It's amazing that a physician comes to this forum with genuine questions about how psychologists should be fairly reimbursed and is met antagonistically. Yet the same psychologists decrying "midlevels" and poor pay also encourage NP degrees so that they can prescribe is absolutely mind-blowing to me. I'm sure psychiatrists will eventually fall to the place you've found yourselves in (that is, making 20-30k more than LCSWs), but I'd be much more willing to take up your cause against crappy trained social workers if every PhD/PsyD I met wasn't ****ting on psychiatrists.
Hey Kirby! Haven't heard from you in awhile
. And really great to see you again! Yea, that initial slew of comments was like...wtf.
Keep in mind that the person being antagonistic as you mentioned isn’t speaking for everyone here nor is he representative of the majority opinion. Hence why a few others chimed in with more nuanced responses that reflected other views.
Because this space is open to all (as are all the forums) sometimes those with extreme opinions answer first. We have no control over that, but the rest of folks who chimed in didn’t seem to have the same perspective.
Going to extremes helps no one, as we’ve seen. I don’t recall a conversation encouraging NP degrees in here—was that a reference to a specific conversation?
Thank you everyone. I really like the discussion. Phew! Well, I'm glad to see a more bell shaped curve in perspectives here. I mean, I understand this is a forum too, and we are talking about pay, so I was bracing myself as well. But there was fortunately some really useful information. Oh yes, btw, the numbers I threw out at my office is outdated by a little by the collections I have from earlier, new ones with new insurance rates are still rolling in and some nice increases are coming as well.
I know those providing psychotherapy feel the burn of the shortage of good prescribing providers. Us as psychiatrists don't really feel the burn part but yes, the midlevel prescribing discussion is a huge hot button. Perhaps another part of the disconnect is that it's harder for non-physicians to tell who is a good prescribing provider and who is not. I've worked with tons of really great psychologists who had patients that spoke the world of their prescribing provider but on further inspection, it was someone prescribing massive benzo plus stimulant to someone who's getting oxycodone. There can also be prescribing messes with non-controlled substances and I don't expect psychologists to be pharmacologists either. It makes it more confusing that some patients can look excellent in therapy sessions but with a prescriber and billing (gasp-the billing department aka me, to pay their bill) there is raging axis II features. Every provider joining my office, including myself, was absolutely shell shocked at how commonly patients treat their bills (our bills are in perfect accordance with insurance in network rates and terms and conditions) and hence treat their providers. This is ugly, but it's the truth. Insurances almost ALWAYS pay what's in their terms and timely (assuming the claim is written correctly and pristine--but thank god there's software for that now because I don't know how to do one manually). Negotiating rates is a different story. Where providers lose LOTS of income in healthcare systems is patients not paying their bill and that's why the schedules are crazy busy there. One of the psychologists joined here full time from a healthcare system and a number of patients followed her. I'd say 1/3 of those (they were all patients who had deductibles too) threw a massive fit (they were used to ignoring their bills) and one tried to sneak by not paying the bills and finding ways to get back on her calendar by calling repeatedly hoping a different person would answer. This happens every time a psychologist joins us from one of the healthcare systems. It's to the point where I warn them that the billing part may result in a percent of patients leaving because they're used to not paying. Where will they go back? The healthcare system that's not on top of the billing.
Also, very similar situation for the VA. Yes, the VA gets funding. But the VA does bill Medicare, Medicaid, and commercial insurance as well. The hard thing with the VA is providers have the eat the cost of the no shows. It's a promised salary with minimum productivity benchmarks. Convert your completed patient visits at the VA, estimate cost based on geographic insurance norms (VA
appears to use Medicare rates as a base determining factor for pay-->the recent increase in annual salary for psychiatrists percentage wise lines up perfectly with the Medicare rate increase the past 2 years). How many visits did you have, how much would insurance generally pay? Subtract then the overhead cost/split in a PP model. You will likely get paid more in PP than the cut the VA left you, because imo, we're subsidizing way more overhead than needed. I've worked at the VA 2 years.
Now, if you actually got paid for all those no shows, the time we spent sitting in that office, still at work, the salary would be even bigger, like, a lot. Plus, plenty of room to get 401k, health, dental, vision benefits etc. At least, that's what I calculated when crunching numbers for a psychiatrist.
That hasn't been my experience here or in the field - regarding psychologists wanting to prescribe. I have seen conversations about that for arguments sake, but I can count on one hand the number of peers I have spoken to or seen on here in the past 10 years that have even remotely considered such a thing. That hasn't been my experience with psychologists attitude towards psychiatrists either for the most part. I do think that when psychiatrists fall into the dunning-kruger effect type process with psychotherapy services that aren't merely supportive, and resistance to hearing feedback about that, that tends to grind some gears.
I can see it from the psychologists view too. At least personally, I feel the therapy I give would be nothing near to a psychologist great at their craft. It can get a little slippery both ways, I've seen psychotherapists chime in with therapy patients about how they have friends who take high dose benzos every day and the friends seem to be doing great and the patient interprets that is a recommendation for daily benzos which they bring to the psychiatrist. But I'm at least open to feedback on my therapy
. Excellent therapy at this clinic is our most valuable service, I'd say even more so than the medication management (because there's so much risk and such a slippery psychodynamic slope patients run into with it). Which is why I'm trying to gather more info on payment models. The great providers here, I don't ever want to lose them. But just like a great psychiatrist the clinic doesn't want to lose, the clinic has finite money and I don't have the means to pay the psychiatrist full time pay if they are working at 0.4 FTE. We're always trying to walk this delicate dance of what to pay a provider that the provider is happy about, what the clinic needs, but at the same time promoting good quality work at an economically sustainable model.
The funny part is the assumption here that we are mean to physicians. I had/have no idea what degree
@randomdoc1 holds and actually assumed he/she was a psychologist. It really does not matter who is running the practice. If you look at the history of those who commented, they are not fans of anyone offering unfair compensation and work for themselves for that reason.
As for psychiatry compensation falling, I see it being just fine and I am actually quite bullish about psychology reimbursement. While technology has led to a decrease in physician owned and led practices in favor of hospital based systems, telehealth has reduced private practice costs for therapists. I am seeing more and more leave for independent/solo practice now that telehealth has become more common.
lol. I was afraid some on here were starting to think I wasn't even a provider, just some evil admin/owner/capitalist villain. Or that perhaps there is some dynamic between psychologists and psychiatrists. Who knows. Anyways, we're all MH professionals and should know to reflect on our automatic/visceral reactions and it's about what we do with those! fyi, physicians are not a fan of being eaten up by hospital based systems and i suspect neither are psychologists. For discussion sake, I think the reason why it went this way is 1)it's not easy running your own shop and 2)tons of physicians are very financially and administratively (working with health insurance) illiterate and prefer to just do their clinical work. I'm a big supporter of providers being independent. This is where we have the autonomy we deserve and believe it or not, if enough of us get independent, have more influence with how insurance treats us. Some of the insurances, I know from inside sources still even pay the hospital systems crappy. And they are notoriously hard to negotiate with. But we have enough strong providers at this office that I told one of them lately, if you are not increasing rates, please start the termination process of this contract and see how your patients/members do with the growing network deficiency they already have. And they raised the rate. It's about banding together.
A side note I think is interesting that probably ruffles some feathers between psychiatrists and psychologists is that our definitions of busy can be SO different. When the clinic first started, I scratched my head at the difference, but I won't argue further. It's a cultural difference and end of the day I'm just trying to find something that works for everyone and won't break the bank.
