CAP job offer

[Merely]

Based on the suggestions, I am convinced that I should stay away from this once unless they negotiate higher salary and I don't have to worry of doing private, enjoy benefits and 4 days of work week. If I have any more appetite, I can do their optional weekend inpatient call for around 25 beds unit and you get around 2200 for rounding both days/no phone calls involved

Omg no...2k is not enough for weekend rounding..

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[DD214_DOC]

I have to ask. I am CAPs and leaving the military. I accepted a position that I know compensated less than I could make due to the job itself (dev peds clinic, no call, faculty appointment at the med school, outpatient only, etc.) but did not realize what the extra income would actually mean in the, "real world".

I started looking for other opportunities to increase income to around what it should be, and have been really shocked at how few there actually are, and how little they seem to pay. I know there's a need in the area I will be living, but it appears nobody is trying to fill this need. The 3-4 positions I did find were paying barely $200k, which is about what I'll be making with the position in dev peds. (One added benefit is I won't be managing high-risk stuff, safety concerns, and any of that. Nice break after being the only CAPS for a huge army installation for several years).

So, am I not looking in the right places?

 

[dl2dp2]

I have to ask. I am CAPs and leaving the military. I accepted a position that I know compensated less than I could make due to the job itself (dev peds clinic, no call, faculty appointment at the med school, outpatient only, etc.) but did not realize what the extra income would actually mean in the, "real world".

I started looking for other opportunities to increase income to around what it should be, and have been really shocked at how few there actually are, and how little they seem to pay. I know there's a need in the area I will be living, but it appears nobody is trying to fill this need. The 3-4 positions I did find were paying barely $200k, which is about what I'll be making with the position in dev peds. (One added benefit is I won't be managing high-risk stuff, safety concerns, and any of that. Nice break after being the only CAPS for a huge army installation for several years).

So, am I not looking in the right places?

This is really common. A lot of people on the job market are like, hey I thought academia pays poorly, and when I go around asking for a new job, I get numbers that are JUST AS LOW if not lower. WTF is going on?

1) "jobs" (i.e. facilities hiring staff), typically get bottom barrel candidates and/or have very high turnovers. These facilities typically ALWAYS have openings because their openings are staffed by either govt (read: Medicaid) block grand line items, or is there to exploit people. There's typically very little room to negotiate, because it's not in their interest to do an impossible job to smooth out need. If patients don't get seen, nobody cares. If people kill themselves waiting, it's not the problem of the facility.

2) the truly good jobs do not advertise because first of all, they often aren't hiring because they are either solo or very small practices. secondly when you OWN the facility that generates the revenue stream, you can set your own rules, which makes the job infinitely better. Any job that offers a fixed salary will be low and painful (exceptions: academia, which is really a very different beast, and perhaps some small proportion of govt jobs i.e. VAs/Kaiser). You need your salary to be tied to RVUs otherwise your employers goals and yours never align.

Psychiatry is a very unique field in medicine with several facts you need to think about.
1. > 40% of practitioners in outpatient work don't take ANY or very few insurances.
2. substantially growing in care utilization due to removal of mental health stigma, etc
3. very low practice overhead
4. low penetrance of large corporate private practice. almost all private work is small group/solo.

The answer to your question is very simple. Start your own practice or join a very small group practice, through word of mouth. You'll find that people with your skills in the community in that kind of context can with some reasonable amount of work make 2-3x the salary offered at a facility. I personally don't know a SINGLE child psychiatrist in private practice full time who makes less than 300-350k. Several make substantially more. Given the low overhead and administrative costs and increasing demand, there's simply little value for administrators to build large systems for behavioral health, hence you won't find these kinds of jobs residing in a facility.

 

[Merely]

I wish families would sue the local hospital if their family member commits suicide waiting for a psych appointment. That way they would actually start taking things more seriously lol

 

[Shufflin]

the truly good jobs aren't advertising because in many cases they already have people in mind to approach for the position.

that's why i keep saying you gotta get your feet wet somewhere, and then build connections

 

[hamstergang]

I wish families would sue the local hospital if their family member commits suicide waiting for a psych appointment. That way they would actually start taking things more seriously lol

This is ridiculous. There's a shortage of psychiatrists -- how is a hospital supposed to solve that issue?

