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

[whopper]

I believe, contrary to your other statement, that an entire freemarket capatilistic system would provide both.

An entire freemarket system would force several doctors to not give care to those in need.

Don't believe me? It's happened already. In one particular case, a person who was fully insured, the EMTs needed that person to be pulled out of a canyon by helicopter. The insurance company refused to pay for it. The EMTs were forced to get her out manually that likely led to her being paralyzed for life. This was a real case that actually happened.

What if you were in a burning car, and your wallet with your insurance card was burned up? You're brought to the ER...now since you can't pay, and you can't provide your insurance #---> no service.

What if someone is brought into the hospital unconcious. Oops, nope, we can't save the person's life because we don't know if the person would pay for the service.

You go to McD's, Wendys and BK. You can figure out the burger you want because you can taste all 3, you know how much all 3 cost.

We got an interesting thing going on in medicine. Our patients don't know what's going on and they're usually expecting their doctor to guide them. Such as process in and of itself is in direct conflict with a system that requires the consumer to make a decision over a product or service.

I've mentioned this before. IMHO, the closest thing you can get to a system of self-responsibility is for healthcare to implement of system of incentives and disincentives based on something the laymen can understand. E.g. if someone smokes, their health care costs should go up, if they are overweight, don't excercise, don't manage their blood sugar or cholesterol--they pay more. IMHO that's the closest we can get, but we're not even doing that.

Such a system would certainly not be capitalist, though it would IMHO be the closest thing we could get to a capitalist system without encouraging the above horror scenarios.

---

Members don't see this ad.

 

[Rhayven44]

You could have your own television show. Quickest way to make big $$$. Your chances of success are exponentially increased if you allow most of your Cluster B patients to melt down on a constant basis.

At least that's what MTV, VH1, and E! do. Of course, none of those are medical shows, but slap a white coat on it, and you got a career!

 

[Doc Samson]

Of course, none of those are medical shows, but slap a white coat on it, and you got a career!

Celebrity Rehab?

 

[nancysinatra]

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.

I guess the entire freemarket capatalistic system doesn't teach people to spell though. And the regular scheduled programming doesn't teach grammar.

 

[nancysinatra]

I've mentioned this before. IMHO, the closest thing you can get to a system of self-responsibility is for healthcare to implement of system of incentives and disincentives based on something the laymen can understand. E.g. if someone smokes, their health care costs should go up, if they are overweight, don't excercise, don't manage their blood sugar or cholesterol--they pay more. IMHO that's the closest we can get, but we're not even doing that.

In a way this sounds great and all, and I'm not advocating for less personal responsibility among our patients--except, it wasn't THAT many years ago that people really didn't know that smoking even caused cancer. We find these things out as we go along. And sometimes "science" is wrong about the causes of diseases. Wasn't schizophrenia thought to be related to poor parenting as recently as the 1970s? (Or at least the 50s?) If bad parents had been taxed or charged higher rates by psychiatrists back then, would that have been good policy? The mechanisms of atherosclerosis are becoming clearer, but they are not completely clear yet, so to charge people for high cholesterol seems premature to me. And some people have genetic predisposition. Among those issues, it would seem better to me to just plain ban smoking.

 

[235750]

In a previous thread with a similar title (along the lines of "are methodone clinics profitable"), OPD said something like, you can make a lot of money in psych as a pi$$ merchant, but that it didn't much appeal to him.

It was hilarious, you should look it up

 

[TheWowEffect]

In a way this sounds great and all, and I'm not advocating for less personal responsibility among our patients--except, it wasn't THAT many years ago that people really didn't know that smoking even caused cancer. We find these things out as we go along. And sometimes "science" is wrong about the causes of diseases. Wasn't schizophrenia thought to be related to poor parenting as recently as the 1970s? (Or at least the 50s?) If bad parents had been taxed or charged higher rates by psychiatrists back then, would that have been good policy? The mechanisms of atherosclerosis are becoming clearer, but they are not completely clear yet, so to charge people for high cholesterol seems premature to me. And some people have genetic predisposition. Among those issues, it would seem better to me to just plain ban smoking.

Your responses are almost always awesome!!!

If you are a girl, will you marry me??? j/k

 

[whopper]

nd some people have genetic predisposition. Among those issues, it would seem better to me to just plain ban smoking.

Since I didn't go along with the full rant, I'll clarify. My plan was that people should be charged higher fees for healthcare if they don't do things within their control that are known by the common person to be dangerous for your health.

E.g. smoke, be overweight, use illicit substances, high cholesterol.

And there should be incentives to maintain health. E.g. normal weight, good cholesterol, regular doctor's visits should all lead to lower fees.

Death planning such as a living will should also allow for lower fees.

Also membership in a gym and other activities that promote health should be tax-deductible or put someone in a better favored category for insurance fees.

Health problems that are beyond one's control (such as a genetic disorder), and things that could prevent disease that are beyond the grasp of the common person should not be included.

The premise is simple--all healthcare pools are communal. If you pee in the well, you ought to drink it, and others should not be punished if you choose not to do your end.

It's not capitalism, but it's the closest model I can think of that encourages personal responsibility.

As for some people being genetically prepositioned, true, but then again that's true for any behavior. That IMHO does not create enough reasonable justification for say someone with genes that may encourage impulsive behavior to be excused for speeding or not be given added points that lead to higher insurance premiums.

As for the argument that what we know now makes the previous medical knowledge look primitive, also true, but that same argument can be applied to any practice in medicine. E.g. What we know 15 years from now will make this SSRI look like a dinosaur, so should we not give the SSRI if it by what we know now makes it an appropriate treatment choice? Heck no. We need to utilize what we do know.

