Any way for Psych. to make big $$$?

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indya

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How does one go about making a lot of money in psychiatry? Do specializations like Pain Medicine or Child Psych increase income a lot? If so, which one pays more?
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like money equivalent to what a urologist makes (>300,000)
 
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indya said:
like money equivalent to what a urologist makes (>300,000)
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Lots of psychiatrists make >300k. Psych is one of the few fields where it is quite possible to not accept insurance and charge "what the market will bear". It's not unheard of for psychiatrists in some markets (NYC, San Francisco, LA) to charge close to $500/hr. This is not the norm of course. But there are many psychiatrists in most big cities that charge in the $200+/hr range, and with very little overhead and a 40 hours work week this is more than $300k/yr net.

Child psych or pain are likely the most lucrative subspecialities. But pain isn't really psychiatry in the traditional sense. Child psych can charge in the $200s /hr in most markets.

Avg for psychiatry are lower than these #s, but the money is there if you're good, have some business sense, and can carve out a niche for yourself.

Would love to hear if any current attendings or senior residents have further thoughts.

Sources: talking to a couple of the private practice psychiatrists that I came across on my psych rotation, this forum, a child fellow I worked with during my week of child psych, a family member who is a private practice psychiatrist.
 
Interventional pain is multidisciplinary, with much of the 'multi' coming from ancillary and associated fields, including PT and psychology.

It is probably the best recompensed if you spend most of your time doing procedures (diagnostic and therapeutic) and less med management. If you plan on continuing to function as a psychiatrist focused on pain/disability who just happens to be able to stick needles in places that it hurts on occasion (as I plan to do), plan on making considerably less than the median.
 
I'm in a very good position where I could've taken a job that payed close to 300K for only about 45 hrs of work/week.

I'm taking the job though only doing 10-20 hrs/week and 30 hrs someplace else that only pays a standard amount. The 10-20 are for the money and for me because I love doing clinical work. The 30 hrs is more for an interest in forensic psychiatry that goes beyond the money.

All in all, I'll still be earning more than the avg. psychiatrist, but if I wanted to, I could've been making a heck of a lot more doing work that was easier than forensics.
 
michaelrack said:
some ways of making $$$ as a psychiatrist:

1. sleep medicine

2. clinical trials

3. drug-company speaker

4. as others have mentioned, have wealthy patients and don't take insurance.
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How so? Doing trials for pharm companies?
 
why would anybody want to make over $300,000 as opposed to say, $200,000? I mean, seriously, how much will you have left over after taxes? It's not worth it.
 
michaelrack said:
some ways of making $$$ as a psychiatrist:
3. drug-company speaker
.
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How much approximately? I have heard in the range of $1500/talk - but thats when you go on a "tour" and give about 3 talks in the week. The math comes about the same as the income one can make if they see 10 patients a day, no?
 
indya said:
like money equivalent to what a urologist makes (>300,000)
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15 minute med checks. No drug company speaking, no clinical trials, no magic. Just work hard. May not be as rewarding as you'd like it to be with such little time spent with patients, but it really should not be a problem clearing 300k putting in 45-50 hours/week with an efficient practice. Also, never expect to be salaried at 300k. You'll only get this as an independent contractor/private practice.

Source: multiple residents I've rotated with plus a family friend who is in child psych.
 
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psychfun said:
How much approximately? I have heard in the range of $1500/talk - but thats when you go on a "tour" and give about 3 talks in the week. The math comes about the same as the income one can make if they see 10 patients a day, no?
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I am not sure of the details of it, but I believe most of the speakers also see patients
 
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how is it In compare to pcp ,15minute level 3, which is about 50-70usd?
 
Most reasonable insurance companies are willing to pay between $50 - $70 for a visit. I'm surprised that no one has mentioned that they turn their practice into a Suboxone Factory (100 person max after the first year at 30).
 
NJWxMan said:
Most reasonable insurance companies are willing to pay between $50 - $70 for a visit. I'm surprised that no one has mentioned that they turn their practice into a Suboxone Factory (100 person max after the first year at 30).
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So you see the same 100 pts month after month?
How is that a money maker @ "$50-70 per visit"?

No one's mentioned it because it's basically not worth that much.
Suboxone is ONE useful tool for docs who are comfortable with opiate addicts. It's not a stand-alone treatment modality.
 
OldPsychDoc said:
I suppose a guy could do this by day, do drug talks by night, and make a killing...but ....oh well...anyone interested in that life doesn't care what I think about soul-selling anyway...
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:thumbup:

The dedication and service it takes to be good at your job precludes medicine from simply being a profession. It's a calling. Nothing wrong with making decent money doing it, and I plan to do so myself. But if you approach the development of your practice with the primary goal of making a profitable business, you've already failed.
 
If you aren't running a profitable business then you have failed. And that's when you run to the government and beg and grovel for their scraps and the delayment of medicare cuts or advancement of maobama's agenda. It is always the primary goal whether you want to admit it or not. Some people choose to neglect the pursuit of it, but it is firmly fixed as the primary goal for everyone.
 
