employment dilemna....

Started by vistaril
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vistaril

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So I'm debating between different jobs for where I move, but aside from that I'm planning on doing suboxone on my own....

I've already done the first year capped at 30, so I plan on managing pts right at the cap of 100.

But obviously there are a few logistical problems I have to deal with:

1) assuming I see 100 suboxoners a month, how many days/hours per month do you think it is going to take to meet that? I am thinking, starting out, 3-4 whole days in clinic per month. I know family medicine guys who are literally spending 1-2 minutes per with their suboxone patients, but I'm pretty good with addiction and want to spend more time and do a better job. I'll get faster as I get more comfortable and experienced Im sure.

2) If I have a m-f schedule(some jobs Im looking at our m-f and some m-thursday), will I be able to find someone to rent me an office on saturday?

3) How do I go about finding a place to do it out of? Just go around to different practices(they wouldnt be psychiatry of course) and offer to give them a cut for so many days/month? Would I get their billing help? How much would it cost me?

4) I guess it depends on the area, but do I bill insurance or just cash pay? I guess it would also depend on whether or not I have access to the billers/coders of whatever office I am operating out of. Also, If I do cash pay(and Im hoping to be able to take insurance), how do I do the drug testing? Are patients going to be able to pay out of pocket for that realistically?

those are just some of the questions......I had more in my head on and off the last month but can't remember them off the top of my head now.
 
vistaril said:
So I'm debating between different jobs for where I move, but aside from that I'm planning on doing suboxone on my own....

I've already done the first year capped at 30, so I plan on managing pts right at the cap of 100.

But obviously there are a few logistical problems I have to deal with:

1) assuming I see 100 suboxoners a month, how many days/hours per month do you think it is going to take to meet that? I am thinking, starting out, 3-4 whole days in clinic per month. I know family medicine guys who are literally spending 1-2 minutes per with their suboxone patients, but I'm pretty good with addiction and want to spend more time and do a better job. I'll get faster as I get more comfortable and experienced Im sure.

2) If I have a m-f schedule(some jobs Im looking at our m-f and some m-thursday), will I be able to find someone to rent me an office on saturday?

3) How do I go about finding a place to do it out of? Just go around to different practices(they wouldnt be psychiatry of course) and offer to give them a cut for so many days/month? Would I get their billing help? How much would it cost me?

4) I guess it depends on the area, but do I bill insurance or just cash pay? I guess it would also depend on whether or not I have access to the billers/coders of whatever office I am operating out of. Also, If I do cash pay(and Im hoping to be able to take insurance), how do I do the drug testing? Are patients going to be able to pay out of pocket for that realistically?

those are just some of the questions......I had more in my head on and off the last month but can't remember them off the top of my head now.
Click to expand...

They'll pay out of pocket because it's a hell of a lot less than paying for heroin or oxycontin or whatever their fix is. The standard practice model for private practice suboxone treatment around here in my major midwest metro area is $100-150 per visit, no greater than 30 day supply, no refills without an appointment. They take cash and cash only. The practices fill quickly.

Assuming you fill with cash paying patient who actually show up, you could generate 10-15K in revenue per month. If you're only doing Saturdays, you should just rent an office space for cheap. They probably won't give you access to their coders/billers without significant overhead cost, but if you take cash only you won't need them.

Your documentation will need to be very good. You will be at relatively higher risk for trouble with medical board if there are adverse outcomes as you're prescribing a highly controlled substance almost exclusively.

You will also need to carefully review your employment contract for your Monday to Friday job to make sure that you are allowed to do so. Some contracts stipulate that you must have permission to do clinical work outside of that care system. Others stipulate that they are entitled to a portion or that income or that it must be routed through them and distributed to you. I would accept neither of those stipulations, but you need to make sure they're not in there and need to get them out if they were.

For whatever it's worth, I wouldn't enjoy this practice model, and the people I've seen do it have been private pay psychiatrists looking to boost their revenue. They haven't seemed to have any particular interest in addictions, but when the suboxone cash cow came along, they jumped on it. So, I'm jaded.