 

[Sneezing]

I guess the entire freemarket capatalistic system doesn't teach people to spell though. And the regular scheduled programming doesn't teach grammar.

Yes, you are correct. I did exhibit poor spelling, and often have poor grammar. Part of it is laziness with fast typing, part of it is style, and part of it is an honest mistake. You did catch me.

I am also right.

 

[nancysinatra]

Yes, you are correct. I did exhibit poor spelling, and often have poor grammar. Part of it is laziness with fast typing, part of it is style, and part of it is an honest mistake. You did catch me.

I am also right.

People make spelling errors due to laziness and speed. But not grammar errors. Grammar errors come only from the heart. I'm no grammar Nazi either--I was teasing you, not regulating what you do or say. If you can't take it, then go back to your regular scheduled program. ;-)

 

[nancysinatra]

Your responses are almost always awesome!!!

If you are a girl, will you marry me??? j/k

What a nice compliment! And who wouldn't want to get married, what with the romantic overtones of cholesterol and obesity?!

 

[Kosebamse]

(...)
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.

I read all of this.

A lot of truth in here, and some economy statements that were out of my league.

I come from a centralist modern western country. Primary Care physicians are funded by the government. They receive a fixed reimbursement per patient treated. This means talking less to the patient, and doing less thorough history and physicals is good, as long as this doesn't result in legal action against you that outweighs the benefits of fast examinations and care.

Patients are uniformly dissatisfied with their primary care physicians, but seeing as they are a mandatory gatekeeper to other physician specialists, if the patient wants a cost refund, they get their customers no matter what. The amount of physicians is also tightly regulated.

This creates a game, and the winning strategy is definitely not tit for tat. It sucks to be a part of such a system. The pleasure of striving towards doing things better is gone, because the most profitable is to do worse.

I just loathe brainwashed individuals who have no solution, but thumping invented moral realism, saying that one should be obliged by conscience to be a bad game player.

I agree with your conclusion that it is hard to become a "morally bankrupted politician" if you aren't wired that way. But I see how rational it is to be a psychopath, if you can combine that with a good self-image and avoid becoming an outcast. (Funny you elaborated on this in a psychiatry thread, where psychopaths are seen as uniformly mentally ill. )

Working in a hospital setting might not be that different, at least it aint that different for me, straight outta med school. The game is just different: you don't work towards doing your best, you work towards fulfilling expectancies and maneuver around conflicting expectancies. You enter a field where the 48 rules to power are important. Play or get played. But this isn't pathognomonic of medicine.

 

[Zap Rowsdower]

An entire freemarket system would force several doctors to not give care to those in need.

Don't believe me? It's happened already. In one particular case, a person who was fully insured, the EMTs needed that person to be pulled out of a canyon by helicopter. The insurance company refused to pay for it. The EMTs were forced to get her out manually that likely led to her being paralyzed for life. This was a real case that actually happened.

What if you were in a burning car, and your wallet with your insurance card was burned up? You're brought to the ER...now since you can't pay, and you can't provide your insurance #---> no service.

What if someone is brought into the hospital unconcious. Oops, nope, we can't save the person's life because we don't know if the person would pay for the service.

You go to McD's, Wendys and BK. You can figure out the burger you want because you can taste all 3, you know how much all 3 cost.

We got an interesting thing going on in medicine. Our patients don't know what's going on and they're usually expecting their doctor to guide them. Such as process in and of itself is in direct conflict with a system that requires the consumer to make a decision over a product or service.

I've mentioned this before. IMHO, the closest thing you can get to a system of self-responsibility is for healthcare to implement of system of incentives and disincentives based on something the laymen can understand. E.g. if someone smokes, their health care costs should go up, if they are overweight, don't excercise, don't manage their blood sugar or cholesterol--they pay more. IMHO that's the closest we can get, but we're not even doing that.

Such a system would certainly not be capitalist, though it would IMHO be the closest thing we could get to a capitalist system without encouraging the above horror scenarios.

I disagree. First, no one should be forced to pay more for their health insurance based on their lifestyle. If a person wants to be fat and lazy then all power to them. The problem is we have these entitlement programs that encourage people to live however the hell they want b/c the bill is never traditionally paid for by the patient. There is no direct exchange of money, or writing a check. It's taxation, and mostly just printing a lot of money. We should be encouraging massive HSA's that cannot taxed. If the person wants to use some of that money on a big screen HD TV then thats their freedom of choice. Just don't keep destroying my currency to pay for some of these people. We should be encouraging catastrophic insurance. I think this is more like true self-responsibility.

As for your insurance horror stories, to me those don't reflect any kind of political agenda (capitalist, socialist, corporatist). That's just plain human indecency. The stories also reflect insurance companies, not physicians.

I completely disagree that a free market system would force doctors to not give care. How can you use the word force when discussing the free market? From my readings, there was far more charity care provided before medicare, medicaid, and the massive insurance industry. The churches ran the hospitals, and less people were turned away. The majority of care was paid for by the patient, directly to the physician. If you couldn't pay at the time, something would be figured out. Later payments, family assistance, neighbors helping out. Not many middlemen in those days. Today, if you want to charge a medicare patient LESS, you have to opt out of the system in order to not be contacted by the government.

 

[whopper]

First, no one should be forced to pay more for their health insurance based on their lifestyle.

No one should have to pay for the choices others make with full knowledge of what it can do to them.

That's just plain human indecency. The stories also reflect insurance companies, not physicians.