Sneezing said:
If you aren't running a profitable business then you have failed. And that's when you run to the government and beg and grovel for their scraps and the delayment of medicare cuts or advancement of maobama's agenda. It is always the primary goal whether you want to admit it or not. Some people choose to neglect the pursuit of it, but it is firmly fixed as the primary goal for everyone.
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EXACTLY. I couldn't have said it better myself. THANK YOU THANK YOU THANK YOU.
 
Sneezing said:
If you aren't running a profitable business then you have failed. And that's when you run to the government and beg and grovel for their scraps and the delayment of medicare cuts or advancement of maobama's agenda. It is always the primary goal whether you want to admit it or not. Some people choose to neglect the pursuit of it, but it is firmly fixed as the primary goal for everyone.
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I thought our primary goal was to do no harm.
 
Sorry it has taken me so long to reply, had to clean the vomit off of myself first.

Your posts smack of Randian Objectivism, which I loathe with a passion only slightly less than that I hold for socialism in all its many forms. Mostly because it is a juvenile and *****ic caricature of the doctrine of self interest.

I've been a free market supporter and armchair libertarian philosopher for years. I've been mentioned positively in the National Review no less than three times. Not sure how I feel about that honestly lol. I also have been flying the Gadsden flag years before it became re-popularized by the tea party.

As a reasoned and reasoning individual with a background in theory of science, game theory and mathematical modeling, I learned long ago that a model is only as good as its assumptions. Free market and limited government theories of governance, economics, and association enjoy assumptions that are much more robust than those of central planning/socialism. Self interest is after all the guiding principle of all life on earth.

However, where things start to fall apart is when one looks at the conditions necessary for a perfect market. None of them apply to medicine and healthcare. A free market is thus going to be determinstically inefficient in both quality and efficiency of healthcare products and services.

This isn't to say that market-based solutions aren't preferred. And I have blogged and written fairly extensively on how the healthcare market could benefit from being made more free. As well as how a better understanding and protection against the phenomena of game theoretic traps such as the commons, moral hazard, and discounting the future can improve efficiency beyond a purely free market and far, far beyond a single-payer/employer-based/government health insurance system while still engendering the maximum amount of freedom, quality, and efficiency.

Again, the free market isn't the be all and end all but a recognition of the primacy of self interest in the determination of our behavior.

And it is on the point of self interest that your comments show themselves to be so shallow. If profitability and profits are your primary goal, you have already failed by going into medicine. The opportunity cost of the years of training, the lost wages, the loss of years of investment in the market and your own enterprise compared to other, more profit-centered ways of doing business, is nearly impossible to recoup, with the possible exception of that spine doc at Wash U who bills for nearly 2 million a year.

Self interest is a pervasive principle that is poorly understood by the market worshipers who also fail to recognize its breadth: Income is not the only thing valued by the individual. If it was, the Laffer Curve wouldn't exist. Individuals value their families, their leisure time, their personal satisfaction, and their value systems. They value art, and entertainment, and the taste of good food. And they are willing to forego income to enjoy these less tangible goods.

And on to ethics. Because of the inherent asymmetries of the healthcare market, the most profitable business model for the physician will almost definitely not be the most ethical. Neither will it be the one that provides the greatest good to our patients. This is because of the limits of rationality and information asymmetry. And this is because in an imperfect market, profits are determined not by simple supply and demand, but by the ability to leverage the inefficiency in one's own favor. In the case of healthcare, this means trading on the irrationality of patients, the low value they place on intrinsic health, and their limited information when compared to the advantage of the decade-plus investment in acquiring information the doctor enjoys comparatively.

Psychotherapy will have a lower profit margin than med checks, procedures a higher profit margin than intensive rehabilitation, and the quick, easy, sexy fixes that trade on the irrationality and limited information of patients will be the surest way to make a lot of money.

Medicine would devolve into a system in which we deliver the most amount of care possible, at high rates of inefficiency, with little regard to long-term impact on patient health, agency, and quality of life. The fact that patients place little import on intrinsic health is seen in the rising rates of chronic disease, the poor effort placed on lifestyle intervention by physician and patient alike, and the atrocious lack of emphasis patients place on rehabilitation, preferring instead to slowly decay or acquiesce to disease. We also see this in how many patients insist that dilaudid is the only thing that helps their pain, confusing dissocation and the pleasurable sensation of getting high to pain relief. The most profitable practice of medicine would trade on this, and exploit the flawed lack of value placed on intrinsic health by our patients' own self interested desire for a minimum of effort and a maximum of comfort. Patients don't pay based on an expectation of health so much as they do based on a desire for comfort.

