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[jbomba]

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[FlowRate]

I'm sure you'll fine plenty of heroin addicts in the affluent suburbs...

 

[splik]

this is a good way to put a massive target on your back for the DEA and medical board to come after you. you could at least disguise your pill mill by diversifying with different treatment offerings. running a bupe mill is usually what docs do when their careers are already over, not how they begin them

 

[dl2dp2]

Depending on where you went to residency, what you describe (275 bup patients) is 1) not necesssary to make a lot of money 2) terrible idea as a base for a private practice.

If you went to a lower tier residency and want to treat a lot of (i.e. 275) indigent opioid patients, the best way is to work for a public facility or facility associated with a large academic program, as the facility as you describe typically is not profitable enough without major government subsidies. There ARE some notable exceptions of companies that somehow made it work with some tricks (several of which I have signed non-disclosure for). Some of the tricks may very well on their way out due to new CMS regulations. But in general, I’ll tell you right now it’s not financially feasible, and the ones that are profitable are already bought out by private equity. So really not a lot of money to be made here.

If your CV is better than average, there are several models of addiction docs focusing on opioid treatment that are highly lucrative but none of which involves a bup mill. Either you offer high end bup treatment with high profit margin, or you run an cash *inaptient* or IOP. The latter, when complete, typically has more stored business value than a typical outpatient practice (i.e. you can SELL it and it has more potential for passive income) but also requires much more sophisticated initial investment and ongoing business activities (i.e. marketing, staff management, etc). Hour by hour, the highest yearly cash income is typically a cash outpatient practice that’s the antithesis of a mill. Mills have low margins. I don’t know why people here constantly want to do mills. Do you really want to be Walmart when you can be Gucci?

I think given how misinformed you are about how addiction treatment actually works, a fellowship is a fantastic idea, not necessarily for the clinical knowledge, which you may already have, but the systems based practice issues.

 

[whopper]

Buprenorphine patients are higher maintenance than usual patients. What I've found is about 1/3 of them fail within months of treatment and it's not because of the medication. The medication unlike antidepressants almost always works. (I've had perhaps less than 5 where it didn't work well out of more than 200 patients I've had total). What causes these people to fail is they have several personality problems and other mental health issues that aren't yet stabilized. E.g. a prostitute with an abusive pimp with a plethora of other problems, if she gets off of Heroin, isn't exactly going to be a completely mentally stable after being on Buprenorphine.

The same cluster B, pathological lying, drug-abusing friends and family, abusive lover, broken home, financial-debt, trying to find the easiest way to most quickly solve an existing problem personality despite that it's going to make the situation 10x worse what have you situation is still with this person and that's why they usually fail despite the med works so well.

And when they fail they'll often try to cheap maneuver to get you to continue to give them the medication. So anyone starting a new Buprenorphine practice at first is going to have to deal with a lot of stressful patients.

Another major problem is most of these people need good treatment outside of the Buprenorphine and many providers only provide the Buprenorphine and nothing else. E.g. the person might also have PTSD but despite that the provider is a psychiatrist they'll tell the patient "no I'm only your Buprenorphine provider," despite that this goes against existing medical ethics and legal responsibilities to a patient. No where does the law clearly state that if you are of an expertise you can ignore treating a patient that you've found to have problems within your expertise to treat, yet so many do it. I've brought this on the fourm before and others have stated they find nothing wrong with it. The law says a doctor has a "fiduciary responsibility" to a patient if there's a doctor-patient relationship.

(IMHO a cunning lawyer could make a very profitable class action lawsuit against physicians that "only" prescribe Buprenorphine without treating their other problems).

Another major problem is the guidelines with the meds are very wrong. E.g. I've never seen a patient on 4,3,2,1 or even 0.5 mg be able to get off of Buprenorphine without significant withdrawal that would last for literally weeks. The guidelines state you can reduce the dosage by up to 4 mg a day. What I've found is you can decrease it about 10-20% every 3-4 days at the fastest. So when you get to smaller dosage you need to cut it down more slowly. E.g. if you're on 16 mg a day you can cut it by 2 mg but if you're on 2 mg you've have to cut it by 0.5 mg at the most. The guidelines don't state this and despite that the majority of experienced clinicians know this, even the manufacturers know this no one has updated the existing guideilnes.