A pure capitalist system would not provide services to those who can't pay. It's actually part of the definition. You pay for a service or product. M'kay? If you don't have your cash or credit card in a store--too bad. Why would a hospital be different in a pure capitalist system?

there was far more charity care provided before medicare, medicaid, and the massive insurance industry

Yes, and there still were several cases of people who couldn't pay for their care even under the system you mentioned.

If you couldn't pay at the time, something would be figured out.

Still happens today under either system. Something would be figured out? How much, 100% of the time? No. And heck, that sounds like evil socialism to me.

As for your insurance horror stories, to me those don't reflect any kind of political agenda (capitalist, socialist, corporatist)

No. Apparently you are not familiar with the ERISA act. Cases like this actually have gone to the Supreme Court. In their rulings the SCOTUS actually stated they felt the insurance company was ethically wrong, but the legislation clearly pointed that HMO companies are a workman's benefit, and workman's benefits cannot be sued. Therefore, the HMO was free from liability, even if what they did have a hand in a bad outcome and would not provide coverage even against the recommendation of the treating physician. The SCOTUS even gave a hint to the legislative and executive branches that this was out of their league, but within the league of the other 2 branches, but to date those branches haven't taken action yet.

If a person wants to be fat and lazy then all power to them.

And if they have to pay higher fees, fine, so long as they, not I pay, for them. Just like in the spirit of capitalism, I should not have to pay for the choices my neighbor makes, but for the choices that I make.

I completely disagree that a free market system would force doctors to not give care

There will always be someone willing to give free care. The problem here is that the doctor willing to give the free care might not be around at the right place and time for someone who can't pay for it.

M'kay, sure. Under your logic----

When the completely free market system comes out, I'll take the insurance plan for those that did what they could to take care of themselves, including those with genetic disorders who had no control over that issue.

You can take the insurance plan where people have the "right to be fat and lazy." You pay for someone's CABG after he does not follow any of his doctor's recommendations to excercise, quit smoking and take a statin.

I don't think anyone has the right to be fat or lazy when it imposes costs on others, but that's just my opinion. Maybe a new Constitutional Amendment? "We the People of the United States feel it is the right of all American citizens to be fat and lazy....To that end, if someone cannot afford to pay for their Spam, the government shall provide it to them. If they do not want to work, then the government shall provide their needs."

The reason why I debate against a completely capitalist system is because in the past (if you've actually read up on the history of insurance companies) they did offer plans only for the "healthy" and intentionally excluded those that had genetic disorders that had no control over that condition. These were unregulated, and thus within the definition of free-market-Capitalism.

If you've actually read the Wealth of Nations, Adam Smith said these problems will happen, and for that reason pure Capitalism would never work. Yes, the founder of Capitilalism said it cannot go completely unregulated. There had to be government intervention concerning monopolies, cabals, and when the almight profit became more important than what most would consider ethical. Capitalism, while impressive, is not an end all be all, even in the eyes of it's founder. Those that think it is are more for a dogma than practicality. Just my opinion.

Oh and by the way, enjoy the free-market ads for cigarettes placed in children's schools and the reintroduction of child labor if the market were to become completely and totally free. Cigarette marketing targetted to kids in several countries outside the US is rampant (e.g. the Phillipines). But oh no, if it's made illegal, I guess then those countries embrace socialism.
http://www.cigarettesflavours.com/smoking-facts/health-philippines-young-lives-up-in-smoke/

 

[Doc Samson]

I don't think I've ever actually seen Whopper p!ssed off before.

 

[TexasPhysician]

Get back on topic people. All this jibber jabber is not making me any richer. I need to pay for my TX plantation before I die.

 

[nancysinatra]

From my readings, there was far more charity care provided before medicare, medicaid, and the massive insurance industry. The churches ran the hospitals, and less people were turned away. The majority of care was paid for by the patient, directly to the physician. If you couldn't pay at the time, something would be figured out. Later payments, family assistance, neighbors helping out. Not many middlemen in those days. Today, if you want to charge a medicare patient LESS, you have to opt out of the system in order to not be contacted by the government.

Are you aware of what just happened to St. Vincent's Hospital, a church-run former charity hospital in New York? And haven't you heard that the cost of medicine itself has gone up just a tad since those days when patients paid with chickens and hospitals were run by nuns? Good luck getting patients and churches to pay for IR-guided procedures, stat MRIs, not to mention some of the 1/2 million dollar chemotherapy drugs.

I'm not defending the massive bureaucracy we have in our system, but going back to a simple straight payment system where "something would be figured" out is really naive.

 

[whopper]

Sorry--yep I was, ahem, passionate.

TXphysician you are right.

And actually, ironically, I'm actually a bit more of a Capitalist than the usual person.

 

[nancysinatra]

No one should have to pay for the choices others make with full knowledge of what it can do to them.

Whopper, have you ever had a lazy or fat relative? I might not want to pay for the CABG of some total stranger who smoked and never exercised, but if it were my uncle I might feel different, even realizing how lazy and irresponsible he was his whole life. Probably I'd actually be mad at that uncle and yet still want the CABG for him, because I'd have spent a lot of time trying to convince him to change his ways, but he never listened--and if he died because he couldn't get the CABG, it would hurt not just him, but me too.

Also, here's a question--if you want our system to make allowances for lifestyles and behaviors, then how do you account for the horrifying lifestyles of most people with mental illness? Do you give them a pass? Almost all schizophrenics smoke. Can we reason with them and get them to stop? What about anorexics? Do we charge them higher insurance too, since they too can run up very high medical bills because of their eating habits? And skin cancer--are you going to charge people higher insurance rates if they sunbathe? Life is full of risk factors, and I bet if you start charging some people for theirs, they will demand that others be charged for theirs as well.

