collaborative care contract work

[theduderino]

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Hello. I'm thinking of doing some contract work in collaborative care. The org I'd work for roughly follows the U Washington model (registry based recommendations with a master's level therapist/care manager intermediary between psychiatry and PCP; recommendations passed along, no direct clinical contact w/ patients). I'm not sure how much I should realistically ask for as the "billing" is not based on CPT codes/payer mix, but whatever potential savings/increased psychiatric access the insurance payer has estimated.

I'm also curious what people think about the liability that goes with this kind of work. I'd be making clinical recommendations but not actually seeing patients or prescribing medications. Patients with SMI are essentially screened out, as are obvious signs of psychiatric + medical acuity (suicidality, violent ideation, ambulatory detox etc.)

 

[splik]

the liability is low. There were all sorts of liability concerns that the anti-collaborative care movement were claiming (collaborative care was actually quite controversial up until a few years ago with people fearing it would be the death of psychiatry!). Ask for an hourly rate that would be agreeable to you. better yet, ask them how much they are offering and negotiate up. There are actually CPT codes for CoCM now they just dont pay very well. some models are paid through block grants from state or federal sources. Others are capitated models (sounds like that is the case for you).

 

[nexus73]

I would ask for $200/hr. This type of work is saving the health system money. Lots of money from reduced psych hospitalizations to reduced medical disease complications and thus reduced medical admissions. This is backed up in research. The quoted claim is $6 saved for every $1 spent.

 

[Merovinge]

I would ask for $200/hr. This type of work is saving the health system money. Lots of money from reduced psych hospitalizations to reduced medical disease complications and thus reduced medical admissions. This is backed up in research. The quoted claim is $6 saved for every $1 spent.

Makes me sad that this is the asking rate per billable hour for psychiatrists. Many CPAs and financial advisors with bill around this level and junior lawyers in essentially the residency stage of their career far outstrip this. I recognize this is a position with very low overhead but that hourly rate really feels like it sells our immense amount of training short unless someone plans to glide through this work and not provide diligent hours worked.

 

[nexus73]

Makes me sad that this is the asking rate per billable hour for psychiatrists. Many CPAs and financial advisors with bill around this level and junior lawyers in essentially the residency stage of their career far outstrip this. I recognize this is a position with very low overhead but that hourly rate really feels like it sells our immense amount of training short unless someone plans to glide through this work and not provide diligent hours worked.

I’d like to get paid more. If psychiatrists were actually paid $200/hour full time it would be nearly $400K per year.

 

[calvnandhobbs68]

Makes me sad that this is the asking rate per billable hour for psychiatrists. Many CPAs and financial advisors with bill around this level and junior lawyers in essentially the residency stage of their career far outstrip this. I recognize this is a position with very low overhead but that hourly rate really feels like it sells our immense amount of training short unless someone plans to glide through this work and not provide diligent hours worked.

I’d like to get paid more. If psychiatrists were actually paid $200/hour full time it would be nearly $400K per year.

Yeah @Merovinge I get what you're saying but there's a large difference between what those lawyers and CPAs bill and what they actually bring home. Very few of them actually bring home anywhere near $200/hr if you look at the average salaries.

However, I'd certainly start higher than 200/hr and let them try to negotiate you down (especially because they won't be paying you a full time salary). Contractor rates are much higher than full time employee rates. I'd start at $300/hr that way it seems like a great deal for them if they get you down to 200ish/hr. 300+/hr is not at all unreasonable for a psychiatrist to bill for private practice so should be presented as the amount of money you're losing to work for them.

 

[Merovinge]

Yeah @Merovinge I get what you're saying but there's a large difference between what those lawyers and CPAs bill and what they actually bring home. Very few of them actually bring home anywhere near $200/hr if you look at the average salaries.