The administration at my hospital keeps caring that I'm either not accepting new patients or the wait is 3-4 months (I do outpatient CAP for the hospital). Thankfully, my chairman and I both know that the problem is the shortage of psychiatrists, and I can't solve that by just doing a bunch more evals which leave me inadequate room for follow ups.

 

[Merely]

This is ridiculous. There's a shortage of psychiatrists -- how is a hospital supposed to solve that issue?

The administration at my hospital keeps caring that I'm either not accepting new patients or the wait is 3-4 months (I do outpatient CAP for the hospital). Thankfully, my chairman and I both know that the problem is the shortage of psychiatrists, and I can't solve that by just doing a bunch more evals which leave me inadequate room for follow ups.

Yeah you’re probably right..I’m sure it has to do with a shortage and not greed or admins choosing money at the cost of human life

 

[Sushirolls]

I wish families would sue the local hospital if their family member commits suicide waiting for a psych appointment. That way they would actually start taking things more seriously lol

I like your sentiments for things to be better but this action if ever succueful would have massive legal ramifications rippling through healthcare. This would then set the precident that if I have a lawn with brown spot, in summer time and I'm unable to get a landscape company to fix it I would then be able to sue them because of emotional damages suffered from the poor aesthics.

Its one thing to sue an HMO like kaiser or the VA where they are charged with delivery of those services by the nature of their contract, but no one else is.

In summary I disagree with this suggested course of action.

 

[Merely]

I like your sentiments for things to be better but this action if ever succueful would have massive legal ramifications rippling through healthcare. This would then set the precident that if I have a lawn with brown spot, in summer time and I'm unable to get a landscape company to fix it I would then be able to sue them because of emotional damages suffered from the poor aesthics.

Its one thing to sue an HMO like kaiser or the VA where they are charged with delivery of those services by the nature of their contract, but no one else is.

In summary I disagree with this suggested course of action.

I too agree with my sentiments but probably not the actual policy set forth

 

[calvnandhobbs68]

I have to ask. I am CAPs and leaving the military. I accepted a position that I know compensated less than I could make due to the job itself (dev peds clinic, no call, faculty appointment at the med school, outpatient only, etc.) but did not realize what the extra income would actually mean in the, "real world".

I started looking for other opportunities to increase income to around what it should be, and have been really shocked at how few there actually are, and how little they seem to pay. I know there's a need in the area I will be living, but it appears nobody is trying to fill this need. The 3-4 positions I did find were paying barely $200k, which is about what I'll be making with the position in dev peds. (One added benefit is I won't be managing high-risk stuff, safety concerns, and any of that. Nice break after being the only CAPS for a huge army installation for several years).

So, am I not looking in the right places?

200 is low for a full time clinical adult position, much less child, even in employed positions with big hospital systems. That is in line for the couple academic places I've been at though.

 

[hamstergang]

Yeah you’re probably right..I’m sure it has to do with a shortage and not greed or admins choosing money at the cost of human life

What are you talking about? I'm trying to guess what scenario you're envisioning it I can't. Hospital greed typically forces doctors to have shorter visits and thereby get more patients in.

Maybe you mean that the hospital won't pay enough to attract a psychiatrist. But it's not as though the psychiatrists turning down the hospital jobs then disappear and don't work anywhere. The number of psychiatrists available doesn't change when a hospital pays them more.

So what is it then that you're talking about?

 

[Merely]

What are you talking about? I'm trying to guess what scenario you're envisioning it I can't. Hospital greed typically forces doctors to have shorter visits and thereby get more patients in.

Maybe you mean that the hospital won't pay enough to attract a psychiatrist. But it's not as though the psychiatrists turning down the hospital jobs then disappear and don't work anywhere. The number of psychiatrists available doesn't change when a hospital pays them more.

So what is it then that you're talking about?