As a freelance author, I guarantee you I would be able to sell more articles if I wrote about how the fanciest formulations of sports supplements taken in absurd doses are better, or wrote "Put 2 inches on your arms. In three weeks!!!!" I value truth and integrity more. So I write fewer articles and spend more time on them. I have never been paid to support a single product, and when I do support one, it is because I myself have researched it extensively and use it myself, without a sponsorship or subsidy. And haven't even tried to sell to the highest bidding magazines. I guess I'm a failure.

As a future interventional pain physician, I'm pretty sure I would make more money by doing nothing but endless ESIs and TPIs, making my patients beholden to me for regular visits to bring them relief, and doing 15 minute med checks titrating their opioids endlessly upwards, instead of a comprehensive approach involving psychodynamic and cognitive-behavioral therapy along with a strong focus on rehab in addition to prudent intervention acting in synergy with the other techniques as I plan to. And to make it worse, I want to find a way to help people that can't pay full fees in cash!!! I guess I'm going to be a failure as a physician as well.

Somehow, though I might fail to turn myself into a prostitute with the ethics of a congressman, I think I'll still manage to be profitable and make an excellent income. Don't worry, I want an end to government healthcare in all its forms (which IMO includes employer-coupled health insurance), believe me I do. But I'm pretty sure that I can make some decent money, run a profitable practice, and still manage to serve my patients' needs without losing my morality and my soul in the process.

So let me repeat myself. I think profitability and sustainability are important goals. I think free market solutions to healthcare are imperative. But if you try to run the most profitable practice possible, you will not be running one in which patients' health even resembles a focus.
 
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masterofmonkeys said:
Sorry it has taken me so long to reply, had to clean the vomit off of myself first.

Your posts smack of Randian Objectivism, which I loathe with a passion only slightly less than that I hold for socialism in all its many forms. Mostly because it is a juvenile and *****ic caricature of the doctrine of self interest.

I've been a free market supporter and armchair libertarian philosopher for years. I've been mentioned positively in the National Review no less than three times. Not sure how I feel about that honestly lol. I also have been flying the Gadsden flag years before it became re-popularized by the tea party.

As a reasoned and reasoning individual with a background in theory of science, game theory and mathematical modeling, I learned long ago that a model is only as good as its assumptions. Free market and limited government theories of governance, economics, and association enjoy assumptions that are much more robust than those of central planning/socialism. Self interest is after all the guiding principle of all life on earth.

However, where things start to fall apart is when one looks at the conditions necessary for a perfect market. None of them apply to medicine and healthcare. A free market is thus going to be determinstically inefficient in both quality and efficiency of healthcare products and services.

This isn't to say that market-based solutions aren't preferred. And I have blogged and written fairly extensively on how the healthcare market could benefit from being made more free. As well as how a better understanding and protection against the phenomena of game theoretic traps such as the commons, moral hazard, and discounting the future can improve efficiency beyond a purely free market and far, far beyond a single-payer/employer-based/government health insurance system while still engendering the maximum amount of freedom, quality, and efficiency.

Again, the free market isn't the be all and end all but a recognition of the primacy of self interest in the determination of our behavior.

And it is on the point of self interest that your comments show themselves to be so shallow. If profitability and profits are your primary goal, you have already failed by going into medicine. The opportunity cost of the years of training, the lost wages, the loss of years of investment in the market and your own enterprise compared to other, more profit-centered ways of doing business, is nearly impossible to recoup, with the possible exception of that spine doc at Wash U who bills for nearly 2 million a year.

Self interest is a pervasive principle that is poorly understood by the market worshipers who also fail to recognize its breadth: Income is not the only thing valued by the individual. If it was, the Laffer Curve wouldn't exist. Individuals value their families, their leisure time, their personal satisfaction, and their value systems. They value art, and entertainment, and the taste of good food. And they are willing to forego income to enjoy these less tangible goods.

And on to ethics. Because of the inherent asymmetries of the healthcare market, the most profitable business model for the physician will almost definitely not be the most ethical. Neither will it be the one that provides the greatest good to our patients. This is because of the limits of rationality and information asymmetry. And this is because in an imperfect market, profits are determined not by simple supply and demand, but by the ability to leverage the inefficiency in one's own favor. In the case of healthcare, this means trading on the irrationality of patients, the low value they place on intrinsic health, and their limited information when compared to the advantage of the decade-plus investment in acquiring information the doctor enjoys comparatively.

Psychotherapy will have a lower profit margin than med checks, procedures a higher profit margin than intensive rehabilitation, and the quick, easy, sexy fixes that trade on the irrationality and limited information of patients will be the surest way to make a lot of money.

Medicine would devolve into a system in which we deliver the most amount of care possible, at high rates of inefficiency, with little regard to long-term impact on patient health, agency, and quality of life. The fact that patients place little import on intrinsic health is seen in the rising rates of chronic disease, the poor effort placed on lifestyle intervention by physician and patient alike, and the atrocious lack of emphasis patients place on rehabilitation, preferring instead to slowly decay or acquiesce to disease. We also see this in how many patients insist that dilaudid is the only thing that helps their pain, confusing dissocation and the pleasurable sensation of getting high to pain relief. The most profitable practice of medicine would trade on this, and exploit the flawed lack of value placed on intrinsic health by our patients' own self interested desire for a minimum of effort and a maximum of comfort. Patients don't pay based on an expectation of health so much as they do based on a desire for comfort.