However, I'd certainly start higher than 200/hr and let them try to negotiate you down (especially because they won't be paying you a full time salary). Contractor rates are much higher than full time employee rates. I'd start at $300/hr that way it seems like a great deal for them if they get you down to 200ish/hr. 300+/hr is not at all unreasonable for a psychiatrist to bill for private practice so should be presented as the amount of money you're losing to work for them.

Salary would depend on how many billable hours/week other professionals are doing. Some actually are completing 40+ but many are much less, this would also be true for psychiatrists though who likely average around 30 billable hours/week. Keep in mind that many of those professionals are having $ siphoned off to partners of the firm (beyond overhead) when looking at salaries, this does not change the reality of what the customer is paying for the service.

I’d like to get paid more. If psychiatrists were actually paid $200/hour full time it would be nearly $400K per year.

That would be before any expenses (malpractice, CME, license, business needs), benefits, FICA, etc as an independent contractor. That's really not an exceptional rate of pay by any stretch of the imagination for a board certified psychiatrist. PP hourly rates around me start around double that (again there is certainly infrastructure/overhead cost going into this but that is still a huge difference). So many people in the business/finance/law world make more than this/year with less training, less risk, less life/death weighing on their heads when they go to sleep at night. I am exposed to a large number of these through extended family so maybe my perspective is different than others but I think most MD's doing full-time work for salaries around $300k or less are being vastly underpaid compared to both revenue generated and value-added to society.

 

[Candidate2017]

So many people in the business/finance/law world make more than this/year with less training, less risk, less life/death weighing on their heads when they go to sleep at night. I am exposed to a large number of these through extended family so maybe my perspective is different than others but I think most MD's doing full-time work for salaries around $300k or less are being vastly underpaid compared to both revenue generated and value-added to society.

Actually, most business/law people don't take home what they bill (though partners/owners of these firms do take home their $1000+/hr fees plus the lion's share of what their employees bill).

But these free market CPA or lawyer fees (willingly paid by large corporate clients for the most part) can't be compared to physician rates set by insurance/government. How many patients can pay $20,000-$50,000 for a week of inpatient psych hospitalization? Meanwhile, $20,000-$50,000 a week is less than what a large corporation spends for legal/accounting/consulting fees. As an aside, $50,000 a day is actually less than what many hospital CEOs make.

What we do is objectively way less valuable than what finance people and lawyers do for large corporations. How do I know this? The average payout for malpractice death is $600,000. Meanwhile, finance people and lawyers working on transactions, each worth billions of dollars, keep capital flowing and jobs maintained, which arguably helps with societal mental health and prevents more suicides than any psychiatrist could in their entire career. Refilling Adderall, weaning a patient off Xanax, convincing a patient to cut down cannabis, getting an anorexic patient to gain weight, or even helping a doctor control their depression touches much fewer lives in the grand scheme of things.

Even the lobbyists and lawyers paid by Pfizer, Moderna, etc to help get COVID vaccines, treatments, and tests approved early will save tens of thousands of lives worldwide per week of early approval. And make billions of dollars or more, some of which will be funneled back for research, enrich pension funds, provide scholarships, etc.

 

[Merovinge]

Actually, most business/law people don't take home what they bill (though partners/owners of these firms do take home their $1000+/hr fees plus the lion's share of what their employees bill).

But these free market CPA or lawyer fees (willingly paid by large corporate clients for the most part) can't be compared to physician rates set by insurance/government. How many patients can pay $20,000-$50,000 for a week of inpatient psych hospitalization? Meanwhile, $20,000-$50,000 a week is less than what a large corporation spends for legal/accounting/consulting fees. As an aside, $50,000 a day is actually less than what many hospital CEOs make.

What we do is objectively way less valuable than what finance people and lawyers do for large corporations. How do I know this? The average payout for malpractice death is $600,000. Meanwhile, finance people and lawyers working on transactions, each worth billions of dollars, keep capital flowing and jobs maintained, which arguably helps with societal mental health and prevents more suicides than any psychiatrist could in their entire career. Refilling Adderall, weaning a patient off Xanax, convincing a patient to cut down cannabis, getting an anorexic patient to gain weight, or even helping a doctor control their depression touches much fewer lives in the grand scheme of things.

