Future of private practice?

[psych844]

---

Members don't see this ad.

So what do you guys think?

 

[WisNeuro]

Without significant healthcare reform, it goes the same was as PP for physicians, the way of the Dodo. Fewer and fewer people want to spend hours haggling with insurance/medicaid/medicare to get 50% of what they bill for.

 

[Sanman]

Agreed with wisneuro regarding small full time private practice. However, large provate practices will likely continue (but mostly with practitioners as employees). Part-time or some full time cash only practices will continue as well. I see most providers taking an employed job with part time provate practice as the hours are different and both positions are easily accommodated.

 

[erg923]

With the qualifier that:

1.) There will always be a (small) market for cash only boutique type practices...most of these will be part time things to supplement a salaried job. Once I no longer have an infant, I do not think I will have difficulty carry 1, 2 or 3 cash clients at a time from the wealthy areas near my home.

2. PP can still flourish by doing legal/forensic work.

3. Insurance based npsych practices with multiple providers and established in their repsevtive communities/areas will be in business for the forseeable future, but the profit margin has been decreasing for years

 

[Doctor Eliza]

Agreed with wisneuro regarding small full time private practice. However, large provate practices will likely continue (but mostly with practitioners as employees). Part-time or some full time cash only practices will continue as well. I see most providers taking an employed job with part time provate practice as the hours are different and both positions are easily accommodated.

I'm curious why you specify that the practitioners will be employees rather than contractors? It seems that being contractors is a much better deal for the practice owner.

Dr. E

 

[erg923]

I'm curious why you specify that the practitioners will be employees rather than contractors? It seems that being contractors is a much better deal for the practice owner.

Dr. E

"Contractor" is only given a percentage of monies brought in and "employee" is required to be offered benefits? Is this the main difference or am I missing some pieces?

I have no interest in joining in PPs...I'm just curious.

 

[psych844]

I haven't done the research but I wonder how different the situation is in Canada. (we don't have any of these insurance issues, that I'm aware of anyways)

Anybody done the research to maybe get the sense of the potential if this insurance mess was fixed in the USA?

 

[psych844]

Also, how does one qualify to do assesments/evaluations for custody cases and insurance claims for injury? You would think this is a big money maker?

 

[erg923]

I haven't done the research but I wonder how different the situation is in Canada. (we don't have any of these insurance issues, that I'm aware of anyways)

Anybody done the research to maybe get the sense of the potential if this insurance mess was fixed in the USA?

I'm not sure I understand what your saying or asking, but certainly, no, insurance issues as they pertain to reimbursement for psychologists is certainly not "fixed." It worse than ever.

I also don't know what you mean by "qualify," (be licensed and know what your doing?) but suffice to say that being able to bill for every minute of your working time makes it more lucrative than clinical evaluations/work. If you like paying a huge malpractice insurance fee and spending time in court being grilled by lawyers, sounds like a winner. I would just assume be a garbage man than do that day in and day out, but whatev.

 

[AcronymAllergy]

I'm not sure I understand what your saying or asking, but certainly, no, insurance issues as they pertain to reimbursement for psychologists is certainly not "fixed." It worse than ever.

I also don't know what you mean by "qualify," (be licensed and know what your doing?) but suffice to say that being able to bill for every minute of your working time makes it more lucrative than clinical evaluations/work. If you like paying a huge malpractice insurance fee and spending time in court being grilled by lawyers, sounds like a winner. I would just assume be a garbage man than do that day in and day out, but whatev.

That's pretty much the reason more people don't get into forensic work, child custody evaluations, etc. It's very, very stressful and emotionally-taxing, often involving hours and hours' worth of combing through boxes of records in addition to conducting a very thorough evaluation of the individual. Then add in that you'll have a lawyer and his/her own neuropsychologist expert witness combing through your report to drag out individual sentences with which to hammer you during deposition and/or court.

 

[Sanman]

I'm curious why you specify that the practitioners will be employees rather than contractors? It seems that being contractors is a much better deal for the practice owner.

Dr. E

I was writing my response quickly, but I was referring to employee rather than sole proprietorships or small group with ownership stakes. I do think that some will offer employee status and be run like a company and many others will offer contractor positions. It will depend on the local market.

 

[psych844]

Sorry, that wasn't clear.

The healthcare system is obviously messed up in the USA at this point. As the person in the second reply said the insurance system is not working well and psychologists are sometimes getting paid half of what they should have been paid. I don't think these issues exist in Canada. So I was curious if anybody knew how well private practice psycholgist are doing in Canada. My perception was that private practice is becoming less common irregardless of these insurance issues.

