedotely, I've also found that most NPs cannot manage complex cases appropriately. Unfortunately, I don't think this matters to administrators because the patients are still being "seen" on paper.

Selfishly, I feel optimistic about my personal future in this changing environment. I truly do think I've targeted my training to provide services an NP usually cannot, and without sounding like a tool think I have the personality to attract and retain patients even in a competitive market.

good post, but a few points:

1) Although it is true that patients can't always choose to be seen by an emergency medicine doc vs an EM PA or NP, there are many scenarios where the physician provider is just going to naturally being the one seeing these people. If someone is literally coding on the table, or is brought in on the verge of death, physician level providers in the appropriate specialties(EM, intensivists, surgery, etc) WILL be the ones tending to that patient. Yes, we all know NPs and PAs are seeing plenty of cases mostly alone in EDs now, but those are typically lower level cases where cases/patients arent so much being stolen from the physicians as just better triaged to a different provider. This is an especially effective model for EM groups because it allows them to capture some of that revenue in a formal supervisery capacity without giving up the real patients where their skills make a difference.

Note that I don't want to lump in Anesthesia here because that is a case that is different. In many cases they have long since given up any power and it's a bad situation there. But for other specialties, I don't think it's bad at all. Unlike our situation.

2) this niche of patients you are presumably referring to is just a very very small portion of the patients. Is there a group of patients that both fit the category of 'complex cases' that you refer to who also are in a situation where they can choose to see an MD/DO MH provider? Sure....but it's just a very very very small group there. it's not a sizable enough group that can support a specialty, or anything close to it. The vast majority of our patients/cases involve clinical situations that psych nps can unfortunately see the patient without a great difference in clinical outcomes(at least that can be
proven). And even when it's questionable whether the psych nps should be seeing those cases, there isn't a mechanism in place that would prevent the bean counters from pushing ahead with that model anyways.....

So anyways....lets fathom a few scenarios of where a psych np shouldn't be seeing the patient- How about a complicated refractory psychosis patient who is now being titrated to Clozaril whose family is paying out of pocket and also requests the patient be seen by a psychiatrist. Or how about a complicated trauma patient that is to undergo psychodynamic work from a private pay/cash pay psychiatrist who does such work?

Ok great....the psych nps will smile and gladly cede those two groups of patients. They'll say "have fun with those....we don't want them anyways and we'll gladly take the simpler 98.5% of other cases".......

it's similar to anesthesia and crnas. They'll happily cede the few challenging cases that take longer and are more ineffecient anyways from a practice standpoint to gobble up the endless and more efficient endoscopy suite cases.....

 

[vistaril]

I'm a medical student who is very interested and passionate about psychiatry, but from my perspective, the writing is on the wall for this specialty. Psych NPs can and do provide horrendous care without immediately obvious dire consequences and the public and admins are more than happy with this because they "save money" and "increase access".

It's really sad because if psych NPs weren't such an issue I would immediately choose psychiatry as my specialty but I am now seriously considering neurology because there is less of an ability for a midlevel to roleplay as a neurologist

good post/choice. Yes the situation in those two fields are completely different. I know a lot of neurologists and nps/pas who work in neurology, and the midlevels in that specialty most definately work COMPLETELY DIFFERENT to the midlevels in psychiatry. In neurology they function to assist the neurologist and most definately do not take the active role in doing the work such that the neurologist is simply 'signing off' on their work, or simply using their collaborative spots to allow them to legally do the work.

 

[vistaril]

Selfishly, I feel optimistic about my personal future in this changing environment. I truly do think I've targeted my training to provide services an NP usually cannot, and without sounding like a tool think I have the personality to attract and retain patients even in a competitive market.

I've got to pick apart this last statement- so what type of patients are you targeting?

Because unless you are seeing cash pay patients at well above market rates, the ability to 'attract and retain patients' isn't a particularly valuable skill. Because even if you have the worst personality in the world and you don't have any special skills, in most places given patience you will be able to get and keep patients. Thats not hard. But so will the psych nps.

I can tell you that your typical 2nd year psych np with no special skill can build up a practice seeing 30 outpt f/us per day. Yes the patients arent worth a lot(assuming a mix of 99213s and 99214s and some add ons, although thats questionable as to whether they should be doing that considering the training), but when you add up all those codes against a very low salary(110k or whatever).....you come out WAY ahead. Compare it to a 300k salary? not so much......

So the only real money to be made is in that delta(between what someone is paying the psych np who is busy and the money they are generating).....the person who is going to make a lot of money is the person who is controlling multiple psych nps like that successfully.

That's why when we as psychiatrists sign over those collaborative spots we have(either to the owner of the group or a mental health or hospital systyem), THAT is where our value in today's market is. There is no value to our bosses in paying us 300k to see those outpts. After overhead and expenses, basically none. They are hoping they just break even on it. But what they are paying the 300k for is for you to sell them those collab agreements so they can make money......so just realize that when you are negotiating.

 

[Candidate2017]

Hey, welcome back.

In my region it seems midlevels do the stuff psychiatrists don't want to do: take heavy call on the inpatient side, or mindlessly please patients with controlled substances on the outpatient side.

Inpatient for most specialties involves unpleasant amounts of call and its only been historically recent that inpatient psych has been considered a cush gig. Psychiatrists left the asylums a long time ago for better outpatient working conditions. If we want to take inpatient back I think it can easily be done by offering to do q1-q3 call for $500k.

 

[PikminOC]

And I was mostly shrugged off.

I'm speaking of course of psychiatric nurse practitioners.

The responses I got at the time were a mix of "but other fields use them too" to "they don't do the same thing".

Even then, however, I could see that other fields(apart from anesthesia of course) were and are using them *different*. They were following a true collaborative model. Not even that actually- the nps will usually serve as more of a helper for example, and were/are not driving treatment choices for their supervisors to just 'sign off' on.