As a freelance author, I guarantee you I would be able to sell more articles if I wrote about how the fanciest formulations of sports supplements taken in absurd doses are better, or wrote "Put 2 inches on your arms. In three weeks!!!!" I value truth and integrity more. So I write fewer articles and spend more time on them. I have never been paid to support a single product, and when I do support one, it is because I myself have researched it extensively and use it myself, without a sponsorship or subsidy. And haven't even tried to sell to the highest bidding magazines. I guess I'm a failure.

As a future interventional pain physician, I'm pretty sure I would make more money by doing nothing but endless ESIs and TPIs, making my patients beholden to me for regular visits to bring them relief, and doing 15 minute med checks titrating their opioids endlessly upwards, instead of a comprehensive approach involving psychodynamic and cognitive-behavioral therapy along with a strong focus on rehab in addition to prudent intervention acting in synergy with the other techniques as I plan to. And to make it worse, I want to find a way to help people that can't pay full fees in cash!!! I guess I'm going to be a failure as a physician as well.

Somehow, though I might fail to turn myself into a prostitute with the ethics of a congressman, I think I'll still manage to be profitable and make an excellent income. Don't worry, I want an end to government healthcare in all its forms (which IMO includes employer-coupled health insurance), believe me I do. But I'm pretty sure that I can make some decent money, run a profitable practice, and still manage to serve my patients' needs without losing my morality and my soul in the process.

So let me repeat myself. I think profitability and sustainability are important goals. I think free market solutions to healthcare are imperative. But if you try to run the most profitable practice possible, you will not be running one in which patients' health even resembles a focus.
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i didnt read this, i just want to know can we get back on topic about making big $$$$$$
 
masterofmonkeys said:
The dedication and service it takes to be good at your job precludes medicine from simply being a profession. It's a calling.
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The priesthood is a calling. Medicine is a profession.

Many fields require a lot of dedication and service to be good at your job. Let's not pat ourselves so hard on the back that we choke.

I agree that keeping firmly in mind that we are in the business of health rather than focusing on the bottom line is important or vital, but the "it's a calling" thing gets tired... We don't all need MD license plates and tee-shirts...
 
notdeadyet said:
The priesthood is a calling. Medicine is a profession.

Many fields require a lot of dedication and service to be good at your job. Let's not pat ourselves so hard on the back that we choke.

I agree that keeping firmly in mind that we are in the business of health rather than focusing on the bottom line is important or vital, but the "it's a calling" thing gets tired... We don't all need MD license plates and tee-shirts...
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Yeah. "It's a calling" because it's a guaranteed six-figure job with relative autonomy, prestige, and unparalleled job security. Funny how that works.
 
I got no problem if someone wants to make tons of money in this field so long as they are doing a good job.

A doctor who does excellent work, treats his patients well, gets them better in accordance with the standard of care or better, IMHO deserves good pay and success.

A problem is someone trying to make the money by cutting corners, e.g. 15 minute med-checks when the patient needs more than that, giving out meds just because the drug-rep is giving you free dinners, etc.

From my own experience, in many clinical scenarios, if a doctor isn't operating in a manner that is generating money, often times it's due to the doctor's laziness and lack of ability. E.g. I knew one attending who tried to hold onto every patient in a unit, even when it was clear that patient needed to be discharged. Medicare or the insurance companies wanted to stop paying the bill....which led to loss of funds. The guy sometimes didn't start patients on medications on the first day (out of laziness), and titrated medications in a very slow manner that had nothing to do with the patient's interests. E.g. a psychotic patient on Risperdal 1 mg for > 1 week.

Compare that to a doctor that is actually getting patients out in an efficient manner that is actually getting that patient appropriate treatment.

Think about it, a hospitalized patient often wants to get discharged ASAP. Wouldn't that mandate that we at least consider titrating the patient up at least 1-2 mg/day so long as the patient is doing well on the medication and is still psychotic or manic?

I don't suggest we start doing things simply in the name of money that leads to poor care, but there's a lot we can do that will generate money that is good care. In an inpatient setting if you practice in this manner, the administration will be more giving to your requests for those patients that truly need the extra care, even at a loss of funds to the institution.

They know you practice well, so when you do cry wolf, they'll listen.

If you aren't running a profitable business then you have failed.
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Not necessarily, and IMHO this statement just unnecessarily fuelds the fire. Our business is highly dependent on the rules made by the government and insurance companies.

The bottom line though is important. IMHO, all things being equal, good practice should lead to a profitable business in the overwhelming majority of cases. It's just that we have to be open to the exceptions.

As for primary care, there's plenty of things going wrong in the healthcare industry where the profit motives are for people to stay sick. E.g. a CABG will generate a heck of a lot more money for a doctor and hospital than getting the patient to keep his cholesterol low and stop smoking.
 