Personally, I kind of agree with a straight law that just outlaws obesity and smoking, where people--like cars--have to go through an evaluation every year and get a sticker to show they pass. Soon, Americans would rival the Japanese for our svelteness.

 

[whopper]

have you ever had a lazy or fat relative?

Yes I have.

I had a grandmother with insulin dependent diabetes who went blind eating too much candy. I have I'm sure just as many relatives that don't take care of themselves as anyone else.

But the bottom line is my grandmother ran up the costs of healthcare for people she didn't know. Several of those people had problems affording that healthcare and her actions tipped the scale against them.

I got no problem with society trying to help those that do what they can, or were put in a medical situation they could not help--e.g. a drunk driver smashes into someone, and now that person requires surgery.

I do, however, have a problem with someone who chronically and knowingly engages in a behavior that they know will have dire consequences, and expects others to pick up the tabs for the costs of the products and services that will be needed to pay for their health.

Being fat historically, since the beginning of history until a few decades ago was a luxury. Now it's common, and guess what? It's costing our healthcare system hundreds of billions of dollars a year. Maybe the problem isn't so much the system itself, but too many people expecting the system to do too much for them.

And remember, I'm not demanding that these people be cut off from healthcare. I'm simply suggesting they pay a higher premium.

If someone speeds over 25 MPH over the speed limit, do you have a problem with that person getting 4 points and their driver's insurance premium going up?

 

[OldPsychDoc]

If someone speeds over 25 MPH over the speed limit, do you have a problem with that person getting 4 points and their driver's insurance premium going up?

I though it was socialist to require them to carry insurance at all...

 

[whopper]

then how do you account for the horrifying lifestyles of most people with mental illness?

Well that's too broad a question IMHO unless you want me to write up a very very long answer and hijack this thread more than I already have. . Some mental illnesses are to the point where people are able to care for themselves in public. Others don't have that same luxury. Of course many of those don't pay insurance either because they can't afford it.

As I said, people should pay premiums based on factors they can control that are within the general grasp of a layman and simple--smoking, cholesterol, BP, weight. Several mental illnesses are such that control is not there, nor were these disorders otherwise avoidable within the knowledge of the layperson.

 

[whopper]

I though it was socialist to require them to carry insurance at all...

I think the socialism tag (in reference to pointing a finger at someone) is for the most part absurd because most of the people doing it in some form or another want the government to interfere in our lives in at least one of several areas...Just not the area they are browbeating on.

I got to get off the soapbox! Apologies to all....

 

[billypilgrim37]

Whopper, I guess I'd like to see some data that differential premiums would actually lead to better health. Because I think that would be pretty difficult to find, for very good reasons. Taxing states of being makes little sense when perfectly good pigovian taxes could be employed in much more simple, straightforward, and fair ways.

 

[michaelrack]

I though it was socialist to require them to carry insurance at all...

Car insurance is an entirely different issue because 1) it is mandated by the state, not the federal government and 2) generally it is only mandatory to have liability insurance for damage you may cause the other driver, not to cover your own bills.

 

[whopper]

True Mike. It's not exactly the fairest analogy in every sense.

I guess I'd like to see some data that differential premiums would actually lead to better health.

Well I haven't put the computations to see how it would affect premiums, but it is IMHO worth investigating. The costs of people being on insulin and treating metabolic disorders alone is in the hundreds of billions per year. There are many more disorders that are caused by poor metabolic status. Getting people to pay for what they take out of the healthcare system instead of continuing to give people the notion that they can do whatever they want to their body--someone else will pay, will not sustain itself indefinitely. I'm not saying people should have to pay for everything single mistake they make, but adjust premiums so their wallets feel at least some of it to the point where they actually think twice about eating another gallon of ice cream. Our government is already on the fast track to bankruptcy like Greece if we continue our current fiscal spending policies.

Taxing states of being makes little sense when perfectly good pigovian taxes could be employed in much more simple, straightforward, and fair ways.

Well, in general, I'm against extra taxes when possible. I'd rather leave more to private industry, but hey, I'll leave it at that. I think I've already hijacked this thread enough for now. If people continue to bring up this issue, maybe then I'll bloviate more.

 

[Therapist4Chnge]

Whopper, I guess I'd like to see some data that differential premiums would actually lead to better health. Because I think that would be pretty difficult to find, for very good reasons. Taxing states of being makes little sense when perfectly good pigovian taxes could be employed in much more simple, straightforward, and fair ways.

Some insurance companies have done this with large employer contracts (lower premiums for using their gym memberships, smoking cessation, etc), though I'd love to see it go the other way and penalize the irresponsible users/abusers within the healthcare system. For political reasons that go against reason, it will probably never happen, but that doesn't mean it isn't the best answer to a failing system.

Sadly our gov't encourages a sense of entitlement amongst its citizens, and now healthcare will be the next target of abuse. For anyone who believes otherwise, check out the data that came out of Massachusett's failed healthcare experiment.

 

[Suenya]

I know there has been evidence on both sides, but wasn't there a recent study that showed that smokers and obese people (<- self included) actually cost less per year they put money into the system?

It might be an artifact of early retirement and medicare or whatnot, but I think it showed that because of a higher rate of earlier mortality, on average being obese or smoking was less of a burden on the system. Individuals who live obviously were more expensive over the years, but as an average, the behaviors actually saved some amount of money.