That said, there are faculty in my department who have suboxone patients and they are treated like any of the rest, vis a vis, 30 minute appointments, comprehensive treatment plan, and no problem of dual agency (i.e. profit motive) on the part of the provider.

Good luck.
 
xlithiumx said:
They'll pay out of pocket because it's a hell of a lot less than paying for heroin or oxycontin or whatever their fix is. The standard practice model for private practice suboxone treatment around here in my major midwest metro area is $100-150 per visit, no greater than 30 day supply, no refills without an appointment. They take cash and cash only. The practices fill quickly.

Assuming you fill with cash paying patient who actually show up, you could generate 10-15K in revenue per month. If you're only doing Saturdays, you should just rent an office space for cheap. They probably won't give you access to their coders/billers without significant overhead cost, but if you take cash only you won't need them.

Your documentation will need to be very good. You will be at relatively higher risk for trouble with medical board if there are adverse outcomes as you're prescribing a highly controlled substance almost exclusively.

You will also need to carefully review your employment contract for your Monday to Friday job to make sure that you are allowed to do so. Some contracts stipulate that you must have permission to do clinical work outside of that care system. Others stipulate that they are entitled to a portion or that income or that it must be routed through them and distributed to you. I would accept neither of those stipulations, but you need to make sure they're not in there and need to get them out if they were.

For whatever it's worth, I wouldn't enjoy this practice model, and the people I've seen do it have been private pay psychiatrists looking to boost their revenue. They haven't seemed to have any particular interest in addictions, but when the suboxone cash cow came along, they jumped on it. So, I'm jaded.

That said, there are faculty in my department who have suboxone patients and they are treated like any of the rest, vis a vis, 30 minute appointments, comprehensive treatment plan, and no problem of dual agency (i.e. profit motive) on the part of the provider.

Good luck.
Click to expand...

See I think it is so dependent on the area for suboxone(in terms of the supply of providers), and I have no idea what the area I'm going to will be like for that as I havent researched it yet. There are many places where there are no shortage of primary care physicians happy to spend 45 seconds writing a script for 75 bucks cash, and that obviously drives down prices. And then you also have some people running it through insurance, what drives down prices for the insured population.

If I could get 100-125 bucks per visit, I'm not even going to worry about insurance.

As for the employers, oh yeah I know this....already made it very clear that *ALL* outside work(and that includes inpatient weekend coverage at local hospitals) within ANY radius is totally ok and all mine.

Im just a bit skeptical I can make an extra 100k+ a year after expenses doing something like this....if it were so easy, why isn't everyone doing it?
 
vistaril said:
See I think it is so dependent on the area for suboxone(in terms of the supply of providers), and I have no idea what the area I'm going to will be like for that as I havent researched it yet. There are many places where there are no shortage of primary care physicians happy to spend 45 seconds writing a script for 75 bucks cash, and that obviously drives down prices. And then you also have some people running it through insurance, what drives down prices for the insured population.

If I could get 100-125 bucks per visit, I'm not even going to worry about insurance.

As for the employers, oh yeah I know this....already made it very clear that *ALL* outside work(and that includes inpatient weekend coverage at local hospitals) within ANY radius is totally ok and all mine.

Im just a bit skeptical I can make an extra 100k+ a year after expenses doing something like this....if it were so easy, why isn't everyone doing it?
Click to expand...

I don't think it is easy work. I think it's really really tough, ****ty work if you're going it alone. You're dealing with people who are dependent upon the substance you're providing, have a manifest history of maladaptive behavior in relation to obtaining similar substances, and likely have pretty significant psychosocial problems. You're going to need to know things like, "where is the nearest ATM" so that when your patient shows up without money, you can direct them to the ATM and then have them come back. It's work that I would feel really bad about doing, and so I won't. I suspect that others might feel the same.

I'd absolutely consider suboxone practice in an academic setting or with a hospital group or something where there's good infrastructure and you can bill insurance, but then the suboxone patient is just another patient that you're offering something specialized to (meeting their needs, not yours) and not the next teat on the metaphorical cash cow.