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It is extremely rare for CL services to make a profit of any description (it's why almost all of us are salaried) - I wouldn't consider the practice of CL psychiatry to be a failure.
 
Doc Samson said:
It is extremely rare for CL services to make a profit of any description...
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You CL folks make a lot of profit for the hospital! Consult psychiatrists make a lot of money (and improve patient care immensely) by putting out fires (via training and educating staff) and assisting with disposition (and freeing up beds that are gonna make a lot more money for the hospital than the delirious guy sitting there for the 23rd day) and many other ways that you could describe much better than me.

It actually amazes me that hospitals are forward-thinking enough to realize that having a poorly-reimbursed service actually improves their bottom line and patient care.
 
billypilgrim37 said:
You CL folks make a lot of profit for the hospital! Consult psychiatrists make a lot of money (and improve patient care immensely) by putting out fires (via training and educating staff) and assisting with disposition (and freeing up beds that are gonna make a lot more money for the hospital than the delirious guy sitting there for the 23rd day) and many other ways that you could describe much better than me.

It actually amazes me that hospitals are forward-thinking enough to realize that having a poorly-reimbursed service actually improves their bottom line and patient care.
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Cost-saving isn't the same as profit, and (probably for this reason) the vast majority of non-academic hospitals are NOT forward-thinking enough to realize that CL psychiatry is a vital service.
 
What profit is, is mandated often times by insurance companies and the government.

E.g. if I'm a cardiologist, and I get a patient to engage in lifestyle changes to the point where that patient does not need a CABG, I'd actually make less money and so would the hospital.

To think the bottom line is the end all be all is, ahem, bogus.

It certainly is something to factor in, it is important, and we as physicians need to encourage the government and insurance companies to make incentives that actually make sense (E.g. doctors usually have no incentive to educate patients on lifestyle interventions). While I still believe a doctor that does a good job will make a good profit, there's a lot of exceptions. If you hold to rigid to the profit/bottom line dogma, you're going to end up hurting a lot of patients.
 
billypilgrim37 said:
You CL folks make a lot of profit for the hospital! Consult psychiatrists make a lot of money (and improve patient care immensely) by putting out fires (via training and educating staff) and assisting with disposition (and freeing up beds that are gonna make a lot more money for the hospital than the delirious guy sitting there for the 23rd day) and many other ways that you could describe much better than me.

It actually amazes me that hospitals are forward-thinking enough to realize that having a poorly-reimbursed service actually improves their bottom line and patient care.
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agree with this. The situation is similar to IM hospitalist groups who need subsidation from the hospital for value they bring to the hospital that is reimbursed to the hospital rather than directly to the IM hospitalist. It is appropriate to include the amount of this subsidy along with the direct insurance co reimbursements the doc/group receives when calculating profitabiltity.
 
Here is a model that should be better supported, but so far it has only happened at a few hospitals.

------
Who is Geisinger Health System?Geisinger was founded in 1915 by Abigail Geisinger, widow of George Geisinger. She used her sizable fortune to build a hospital intended to be a regional medical center modeled on the Mayo Clinic. As such it was a small rural hospital of seventy (70) beds. Since that time Geisinger has grown to become Geisinger Health System (GHS) and now encompasses a forty-three (43) county area with a total of sixty-seven (67) sites.

These sites include single physician offices, in-store clinics, and a large campus in Danville, Pennsylvania. Geisinger is not only a provider, it is also an insurer with approximately 30% of it's patients on it's plan. The other 70% are served by other plans. This represents a total of seven hundred eighty-three thousand (783,000) patients currently serviced by Geisinger. The Danville, Pennsylvania hospital serves a community of roughly two million.

How they pay doctors

Doctors working for Geisinger initially have to get used to it's pay schedule. They are essentially employees of the system, not free-agents. As an employee doctors initially make 80% of the national pay rates for their profession. This may not sound all that good but GHS CEO Dr. Glenn Steele has a plan...and a good one at that.

General practitioners in the system, like most GPs, initially make less money than their specialist counter-parts. But this is only temporary. To help narrow the pay gap Geisinger specialist fields help subsidize the GPs. The trick is to not to take too much from the specialists such as orthopedists and cardiologists.

Dr. Glenn Steele, CEO of GHS stated that: "I couldn't recruit if I didn't do that. We don't want our family doctors setting up their own radiology clinics." In saying this Dr. Steele highlights a common practice among general practitioners & family doctors. Many routinely set up clinics and specialized services (such as XRay or hematology labs) to help supplement their earnings.

Even though GHS doctors are salaried employees, their pay is not fixed in advance. Salaries are geared to stay within eighty (80%) percent of the national average, but they are also set up to close the gap on the twenty (20%) percent based on performance goals; a bonus for lowering the return rate of patients. If, for example, the coronary care group can keep it's re-admission rates below a set level, doctors are compensated with bonuses. These bonuses come out of the savings Geisinger Health System realizes with reduced complication rates.