The situation was troubling ten years ago. Now, it's become 10x worse.

As far as how bad it is, the state I am in(Alabama currently, but I've practiced in 3 other states over the last 4 years as well) is sort of in the middle. NPs don't have their own independent practice and they do need on paper a collaborating physician, but the 'on paper' part is key.

What I see going on in terms of day to day practice with psych nps:

1) they have pretty much their own total autonomy in clinic now. It's rare that in community health systems especially a pt will see a psychiatrist. Many of them think the psych np they are seeing is their psychiatrist. After all, how would they know any different? What you will typically see is a large community mental health system that may span several counties has one nominal director(which may be a part time position). The director is basically selling their collaborative slots so that the nps can actually see all the patients. You can have 5 psych np slots used I think, and those 5 psych nps can run the entire outpt MH system and see all the patients. There is no collaboration needed beyond some impractical 'chart review' which is meaningless.

2) psych nps are increasingly taking over inpatient roles. Unlike outpt(at least here), the patients do have to be technically be seen face to face by a psychiatrist. This could take the form of anything though- it could literally take the form of 'eyeballing' the patient. At one of my previous hospitals(an extremely large psych hospital that had about 95 inpatients), 2 to 3 psych nps(depending on whether they had any outpt responsibilities as well) would see all the patients there. This included the interview, notes, making out treatment plans, starting and changing meds, discharge decisions, etc and at the end of the day one of the psychiatrists who was assinged to 'sign off' on the patients that day after their clinic did so. I've discovered that this isn't unusual at all now in situations where the providers are not hospital employed. The hospitals save a ton of money of course but selling this off to a group as the group will often take far reduced stipends if it can be covered by psych nps.

In fact one of my previous positions involved working for a group that assigned me to cover about 40 inpatient geri beds. That was my whole day. I didnt have to do clinic or anything too. For it I got a pretty typical salary(almost 300k with benefits from the group). Well, this worked fine for awhile but after awhile I was told things were going to shift. now a psych np(paid around 100k Im sure) was going to do that geri inpatient and I would 'sign off' on it in the afternoon. I still had a job if I wanted, but I was going to do outpatient all day and then come by and sign off on those 40 geri notes. I decided not to, and so I left there and thats exactly how they are doing it now. And everyone is happy- the practice is happy because they are saving 200k because a psych np now does it rather than a psychiatrist. The hospital is happy because they dont have to hire a psychiatrist and the stipend can stay really low because the practice is covering it so cheaply. The np is happy because she has a job and gets a ton of autonomy. The only person who isnt happy(assuming he is an employee and not a partner/revenue sharer) is the psychiatrist who feels like he has to 'sign off' on 40 notes at the end of the day for no extra compensation to keep his job. Situations like the above have increased a lot in the last decade, and will only continue to become more common.

3) Hospitals and mental health systems are very much in on it. If they wanted to they could very much demand that for the stipend they are offering there has to be more hands on psychiatric involvement, but they would prefer to pretend not to see whats going on. Why? To get it covered for as little stipend cost on their end. They have already gone away from hospital employment in most cases to cover their psych units. Now by turning a blind eye to whats going on, they can get by paying as little possible stipend as possible on top of that and still some group will take the contract in the hopes of having their nps do it. So they really are to blame for how we've gotten where we are, because if they wanted to they could demand for psychs to see the patients and direct care. Of course they wouldn't find many takers under those terms with the stipend they want to
pay. And they never would allow that with their hospitalist service for example- that hospital I used to work at where psych nps saw everyone and a psych just 'signed off'? They employed a ton of salaried 7/7 hospitalists. Nps worked with them too but in a true collaborative model.

Sadly, I was 100% right about my prediction almost ten years ago with psych nps. It's too late to do anything. Hell it was probably too late to do anything then. For now certain practice settings(the VA and academic places) are still pretty safe from it....so thats a more appealing option than ever.

I have an endocrinologist friend and it is the same for her. Not just psych.

 

[vistaril]

Hey, welcome back.

In my region it seems midlevels do the stuff psychiatrists don't want to do: take heavy call on the inpatient side, or mindlessly please patients with controlled substances on the outpatient side.

Inpatient for most specialties involves unpleasant amounts of call and its only been historically recent that inpatient psych has been considered a cush gig. Psychiatrists left the asylums a long time ago for better outpatient working conditions. If we want to take inpatient back I think it can easily be done by offering to do q1-q3 call for $500k.

I'm not sure what this call you are referring to is. Since you have 24 hrs to see a patient and do an H/P, inpatient call at hospitals(even large community ones) is a joke. What happens in our group is that all the psychs just divide it up and split it, but it just consists of getting a phone call or two in the evening most nights, usually about something silly.

It's generally considered part of our overall package, but if you do extra call I think it comes out to something like 50 bucks a night. Which hell is probably an overpayment. I'd answer one or two extra 20 second calls for 50 bucks, so I think it may not even be that much now. Basically it's very little of an inconvenience if set up right and thus there is very little extra financial reward for it.

As for inpatient workloads and salary, it all depends on a few factors: 1) what your stipend is 2) what the collections will be(how many uninsured, which will affect the stipend)

If you can get the right contracts(hospitals with good stipends) and are willing to see a ton of inpatients per day(> 45 solo, or maybe 40 solo plus 30 with psych nps), inpatient psych can be very lucrative.

 

[PikminOC]

I'm a medical student who is very interested and passionate about psychiatry, but from my perspective, the writing is on the wall for this specialty. Psych NPs can and do provide horrendous care without immediately obvious dire consequences and the public and admins are more than happy with this because they "save money" and "increase access".

It's really sad because if psych NPs weren't such an issue I would immediately choose psychiatry as my specialty but I am now seriously considering neurology because there is less of an ability for a midlevel to roleplay as a neurologist- they would cause immediate, obvious and considerable harm to patients if they were practicing independently.