Second, from what I gather, psycholgists who are hired to evaluate people for insurance/custody cases, seem to get paid tons.I was curious why more people didn't go into that area, but I guess I got my answer with the malpractice issue. Again, I wouldn't be able to tell you if the chances of getting sued for malpractice are less here in Canada, but I'd wager that it is.

I'm not sure I understand what your saying or asking, but certainly, no, insurance issues as they pertain to reimbursement for psychologists is certainly not "fixed." It worse than ever.

I also don't know what you mean by "qualify," (be licensed and know what your doing?) but suffice to say that being able to bill for every minute of your working time makes it more lucrative than clinical evaluations/work. If you like paying a huge malpractice insurance fee and spending time in court being grilled by lawyers, sounds like a winner. I would just assume be a garbage man than do that day in and day out, but whatev.

 

[erg923]

Your system actually increases the cost of healthcare and often creates more waste than we have here. You guys just spread it around to everybody so it doesn't feel quite as bad. No thanks.

 

[psych844]

Your system actually increases the cost of healthcare and often creates more waste than we have here. You guys just spread it around to everybody so it doesn't feel quite as bad. No thanks.

Psychologists here are not covered by our health system. If you want to see one you have to pay out of pocket, insurance, credit cards.

 

[erg923]

Psychologists here are not covered by our health system. If you want to see one you have to pay out of pocket, insurance, credit cards.

I know.

 

[Doctor Eliza]

"Contractor" is only given a percentage of monies brought in and "employee" is required to be offered benefits? Is this the main difference or am I missing some pieces?

I have no interest in joining in PPs...I'm just curious.

Correct. In my area, large PP's only have contractors. 🙁

 

[edieb]

I know.

Then are only social workers and LPCs covered to conduct psychotherapy? What about psychological testing?

 

[edieb]

Your system actually increases the cost of healthcare and often creates more waste than we have here. You guys just spread it around to everybody so it doesn't feel quite as bad. No thanks.

Very true -- when i was on pre-doc internship in Detroit, which borders Canada, the hospital I was at would always get patients from Canada wanting healthcare because wait times in their homeland of Canada were crazy long

 

[psych844]

Yet healthcare is by far the most popular thing in Canada..in many of the survey's it enjoys 80 to 85% support. The healthcare system is not perfect but it is really really good.

I find the concept that people have to file for bankruptcy or go into major debt because of a cancer diagnosis much more alarming.

Very true -- when i was on pre-doc internship in Detroit, which borders Canada, the hospital I was at would always get patients from Canada wanting healthcare because wait times in their homeland of Canada were crazy long

 

[psych844]

Your system actually increases the cost of healthcare and often creates more waste than we have here. You guys just spread it around to everybody so it doesn't feel quite as bad. No thanks.

Spread it around how?

 

[erg923]

Spread it around how?

I dont know. And that's the point. Somebody is paying for it, but because you dont get a direct bill for it...it feel better.

 

[Pragma]

Very true -- when i was on pre-doc internship in Detroit, which borders Canada, the hospital I was at would always get patients from Canada wanting healthcare because wait times in their homeland of Canada were crazy long

Yeah I had some patients come from Canada as well - said they couldn't get the care they needed there.

 

[psych844]

It really depends what kind of doctor/specialist you need to see. Seeing your GP is easy, acess to certain tests are easy, while others you have to wait longer. It also depends where in the country you are. But it could take months to see a Psychologist so I'm not surprised that some are going to the USA for that. But easy access is not everything.

 

[Therapist4Chnge]

We used to make the bulk of our revenue from Medicaid cases before preauthorization was required and reimbursement was actually decent, but now with a reimbursement rate at 20% of our hourly rate and an average of 75% of all testing requested being denied it's difficult to keep this system going.

I don't know how anyone can afford to take Medicaid, either for therapy or for assessment; the system is definitely broken.

 

[Goobernut]

Yeah I had some patients come from Canada as well - said they couldn't get the care they needed there.

Just to be fair, Americans cross the border to receive care in Canada (illegally) as well. Americans also cross the border and go into Mexico for some health services that they can't get in the US. Not that all those services are legitimate, but they do it because they feel they need it.

 

[PHD12]

Just to be fair, Americans cross the border to receive care in Canada (illegally) as well. Americans also cross the border and go into Mexico for some health services that they can't get in the US. Not that all those services are legitimate, but they do it because they feel they need it.