The same holds true for a pediatric orthopedic team. These teams must treat kids for spinal problems without being in too much of a hurry to operate on children who don't need it while not being too slow for those who do. Again the ultimate goal is to reduce the rate of readmission. interestingly, lowering readmission also means better patient care. Dr. Steele's example: "We keep cash compensation flexible with incentives. That takes away some of the insane piecework."

Former Treatment Practices
Before the transformation GHS used to use the a la carte method of billing, where each separate specialist billed for his/her time. This approach also extended to post-op where patient care fell to whoever happened to be on duty at the time.

Beside the billing nightmare, this method of treatment posed other problems. If a patient had a problem the nursing staff had to ask "who's patient is this" before asking "what is the problem." This stemmed from the fact that different doctors used differing methods of treatment.These differences could even extend to how a patient might be wired to a monitor.This is how most hospitals, specialists, and health-professional operate across the United States today.

GHS Solution
Starting in 2004, Dr. Steele decided to fix these problems by switching GHS over to a prix fixe (French for fixed price), episode-care model for surgery. Beginning with heart bypass surgery, a tight knit team of caregivers are responsible for every stage of the bypass procedure. This includes the patient's post-op treatment and recov*ery. GHS submits a single bill to the patient for all work performed. Gone is a separate bill from the anesthesiologist, surgeon, etc.

GHS even includes a 30 day pre-op and 90 day post-op warranty. The warranty guarantees that if a patient checks back into the system with any complications during the warranty period, those expenses are picked up 100% by GHS. Of this method Dr. Steele states: "We'll do it right, or we won't send a bill."

Heart Bypass Surgery was the first model to change.This first step toward this goal was to codify twenty (20) steps performed in a bypass operation and standardize them. This standardization was geared toward reducing any variability in care. The steps went so far as to determine precisely what drugs and dosages doctors would use for every patient. As the checklist was fine tuned it expanded to forty (40) steps. Initially doctors objected calling the process "cookbook medicine." But when patient readmission rates began to fall and the savings became apparent (along with bonuses) GHS doctors overwhelmingly signed on to the new methods.

After a three hundred twenty (320) bypasses had been performed under the new rules it was noted that patients had far fewer complications and went home sooner. This reduced complication rate cut patient cost by about $2,000 each. The savings were promptly passed on to the doctors as bonuses. Since then GHS doctors have begun creating similar checklists for hip-replacement, bariatric & cataract surgeries.

ProvenCare
GHS calls this practice ProvenCare and this practice hinges on three principals:

  • a strict reliance on evidence-based standards in medicine
  • a financial mechanism to pay for certain procedures
  • patient engagement/activation
Danville, PA
Janet Tomcavage, an R.N. at GHS, said that changing the health care system is contingent upon bringing the quality of care up while paring the expenses down."It's going to require a whole new attitude," she said. "This has driven some good outcomes," she continued "Mortality has dropped. Readmissions have dropped. And the hospital has not lost money."
Tomcavage went on to say: "A lot of hospitals will tell you they literally throw people over the wall, ‘You need to be out of here by 11 o'clock,' that sort of thing, [but] If the patient can't manage the tubes or the pills they're going to be right back in the hospital. The sensible thing to do is make sure they can cope first."Tomcavage summarized with: "More service upstream, and we can keep people well, at home."

She also stressed the need for different specialists to talk. As an example she cited a patient with kidney problems. More fluids are good for the kidneys; less are better for the heart. Specialists tend to think only of "their organ" so its important for the cardiologist and renal specialist to talk to each other about the same patient. This communication also reduces readmission rates.

Wyoming Valley, PA
Victoria Keeler, R.N. states of a special position called Nurse Navigator: "Being diagnosed and coping with a breast disease can be confusing, stressful and incredibly overwhelming. Breast care navigators can help patients sort through the many questions and uncertainties that arise throughout their course of treatment." Nurse Navigators provide comfort and support regarding both malignant and benign breast diseases. They are also charged with helping the patient understand various treatment options. Nurse Keeler went on to say: "Navigators do not offer opinions or advice on treatments; they support physicians and their decisions. A navigator is an extra resource that can provide additional information to patients."

As of 2008, Geisinger Health Systems operating revenue was nine hundred forty-three ($943,000,000) million dollars.Medicare contributed roughly thirty-three (32.7%) percent of these funds.Medical Assistance contributed to approximately seven (6.6%) percent of the hosptial net patient revenue. Roughly one point five (1.5%) percent of inpatient care was uncompensated care.