I refuse to enter a specialty where I will be forced into a managerial position where I will be signing off on substandard care. I would love to hear some contrasting points of view because I really do want to pursue psychiatry but do not think it is a smart decision considering what the future landscape of the specialty will look like.

There are neurology midlevels too. When I refer a patient to a neurologist, they see a midlevel. Neurologist signs off.

 

[PikminOC]

Vistaril, these midlevels are saturating themselves too.

 

[vistaril]

I have an endocrinologist friend and it is the same for her. Not just psych.

the difference is endocrinology is specialized enough that the endo is going to have to train the np/pa they hire. So they control that to some degree. Not a single NP/PA comes out of np school having anywhere near the skill set or knowledge base where they can see endocrinology consults/patients independently. None.

Thats not true in psych, since psych nps come out of np school already specialized in psych.

 

[Candidate2017]

I'm a medical student who is very interested and passionate about psychiatry, but from my perspective, the writing is on the wall for this specialty. Psych NPs can and do provide horrendous care without immediately obvious dire consequences and the public and admins are more than happy with this because they "save money" and "increase access".

It's really sad because if psych NPs weren't such an issue I would immediately choose psychiatry as my specialty but I am now seriously considering neurology because there is less of an ability for a midlevel to roleplay as a neurologist- they would cause immediate, obvious and considerable harm to patients if they were practicing independently.

I refuse to enter a specialty where I will be forced into a managerial position where I will be signing off on substandard care. I would love to hear some contrasting points of view because I really do want to pursue psychiatry but do not think it is a smart decision considering what the future landscape of the specialty will look like.

In my opinion, neurology working conditions suck. Neurologists always complain about pay and how their psychiatry colleagues/spouses/friends make more. Even when I was an intern, neurology attendings would tell me I made the right choice for choosing psychiatry.

As a med student, you only see the hospital/inpatient side which is not a fair portrait of psychiatry since 90% of psychiatrists practice in the outpatient setting. If you choose to work for a hospital then you've consented to being treated as an employee rather than a professional.

 

[vistaril]

There are neurology midlevels too. When I refer a patient to a neurologist, they see a midlevel. Neurologist signs off.

sure, but I'll bet in 9/10 situations the level of collaboration is a lot different. Thats certainly the case with what I see, on both an inpatient and outpt level.

 

[PikminOC]

sure, but I'll bet in 9/10 situations the level of collaboration is a lot different. Thats certainly the case with what I see, on both an inpatient and outpt level.

Nope. The neurologist or endo has a full load of patients and then signs off on the midlevels. But is of course responsible for any problems that arise. My endo friend has 2 midlevels. One actively tells patients she is currently a doctor (going to get dnp) and the other did insurance fraud under her license.

 

[vistaril]

Vistaril, these midlevels are saturating themselves too.

no doubt, and it's harder to get a psych np job today than 10 years ago just because there are so many. But that bottleneck is bad for us too.....

our only real power right now is praying that states still make our collab agreements mean something. Because as long as we still have the collab agreements to sell, we will still be ok. I know I hold onto my collab agreements and have sold them(essentially) to highest bidder. Basically using the leverage of my collab agreements to negotiate more psychiatric work for myself.

Thats why I always encourage early career psychs to do a hard bargain for those collabs, because those(and not your skill set or clinical acumen) are your biggest leverage

 

[PikminOC]

the difference is endocrinology is specialized enough that the endo is going to have to train the np/pa they hire. So they control that to some degree. Not a single NP/PA comes out of np school having anywhere near the skill set or knowledge base where they can see endocrinology consults/patients independently. None.

Thats not true in psych, since psych nps come out of np school already specialized in psych.

The endo does not train the np/pa. They have full loads of patients. And are now given this responsibility.

 

[calvnandhobbs68]

good post, but a few points:

1) Although it is true that patients can't always choose to be seen by an emergency medicine doc vs an EM PA or NP, there are many scenarios where the physician provider is just going to naturally being the one seeing these people. If someone is literally coding on the table, or is brought in on the verge of death, physician level providers in the appropriate specialties(EM, intensivists, surgery, etc) WILL be the ones tending to that patient. Yes, we all know NPs and PAs are seeing plenty of cases mostly alone in EDs now, but those are typically lower level cases where cases/patients arent so much being stolen from the physicians as just better triaged to a different provider. This is an especially effective model for EM groups because it allows them to capture some of that revenue in a formal supervisery capacity without giving up the real patients where their skills make a difference.

Note that I don't want to lump in Anesthesia here because that is a case that is different. In many cases they have long since given up any power and it's a bad situation there. But for other specialties, I don't think it's bad at all. Unlike our situation.

2) this niche of patients you are presumably referring to is just a very very small portion of the patients. Is there a group of patients that both fit the category of 'complex cases' that you refer to who also are in a situation where they can choose to see an MD/DO MH provider? Sure....but it's just a very very very small group there. it's not a sizable enough group that can support a specialty, or anything close to it. The vast majority of our patients/cases involve clinical situations that psych nps can unfortunately see the patient without a great difference in clinical outcomes(at least that can be
proven). And even when it's questionable whether the psych nps should be seeing those cases, there isn't a mechanism in place that would prevent the bean counters from pushing ahead with that model anyways.....

So anyways....lets fathom a few scenarios of where a psych np shouldn't be seeing the patient- How about a complicated refractory psychosis patient who is now being titrated to Clozaril whose family is paying out of pocket and also requests the patient be seen by a psychiatrist. Or how about a complicated trauma patient that is to undergo psychodynamic work from a private pay/cash pay psychiatrist who does such work?

Ok great....the psych nps will smile and gladly cede those two groups of patients. They'll say "have fun with those....we don't want them anyways and we'll gladly take the simpler 98.5% of other cases".......

it's similar to anesthesia and crnas. They'll happily cede the few challenging cases that take longer and are more ineffecient anyways from a practice standpoint to gobble up the endless and more efficient endoscopy suite cases.....