I've seen papers going both ways, but IF it turned out that's right, do you think it's okay to charge either group more for health insurance? (For the sake of argument, say it's the govt doing so, because that seems most likely despite my libertarian wishes). They are likely to need extra treatment due to their behavior, but they are also less likely to need treatment for unrelated things, due to their increased mortality.

I would personally say no, since people are doing what they want and it saves people money (even if those that get away with it cost people more money). Of course, even if this is right, as technology progresses further, the mortality increase could disappear and then they might just be more expensive again, but in a period of time where as a group they cost less, I wonder if you think it would be okay to charge them more because some individuals end up costing more.

 

[daru1]

I agree with TP, let's get back on topic, I need to pay for MY Texas ranch!

 

[DrBacchi]

How much can you make as an addiction psychiatrist, and are there plenty of private practice opportunities? Is fellowship necessary, or can you also do it right after residency?

 

[whopper]

Agree with TP. I think I've hijacked this thread enough. If people still want to debate the healthcare issue let's start another thread.

As for addiction psychiatry, a fellowship is not needed, and I've not seen it make any difference with $$. It does, however, help you if you want to academically pursue more research in the field, obtain an academic position, or just out of self motivation want to know more.

I recommend anyone do fellowship if possible. My own experience in my fellowship has taught me much more than my general psychiatry residency and not just about forensics, but about psychiatry in general.

 

[OldPsychDoc]

Agree with TP. I think I've hijacked this thread enough. If people still want to debate the healthcare issue let's start another thread.

As for addiction psychiatry, a fellowship is not needed, and I've not seen it make any difference with $$. It does, however, help you if you want to academically pursue more research in the field, obtain an academic position, or just out of self motivation want to know more.

I recommend anyone do fellowship if possible. My own experience in my fellowship has taught me much more than my general psychiatry residency and not just about forensics, but about psychiatry in general.

A fellowship IS necessary if you wish to be a "Board Certified Addiction Psychiatrist". It is not at all necessary if you merely wish to treat addicts in your day to day practice.

(And no, there is not appreciably more money in it--unless you're the entrepeneurial type who opens one's own rehab facility...)

 

[MellowYellowCA]

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.

How likely is it that with healthcare reform, #4 will no longer be possible? Are we nearing a time in which we will not be able to choose our patients in private practice? or that we will be required to take insurance? or that there will be a cap on how much we are allowed to charge per visit?

Does the present healthcare bill(s) attempt to regulate any of this?

 

[Therapist4Chnge]

How likely is it that with healthcare reform, #4 will no longer be possible? Are we nearing a time in which we will not be able to choose our patients in private practice? or that we will be required to take insurance? or that there will be a cap on how much we are allowed to charge per visit?

Does the present healthcare bill(s) attempt to regulate any of this?

There will always be people willing to private pay for "the best" services, so I don't believe the market will go away.

 

[newpsych]

While I completely agree with an element of personal responsibly should ideally be included in healthcare coverage, the problem arises when you try to really distinguish where to draw the line. People who ride motorcycles, work on latters, do stupid things...these people contribute to the majority of our neurosurgery patients (outside of bleeds and tumors) which is a huge drain on our healthcare dollars. I have a patient right now who basically blew himself up cooking meth, his injuries, which have kept him in the burn ICU hanging on to life by a thread for over 3 weeks, were a direct result of his life choices. Are we supposed to just let him die? He hasn't reached thirty.

My point is "risky health behavior" is more than laziness.

 

[newpsych]

And I'll apologize in advance for all spelling/grammar errors, writing from phone in hand wraps bc I'm about to go boxing...so much fun if you haven't tried it...

 

[OldPsychDoc]

And I'll apologize in advance for all spelling/grammar errors, writing from phone in hand wraps bc I'm about to go boxing...so much fun if you haven't tried it...

Sounds like good stress relief from a week of dealing with cluster B's...

 

[michaelrack]

How likely is it that with healthcare reform, #4 will no longer be possible? Are we nearing a time in which we will not be able to choose our patients in private practice? or that we will be required to take insurance? or that there will be a cap on how much we are allowed to charge per visit?

I am not sure; the tea leaves aren't very clear right now

 

[Manicsleep]

I am not sure concierge psychiatry is really done in any significant way although it is probably possible. I am in a group where we have a few concierge primary care doctors. It is likely that this model will spread to other specialties eventually.

I had serious reservations about this model initially but their patients are almost never referred to psychiatry and they handle all the problems themselves including most minor procedures. Its almost like going back to the days of the old school doctor who did everything.

 

[notdeadyet]

I am not sure concierge psychiatry is really done in any significant way although it is probably possible. I am in a group where we have a few concierge primary care doctors. It is likely that this model will spread to other specialties eventually.

Not psychiatry, though.

In concierge primary care, the patient pays a high price for the accessibility of an unpleasant task (seeing his doctor).

For concierge psychiatry, can you imagine the abuse potential? Rich patients that you are beholden to 24/7? Scary...

 

[Manicsleep]

Not psychiatry, though.

In concierge primary care, the patient pays a high price for the accessibility of an unpleasant task (seeing his doctor).

For concierge psychiatry, can you imagine the abuse potential? Rich patients that you are beholden to 24/7? Scary...

Well, I have spoken to the concierge guys and its not an all or none model. Its not like you have concierge or you don't. Most of their patients are either older, richer and have medicare or relatively young with small children. Call that Tier 1. They then offer up to Tier 5 for various amounts per month starting at $50/month and going to a customized tier 4/5 plans which can be very expensive.