After listening to President Obama's speech to congress I became curious as to who Geisinger Health System was. This hub is the result.With all of the Republican nay-saying regarding a health care overhaul, especially in light of the fact that they keep referring to the attempts at reform as "socialized medicine", I thought i particularly important to concentrate on the fact that doctors are paid and earn bonuses for performance. Also, GHS is profitable.This is not socialized medicine by any stretch of the imagination.
------------------
Source: http://hubpages.com/hub/Why-President-Obama-Named-Geisinger-in-His-Speech-to-Congress
 
I'm not advocating a physician step outside the physician duty of offering the best and most appropriate care for their patient. This I felt was a safe assumption, but some felt my belief in pursuing money effeciently would denigrate to poor medicine.

People can cross the line into poor medicine and make a greater profit. Yes, this is true, but I'm not advocating that.

Even in employed positions like C&L psych, you still have a value and a worth. To not know what your salary and profitability is means a greater profit for your employer. Hospitalists know their worth and adequately get their subsidies. Same thing applies for C&L. The down side is your only real bargaining chip with these positions is quitting. No thanks, not for me.

Outpatient docs can choose their insurance plans carefully. Maximize their office IT. Or even go cash only. For instance, Neurosurgeons will walk away from hospitals and trauma call to focus on spine. That isn't bad medicine but focusing on good medicine for the patients they do see. Their reasons for not taking call or doing trauma is the fault of the hospital, government, and society as a whole. If a psychiatrist only wanted to do ECT and focus on calibrating vagal nerve stimulators or just suboxone or whatever niche you can think of, so what? There is nothing wrong with that (as long as the treatment is warranted). If certain treaments all of a sudden have no one to do them then the system needs to change or patients need to pay up. Patients want a psychiatrist to also do therapy, well the system should pay more, or the patients should pay for it (some do).

As for the idea of all hospitals becoming like geisner, kaiser, etc. Hell no! That is essentially resigning all your rights as a physician to a suit. They are the reasons many physicians hate medicine in the first place. Why people walk right into the heart of lions den baffles me. You as a psychologist I can understand the allure. Those are the systems that often look to circumvent physicians and give more power to allied practitioners in hopes of maximizing their profit. I have no desire to be employee who needs to jump through hoops to earn a bonus biscuit. I aim to be a professional who is sought out by patients and paid accordingly and all the "bonus money" already goes to me. No thanks, you can keep McHealthCare.

I'm focused on the patient and eventually making sure I'm paid for what I'm worth - and not letting some parasite steal my money. Whether that parasite is an insurance company, goverment insurance, employed status, poor office structure, horrible IT, poor bedside manner, etc. I aim to avoid it.
 
Sneezing said:
If a psychiatrist only wanted to do ECT and focus on calibrating vagal nerve stimulators or just suboxone or whatever niche you can think of, so what? There is nothing wrong with that (as long as the treatment is warranted). .
Click to expand...

agree with this. Superspecialization is one way of making $, but there are sacrifices. In my own sleep practice, I treat mainly sleep apnea. I certainly don't turn away patients with restless legs, insomnia, or other conditions that bring less $, but I don't focus my advertising on those conditions. Treating one case of sleep apnea after another isn't exciting, but I think I do a good job of it and it brings in a decent income. My professional life would be more interesting if I had a more general sleep practice or did a combo of sleep/psych, but it is a sacrifice I choose to make for more $.

I provide good care to my patients (providing much more follow up - the unprofitable part of sleep med as compared to sleep studies- than many other sleep docs/clinics).

There are ways to honorably make a lot of $ in medicine, including in psychiatry, but in general the more $ you make the less interesting your practice is. As another example, clinical trials can be very profitable, but they are tedious to carry out.
 
Agree with you Sneezing, but don't lose sight of the goal of quality care. Unless that priority is high, you might not give good care.

If you wanted to do ECT, great.

But the reality is that ECT is super-specialized. You're going to have to do a lot of work outside that before you get there.

Even if money ultimately is your goal, you still have to make good patient care a high priority. I recommend that you make high patient care the highest priority, make money the second....

and unless the healthcare system dramatically changes (which it might), you still will make a lot of money and do a good job as a doctor.
 
Sneezing said:
I'm not advocating a physician step outside the physician duty of offering the best and most appropriate care for their patient. This I felt was a safe assumption, but some felt my belief in pursuing money effeciently would denigrate to poor medicine.

People can cross the line into poor medicine and make a greater profit. Yes, this is true, but I'm not advocating that.

Even in employed positions like C&L psych, you still have a value and a worth. To not know what your salary and profitability is means a greater profit for your employer. Hospitalists know their worth and adequately get their subsidies. Same thing applies for C&L. The down side is your only real bargaining chip with these positions is quitting. No thanks, not for me.

Outpatient docs can choose their insurance plans carefully. Maximize their office IT. Or even go cash only. For instance, Neurosurgeons will walk away from hospitals and trauma call to focus on spine. That isn't bad medicine but focusing on good medicine for the patients they do see. Their reasons for not taking call or doing trauma is the fault of the hospital, government, and society as a whole. If a psychiatrist only wanted to do ECT and focus on calibrating vagal nerve stimulators or just suboxone or whatever niche you can think of, so what? There is nothing wrong with that (as long as the treatment is warranted). If certain treaments all of a sudden have no one to do them then the system needs to change or patients need to pay up. Patients want a psychiatrist to also do therapy, well the system should pay more, or the patients should pay for it (some do).