With what you've said about your fiancee's financial prospects (and I have no reason to doubt them, as others have, because i've seen the job listings for GI, and they pay GOOFY high money), why bother with trying to eek out another 100K? Who cares. Do the suboxone practice in your employed job. Spend Saturday on a boat, or on a golf course, or in your garden, or for god's sake at a strip club if that's what turns your crank.

I just find it very hard to believe that actually doing a cash outpatient suboxone practice in your "spare" time would be fulfilling and restorative rather than painful. Of course, I'm biased by my observation that a slow, intense, relational approach is the one that has afforded the best outcomes for my patients. It would be hard for me to do that kind of practice without feeling like I was cheating at least my patients and probably myself.
 
xlithiumx said:
I don't think it is easy work. I think it's really really tough, ****ty work if you're going it alone. You're dealing with people who are dependent upon the substance you're providing, have a manifest history of maladaptive behavior in relation to obtaining similar substances, and likely have pretty significant psychosocial problems. You're going to need to know things like, "where is the nearest ATM" so that when your patient shows up without money, you can direct them to the ATM and then have them come back. It's work that I would feel really bad about doing, and so I won't. I suspect that others might feel the same.

I'd absolutely consider suboxone practice in an academic setting or with a hospital group or something where there's good infrastructure and you can bill insurance, but then the suboxone patient is just another patient that you're offering something specialized to (meeting their needs, not yours) and not the next teat on the metaphorical cash cow.

With what you've said about your fiancee's financial prospects (and I have no reason to doubt them, as others have, because i've seen the job listings for GI, and they pay GOOFY high money), why bother with trying to eek out another 100K? Who cares. Do the suboxone practice in your employed job. Spend Saturday on a boat, or on a golf course, or in your garden, or for god's sake at a strip club if that's what turns your crank.

I just find it very hard to believe that actually doing a cash outpatient suboxone practice in your "spare" time would be fulfilling and restorative rather than painful. Of course, I'm biased by my observation that a slow, intense, relational approach is the one that has afforded the best outcomes for my patients. It would be hard for me to do that kind of practice without feeling like I was cheating at least my patients and probably myself.
Click to expand...

well the fiance's money is her money....we are going to keep our monies separate to some extent. I have student loans to pay(as many of us do), and my income is already sorta limited by having to work where my fiance took a job.(i do like the area and want to live there too so sorta made the decision for her to take it, so I can't complain about that)

I've worked suboxone clinic before in an outpatient setting as a resident, and we took insurance.(there was some cash pay as well just because not everyone had insurance) But it was also high volume so we were hustling, so I know what it is like.

I definately wouldn't feel bad about doing high volume suboxone because the patients would just be going to even more of a mill otherwise, and likely from someone who doesn't understand suboxone as much as someone who did 4+ months in residency on addiction units and working with suboxone in all those months. Maybe the new area I'm going will be different, but here bunches of primary care physicians who just took the quick online course are providing most of the suboxone in the community.
 
I don't know if heroin is getting cheaper or if south Chicago is just full of low-quality drugs, but it seems like people keep telling me that they're paying $20-30/day now...
 
vistaril said:
I definately wouldn't feel bad about doing high volume suboxone .
Click to expand...

ya i dont think theres any reason to feel bad.. if theyre actually taking it instead of their drug of choice then you're doing them a favor i would think. Im assuming a decent chunk just divert them to buy pills or whatever though, but hopefully you could weed those out. But for drug tests cant you buy the 50$ ones where you just read the results 5 min later and just add it onto the bill?
 
shan564 said:
I don't know if heroin is getting cheaper or if south Chicago is just full of low-quality drugs, but it seems like people keep telling me that they're paying $20-30/day now...
Click to expand...

supply is up since we've been protecting the poppy's from the taliban in Afghanistan
 
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someguy321 said:
ya i dont think theres any reason to feel bad.. if theyre actually taking it instead of their drug of choice then you're doing them a favor i would think. Im assuming a decent chunk just divert them to buy pills or whatever though, but hopefully you could weed those out. But for drug tests cant you buy the 50$ ones where you just read the results 5 min later and just add it onto the bill?
Click to expand...

are you referring to dipstick tests? They don't cost 50 dollars for sure, or anywhere close. Dipstick testing has a lot of limitations.
 
vistaril said:
So I'm debating between different jobs for where I move, but aside from that I'm planning on doing suboxone on my own....