Even the lobbyists and lawyers paid by Pfizer, Moderna, etc to help get COVID vaccines, treatments, and tests approved early will save tens of thousands of lives worldwide per week of early approval. And make billions of dollars or more, some of which will be funneled back for research, enrich pension funds, provide scholarships, etc.

Average payout for malpractice death is a very unusual way to value life, if you look at how life is valued by the courts or by independent adjudicators (such as after 911), average values are closer to $10,000,000. This is discussed in multiple sources both in the law and by economists. The number one cause of morbidity and loss of economic function worldwide is depression, this has been well delineated by the WHO for many years. Lifesaving work, particularly in younger individuals, is worth millions of dollars in net-GDP to the country, although simply viewing human life and improvement in suffering in a $$ only context is definitely missing a significant piece of the picture.

I am not sure how to follow inpatient psychiatric hospitalization fees that you are quoting which have nothing to do with the fees the psychiatrist is charging. This is akin to saying the price to build a new skyscraper is 10 billion and thus architects are directly attributable for a 10 billion dollar cost. You point out the economic benefit of COVID treatment (which is obviously dramatic) being pushed out by lawyers and lobbyists and completely neglect the large amount of economic harm caused by crony capitalism and the substantive rent-seeking behaviors involved in these fields, particularly at the level of national governance.

I will assure that not every lawyer or person in finance A) operates on exclusively billion dollar + transactions B) generate value over replacement that is even necessarily positive. If we took each stock picker in the last 2 decades and saw the fees they charged and compared that to having each of those investments in a broad based index fund, well past the time that noble prizing winning research indicated this being the better course, you would see astronomical net society fees paid that directly worsen standard of living for the populace as a whole.

I will end by saying I will strongly agree to disagree, after re-reading your post on several occasions I have absolutely no idea why you would choose to go into medicine with that world view, but to each their own.

 

[Mass Effect]

I'm confused. Why would an organization pay you $200/hr+ to give recommendations for a patient you haven't seen (I understand that's the collab care framework) rather than them saving that money and either hiring a psychiatrist or referring out despite wait times? When you say organization, I assume hospital group or private practice group which could probably hire a psychiatrist to see the patients either under salary or 1099 for less than what they'd be paying you.

 

[hamstergang]

I'm confused. Why would an organization pay you $200/hr+ to give recommendations for a patient you haven't seen (I understand that's the collab care framework) rather than them saving that money and either hiring a psychiatrist or referring out despite wait times? When you say organization, I assume hospital group or private practice group which could probably hire a psychiatrist to see the patients either under salary or 1099 for less than what they'd be paying you.

There aren't enough psychiatrists to see all the patients. In a collaborative care model, the psychiatrist is helping multiple primary care doctors manage more patients. Plus, it helps the primary care doctors to feel more comfortable managing some of the basic psychiatric issues on their own without needing to get every patient to a psychiatrist.

 

[calvnandhobbs68]

I'm confused. Why would an organization pay you $200/hr+ to give recommendations for a patient you haven't seen (I understand that's the collab care framework) rather than them saving that money and either hiring a psychiatrist or referring out despite wait times? When you say organization, I assume hospital group or private practice group which could probably hire a psychiatrist to see the patients either under salary or 1099 for less than what they'd be paying you.

No because you’re providing recommendations on a way larger patient panel than you would typically see by yourself. Most of these models are hiring a psychiatrist to review patient charts 1-2x a week with a psychiatric social worker/case manager who brings patients the pcp has questions about. Honestly sometimes this is like “what would you do with this patient who’s GAD7 is still 18 on 20mg of Prozac”…helps the PCPs not refer a lot of easy stuff (for us) out. Or for PCPs who are out in the middle of nowhere without a real psychiatrist for 30 miles.