I've seen many investigative pieces in the nytimes about how much cheaper medical procedures are abroad (cost comparing different procedures), and the outcomes are just as good. Longevity is also higher in most developed and some developing countries. They did some cost comparisons on hip/knee replacements and they were something like 10x cheaper in Brussells. I've met senior citizens who go to India, Europe, Thailand for medical care. They have stayed in luxury hotels for their recovery with full-time nursing staff and it was still cheaper than in the US. These people knew where to go and did research first so they went to good places.

 

[Goobernut]

I've seen many investigative pieces in the nytimes about how much cheaper medical procedures are abroad (cost comparing different procedures), and the outcomes are just as good. Longevity is also higher in most developed and some developing countries. They did some cost comparisons on hip/knee replacements and they were something like 10x cheaper in Brussells. I've met senior citizens who go to India, Europe, Thailand for medical care. They have stayed in luxury hotels for their recovery with full-time nursing staff and it was still cheaper than in the US. These people knew where to go and did research first so they went to good places.

Yes, I have read quite a few of those articles! This is a good point. I have a lot articles gathered on health outcomes in the US vs. other countries, but I'll admit I don't have many on mental health outcomes. I have read recently that inpatient dependency programs are much longer, and those longer programs have a better success rate than our 28 day programs, but as for actual numbers I'd have to look it up again.

 

[edieb]

I agree with the general consensus that PP's future does not look good. We've had repeated meetings in the PP where I work to discuss the impact of slashes to reimbursement for therapy & assessment. We used to make the bulk of our revenue from Medicaid cases before preauthorization was required and reimbursement was actually decent, but now with a reimbursement rate at 20% of our hourly rate and an average of 75% of all testing requested being denied it's difficult to keep this system going. We have a lot of contracts with attorneys' offices and different government agencies, which keeps the lights on, and there are a total of three psychologists working as part of the same LLC, but profits are definitely shrinking. My own experience here has made it clear that full-time PP is not a viable career for me following graduate school - Ideally I see myself working full time in a research position, or split research/clinical position, and seeing patients on evenings & weekends on a cash only basis.

While I believe that RxP may offer some relief to this issue, I feel that a disproportionate number of the RxP proponents are psychologists who either have PsyD's which prevent them from taking advantage of most available research and faculty positions, or psychologists who attended non-accredited programs, internships, or post-doc's, which limits their employment options. It seems that a lot of the thrust in the RxP movement has come from clinicians who lack career options but want (or need) to make more money from clinical work, and less from the perspective of clinicians trying to integrate patient care. I firmly believe that a psychologist with a strong background in his or her own specialty and strong postdoctoral training in clinical psychopharmacology has the potential to be an excellent provider of assessment, therapy, and medication management; however, I believe equally as strongly that the last thing our field needs is a seemingly 'easy' way for psychologists who attend programs that lack accreditation or have horrible match rates to make $100-$200 after graduating - There are plenty of online and cut rate MSCP programs, which does not sit well with me.

I support RxP legislation with the caveat that a clinician must have attended an APA accredited doctoral program, APA accredited internship, & APA accredited post-doc. There is no reason why PP should not be a viable career for clinical psychologists, and I believe that RxP is one of the few forms of legislation that could help resuscitate PP work for psychologists, but I also believe that the field of RxP should be carefully regulated.[/QUOT



1) Almost no post-docs are APA approved and a lot of the better ones are not APA approved, so that point makes no sense. For example, Western Psychiatric, Yale, Harvard, UCLA-Harbor, Wayne State School of Medicine, Baylor, etc all have non-APA post-docs
2) The APA approves post-doctoral training programs in psychopharmacology and there are not "plenty" of them; there are only 3
3) As someone who attended a training program and is now a prescriber, I can tell you that 23:24 people in the class had APA approved programs and internships. If you look at the staff of Louisiana State University, the prescribing psychologists there have good internships and post-docs (University of California San Francisco School of Medicine, Wayne State University School of Medicine, Medical University of South Carolina).

It seems like you are just saying "things" with no evidence

 

[Therapist4Chnge]

While I believe that RxP may offer some relief to this issue, I feel that a disproportionate number of the RxP proponents are psychologists who either have PsyD's which prevent them from taking advantage of most available research and faculty positions, or psychologists who attended non-accredited programs, internships, or post-doc's, which limits their employment options. It seems that a lot of the thrust in the RxP movement has come from clinicians who lack career options but want (or need) to make more money from clinical work, and less from the perspective of clinicians trying to integrate patient care.

 

[bcliff]

ok you're right - got off on a tangent without really knowing what i was talking about and hit the submit button before fact checking myself.

apologies.