Yeah I was talking about a hospital that doesn’t pay enough to attract which results in a shortage in that particular area and a saturation in other areas where they’re willing to pay

 

[dl2dp2]

The number of psychiatrists available doesn't change when a hospital pays them more.

This is not entirely true. If hospital jobs paid uniformly 500k a pop, many private psychiatrists would probably come out of the woodwork and start working for the hospital.

Interestingly, this sort of thing did happen once in medicine, during the HMO consolidation, and some in the late 90s early 2000s, when hospitals bought up PMD practices and gave them all a 30% pay raise because they can now charge "facility fee". Sadly, CMS heard about it 10 years later and now decided to start "location neutral reimbursement". I don't think hospitals are any more greedy than anyone else. As is, they aren't greedy because they are willing to do the work of try to figure out how to deliver care at a much lower cost to a population that's arguably more difficult. The bottom line is that timely and good quality, evidence based psychiatric treatment is very expensive. The money either goes to the provider or the institution hiring the provider.

 

[hamstergang]

This is not entirely true. If hospital jobs paid uniformly 500k a pop, many private psychiatrists would probably come out of the woodwork and start working for the hospital.

Yes, but those psychiatrists existed before this hospital upped the salary to $500k. In private practice, the psychiatrists are seeing patients. How does the hospital hiring the psychiatrists get more patients seen?

 

[clausewitz2]

Yes, but those psychiatrists existed before this hospital upped the salary to $500k. In private practice, the psychiatrists are seeing patients. How does the hospital hiring the psychiatrists get more patients seen?

Low-quality high-volume brief admissions

 

[dl2dp2]

Low-quality high-volume brief admissions

That's one way. Another way is for the hospitals to collectively bargain for a higher reimbursement through insurance "carve-outs", so the same billing codes all of a sudden gets paid 30% more if the right people see these patients.

Sadly, this doesn't work in psychiatry. 1) many of us don't take insurance, so carve outs don't benefit us. 2) hospitals start to realize that insurance companies don't really care about care rationing, and refuses to negotiate a higher reimbursement. Why? Because generally people can wait when they are depressed, but they can't when they need bypass surgery. Insurance companies really don't care about how long you wait.

So then what happens is that hospital hired psychiatrists start to convert to cash also! Which then of course worsens the shortage (for those who can only afford to use insurance). It's like rent control in NYC. Rent control worsens shortage and makes market rates rent even higher! Isn't economics fascinating? Poorly designed cost control measures end up costing more in the long run through non-linear market responses.

 

[DD214_DOC]

This is really common. A lot of people on the job market are like, hey I thought academia pays poorly, and when I go around asking for a new job, I get numbers that are JUST AS LOW if not lower. WTF is going on?

1) "jobs" (i.e. facilities hiring staff), typically get bottom barrel candidates and/or have very high turnovers. These facilities typically ALWAYS have openings because their openings are staffed by either govt (read: Medicaid) block grand line items, or is there to exploit people. There's typically very little room to negotiate, because it's not in their interest to do an impossible job to smooth out need. If patients don't get seen, nobody cares. If people kill themselves waiting, it's not the problem of the facility.

2) the truly good jobs do not advertise because first of all, they often aren't hiring because they are either solo or very small practices. secondly when you OWN the facility that generates the revenue stream, you can set your own rules, which makes the job infinitely better. Any job that offers a fixed salary will be low and painful (exceptions: academia, which is really a very different beast, and perhaps some small proportion of govt jobs i.e. VAs/Kaiser). You need your salary to be tied to RVUs otherwise your employers goals and yours never align.

Psychiatry is a very unique field in medicine with several facts you need to think about.
1. > 40% of practitioners in outpatient work don't take ANY or very few insurances.
2. substantially growing in care utilization due to removal of mental health stigma, etc
3. very low practice overhead
4. low penetrance of large corporate private practice. almost all private work is small group/solo.