To say this isn't similar in other specialities besides anesethesia is a bit incorrect. In fact, it's most specialities outside of surgical subspecialities. Family medicine/peds NPs are all over the place on the outpatient side. There are a growing number of NP "dermatologists". NP "hospitalists" are a huge thing in IM. NPs are a big problem in the ED too now...a group in Illinois just got their contract basically replaced with NPs.

Your example of someone "coding in the ER" honestly doesn't happen enough to support multiple MDs in most ERs. Yeah, they'll probably keep 1 MD/DO on to sign charts for their 3-4 NPs but ERs don't make their money off of the major traumas and codes. They make their money off the thousands of minor complaints that could probably be handled by primary care. We're seeing now across the country what happens in ERs when the volume just gets cut down to true emergencies. They aren't particularly profitable.

And again, what did we see in anesthesia? CRNAs have been going wild all over the place for 10+ years now. Anesthesia salaries are as good as ever, they certainly aren't living on the streets.

 

[vistaril]

Nope. The neurologist or endo has a full load of patients and then signs off on the midlevels.

thats very fishy....how did these midlevels learn to do what a neurologist or endo does? Certainly not in their np school/training(unlike psych)

 

[PikminOC]

no doubt, and it's harder to get a psych np job today than 10 years ago just because there are so many. But that bottleneck is bad for us too.....

our only real power right now is praying that states still make our collab agreements mean something. Because as long as we still have the collab agreements to sell, we will still be ok. I know I hold onto my collab agreements and have sold them(essentially) to highest bidder. Basically using the leverage of my collab agreements to negotiate more psychiatric work for myself.

Thats why I always encourage early career psychs to do a hard bargain for those collabs, because those(and not your skill set or clinical acumen) are your biggest leverage

I dont collab with anyone. I like to sleep at night.

 

[PikminOC]

thats very fishy....how did these midlevels learn to do what a neurologist or endo does? Certainly not in their np school/training(unlike psych)

I dont know. But my friend is not teaching anything. She's extremely busy as is.

 

[Candidate2017]

I'm not sure what this call you are referring to is. Since you have 24 hrs to see a patient and do an H/P, inpatient call at hospitals(even large community ones) is a joke. What happens in our group is that all the psychs just divide it up and split it, but it just consists of getting a phone call or two in the evening most nights, usually about something silly.

It's generally considered part of our overall package, but if you do extra call I think it comes out to something like 50 bucks a night. Which hell is probably an overpayment. I'd answer one or two extra 20 second calls for 50 bucks, so I think it may not even be that much now. Basically it's very little of an inconvenience if set up right and thus there is very little extra financial reward for it.

As for inpatient workloads and salary, it all depends on a few factors: 1) what your stipend is 2) what the collections will be(how many uninsured, which will affect the stipend)

If you can get the right contracts(hospitals with good stipends) and are willing to see a ton of inpatients per day(> 45 solo, or maybe 40 solo plus 30 with psych nps), inpatient psych can be very lucrative.

Yes, what I mean is inpatient psychiatrists can easily push out mid-levels by offering to cover and see everything (inpatient, ED, consult, clinic) and work 60-70 hrs/week like other inpatient physicians. I knew a couple of med school psychiatry attendings that did all of the above and probably made as much or more than any orthopod. Most psychiatrists don't want to do that, hence midlevels.

 

[PikminOC]

Yes, what I mean is inpatient psychiatrists can easily push out mid-levels by offering to cover and see everything (inpatient, ED, consult, clinic) and work 60-70 hrs/week like other inpatient physicians. I knew a couple of med school psychiatry attendings that did all of the above and probably made as much or more than any orthopod. Most psychiatrists don't want to do that, hence midlevels.

Wrong, its all about the cheapest widget. Three midlevels can be hired for one physician. My endo friend works a ton. Hospital wants more RVU's, so they hire midlevels.

 

[vistaril]

To say this isn't similar in other specialities besides anesethesia is a bit incorrect. In fact, it's most specialities outside of surgical subspecialities. Family medicine/peds NPs are all over the place on the outpatient side. There are a growing number of NP "dermatologists". NP "hospitalists" are a huge thing in IM. NPs are a big problem in the ED too now...a group in Illinois just got their contract basically replaced with NPs.

Your example of someone "coding in the ER" honestly doesn't happen enough to support multiple MDs in most ERs.

but you are still talking about fields with the potential for highly visibly negative acute outcomes(anesthesia and EM)....that will always be an advantage for the physician provider in those fields in dealing with hospitals, administrators. Psych doesn't have that.

Yes, some of this problem does exist in outpt primary care. For whatever reason though the inpatient hospitals have been able to hold onto a truly collaborative model vs us.

As for things like derm nps, it is different because it is the derm themselves that take on general nps and then mostly train these people to do it 'their way'. They have much more control over their employees. they are also more involved in the cases. In derm there is no 'community derm' where community clinics employ large number of derm nps who are completely independent of the dermatologist(apart from a collab agreement) and can be hired and fired completely independent of that as well.....

The *vast majority* of derm midlevels are employed by the dermatologists who actually works with them on a clinical day to day basis. That's not true in psych, and is a huge difference in terms of the power balance going forward.

It's not even close to the same. The vast majority of nps who work in a derm setting will tell you that they don't have nearly the ability to do the same things as the derm on a patient by patient basis. They work *under* the derm and truly help them and collaborate with them. Ask most psych nps about that with their psych collaborator and they will chuckle and say "ha...what collaborator? You mean the guy who pops in and signs my charts because they told him to at the end of the day"......

but we can keep telling ourselves it's this way in every specialty if it makes us feel better....