As for the idea of all hospitals becoming like geisner, kaiser, etc. Hell no! That is essentially resigning all your rights as a physician to a suit. They are the reasons many physicians hate medicine in the first place. Why people walk right into the heart of lions den baffles me. You as a psychologist I can understand the allure. Those are the systems that often look to circumvent physicians and give more power to allied practitioners in hopes of maximizing their profit. I have no desire to be employee who needs to jump through hoops to earn a bonus biscuit. I aim to be a professional who is sought out by patients and paid accordingly and all the "bonus money" already goes to me. No thanks, you can keep McHealthCare.

I'm focused on the patient and eventually making sure I'm paid for what I'm worth - and not letting some parasite steal my money. Whether that parasite is an insurance company, goverment insurance, employed status, poor office structure, horrible IT, poor bedside manner, etc. I aim to avoid it.
Click to expand...

Ok I believe we may actually be on the same page then. I was merely making the point that if money were the primary goal, you would inevitably prey on your patients rather than make them healthier. Using my personal example, choosing conservative therapy, low-margin psychotherapy, and a more judicious use of procedures would indeed hurt my bottom line considerably.

On the other hand, as I also stated, I am all for the maximization of profit and profitability within one's clinical and ethical framework. As a friend also traversing the psych-pain route said, he could easily fill up a full-time procedure only practice doing only medically indicated and prudent work that would benefit patients. Or as you said, ECT, suboxone, methadone, etc.

Totally agree with you on everything else. Which is why I won't take medicaid, because I don't want to be placed in a situation in which I will lose money by offering psychotherapy. And I don't want to support a flawed and ultimately immoral system that I believe Medicaid to be, both in its treatment of society and of physicians specifically. I'll find my own way to treat the less pecunious among us.
 
notdeadyet said:
The priesthood is a calling. Medicine is a profession.

Many fields require a lot of dedication and service to be good at your job. Let's not pat ourselves so hard on the back that we choke.

I agree that keeping firmly in mind that we are in the business of health rather than focusing on the bottom line is important or vital, but the "it's a calling" thing gets tired... We don't all need MD license plates and tee-shirts...
Click to expand...

Trite though the saying may be, I do believe it is true. Using the language of behavioral ecology, medicine lies outside the market by virtue of the amazing information asymmetry between physician and patient. The power differential is huge, and must be respected. As a corollary to that, the information differential being what it is, and the work necessary to continue assimilating information and applying it in a clinically beneficial way, requires an intense amount of work that...may not always be noted.

That there is the critical thing for me. Everyone knows terrible docs whose patients love them, never knowing how they've been hurt along the way, because their patients lack the information and the ability to utilize it to realize what's happened to them. This blindness is what makes them so vulnerable: They might never even know they were hurt by us.

As for t-shirts and license plates, big fat meh. There are very few MDs who I would choose the company of over other friends in other professions with less education and less prestige.
 
masterofmonkeys said:
Using the language of behavioral ecology, medicine lies outside the market by virtue of the amazing information asymmetry between physician and patient. The power differential is huge, and must be respected.
Click to expand...
Very true. Of course, the same is true of my mechanic, at least when he's dealing with slobs like me. But I doubt he'd gaze into the distance and talk about his calling.
 
If the healthcare system actually had real incentives and punishments that actually made sense, that'd probably fix half of the healthcare mess we have now.

Right now, for doctors it pays for their patients to be sick. It doesn't pay for us to educate them, and it doesn't pay to be in primary care. For patients, several don't know what hospice is, and expect a pill to solve everything.

With the above problems, it's certainly a no-brainer that a pure capitalist model doesn't work in the healthcare system. A patient could go to 3 different doctors and get 3 different opinions. As a consumer, since the patient doesn't know which is the superior doctor, that patient doesn't know what to do. This isn't like fast-food where after a person eats the hamburgers from 5 different places, he knows where to go from now on.
 
notdeadyet said:
Very true. Of course, the same is true of my mechanic, at least when he's dealing with slobs like me. But I doubt he'd gaze into the distance and talk about his calling.
Click to expand...

Yeah, but with a Chilton's manual and a modicum of effort, even a slob like you can do most of your car repair work yourself, or at least learn enough not to screw yourself in the deal. But while Swan did his own cut-down and inserted his own catheter to figure out his PCWP, I doubt you'll find too many average joes capable of doing the same.

A patient who spent 30 minutes on the internet is a pain in the butt because they think they know more than they do. A customer who's done thirty minutes of research on the internet about their car and its problem is a pain in the butt because she can actually tell when her mechanic is trying to exploit her ignorance.
 
Now, back to our regular scheduled programming. Whopper you mentioned real incentives and real punishments. I believe, contrary to your other statement, that an entire freemarket capatilistic system would provide both.
 
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