The answer to your question is very simple. Start your own practice or join a very small group practice, through word of mouth. You'll find that people with your skills in the community in that kind of context can with some reasonable amount of work make 2-3x the salary offered at a facility. I personally don't know a SINGLE child psychiatrist in private practice full time who makes less than 300-350k. Several make substantially more. Given the low overhead and administrative costs and increasing demand, there's simply little value for administrators to build large systems for behavioral health, hence you won't find these kinds of jobs residing in a facility.

Thank you! This is a exceptional advice and useful information. While the military saved me money by reducing overall student loan debt, it also put me about 5 years behind the learning curve for everything on the outside.

Ironically, a few days after posting on this thread, I stumbled on to something that is a great fit for me and what I believe to be an excellent, "first step", to transition out of the military, build up cash flow, and establish myself in the community in preparation for future endeavors.

I am definitely going to jump ship to this new opportunity, which is 1099 work at nearly twice the salary my original place was going to pay. I will also be reimbursed on license-related expenses and be in a medical director position. I had my original contract reviewed, and it's actually more terrible than I thought. Not only is the compensation abysmal (academic salary for what is technically not an academic position -- it's a private, non-profit organization with an academic affiliation. I'm thinking they are using the academic affiliation to justify lower compensation. It was also a position that was advertised, when looking at it again, for a child psychiatrist or dev pediatrician -- also why it pays crap), but the RVU production bonus was capped at $10k, and they also wrote the contract for an additional year than what I said I wanted but didn't catch. Thankfully I can easily get out of it due to an effective date in the future.

This new gig I'm moving over to actually came out of someone contacting me based on my LinkedIn profile.

 

[Haldol Lorazepam]

A little update on the original offer..They are planning to start a new psych residency on site and I would be expected to spend %20 of the time in teaching activities vs %80 clinical. Wrvu threshold was reduced to from 3750 to 3100, after which it would be $63 for each extra wrvu. Plan is to see initial eval in 75 min& f/u in 30 min. No show rate is around %25.

 

[splik]

A little update on the original offer..They are planning to start a new psych residency on site and I would be expected to spend %20 of the time in teaching activities vs %80 clinical. Wrvu threshold was reduced to from 3750 to 3100, after which it would be $63 for each extra wrvu. Plan is to see initial eval in 75 min& f/u in 30 min. No show rate is around %25.

275k for 3100 wRVUs is very good. $63 for additional RVUs is also very good. 20% protected time for teaching is good. However you should request 90 mins for new evals if you are doing child psych. Or alternatively, that you get 2x 1 hr separate visits for initial evaluation of children (with and without parents). Particularly if you are getting complex cases. I suspect in this locale it's not going to be lots of straightforward ADHD. Also remember if you are on a production model (once the guarantee disappears) that you are effectively not being paid to teach (unless they work something out) and get no paid vacation or sick days (since everyday taken off detracts from productivity). You should also retain the ability to schedule follow ups for 45mins in cases where that is indicated. 20-30 mins may be fine for stable pts, but you may have more complex pts who need more time. Make sure that you are able to use the psychotherapy add-on codes (this is not possible in some cmhc settings) because if you not you will have a much harder time meeting RVU requirements. the 1:4 inpt call coverage is still bad.

Clarify how they deal with no-shows. Overbooking can be bad. But once on productivity, a high no show without overbookings will dent your income.

The level of support staff is also important. Do they have MAs/nurses to help with prior authorizations? Is there is social worker or someone who will be answering pt calls? If you have to do all that stuff yourself, you are stuck.

 

[Haldol Lorazepam]

Thanks so much, splik! That was very helpful! I will definitely keep all of the above in mind as negotiations continue..

 

[Fabio001]

Hey all, I have a CAP position I'm looking at very seriously that I would love some feedback on, and it fits well within the title of this thread. I'm intentionally being somewhat vague and I hope you all will forgive me.

This is a full time position in a moderately sized city on the western side of the country. It is entirely outpatient and I'd be employed by a CMHC. Salary is $300,000 with a 3 years contract, and $15,000 sign-on/relocation bonus. 90 minute new evals, 30 minute follow-ups, total of 32 patient contact hours per week (four 10's with 2 admin hours per day). 15% no-show rate. 5 weeks of PTO plus 2 weeks of CME per year. No productivity pay. Mandatory call a few weeks a year cross-covering and handling admissions to the inpatient unit from home overnight (pays $800 for the week and some NP's have been interested in doing more of this work, so may be able to be given away).