Also, its not the high price only for accessibility of an unpleasant task as you say, although that is partially true. In todays world of internet searches, patients are becoming very savvy with treatment/diagnosis while at the same time not having the expertise of a good physician. They get educated by their concierge doctor. I have one and a 30-45 minute visit is a big difference from a 10-15 minute visit of 2 years ago. 3 of the concierge doctors were chiefs, a couple are AOA and they have all graduated in the top 25% of their class from very good schools. We had a physician that most people loved but did not have the credentials above try to be a concierge doctor and he wasn't that successful.

These models are getting very complicated and sophisticated with time. Also, if you really want to make a lot of money, you have to be willing to put in the work and serve your patients. With psychiatry, it is definitely possible. I would just do the $50 dollar model to start where there are longer visits, next day appointments and contact by email/phone to be screened by mid level and returned by the physician in a 24 hour period. If it is too much work, increase the price. If more services need to be offered or are demanded, increase the price. If certain behaviors are unacceptable, don't allow them. I think the idea that only PCPs can do it is just not true although they are best placed. You think PCPs don't have patients with psychiatric illness? Trust me, they do and they deal with it and if they feel their model isn't working, they adjust it. You can decide what you are willing to do and for what price. We all already do that, in the concierge setting it is just spelled out.

 

[MellowYellowCA]

I am not sure concierge psychiatry is really done in any significant way although it is probably possible. I am in a group where we have a few concierge primary care doctors. It is likely that this model will spread to other specialties eventually.

I had serious reservations about this model initially but their patients are almost never referred to psychiatry and they handle all the problems themselves including most minor procedures. Its almost like going back to the days of the old school doctor who did everything.

I don't know much about concierge psychiatry, how is concierge psychiatry related to #4?

 

[Manicsleep]

I wasn't specifically replying to that post but the thread in general. That post was part of it. You were concerned about being forced to take insurance, others mentioned wealthy patients or paying for "the best" services.

So having wealthy patients and not taking insurance is one way but having wealthy patients who pay extra for premium non billable services and taking insurance is another way. You get to spend more time, do psychotherapy, treat patients the way its supposed to be done and get excellent reimbursement as well as job satisfaction.

 

[Majesty]

I would think that forensics is the most consistent answer.

Sleep is ok but most people don't want to hire psychiatrists as their sleep experts.

 

[sunlioness]

I would just do the $50 dollar model to start where there are longer visits, next day appointments and contact by email/phone to be screened by mid level and returned by the physician in a 24 hour period. I

Crap, all I do all that now for "free". I have no appointment scheduled for less than 30 minutes. I do all my own phone and email and all are returned within 24 hours. I do next day appointments, etc. etc. And all I get for it is whatever people's insurance companies say I deserve for a 90805. And to be honest, it's not very appreciated by patients and gets taken for granted a lot. I have people who feel I need to be at their beck and call 24/7. Like on Thursday, I saw a patient who hadn't been seen for 6 months even though she was supposed to be seen in three. She refused to come in at the recommended interval because she said she was "doing fine." All of sudden last week, her boyfriend dumps her and she's not doing fine anymore and demands to be seen because her "meds aren't working." I schedule her quickly. I review what's been going on and it seems that she was having some relapse of symptoms prior to the boyfriend thing, but that it was tolerable. I recommend more frequent visits with her psychotherapist and given that she was already having some symptom relapse offer the choice of changing her SSRI, which she elects to do. I tell her very clearly that this is not the magic answer . . . she needs time and more consistent contact with her therapist.

Based on her insurance, I know that I am going to have to do a prior authorization. I tell her so. I show her the form. "Don't go to the pharmacy," I say. "Until I call you and let you know that it's gone through." She voices understanding. I submit the auth within 30 minutes of her leaving my office. The next day, she calls and says, "OMG! Did you know my insurance requires an auth for this? You need to call my insurance company!!' At about the same time I receive a fax from her insurer saying the medication has been denied. So I call her back and tell her that the medication has been denied and that we need to submit an appeal. It's now 4pm on a Friday afternoon and I tell her it's not going to happen over the weekend. I call in a supply of her old med so she doesn't go without. She voices understanding. So yesterday, she calls my cell phone (which is my emergency number since I am solo and can't afford an answering service) and leaves a message saying, "OMG! Have you talked to my insurance company! I need a new medication NOW! This one isn't working and I can't deal anymore." I don't return her call. She calls again. When I don't answer, she calls again. When I don't answer she calls again. She hung up and re-dialed at least three times in a row. How long that went on for I don't know because after the third time, I turned my cell phone off for 30 minutes. There were no additional messages when I turned it back on. And I still plan to get back to her tomorrow during normal business hours. And all of this for just what her insurance deigns to pay me for the 90805 I billed on Thursday.

I have two other patients, a married couple, who when they scheduled their initial evaluations with me actually asked if I employed an office staff. I told them I didn't and they were pleased. That's why they didn't like their former psychiatrist. "I hate it that when I call him it's always the nurse who gets back to me." At the time, I didn't think much of it, but now several months later I recognize the red flag. These people are calling and emailing all the time. They hiccough after drinking soda pop and they're on the phone with me wanting to know if it's a med side effect. They feel a little stressed one day and they're on the phone with me wanting to know if their antidepressant dose needs to be increased. If it does need to be increased, they are quick to point out that they don't need to come in. "We can just do it over the phone." This means, of course, that Dr. Lioness doesn't get paid. Which in fairness, I don't think they actually realize.