 

[AcronymAllergy]

I do think the concerns about RxP are valid, in that I, too, would worry that it'd be particularly appealing to folks with essentially lackluster doctoral training (and thus lackluster career options otherwise), particularly given our difficulties maintaining consistent and adequate training standards.

That being the case, it may not yet be a problem in LA and NM because folks who've thus far pursued RxP privileges were likely go-getters to begin with, given that it's still relatively early since they've been granted. Although knowing people who are MP's and have (obviously) gone through the training, I was glad to hear about how relatively intense it was all things considered, so the fears may end up remaining unfounded.

 

[bcliff]

The two MP's I've worked with have been PsyD's who attended the Forest Institute & both earned their MSCP's from Alliant's online program - Just seems like a lot of red flags for someone seeking prescription privileges.

 

[psych844]

For those of you who don't like Canada's healthcare system, what kind of system would be ideal?

 

[Therapist4Chnge]

The two MP's I've worked with have been PsyD's who attended the Forest Institute & both earned their MSCP's from Alliant's online program - Just seems like a lot of red flags for someone seeking prescription privileges.

I'd be curious to see how the cohorts of the various RxP programs break down. My cohort of 8 had 2 PsyDs and 6 Ph.Ds, all from university-affiliated programs; too small of a sample to really make any conclusions.

For those of you who don't like Canada's healthcare system, what kind of system would be ideal?

One that paid practitioners a fair reimbursement. 😉 I doubt I'll be on any insurance panels 5 years from now, as the reimbursements are becoming less and less manageable.

 

[psych844]

One that paid practitioners a fair reimbursement. 😉 I doubt I'll be on any insurance panels 5 years from now, as the reimbursements are becoming less and less manageable.

I'll verify my sources but in Canada's biggest province (Ontario) psychologists tend to get reimbursed 80 to 100% of claims. Ontario college of psychologists suggest $180/hr for psychotherapy for example.

The other thing is, most insurers require that a person is registered with the college of psychologists for the client to be able to claim that insurance.

Here, clinical Psychologists are authorized in law to diagnose mental disorders while psychotherapists are not.

I don't see how things are so bad in Canada.

Also:

"Psychologists in private practice are paid directly by the client on a fee-for-service basis. The client is then reimbursed by his or her insurance company, or uses the receipt as a tax deduction. Thus, psychologists in private practice run their business more like a dentist than a physician. In private practice, psychologists' incomes are comparable to other professions requiring similar lengths of time acquiring their education. For example, the average psychologist earns a similar amount of money to a lawyer. Most psychologists in private practice earn a lot more than family physicians or community-based psychiatrists do. This is due, in part, because OHIP fees, which pay physicians, have not kept up with the times, while private practice psychologists have been free to raise their fees appropriately over the years without government interference. However, salaried psychologists earn slightly less that salaried physicians in hospitals."

http://www.ottawa-psychologists.com/questions.php#psy-08

 

[CriminalPsych]

I do think the concerns about RxP are valid, in that I, too, would worry that it'd be particularly appealing to folks with essentially lackluster doctoral training (and thus lackluster career options otherwise), particularly given our difficulties maintaining consistent and adequate training standards.

I would definitely agree with your statement about being overpaid. Unlike in Louisiana, where Rx Psychologists bill under the same codes as physicians, the billing codes for Rx psychologists in New Mexico are in between that of a master's level provider, such as NP, and a MD/DO psychiatrist. Even with this in-between compensation rate and working < 40 hours a week seeing Medicaid patients, I can't keep up with how much money I make. I will likely go part time next year because even at that income level, I will making WAY over double what I made as a GS-13 in the V.A.

Sometimes when I am seeing patients, I keep a mental tally of how much I am making and by the time lunch rolls around, I am in shock at how much I have netted in just 4 hours and it doesn't even feel like work. I have managed to pay off all my student loans, my parents medical bills in less than a year and have a huge savings account.

I remember when I would 100 percent EBTs and assessment, how tired I would be at the end of the day. However, for some reason, med management isn't that draining. Part of it is that there are algorithms for it and the other part is that you don't have that many choice points like one does in EBT.

So let me preface this by saying that I am asking this as innocently as possible...

It seems to me that it does not take a genius to prescribe, so long as they have adequate training and an ability to fill in the blanks for an algorithm, as edideb pointed out in an earlier thread. If masquerading as a psychiatrist, then why would the stringent research requirements of a PhD be particularly relevant as most psychiatrists don't have that backing either. Is there any "Why should they make that much money when they didn't work half as hard as me" going on? And I'm not pointing any fingers at anyone, just asking more in general.