 

[vistaril]

Yes, what I mean is inpatient psychiatrists can easily push out mid-levels by offering to cover and see everything (inpatient, ED, consult, clinic) and work 60-70 hrs/week like other inpatient physicians. I knew a couple of med school psychiatry attendings that did all of the above and probably made as much or more than any orthopod. Most psychiatrists don't want to do that, hence midlevels.

lmao....oh my you are naive. keep telling yourself this.

 

[Taddy Mason]

thats very fishy....how did these midlevels learn to do what a neurologist or endo does? Certainly not in their np school/training(unlike psych)

This was my experience while on neuro in med school - 2 neurologists “supervising” 5 NPs who rotated between covering clinic, inpatient consults, and stroke service. 3 of the NPs were less than 1 year out of school and were pretty much on their own.

 

[hebel]

I've got to pick apart this last statement- so what type of patients are you targeting?

Because unless you are seeing cash pay patients at well above market rates, the ability to 'attract and retain patients' isn't a particularly valuable skill. Because even if you have the worst personality in the world and you don't have any special skills, in most places given patience you will be able to get and keep patients. Thats not hard. But so will the psych nps.

I can tell you that your typical 2nd year psych np with no special skill can build up a practice seeing 30 outpt f/us per day. Yes the patients arent worth a lot(assuming a mix of 99213s and 99214s and some add ons, although thats questionable as to whether they should be doing that considering the training), but when you add up all those codes against a very low salary(110k or whatever).....you come out WAY ahead. Compare it to a 300k salary? not so much......

So the only real money to be made is in that delta(between what someone is paying the psych np who is busy and the money they are generating).....the person who is going to make a lot of money is the person who is controlling multiple psych nps like that successfully.

That's why when we as psychiatrists sign over those collaborative spots we have(either to the owner of the group or a mental health or hospital systyem), THAT is where our value in today's market is. There is no value to our bosses in paying us 300k to see those outpts. After overhead and expenses, basically none. They are hoping they just break even on it. But what they are paying the 300k for is for you to sell them those collab agreements so they can make money......so just realize that when you are negotiating.

In my last statement, I was referring to cash-pay private practice patients with a particular focus on combined therapy and "medication management."

Looking at all of the medical specialties, I only see surgery and some procedural heavy IM subspecialties as pseudo-immune from the midlevel movement. However, these specialties could have troubles of their own, should movements towards bundled payment or capitation payment schemes gain more momentum. MFA is always a possibility too, but I doubt this will happen anytime soon. The partner-based private practice sector has largely been bought out over the past few decades leaving them highly dependent on hospital systems, which may lead to some unseen pain down the line.

I didn't avoid psych to go with surgery or an IM subspecialty because in the moment I think they are an inferior choice for me personally, and lead to a lifestyle that I would not tolerate just to avoid the possibility of an NP someday meaningfully affecting my job market. Looking at the remaining specialty choices, I actually see psychiatry as one of the better-positioned specialties, again mostly due to demand and the ease of private practice as an "escape hatch." Again, the relative ease of creating a lean, low-overhead private practice (for some individuals) cannot be overstated.

One other important factor that I didn't realize as a med student is that psychiatry can actually be pretty hard, despite the [checklist DMS-5 dx -> SSRI +/- CBT -> done] fantasy that the med school boards make you believe psychiatry is. There are noticeable tiers of psychiatrist talent, and if you are in that upper tier I believe you can end up in a very good place regardless of what happens with midlevels.

Which specialties do you favor for the future Vistaril? I agree that we're in a worsening storm, but I still like the boat I chose.

 

[hebel]

thats very fishy....how did these midlevels learn to do what a neurologist or endo does? Certainly not in their np school/training(unlike psych)

Vistaril, 90% of my patients with neuro follow-up see NP's. I've had to call some of them before with concerns about their management choices that even a psychiatrist could notice.

 

[vistaril]

This was my experience while on neuro in med school - 2 neurologists “supervising” 5 NPs

if thats the case then these nps were getting a lot more supervision than most psych nps.....

I think it's important to point out that many psych nps get virtually no supervision. Thats why I encourage all early career psychiatrists who give up their collab agreements(and then those nps go out and do god knows what) make sure when they sell those collabs that they are at least getting
something in return...be it straight cash homey, or extra hours paid at psychiatric level compensation for them.

I did the latter when I agreed to give away 3 of my collab agreements to the practice. I said "if I don't get the extra hours that will pay me psychiatric wages to do extra work in my field that doesnt require mindless supervision, I'm pulling the 3 collabs"......and I got the extra work.

 

[hebel]

To say this isn't similar in other specialities besides anesethesia is a bit incorrect. In fact, it's most specialities outside of surgical subspecialities. Family medicine/peds NPs are all over the place on the outpatient side. There are a growing number of NP "dermatologists". NP "hospitalists" are a huge thing in IM. NPs are a big problem in the ED too now...a group in Illinois just got their contract basically replaced with NPs.

Your example of someone "coding in the ER" honestly doesn't happen enough to support multiple MDs in most ERs. Yeah, they'll probably keep 1 MD/DO on to sign charts for their 3-4 NPs but ERs don't make their money off of the major traumas and codes. They make their money off the thousands of minor complaints that could probably be handled by primary care. We're seeing now across the country what happens in ERs when the volume just gets cut down to true emergencies. They aren't particularly profitable.

And again, what did we see in anesthesia? CRNAs have been going wild all over the place for 10+ years now. Anesthesia salaries are as good as ever, they certainly aren't living on the streets.

Agreed, go read the EM forums. That specialty was on fire when I was an MS4 about 4-5 years ago. Now the bull market is over and the tone has changed substantially with CMG and midlevel take-overs.

 

[Taddy Mason]

if thats the case then these nps were getting a lot more supervision than most psych nps.....

“Supervision” for clinic patients consisted of hitting the co-sign button for 20-30 patients over the course of 1-2min.

 

[sloh]

Solution is just to make hay while the sun shines and get that “f u” money.