I've already done the first year capped at 30, so I plan on managing pts right at the cap of 100.

But obviously there are a few logistical problems I have to deal with:

1) assuming I see 100 suboxoners a month, how many days/hours per month do you think it is going to take to meet that? I am thinking, starting out, 3-4 whole days in clinic per month. I know family medicine guys who are literally spending 1-2 minutes per with their suboxone patients, but I'm pretty good with addiction and want to spend more time and do a better job. I'll get faster as I get more comfortable and experienced Im sure.

2) If I have a m-f schedule(some jobs Im looking at our m-f and some m-thursday), will I be able to find someone to rent me an office on saturday?

3) How do I go about finding a place to do it out of? Just go around to different practices(they wouldnt be psychiatry of course) and offer to give them a cut for so many days/month? Would I get their billing help? How much would it cost me?

4) I guess it depends on the area, but do I bill insurance or just cash pay? I guess it would also depend on whether or not I have access to the billers/coders of whatever office I am operating out of. Also, If I do cash pay(and Im hoping to be able to take insurance), how do I do the drug testing? Are patients going to be able to pay out of pocket for that realistically?

those are just some of the questions......I had more in my head on and off the last month but can't remember them off the top of my head now.
Click to expand...

1) It's up to you to determine how often and how long you want to see your patients for. I have been on the Suboxone registry for over a year and I have only received 2-3 calls from individuals who are looking for a discount clinic or insurance provider.
2) Rent your own office or share an office. Some facilities let you rent an office by the hour. Depending on where you live, you can get some nice executive office suites at a decent hourly rate.
3) Contact a group practice if you want to use their facility or administrative services for a %.
4) Hire your own biller or outsource to a billing company. You will also need someone to handle the prior auths. You can buy your own urine drug screens or send them to a lab. You've mentioned in previous posts that you need to walk on water for patients to pay you in cash. Do you think the same principles might apply here?
 
F0nzie said:
1) Do you think the same principles might apply here?
Click to expand...

I think it really depends on the area and what the suboxone market is like.....I've heard that in some areas cash pay for suboxone is very common, and that in others insurance is more common. Also, one thing about cash pay with suboxone(as a solo practice) that sorta scares me is wouldnt the clinic be a tempting target for a robbery?

Also, keep in mind that suboxone is different than typical med mgt in the sense that most all med mgt patients are going to have insurance. Lots of people wanting to get on suboxone are going to be junkies and thus not have insurance. additionally, I have to believe pts are more willing to pay for suboxone out of pocket than visits to get wellbutrin or a tricyclic or whatever out of pocket.
 
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F0nzie said:
Don't know what the risk is but you can always refuse cash and accept credit cards
Click to expand...

yeah i know but if my main job is a salaried position somewhere I am not going to have all that stuff....then i have to lay out the capital for all that. And then of course there is the 7% cut on average they take(I know the advertised rate is much lower....but talking to people they charge more for all the different reward options cards people use nowadays....have a friend who works in another business and she said on 20,000 dollars in monthly cc sales she ends up paying 1300+ dollars due to all the extra fees associated with different cards)....
 
F0nzie said:
Don't know what the risk is but you can always refuse cash and accept credit cards
Click to expand...

oh i forgot to add...isn't the risk obvious? You have opiate addicts who know you are seeing bunches of patients a day alone in an office somewhere and some are paying cash....doesn't take a brain surgeon to add up that 1 + 1 = 2 and there may be a lot of hard cold cash(several thousand dollars) laying around without a lot of other people or security around.....
 
vistaril said:
oh i forgot to add...isn't the risk obvious? You have opiate addicts who know you are seeing bunches of patients a day alone in an office somewhere and some are paying cash....doesn't take a brain surgeon to add up that 1 + 1 = 2 and there may be a lot of hard cold cash(several thousand dollars) laying around without a lot of other people or security around.....
Click to expand...