In short there's plenty, IMHO, that should be taught on this issue that isn't.

 

[TexasPhysician]

I'd really like to start a fee for service suboxone practice once I'm out. I'd like to offer the whole nine; group classes, individual therapy, AA, etc. Any idea how long it typically takes to fill a practice (let's assume the 275 threshold) in an affluent area?

What you imagine will be very difficult to build if cash only. Most addiction patients are not thriving financially. They generally receive such comprehensive services through insurance which in my area is not hard to find.

The patients that can pay cash often do not want to also continue frequent counseling as their life is coming together, and they don’t believe they need it. Many bup providers (non-psych) in my area will not enforce these counseling recommendations.

The result is that cash bup providers that function as quick appointments with minimal check-ins will generally fill as it’s easy/convenient.

A more reasonable plan is a general cash-only outpatient psych practice that does bup when needed with the occasional dedicated patient.

 

[uhmocksuhsillen]

What is a pill Mill vs an actually legit business?

 

[dl2dp2]

I am not suggesting I want to run an unethical "pill mill". I want my shop to be an all-inclusive place for therapy, group classes, and a place to have other psychiatric needs treated. Would this model fall into the high end bup treatment with high profit margin you referenced?

Therapy is not particularly profitable. Building a facility that includes other services will generally reduce profitability, especially if the practice is insurance driven. As I said, it IS possible to build a high profit margin “treatment program” with mostly cash patients and derive a profit margin off providing therapy. However, this is not very easy and depending on the geography you’ll have a lot of competition.

It’s difficult to give you an estimate because this depends too much on local conditions. But suffice it is to say, if you want to build a “treatment program”, there’ll be a startup cost that’s in the several hundred thousand range. It’s probably best to project out your profitability prior to applying for a business loan. This is fairly complicated, which is why I don’t recommend it unless you know what you are doing.

Starting a solo outpatient addiction psychiatry practice can be trivially easy. However, these practices don’t typically have a “pill mill” model. Similar to a general outpatient private practice, you treat general high functioning working professionals with a substance use disorder, and spend 30 min for med management and 45 min for combined therapy or meds. Addiction psychiatrists who are the best paid that I know are typically in this kind of arrangement. There are a FEW who have majority stakes in large treatment facilities and become wealthy in that way, but as I’ve said, that’s rare and involves taking on a lot of business risk.

What is a pill Mill vs an actually legit business?

A “pill mill” refers to a very specific kind of outpatient Suboxone practice, where most of the patients have public insurances and the provider writes only Suboxone scripts with some specific add on service (i.e. onsite therapy as dictated by certain regulatory requirements, UTOX, etc). Typically these practices will have 5-10 Suboxone visits per hour for each “prescriber”, who can be anywhere between an addiction psychiatrist (rare), to a general NP who has an X number (common). Given people have poor access to buprenorphine and there’s a crisis, I don’t necessarily think that this model is “unethical”. However from a purely business perspective, the profit margin of such a business in general is very low, and is especially low on a per hour basis for an addiction psychiatrist. This is why many of them are actually structured as non-profits, and plenty of them actually have partnerships with government entities and get subsidies. If you are addiction boarded, I don’t actually recommend starting such a program unless you really want to serve the indigent, as I said above. In fact if you want to serve the indigent, it’s best to just work as an employee, IMHO.

 

[TexasPhysician]

I would agree, starting a solo outpt addiction practice would probably be a more wise decision before diving into a treatment program with all of those associated costs. At least this would allow me to get my feet wet in a lower risk business venture.

In my head, 30-45 minute appointments was what I was figuring on. If I were able to fill my entire suboxone panel of 275, that would work out to roughly 45-50 hours a week. In a cash practice, from what I've seen, $250/month is on the fair end of things for a patient to receive meds + therapy at an appointment each month. Of course, some will require biweekly appointments from the getgo, and more stable patients perhaps less than once a month, but for argument sake, lets assume an average of 1 appointment/month per patient. So, $250*275 = 68k/month. When you say trivially easy, are you saying filling that 275 with INSURANCE is easy? Or finding cash paying clients in the right environment would be easy? I'm going to guess insurance paying patients will be bringing in far less than $250/per appointment...any idea what ballpark figure I'd be looking at?