Sent from my iPhone using Tapatalk

 

[vistaril]

In my last statement, I was referring to cash-pay private practice patients with a particular focus on combined therapy and "medication management."

Looking at all of the medical specialties, I only see surgery and some procedural heavy IM subspecialties as pseudo-immune from the midlevel movement. However, these specialties could have troubles of their own, should movements towards bundled payment or capitation payment schemes gain more momentum. MFA is always a possibility too, but I doubt this will happen anytime soon. The partner-based private practice sector has largely been bought out over the past few decades leaving them highly dependent on hospital systems, which may lead to some unseen pain down the line.

I didn't avoid psych to go with surgery or an IM subspecialty because in the moment I think they are an inferior choice for me personally, and lead to a lifestyle that I would not tolerate just to avoid the possibility of an NP someday meaningfully affecting my job market. Looking at the remaining specialty choices, I actually see psychiatry as one of the better-positioned specialties, again mostly due to demand and the ease of private practice as an "escape hatch." Again, the relative ease of creating a lean, low-overhead private practice (for some individuals) cannot be overstated.

One other important factor that I didn't realize as a med student is that psychiatry can actually be pretty hard, despite the [checklist DMS-5 dx -> SSRI +/- CBT -> done] fantasy that the med school boards make you believe psychiatry is. There are noticeable tiers of psychiatrist talent, and if you are in that upper tier I believe you can end up in a very good place regardless of what happens with midlevels.

Which specialties do you favor for the future Vistaril?

Sure...I think if you can do cash pay private practice and get the patients. Sure, go for it. I just think that is always going to be an uphill battle. Can it be done? Sure....but most patients just arent going to want to pay that much. And by 'that much', I mean at least 175 or so for a 30 minute f/u because thats what it is going to take to really do well doing it. Most patients are going to say "I already pay a ton for my insurance, now I have to pay even more for the appts". but again, if you can make it work go for it. If you want to do hr appts, I think you need to charge at least 300-325/hr to really do well. It's not easy to fill up 40 clinical hours a week like that in most areas.

Another common mistake I see very early career psychiatrists(often still in residency....are you still in residency?) make is to assume that hospital systems taking over the practices is a sign of weakness? Well.....it's complicated. In psychiatry, thats actually a sign of weakness for psychiatrists. Because it's a sign of the hospital systems themselves saying "eh, we'll pass thanks. Here is a small stipend....now have fun!". Do you know the average per patient compensation for the psychiatrist is on average MUCH GREATER when they are hospital employed vs not on an inpatient basis? Basically what I'm saying is when the hospital muscles in on a cardiology group and makes everything hospital employed, thats a sign that they wanted the practice and isn't good for the cards guys. But when a hospital gives a psych group a small stipend, it's the opposite- it's a sign that the hospital system doesn't even want to deal with the burden of paying the psych guys and just wants them to fend for themselves. The small stipend is to deal with all the uninsureds......but bottom line, worker bee psychs are going to MAKE LESS per patient under those arraingments than in hospital employment. So whenever I see an early career psychiatrist(especially a resident) talking about this, I sense they don't know the score. no offense- when I was a resident I didn't pick up on these subtle things either. I'm just telling you that as a hospital employee psychs were getting offers of 270k or so for them to see 14 inpts themselves and supervise another 13 with nps plus consults daily. Calculate the per inpatient rate there. Now ask some of the psychs who work in groups that have those same contracts...after the hospital dropped them and gave them a stipend and made them bill themselves. You will find that 95% of the time the per inpatient rate is much less for the psychiatrist who doesn't own the contract.......again, these are things you won't learn until you are several years out.

Private practice psych is very cutthroat...and will only continue to be moreso in the future. Is it hard to 'get patients'(especially insured patients?). no. but that doesnt mean it isn't still difficult to make it.

What fields do I see having good futures? Well surgery. Procedure based IM subspecialties(cards, GI)......those two areas alone make up a good portion of doctors.

That said, I wasn't going to be a surgeon or whatever. That wasn't going to happen. most psychs I know were in the same boat. So we are going to make the best of it....

 

[vistaril]

Solution is just to make hay while the sun shines and get that “f u” money.


Sent from my iPhone using Tapatalk

this is true!! And why it is so important to get something for your collabs....

 

[vistaril]

“Supervision” for clinic patients consisted of hitting the co-sign button for 20-30 patients over the course of 1-2min.

well if thats the case they were doing the same thing as most psychs. This is another example of why it's so important to at least make sure you are getting something in return for selling your collabs then....

 

[calvnandhobbs68]

Let me also clarify here that I don't disagree with vistaril. I think NP encroachment is a problem. I just think it's a problem across the board and it's not particularly worse in psychiatry than many of the other specialities mentioned here.

I also think like some of the posters above that private practice is where psychiatry shines. If you want to be an old school spend a few years building up your practice doctor, psychiatry is second to none in that aspect. You just need a decent office, a phone, a computer, a website and a prescription pad. Low overhead, low facility expenses. People will absolutely pay to see someone with an MD after their name or who offers some interesting service. Psychiatry is also relatively immune from private equity because there's very little benefit to psychiatry mega-groups (unlike derm, outpatient multi-speciality groups, EM, anesthesia, etc).

 

[calvnandhobbs68]

but you are still talking about fields with the potential for highly visibly negative acute outcomes(anesthesia and EM)....that will always be an advantage for the physician provider in those fields in dealing with hospitals, administrators. Psych doesn't have that.

No man, no there isn't. Go read the EM forum. People are literally having their jobs replaced by NPs. Admins don't care about negative outcomes as long as the amount of people dying falls within some normal range. You think all those ED low acuity patients have immediate negative outcomes? No way, most of that is literally primary care outpatient level stuff that people just come to the ED for bc they don't have a PCP or can't get an appointment with one.