If you look up this type of model there’s a lot of info out there about it.

 

[Mass Effect]

No because you’re providing recommendations on a way larger patient panel than you would typically see by yourself. Most of these models are hiring a psychiatrist to review patient charts 1-2x a week with a psychiatric social worker/case manager who brings patients the pcp has questions about. Honestly sometimes this is like “what would you do with this patient who’s GAD7 is still 18 on 20mg of Prozac”…helps the PCPs not refer a lot of easy stuff (for us) out. Or for PCPs who are out in the middle of nowhere without a real psychiatrist for 30 miles.

If you look up this type of model there’s a lot of info out there about it.

I've read about it in the past. It's a model I like, but I see it employed at academic centers. I didn't realize psychiatrists are contracting this model. But guess it's no different than nursing home consults.

 

[Merovinge]

I'm confused. Why would an organization pay you $200/hr+ to give recommendations for a patient you haven't seen (I understand that's the collab care framework) rather than them saving that money and either hiring a psychiatrist or referring out despite wait times? When you say organization, I assume hospital group or private practice group which could probably hire a psychiatrist to see the patients either under salary or 1099 for less than what they'd be paying you.

The real value that (hopefully) comes with this is (if/when) payment shifts to capitated systems of reimbursement. I'm curious if Kaiser has done this as they would be as close to this setup as we have in the US.

 

[theduderino]

Thanks for the input everyone. They ended up offering around 150/hr (1099) with possible increase to 200 with new contracts in my state of choice (I declined).

This is a private company that partners with individual PCPs and networks of PCPs through ACOs. So I guess reimbursement is a mixture of CPT codes + capitated payments from larger organizations? Still was muddled to me, so hard to really make any reasonable guess as to how much $ I'm producing per hour.

Perhaps naively, I thought this work would be a nice break from the intensity of normal clinical work. It sounded quite busy when described to me (staffing and writing up a "case" q15m or so).

 

[Merovinge]

Thanks for the input everyone. They ended up offering around 150/hr (1099) with possible increase to 200 with new contracts in my state of choice (I declined).

This is a private company that partners with individual PCPs and networks of PCPs through ACOs. So I guess reimbursement is a mixture of CPT codes + capitated payments from larger organizations? Still was muddled to me, so hard to really make any reasonable guess as to how much $ I'm producing per hour.

Perhaps naively, I thought this work would be a nice break from the intensity of normal clinical work. It sounded quite busy when described to me (staffing and writing up a "case" q15m or so).

Yeah, no, that sounds absolutely worse than seeing patients for medicore pay. 15 minutes to review a chart, staff and write something sounds brutal. I cannot imagine doing 28 of those in a day, going home and feeling good about my day. Better than working for insurance and denying care all day but not much else.

 

[calvnandhobbs68]

Thanks for the input everyone. They ended up offering around 150/hr (1099) with possible increase to 200 with new contracts in my state of choice (I declined).

This is a private company that partners with individual PCPs and networks of PCPs through ACOs. So I guess reimbursement is a mixture of CPT codes + capitated payments from larger organizations? Still was muddled to me, so hard to really make any reasonable guess as to how much $ I'm producing per hour.

Perhaps naively, I thought this work would be a nice break from the intensity of normal clinical work. It sounded quite busy when described to me (staffing and writing up a "case" q15m or so).

🙄 I can make more than that seeing 1 patient an hour. Hard pass.

 

[theduderino]

I do a little bit of addiction consulting work through one of the national psych orgs - they pay $125/hr. Admittedly low, but it's grant funded and involves helping clinics build MOUD treatment capacity. No liability and no documentation required.

I'm willing to take a pay cut from a clinical rate for work that scratches my itch to do systems level work, if it's some combination of interesting + easy enough.

Even if I got a higher rate, I don't think collaborative care fits the bill.