Easy nonprofit work?

[Animal Mother]

I started a community psych job in July after finishing residency and have found it to be more stressful than I was expecting. I’m not even completely sure why it is so much more stressful. I initially wrote it off as just needing a period to adjust, but I think the patients are generally just more difficult + some systemic issues as well that might be contributing to my feelings. At least half of the patients are personality disorder who just got out of prison and/or substance abusers. Some patients have treatment resistant psychosis who I’ve been switching off their 3 antipsychotics + several other drugs to clozapine, but in general, I feel there’s no primary mental illness or anything I can do to help most of the patients. High turnover rate here amongst physicians and prior paper documentation is often missing or of very poor quality. Frequently get patients from departing colleagues who are on inappropriate medication regimens for unknown reasons. I have no real prior experience in community psych. Is this how it typically is outside of an academic center? Are there better options for PSLF-qualifying work?

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[Attending1985]

I started a community psych job in July after finishing residency and have found it to be more stressful than I was expecting. I’m not even completely sure why it is so much more stressful. I initially wrote it off as just needing a period to adjust, but I think the patients are generally just more difficult + some systemic issues as well that might be contributing to my feelings. At least half of the patients are personality disorder who just got out of prison and/or substance abusers. Some patients have treatment resistant psychosis who I’ve been switching off their 3 antipsychotics + several other drugs to clozapine, but in general, I feel there’s no primary mental illness or anything I can do to help most of the patients. High turnover rate here amongst physicians and prior paper documentation is often missing or of very poor quality. Frequently get patients from departing colleagues who are on inappropriate medication regimens for unknown reasons. I have no real prior experience in community psych. Is this how it typically is outside of an academic center? Are there better options for PSLF-qualifying work?

If there’s no primary mental illness why treat them? Can you just refer them to other servicesin the agency that would better serve them?

 

[Animal Mother]

If there’s no primary mental illness why treat them? Can you just refer them to other servicesin the agency that would better serve them?

Some people come here out of prison on half a dozen different drugs for their antisocial behaviors (multiple antipsychotics and antiepileptics). Also see lots of people diagnosed with schizophrenia or schizoaffective disorder who’ve been on meth consistently since their teens and aren’t interested in getting clean. I’ve been told I can’t change their diagnosis due to billing. because of poor documentation it’s hard sometimes to piece together a timeline, but I suspect most are probably just substance induced conditions. I always try to do some motivational interviewing and offer substance use referrals, but most are not interested. A couple have gotten clean, and I’ve tapered some of these off their antipsychotics.

 

[TexasPhysician]

I’ve been told I can’t change their diagnosis due to billing.

That smells of fraud to me. Diagnosing an illness that doesn’t exist to receive reimbursement.......

 

[Attending1985]

I started a community psych job in July after finishing residency and have found it to be more stressful than I was expecting. I’m not even completely sure why it is so much more stressful. I initially wrote it off as just needing a period to adjust, but I think the patients are generally just more difficult + some systemic issues as well that might be contributing to my feelings. At least half of the patients are personality disorder who just got out of prison and/or substance abusers. Some patients have treatment resistant psychosis who I’ve been switching off their 3 antipsychotics + several other drugs to clozapine, but in general, I feel there’s no primary mental illness or anything I can do to help most of the patients. High turnover rate here amongst physicians and prior paper documentation is often missing or of very poor quality. Frequently get patients from departing colleagues who are on inappropriate medication regimens for unknown reasons. I have no real prior experience in community psych. Is this how it typically is outside of an academic center? Are there better options for PSLF-qualifying work?

Sometimes it can be satisfying to take people off meds. You’re saving them nasty side effects and saving the system money. Th diagnosis thing sounds crazy.

 

[calvnandhobbs68]

Some people come here out of prison on half a dozen different drugs for their antisocial behaviors (multiple antipsychotics and antiepileptics). Also see lots of people diagnosed with schizophrenia or schizoaffective disorder who’ve been on meth consistently since their teens and aren’t interested in getting clean. I’ve been told I can’t change their diagnosis due to billing. because of poor documentation it’s hard sometimes to piece together a timeline, but I suspect most are probably just substance induced conditions. I always try to do some motivational interviewing and offer substance use referrals, but most are not interested. A couple have gotten clean, and I’ve tapered some of these off their antipsychotics.

Yea I've never gotten this. PCPs get reimbursed for treating people with T2DM and HTN from eating too many cheeseburgers and bags of candy. ****, first line treatment is lifestyle modification amirite? Why would psychiatrists not get reimbursed for getting people proper treatment for their substance abused psychosis/depression?

To be fair, I've seen the same thing. People in prison coming out with a bunch of meds for being antisocial or people with substance induced psychosis put on an antipsychotic but their symptoms magically clear after being off meth/stimulants for a few weeks as well...