 

[AD04]

@vistaril

I appreciate the advice about valuing and bargaining with your supervising slots. And what you say about the proliferation of NPs is true. But you are too negative about psychiatry, much like before.

There isn't much psychiatrists can do to prevent the winds of change (i.e. proliferation and saturation of NPs), but psychiatrists are not in as bad a position as you make it out to be.

Sure, it is harder to get some employed psychiatric positions. But how good are those positions in the first place if the employers want to pay a little as possible? There are still a bunch of places hiring psychiatrists. I am still inundate with job offers. None of my peers have trouble getting work in psychiatry. Not all places want to pay bottom dollar for a provider.

A lot of positions go unfilled because psychiatrists want to work in private practice. If hiring NPs are really that profitable, hire a bunch of them in your own private practice and get the most bang out of your supervising slots. Why not work a chill gig in the VA and start the practice on the side and then grow it with NPs? Private practice is not as cutthroat as you make it out to be.

All specialties much adapt to changes, not just psychiatry.

By the way, why did you work in so many states in such a short period of time?

 

[vistaril]

@vistaril

I appreciate the advice about valuing and bargaining with your supervising slots. And what you say about the proliferation of NPs is true. But you are too negative about psychiatry, much like before.

There isn't much psychiatrists can do to prevent the winds of change (i.e. proliferation and saturation of NPs), but psychiatrists are not in as bad a position as you make it out to be.

Sure, it is harder to get some employed psychiatric positions. But how good are those positions in the first place if the employers want to pay a little as possible? There are still a bunch of places hiring psychiatrists. I am still inundate with job offers. None of my peers have trouble getting work in psychiatry. Not all places want to pay bottom dollar for a provider.

A lot of positions go unfilled because psychiatrists want to work in private practice. If hiring NPs are really that profitable, hire a bunch of them in your own private practice and get the most bang out of your supervising slots. Why not work a chill gig in the VA and start the practice on the side and then grow it with NPs? Private practice is not as cutthroat as you make it out to be.

All specialties much adapt to changes, not just psychiatry.

By the way, why did you work in so many states in such a short period of time?

there were a lot of reasons....I have a kid and he would move with his mom and that played a role. At another job, basically the hospital switched from a hospital employed position to sold to a large group. The owner of the new group came in(after he bought the contract) and said "you want to work for me?". Except my role at the hospital I worked would be to see all the inpatients(about 32) in only a supervisory of np role, which meant i was being asked to come in at 330 after clinic, shake hands quickly with patients, and then sign the notes. I was going to have to work 8-3 in outpatient setting too...and make the sense money. I said "no thanks" and then went to the hospital and said "you ****** me". They said "what do you mean?" and I said "you had a hospital employed psychiatrist who saw each and every one of those inpatients for a reasonable salary. Now to save a few bucks you've basically hired a just out of school np with little to no supervision to see them. Good luck with that".......they balked and said that they were told the np would only be 'helping'....I just laughed and walked out.

So that was one move.

The problem for psych in outpt private practice is that the reimbursements are trending in a bad direction. I am in a bad state(maybe the worst in the country) for this, but it's easy to fill up with 30 insured outpatients a day. The problem is I can't make good money with that here after overhead....even coding 90214 and 90833. Unless I am using the delta from multiple nps in addition to that......

I really don't get the allure of outpatient private practice in low reimbursement areas. I could see 30 patients a day for about the same money(less if you count retirement) than I could get seeing 10 outpts a day working for the VA. No thanks.....

Now I have a job where I do make good money.....but I really hustle for it(and give away 3 collabs where the nps really do whatever the practice wants at various places)....but eventually this may end. Eventually the practice may get someone else to give up their collabs for even less money.

 

[TexasPhysician]

the difference is endocrinology is specialized enough that the endo is going to have to train the np/pa they hire. So they control that to some degree. Not a single NP/PA comes out of np school having anywhere near the skill set or knowledge base where they can see endocrinology consults/patients independently. None.

Thats not true in psych, since psych nps come out of np school already specialized in psych.

This hasn’t been my experience at all. Midlevels come straight out and open hormone clinics all the time. There has been a slew of deaths over this, but medical boards can’t keep up.

Derm and aesthetics is also quite popular. There are weekend midlevel courses that train you to “be a dermatologist”.

Midlevel academic centers are starting surgical fellowships.

Neuro headache clinics are popular for midlevels.

DPC and cash family clinics are popping up. Near me is a NP clinic where you can be seen for “simple” issues for only $50. 5-10 min visits and they churn cash patients. That’s $300+/hr.

Peds is effected so much that I’ve seen private equity cut a 20+ doc peds clinic and replace 80% with midlevels in 1 day.

Midlevels are invading everywhere.

 

[splik]

Psychiatry is also relatively immune from private equity because there's very little benefit to psychiatry mega-groups (unlike derm, outpatient multi-speciality groups, EM, anesthesia, etc).

You would think so, but addictions, eating disorders, autism, residential, and several group practices are all being eaten by PE now. It's not like derm or some other specialties but most of the major groups here have bought by PE or merged with other groups that are PE-backed. The largest provider of acute county mental health services in CA was taken over by PE. But certainly a solo practice is unlikely to fall foul of this.

The comparison is an apt one because both NPs and PE have become a thing because some people are making a killing out of it but it's the younger people in the profession who will be shafted.

 

[Sushirolls]

Sleep Medicine too. They are getting fired, keep one Sleep Medicine director around and the rest are mid-levels.

 

[Sushirolls]

I've said this before, healthcare is going to fracture on two lines. Large Big Box shops that are keeping around a token director MD, who over sees (if at all) a bunch of midlevels for all types of care be it inpatient or outpatient. Outpatient practices and groups will emerge that focus on better paying insurance, and MD only groups.

The future is a two tiered system.

For Psychiatry that means solo practice psychiatrists doing their thing how they see fit, or small groups of DO/MD with PhD/PsyD.