I think that's a very legitimate worry! Mugging is a risk too, because you will no doubt have some pissed off patients from time to time. You'd have to be careful that you don't have staff (or yourself) coming and going alone at hours when it's dark.
 
vistaril said:
assuming I see 100 suboxoners a month, how many days/hours per month do you think it is going to take to meet that? I am thinking, starting out, 3-4 whole days in clinic per month. I know family medicine guys who are literally spending 1-2 minutes per with their suboxone patients, but I'm pretty good with addiction and want to spend more time and do a better job. I'll get faster as I get more comfortable and experienced Im sure.
Click to expand...

This is just out of curiosity, but say you're that fast, and you're in family medicine. You're not asking the patients about anything that's not directly related to suboxone. Say one of the patients leaves your office and later that day has a heart attack and dies. Can you be held responsible for only doing a suboxone check in and not assessing the patient more generally?

Or say they kill themselves--and you didn't ask about SI... The laws of probability are such that if you see 100 patients per month, eventually this might happen. What's the expectation of a psychiatrist running just a suboxone clinic in that case?
 
nancysinatra said:
This is just out of curiosity, but say you're that fast, and you're in family medicine. You're not asking the patients about anything that's not directly related to suboxone. Say one of the patients leaves your office and later that day has a heart attack and dies. Can you be held responsible for only doing a suboxone check in and not assessing the patient more generally?

Or say they kill themselves--and you didn't ask about SI... The laws of probability are such that if you see 100 patients per month, eventually this might happen. What's the expectation of a psychiatrist running just a suboxone clinic in that case?
Click to expand...

The Suboxone checks for family medicine and psychiatry are conducted differently. Psychiatrists typically bill for Suboxone just like any other psych med check which involves a mental status examination assessing for SI. Family medicine doctors on the other hand will bill Suboxone like a typical family med check focusing on the addiction and refer any other psychiatric symptoms ie. depression, mood, psychosis, SI to a psychiatrist. So basically being a psychiatrist increases your liability if you ignore the psychiatric component and a patient commits suicide. Kinda like a surgeon ignoring a life saving extraction of an intrabdominal abscess and instead only giving antibiotics because he wanted to practice like an ID doc.
 
F0nzie said:
The Suboxone checks for family medicine and psychiatry are conducted differently. Psychiatrists typically bill for Suboxone just like any other psych med check which involves a mental status examination assessing for SI. .
Click to expand...
\

I don't specifically ask about SI for every single encounter with every single patient.
 
F0nzie said:
The Suboxone checks for family medicine and psychiatry are conducted differently. Psychiatrists typically bill for Suboxone just like any other psych med check which involves a mental status examination assessing for SI. Family medicine doctors on the other hand will bill Suboxone like a typical family med check focusing on the addiction and refer any other psychiatric symptoms ie. depression, mood, psychosis, SI to a psychiatrist. So basically being a psychiatrist increases your liability if you ignore the psychiatric component and a patient commits suicide. Kinda like a surgeon ignoring a life saving extraction of an intrabdominal abscess and instead only giving antibiotics because he wanted to practice like an ID doc.
Click to expand...

How one bills has little to do with malpractice risk. By the way, when I did suboxone (as a psychiatrist), I billed E and M codes (99213 or 99214 for f/u's). Malpractice risk is more related to how one presents oneself to the public (if you advertise yourself as a psychiatrist, bc psychiatrist, etc- you will be held to psychiatrist standards)
 
michaelrack said:
How one bills has little to do with malpractice risk. By the way, when I did suboxone (as a psychiatrist), I billed E and M codes (99213 or 99214 for f/u's). Malpractice risk is more related to how one presents oneself to the public (if you advertise yourself as a psychiatrist, bc psychiatrist, etc- you will be held to psychiatrist standards)
Click to expand...

Why did you get out of prescribing Suboxone?
 
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