$250 for 30 min sessions would put you as the highest cost follow-ups in my large city. Maybe normal if NYC or LA. In Texas, I doubt such a practice would ever fill.

45-60 min $250 fu is more reasonable if including quality therapy which you mention. Add additional overhead costs for drug screen cups and staff to review/monitor drug screens and monitor detoxing/induction patients. You’ll also need a bigger suite to have a separate detox area. Other patients can be put off by those actively detoxing. This is extra overhead.

45-60 min/patient. 275 patients seen at least 1x/month puts you at about 60-70+ hours/week of work. I certainly couldn’t handle that.

You won’t keep 275 stable patients either. Many will transfer to lower cost providers or relapse to inpatient or move, etc. This means you will have many inductions/month. Inductions involve being seen 2-4x in week 1 and then maybe weekly for awhile. The first day, the patient could have an eval, pick up meds, take meds in your office, be monitored by staff for 1-2 hours, and seen by you again before leaving for day 1. These patients can’t afford $250/session x 4 in 1 week either, so you’ll likely need to set a reduced induction week 1 combo pricing which lowers your income.

Addiction work can be quite rewarding. I plan to grandfather into addiction medicine. I do it because I enjoy it, but general outpatient psych is in much higher demand at the cash pay level. It also has lower overhead than suboxone work.

 

[dl2dp2]

In my head, 30-45 minute appointments was what I was figuring on. If I were able to fill my entire suboxone panel of 275, that would work out to roughly 45-50 hours a week. In a cash practice, from what I've seen, $250/month is on the fair end of things for a patient to receive meds + therapy at an appointment each month. Of course, some will require biweekly appointments from the getgo, and more stable patients perhaps less than once a month, but for argument sake, lets assume an average of 1 appointment/month per patient. So, $250*275 = 68k/month. When you say trivially easy, are you saying filling that 275 with INSURANCE is easy? Or finding cash paying clients in the right environment would be easy? I'm going to guess insurance paying patients will be bringing in far less than $250/per appointment...any idea what ballpark figure I'd be looking at?

99214 = between 100 and 130
90833 = around 70

Your math is roughly correct, but you don’t need 275 to fill 40 hours a week. It’s very rare for addiction psychiatrists to only see Suboxone patients. There are many other addiction problems, and if you take insurance you’ll fill very quickly, but not all Suboxone patients. With CMS payment rates, you will gross between 200 and 400 dollars an hour. Remember (real) opioid use disorder only has a prevalence of about 1%, but addiction in general has a prevalence in the low teens.

40 clinical hours is definitely above average—as someone said, with admin you are looking at around 50-60 hours a week all in. If you work this hard you’ll make a lot of money, but this kinda of practice is usually not very fun. Fairly repetitive. You’ll need a biller and a secretary.

 

[Shufflin]

I would agree, starting a solo outpt addiction practice would probably be a more wise decision before diving into a treatment program with all of those associated costs. At least this would allow me to get my feet wet in a lower risk business venture.

In my head, 30-45 minute appointments was what I was figuring on. If I were able to fill my entire suboxone panel of 275, that would work out to roughly 45-50 hours a week. In a cash practice, from what I've seen, $250/month is on the fair end of things for a patient to receive meds + therapy at an appointment each month. Of course, some will require biweekly appointments from the getgo, and more stable patients perhaps less than once a month, but for argument sake, lets assume an average of 1 appointment/month per patient. So, $250*275 = 68k/month. When you say trivially easy, are you saying filling that 275 with INSURANCE is easy? Or finding cash paying clients in the right environment would be easy? I'm going to guess insurance paying patients will be bringing in far less than $250/per appointment...any idea what ballpark figure I'd be looking at?

Go start doing, not so much talking.

There's so many variables at play that it's better you just hang a shingle and start seeing patients. Questions will answer themselves as you go through the doing part.

 

[Shufflin]

Totally agree. With <2 years of residency left, I'm starting to think about jobs. I'm wondering if I should look for something full-time around this time next year, or if I can assume a practice will fill enough to allow me to pay down my massive student loans and live a little too (either cash or insurance).

FWIW I'll be in a large west coast city.

As I can attest to, the curve will be steep but full of learning and things will fall into place. I did something similar, looking for work as I started my practice on the west coast. Albeit it's a straight up adult psychiatry practice, not addiction or suboxone. Feel free to PM me at any point.