So yeah, if people can get concierge rates to do what I am doing anyway. I say, go for it. Me? I'm getting out of solo practice and going back to inpatient. I'll be making more than twice what I am making now and it will be deposited into my account at regular intervals and I won't have to argue with insurance companies and/or patients to get it. I will be on call one week out of every 1-2 months during which time other professionals will be calling me and not patients. And I can't wait.

 

[Manicsleep]

Ouch Sun.

That sounds like pain but it also sounds like you would be a perfect person for a concierge service. Why not try it out before going to inpatient if you are going to leave the practice anyways.

Tell your patients that in January 2011, you will be going to a new model. 15 minute visits will be the norm and filling out forms, next day/same day visits costing 25 dollars extra. Phone calls/emails not regarding scheduling will be 50 dollars. Offer them a 50 dollar plan where all these will be free including 30 minute visits and add a 100 dollar plan where you will come see them with their PCP once as well as see them if they are every admitted to an inpatient hospital and coordinate their care with their physician.

PS. let me know how it goes, this is roughly how we are thinking of having ours set up.

 

[MissAmanda]

Crap, all I do all that now for "free". I have no appointment scheduled for less than 30 minutes. I do all my own phone and email and all are returned within 24 hours. I do next day appointments, etc. etc. And all I get for it is whatever people's insurance companies say I deserve for a 90805. And to be honest, it's not very appreciated by patients and gets taken for granted a lot. I have people who feel I need to be at their beck and call 24/7. Like on Thursday, I saw a patient who hadn't been seen for 6 months even though she was supposed to be seen in three. She refused to come in at the recommended interval because she said she was "doing fine." All of sudden last week, her boyfriend dumps her and she's not doing fine anymore and demands to be seen because her "meds aren't working." I schedule her quickly. I review what's been going on and it seems that she was having some relapse of symptoms prior to the boyfriend thing, but that it was tolerable. I recommend more frequent visits with her psychotherapist and given that she was already having some symptom relapse offer the choice of changing her SSRI, which she elects to do. I tell her very clearly that this is not the magic answer . . . she needs time and more consistent contact with her therapist.

Based on her insurance, I know that I am going to have to do a prior authorization. I tell her so. I show her the form. "Don't go to the pharmacy," I say. "Until I call you and let you know that it's gone through." She voices understanding. I submit the auth within 30 minutes of her leaving my office. The next day, she calls and says, "OMG! Did you know my insurance requires an auth for this? You need to call my insurance company!!' At about the same time I receive a fax from her insurer saying the medication has been denied. So I call her back and tell her that the medication has been denied and that we need to submit an appeal. It's now 4pm on a Friday afternoon and I tell her it's not going to happen over the weekend. I call in a supply of her old med so she doesn't go without. She voices understanding. So yesterday, she calls my cell phone (which is my emergency number since I am solo and can't afford an answering service) and leaves a message saying, "OMG! Have you talked to my insurance company! I need a new medication NOW! This one isn't working and I can't deal anymore." I don't return her call. She calls again. When I don't answer, she calls again. When I don't answer she calls again. She hung up and re-dialed at least three times in a row. How long that went on for I don't know because after the third time, I turned my cell phone off for 30 minutes. There were no additional messages when I turned it back on. And I still plan to get back to her tomorrow during normal business hours. And all of this for just what her insurance deigns to pay me for the 90805 I billed on Thursday.

I have two other patients, a married couple, who when they scheduled their initial evaluations with me actually asked if I employed an office staff. I told them I didn't and they were pleased. That's why they didn't like their former psychiatrist. "I hate it that when I call him it's always the nurse who gets back to me." At the time, I didn't think much of it, but now several months later I recognize the red flag. These people are calling and emailing all the time. They hiccough after drinking soda pop and they're on the phone with me wanting to know if it's a med side effect. They feel a little stressed one day and they're on the phone with me wanting to know if their antidepressant dose needs to be increased. If it does need to be increased, they are quick to point out that they don't need to come in. "We can just do it over the phone." This means, of course, that Dr. Lioness doesn't get paid. Which in fairness, I don't think they actually realize.

So yeah, if people can get concierge rates to do what I am doing anyway. I say, go for it. Me? I'm getting out of solo practice and going back to inpatient. I'll be making more than twice what I am making now and it will be deposited into my account at regular intervals and I won't have to argue with insurance companies and/or patients to get it. I will be on call one week out of every 1-2 months during which time other professionals will be calling me and not patients. And I can't wait.

All I can say is wow, what a shame, what was happening sounds really terrible - especially because I know not so many physicians are so accommodating to their patients. It seems like when you are accommodating, it is just taken advantage of.

Can someone explain or direct me to a good explanation of "concierge psychiatry" ... I am still in training and keep hearing about this, but don't actually know what it is?

Also are these problems with emailing and phone use more a problem in adult psychiatry than in child psychiatry? I can imagine they would be the case for both, I guess.

 

[MissAmanda]

Ouch Sun.

That sounds like pain but it also sounds like you would be a perfect person for a concierge service. Why not try it out before going to inpatient if you are going to leave the practice anyways.

Tell your patients that in January 2011, you will be going to a new model. 15 minute visits will be the norm and filling out forms, next day/same day visits costing 25 dollars extra. Phone calls/emails not regarding scheduling will be 50 dollars. Offer them a 50 dollar plan where all these will be free including 30 minute visits and add a 100 dollar plan where you will come see them with their PCP once as well as see them if they are every admitted to an inpatient hospital and coordinate their care with their physician.

PS. let me know how it goes, this is roughly how we are thinking of having ours set up.