Additional stuff: There is opportunity to work one or two days in another clinic, one with much higher percentage private pay patients. Two half-days per week are with a resident and are completely protected (I'm 99% sure I heard this right; I know!). Support is primarily a Nurse/MA that is tied to me regardless of site. Most patients also have a case manager.

Any thoughts or insights would be greatly appreciated, particularly as they relate to items that I should be sure are clearly spelled out in the contract.

 

[TexasPhysician]

Hey all, I have a CAP position I'm looking at very seriously that I would love some feedback on, and it fits well within the title of this thread. I'm intentionally being somewhat vague and I hope you all will forgive me.

This is a full time position in a moderately sized city on the western side of the country. It is entirely outpatient and I'd be employed by a CMHC. Salary is $300,000 with a 3 years contract, and $15,000 sign-on/relocation bonus. 90 minute new evals, 30 minute follow-ups, total of 32 patient contact hours per week (four 10's with 2 admin hours per day). 15% no-show rate. 5 weeks of PTO plus 2 weeks of CME per year. No productivity pay. Mandatory call a few weeks a year cross-covering and handling admissions to the inpatient unit from home overnight (pays $800 for the week and some NP's have been interested in doing more of this work, so may be able to be given away).

Additional stuff: There is opportunity to work one or two days in another clinic, one with much higher percentage private pay patients. Two half-days per week are with a resident and are completely protected (I'm 99% sure I heard this right; I know!). Support is primarily a Nurse/MA that is tied to me regardless of site. Most patients also have a case manager.

Any thoughts or insights would be greatly appreciated, particularly as they relate to items that I should be sure are clearly spelled out in the contract.

Define “few weeks of call”. How busy are they? What are you managing at night?

 

[Fabio001]

Define “few weeks of call”. How busy are they? What are you managing at night?

3 or 4 weeks per year. I don't have a ton of details beyond that I would be covering overnight admissions to an adult inpatient unit (doc to docs with outside hospitals, putting In admission orders, etc.) cross covering standard ibuprofen orders and the like on admitted patients, restraint orders, and maybe occasionally handling a transfer to an ED. I was also told usually no calls during the night and rarely more than 2, and that I would never need to come in because of a call issue.

 

[Merovinge]

Hey all, I have a CAP position I'm looking at very seriously that I would love some feedback on, and it fits well within the title of this thread. I'm intentionally being somewhat vague and I hope you all will forgive me.

This is a full time position in a moderately sized city on the western side of the country. It is entirely outpatient and I'd be employed by a CMHC. Salary is $300,000 with a 3 years contract, and $15,000 sign-on/relocation bonus. 90 minute new evals, 30 minute follow-ups, total of 32 patient contact hours per week (four 10's with 2 admin hours per day). 15% no-show rate. 5 weeks of PTO plus 2 weeks of CME per year. No productivity pay. Mandatory call a few weeks a year cross-covering and handling admissions to the inpatient unit from home overnight (pays $800 for the week and some NP's have been interested in doing more of this work, so may be able to be given away).

Additional stuff: There is opportunity to work one or two days in another clinic, one with much higher percentage private pay patients. Two half-days per week are with a resident and are completely protected (I'm 99% sure I heard this right; I know!). Support is primarily a Nurse/MA that is tied to me regardless of site. Most patients also have a case manager.

Any thoughts or insights would be greatly appreciated, particularly as they relate to items that I should be sure are clearly spelled out in the contract.

The call sounds a bit meh, but its 1:12 so I could definitely live with it. Otherwise that job sounds pretty ideal, 1/4 time with a resident, dedicated support staff, 4 day week, 7 weeks combined PTO with $305k flat salary (awesome that no-shows help you). Retirement accounts/matching, holidays coming out of PTO, non-compete clauses are a few questions I would have but I would definitely get more info.