 

[clausewitz2]

Yea I've never gotten this. PCPs get reimbursed for treating people with T2DM and HTN from eating too many cheeseburgers and bags of candy. ****, first line treatment is lifestyle modification amirite? Why would psychiatrists not get reimbursed for getting people proper treatment for their substance abused psychosis/depression?

To be fair, I've seen the same thing. People in prison coming out with a bunch of meds for being antisocial or people with substance induced psychosis put on an antipsychotic but their symptoms magically clear after being off meth/stimulants for a few weeks as well...

There are some places where community health centers are only meant to be available to people with a very limited menu of SMI sort of diagnosed (often schizophrenia, schizophrenics, bipolar I, MDD severe and recurrent) and thus CMHCs will not get paid by whoever is cutting the checks if their clients do not have such a diagnosis.

Still obviously fraudulent, but the pressure is understandable. I am mostly very glad in my neck of the woods no one imposes diagnosis-based restrictions like this because it leads to situations like that described by the OP.

 

[splik]

Yea I've never gotten this. PCPs get reimbursed for treating people with T2DM and HTN from eating too many cheeseburgers and bags of candy. ****, first line treatment is lifestyle modification amirite? Why would psychiatrists not get reimbursed for getting people proper treatment for their substance abused psychosis/depression?

There is also the issue of mental health parity... in my state insurers are only required to cover "parity diagnoses" which means they do not have to pay for mental health services for patients unless they have: schizophrenia, schizoaffective disorder, bipolar, MDD, panic disorder, OCD, autism, anorexia, and bulimia...that is all.

 

[Amygdarya]

There is also the issue of mental health parity... in my state insurers are only required to cover "parity diagnoses" which means they do not have to pay for mental health services for patients unless they have: schizophrenia, schizoaffective disorder, bipolar, MDD, panic disorder, OCD, autism, anorexia, and bulimia...that is all.

(Sigh) Parity, my @ss.

 

[Crayola227]

what does parity in this setting even mean?

 

[clausewitz2]

what does parity in this setting even mean?

It means that insurance companies have to reimburse relevant RVUs at the same rate, instead of just saying "nah, we don't do mental health" or "here is our mental health carve out that will pay pennies on the dollar." This was fairly typical until Pete Domenici pushed through parity almost a decade ago.

 

[splik]

It means that insurance companies have to reimburse relevant RVUs at the same rate, instead of just saying "nah, we don't do mental health" or "here is our mental health carve out that will pay pennies on the dollar." This was fairly typical until Pete Domenici pushed through parity almost a decade ago.

This is not correct. parity has nothing to do with how much insurance companies reimburse physicians. MH parity is about coverage (does nothing to how sh*tty that coverage might be). For example if a plan covers x days' worth of medical inpatient day, they must cover x days worth of psychiatric inpatient. If they cover y outpatient visits a year for medical specialty visits, they must cover y visits for psychiatric stays. If they cover residential medical treatment, they must cover residential mental health and substance use treatment.

There are actually large variations of reimbursement of E/M codes per specialty. For example a level 4 cardiology or neurology outpatient visit will typically pay out more than a level 4 psychiatry outpatient visit. a PCP level 3 visit will either often pay more or less depending on the plan than a psychiatry level 3 visit. MH parity laws do not govern this.

Another common misconception is that the MHEAPA of 2008 brought us mental health parity. Actually, almost nothing changed after this law was passed by congress in 2008. Most of the current mental health parity laws came into force in 2013 and are part of the Affordable Care Act. So if this latter law dies (which is likely to happen as it's facing another constitutional challenge in the Texas courts and may make its way to the newly heavily conservative SCOTUS), then mental health parity will die too.

Another interest fact is that mental health parity laws do not apply to medicare or medicaid or plans that were grandfathered in pre-2010.

 

[Mad Jack]

I started a community psych job in July after finishing residency and have found it to be more stressful than I was expecting. I’m not even completely sure why it is so much more stressful. I initially wrote it off as just needing a period to adjust, but I think the patients are generally just more difficult + some systemic issues as well that might be contributing to my feelings. At least half of the patients are personality disorder who just got out of prison and/or substance abusers. Some patients have treatment resistant psychosis who I’ve been switching off their 3 antipsychotics + several other drugs to clozapine, but in general, I feel there’s no primary mental illness or anything I can do to help most of the patients. High turnover rate here amongst physicians and prior paper documentation is often missing or of very poor quality. Frequently get patients from departing colleagues who are on inappropriate medication regimens for unknown reasons. I have no real prior experience in community psych. Is this how it typically is outside of an academic center? Are there better options for PSLF-qualifying work?

Inpatient nonprofit hospital work and nonprofit hospital network employee positions can qualify for PSLF. You don't need to do community mental health center work.