I suspect to see a rise in ARNP / MSW / LMFT / LMHC / etc clinics. And with this, the more, how shall we say this, fluid advertising and fluid patient interaction styles.

 

[vistaril]

I've said this before, healthcare is going to fracture on two lines. Large Big Box shops that are keeping around a token director MD, who over sees (if at all) a bunch of midlevels for all types of care be it inpatient or outpatient. Outpatient practices and groups will emerge that focus on better paying insurance, and MD only groups.

but that is going to be a BRUTAL OUTCOME for the practices who want to do an MD-only route.....simply because they won't be able to compete rate-wise or stipend wise with the psychiatrist who has 5 nps for every psych(thats the collabs allowed per physician here).......

A group that has 4 psychiatrists and 2 psychologists has NO CHANCE to compete in bidding against a group with 2 psychs and 9 nps. The group with the 2 psychs and 9 nps can bid on a 65 bed psych hospital and take a stipend that is a fraction of what the MD only group can. And the hospital is going to take the lower bid.

Same dynamic for outpt contracts with insurers. The largest insurers don't give a ****.....they just don't. The 2 psychs will just pay the 9 nps 107k each, fill their clinics up with insured patients at the low rates, and the MD only groups are screwed......

 

[PikminOC]

Vistaril, 90% of my patients with neuro follow-up see NP's. I've had to call some of them before with concerns about their management choices that even a psychiatrist could notice.

Even a psychiatrist? We are physicians first. Much more education than ANY midlevel.

 

[PikminOC]

but that is going to be a BRUTAL OUTCOME for the practices who want to do an MD-only route.....simply because they won't be able to compete rate-wise or stipend wise with the psychiatrist who has 5 nps for every psych(thats the collabs allowed per physician here).......

A group that has 4 psychiatrists and 2 psychologists has NO CHANCE to compete in bidding against a group with 2 psychs and 9 nps. The group with the 2 psychs and 9 nps can bid on a 65 bed psych hospital and take a stipend that is a fraction of what the MD only group can. And the hospital is going to take the lower bid.

Same dynamic for outpt contracts with insurers. The largest insurers don't give a ****.....they just don't. The 2 psychs will just pay the 9 nps 107k each, fill their clinics up with insured patients at the low rates, and the MD only groups are screwed......

This is no different with hospitalist or ER groups and their negotiations. It's really no different in other fields.

M.D. is no prescription for job security at hospital chains

Physicians who become employees are just as susceptible as other workers when hospitals are under pressure to cut costs. Just ask staffers at Edward-Elmhurst.

www.chicagobusiness.com

 

[PikminOC]

there were a lot of reasons....I have a kid and he would move with his mom and that played a role. At another job, basically the hospital switched from a hospital employed position to sold to a large group. The owner of the new group came in(after he bought the contract) and said "you want to work for me?". Except my role at the hospital I worked would be to see all the inpatients(about 32) in only a supervisory of np role, which meant i was being asked to come in at 330 after clinic, shake hands quickly with patients, and then sign the notes. I was going to have to work 8-3 in outpatient setting too...and make the sense money. I said "no thanks" and then went to the hospital and said "you ****** me". They said "what do you mean?" and I said "you had a hospital employed psychiatrist who saw each and every one of those inpatients for a reasonable salary. Now to save a few bucks you've basically hired a just out of school np with little to no supervision to see them. Good luck with that".......they balked and said that they were told the np would only be 'helping'....I just laughed and walked out.

So that was one move.

The problem for psych in outpt private practice is that the reimbursements are trending in a bad direction. I am in a bad state(maybe the worst in the country) for this, but it's easy to fill up with 30 insured outpatients a day. The problem is I can't make good money with that here after overhead....even coding 90214 and 90833. Unless I am using the delta from multiple nps in addition to that......

I really don't get the allure of outpatient private practice in low reimbursement areas. I could see 30 patients a day for about the same money(less if you count retirement) than I could get seeing 10 outpts a day working for the VA. No thanks.....

Now I have a job where I do make good money.....but I really hustle for it(and give away 3 collabs where the nps really do whatever the practice wants at various places)....but eventually this may end. Eventually the practice may get someone else to give up their collabs for even less money.

Hospitals know exactly what is happening with nurses and they like it. They dont care about the malpractice as the physician "collaborator" takes the hit. Hospital makes tons of money, certainly doesnt correct the patients if they think they are getting a physician. The large hospital system in my area touts everyone as a physician, even social workers, to attract patients. What's anyone going to do about it?

 

[birchswing]

I've said this before, healthcare is going to fracture on two lines. Large Big Box shops that are keeping around a token director MD, who over sees (if at all) a bunch of midlevels for all types of care be it inpatient or outpatient. Outpatient practices and groups will emerge that focus on better paying insurance, and MD only groups.

The future is a two tiered system.

For Psychiatry that means solo practice psychiatrists doing their thing how they see fit, or small groups of DO/MD with PhD/PsyD.

I suspect to see a rise in ARNP / MSW / LMFT / LMHC / etc clinics. And with this, the more, how shall we say this, fluid advertising and fluid patient interaction styles.

There are what I would call "boutique" psychiatry offices, cash-only that have only psych NPs. The one I'm thinking of in particular has two psych NPs and recently added a psychologist. No psychiatrist (although in my state they do at some level collaborate with one, but they don't need to physically work together). Rates are the same as what I've seen from cash-only psychiatrists. They actually offer some services that I have not seen at other offices (like calibration of DBS devices) that you'd otherwise have to travel quite far to have done. I don't want to get too specific as to not identify the area I'm in or location, but I find some of their specializations outside of psych NP to be interesting and impressive and they have created various niches based on expertise that sort of dovetails with various areas of psychiatry. The people I'm thinking about were experienced in their fields and well established and then pursued becoming a nurse practitioner specializing in psychiatry. They both have doctorates but not in medicine.