This sounds like a good idea. However, won't your patients be upset if they send short emails or have 2 minute phone calls and it is $50? On the same token, this could be abused where they try to get the most bang for the buck and type out a 2 page email of concerns and expect you to get back to them, still for $50.

I want to be available for my patients in serious cases, but I too am interested in ways to prevent these types of abuses?

 

[sunlioness]

That sounds like pain but it also sounds like you would be a perfect person for a concierge service. Why not try it out before going to inpatient if you are going to leave the practice anyways.

I'm already in the process of closing and my new job starts in November. I like your idea though and wish you every success with it. For me, I still don't think it would make my work any more enjoyable at this point because I think I fundamentally just don't have the "lobes for business" (to borrow a phrase from the Ferengi on Star Trek). I mean right now I charge people a $50 fee for missed appointments or appointments not canceled with 24 hours notice. Do you know how hard it is to collect that when you don't pay for some sort of agency to do it for you? People blow me off all the time. I have had people yell at me for this. I have had people give me sob stories over this. I have had people avoid these fees by not scheduling to see me to the point I've discharged them for failure to follow up with recommended appointments. And these fees shouldn't be a surprise. Not only is it fully spelled out in the material they must sign at their initial visit, I also verbally make them aware of at that time when I take their paperwork from them and ask them if they have any questions. I went into this field because I'm interested in psychiatry not because I like chasing down mentally ill people for $50 no show fees. I should mention that this isn't everyone. I do have several patients who not only remember that they signed something to this effect but who will bring it up and offer to pay it before I do. I really appreciate that.

Also, you have to be careful what your contracts with various insurance companies allow you to do. For instance, some insurers don't allow me to bill their patients for anything. Medical assistance is like this and thus I can't charge my MA patients no show fees.

All in all, I think if I ever do private practice again, I would only do it by either starting or joining a group practice with at least a few other physicians. Then together we could afford to hire an office staff, a collection agency, etc and probably even a lawyer to figure out all the ins and outs of everything and then go from there. But for now, I'm actually kind of burned out on outpatient psychiatry and am looking forward to a change.

 

[strangeglove]

Crap, all I do all that now for "free". I have no appointment scheduled for less than 30 minutes. I do all my own phone and email and all are returned within 24 hours. I do next day appointments, etc. etc. And all I get for it is whatever people's insurance companies say I deserve for a 90805. And to be honest, it's not very appreciated by patients and gets taken for granted a lot. I have people who feel I need to be at their beck and call 24/7. Like on Thursday, I saw a patient who hadn't been seen for 6 months even though she was supposed to be seen in three. She refused to come in at the recommended interval because she said she was "doing fine." All of sudden last week, her boyfriend dumps her and she's not doing fine anymore and demands to be seen because her "meds aren't working." I schedule her quickly. I review what's been going on and it seems that she was having some relapse of symptoms prior to the boyfriend thing, but that it was tolerable. I recommend more frequent visits with her psychotherapist and given that she was already having some symptom relapse offer the choice of changing her SSRI, which she elects to do. I tell her very clearly that this is not the magic answer . . . she needs time and more consistent contact with her therapist.

Based on her insurance, I know that I am going to have to do a prior authorization. I tell her so. I show her the form. "Don't go to the pharmacy," I say. "Until I call you and let you know that it's gone through." She voices understanding. I submit the auth within 30 minutes of her leaving my office. The next day, she calls and says, "OMG! Did you know my insurance requires an auth for this? You need to call my insurance company!!' At about the same time I receive a fax from her insurer saying the medication has been denied. So I call her back and tell her that the medication has been denied and that we need to submit an appeal. It's now 4pm on a Friday afternoon and I tell her it's not going to happen over the weekend. I call in a supply of her old med so she doesn't go without. She voices understanding. So yesterday, she calls my cell phone (which is my emergency number since I am solo and can't afford an answering service) and leaves a message saying, "OMG! Have you talked to my insurance company! I need a new medication NOW! This one isn't working and I can't deal anymore." I don't return her call. She calls again. When I don't answer, she calls again. When I don't answer she calls again. She hung up and re-dialed at least three times in a row. How long that went on for I don't know because after the third time, I turned my cell phone off for 30 minutes. There were no additional messages when I turned it back on. And I still plan to get back to her tomorrow during normal business hours. And all of this for just what her insurance deigns to pay me for the 90805 I billed on Thursday.

I have two other patients, a married couple, who when they scheduled their initial evaluations with me actually asked if I employed an office staff. I told them I didn't and they were pleased. That's why they didn't like their former psychiatrist. "I hate it that when I call him it's always the nurse who gets back to me." At the time, I didn't think much of it, but now several months later I recognize the red flag. These people are calling and emailing all the time. They hiccough after drinking soda pop and they're on the phone with me wanting to know if it's a med side effect. They feel a little stressed one day and they're on the phone with me wanting to know if their antidepressant dose needs to be increased. If it does need to be increased, they are quick to point out that they don't need to come in. "We can just do it over the phone." This means, of course, that Dr. Lioness doesn't get paid. Which in fairness, I don't think they actually realize.

So yeah, if people can get concierge rates to do what I am doing anyway. I say, go for it. Me? I'm getting out of solo practice and going back to inpatient. I'll be making more than twice what I am making now and it will be deposited into my account at regular intervals and I won't have to argue with insurance companies and/or patients to get it. I will be on call one week out of every 1-2 months during which time other professionals will be calling me and not patients. And I can't wait.

And people ask why it is important for psychiatrists to learn about psychodynamic psychotherapy?!