how long for partnership

[kumar28]

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Hey all
With this group who are doing well, they hired me in August and things going really well and im really seeing way more patients than expected. They really like me and are trying hard to retain me. I would only stay here if there was a partnership option. How reasonable is it to ask for a partnership into the group after being in it for only one year? Most of the docs here are in their 60s so they really need me. Any thoughts? Thanks in advance

 

[vistaril]

Hey all
With this group who are doing well, they hired me in August and things going really well and im really seeing way more patients than expected. They really like me and are trying hard to retain me. I would only stay here if there was a partnership option. How reasonable is it to ask for a partnership into the group after being in it for only one year? Most of the docs here are in their 60s so they really need me. Any thoughts? Thanks in advance

ummm....psychiatry isn't an opthalmology practice or a GI practice or pathology whatever where there is a typical 'partnership track'. That is partly due to the nature of psychiatry, and partly due to the fact that less money overall is involved.

Unlike other fields, there is really no advantage to a partnership model in private practice. In psychiatry, you get paid to see patients....period. Usually rent/office space/overhead is shared. That is the essence I guess of any 'partnership'. Usually if a group of psychiatrists owns the building or whatever and wants to bring on a non-partner, they will just ask a % of his billing(or more commonly revenue seen) to pay for his rent, sharing the office, etc....

What exactly in this case would be the advantage for you(and how would it be different) of being a partner? whatever that means in this case

 

[kumar28]

There are plenty of reasons to become a partner ie profit sharing. Especially when you are dealing with a private psych/addictions facility. Guess I should've mentioned this. Anyone (besides vistaril) have any comments. Thanks

 

[vistaril]

There are plenty of reasons to become a partner ie profit sharing. Especially when you are dealing with a private psych/addictions facility. Guess I should've mentioned this. Anyone (besides vistaril) have any comments. Thanks

well yes an addiction facility is different. But addiction is not really psychiatry. Lots of different specialties run these.

As for profit sharing, again, the concept of 'profit sharing' in other fields is important because the revenue is coming from so many different sources, and so many of those sources require lots of overhead. Additionally, some of the sources of revenue are very high yield/efficient whereas others are lower profit margins but are still needed to ensure flow of the higher profit sources of revenue.

In psychiatry, again, you get paid to.....see patients. If I'm seeing more insured patients under 90805's(or whatever) than someone else in the practice, I don't want to 'share' my profits with him. Furthermore, if it's a cash pay analysis shop then the individual rep of the practitioner is what is going to drive demand and prices, and so this makes even less sense in psychiatry.

The typical setup in outpt psychiatry is to share expenses amongst practitioners....yes. But that's a much different setup than what other specialties involve. Whenever I hear the term 'partner' it's either generally meaningless(like just sharing expenses) or it involves someone being screwed over so his hard work can be 'shared' with others doing less volume.

 

[BS81]

Maybe if you are buying in to the name or reputation of the group and their referral base?

 

[vistaril]

Maybe if you are buying in to the name or reputation of the group and their referral base?

which matters less(and is much less valuable) in psychiatry than say....being a dentist.

If an upper middle class self pay patient patient has been doing non-manualized therapy once a week for 2 years from a psychiatrist who suddenly retires, she isn't just going to transition smoothly with few questions or concerns into the next guy with an open spot in that practice. That's much different than a dental practice, where if you've going to one office to have your teeth cleaned every 6 months and he dies/retires, you are very likely to just make the same transition to another dentist or a new dentist in the same practice.

Furthermore, the large(think > 8 psychiatrists) outpt groups are often considered 'factories' and there reputation is as such. When I refer patients to psychiatrists, I tend to not refer to these places(which really dont exist as partnerships anyways....more like expense sharing and not profit sharing), but rather to individual providers who do better work.

 

[digitlnoize]

which matters less(and is much less valuable) in psychiatry than say....being a dentist.

If an upper middle class self pay patient patient has been doing non-manualized therapy once a week for 2 years from a psychiatrist who suddenly retires, she isn't just going to transition smoothly with few questions or concerns into the next guy with an open spot in that practice. That's much different than a dental practice, where if you've going to one office to have your teeth cleaned every 6 months and he dies/retires, you are very likely to just make the same transition to another dentist or a new dentist in the same practice.

Furthermore, the large(think > 8 psychiatrists) outpt groups are often considered 'factories' and there reputation is as such. When I refer patients to psychiatrists, I tend to not refer to these places(which really dont exist as partnerships anyways....more like expense sharing and not profit sharing), but rather to individual providers who do better work.

This might be your best post ever!

I will only say that dentistry has changed. Practice value is no longer what it once was and it has become very difficult for a retiring dentist to sell their practice to a new guy. Most people are selling to big conglomerates for that reason...

 

[Frazier]

This might be your best post ever!

I will only say that dentistry has changed. Practice value is no longer what it once was and it has become very difficult for a retiring dentist to sell their practice to a new guy. Most people are selling to big conglomerates for that reason...

👍

 

[michaelrack]

As for profit sharing, again, the concept of 'profit sharing' in other fields is important because the revenue is coming from so many different sources, and so many of those sources require lots of overhead. Additionally, some of the sources of revenue are very high yield/efficient whereas others are lower profit margins but are still needed to ensure flow of the higher profit sources of revenue.

In psychiatry, again, you get paid to.....see patients. If I'm seeing more insured patients under 90805's(or whatever) than someone else in the practice, I don't want to 'share' my profits with him. Furthermore, if it's a cash pay analysis shop then the individual rep of the practitioner is what is going to drive demand and prices, and so this makes even less sense in psychiatry.

The typical setup in outpt psychiatry is to share expenses amongst practitioners....yes. But that's a much different setup than what other specialties involve. Whenever I hear the term 'partner' it's either generally meaningless(like just sharing expenses) or it involves someone being screwed over so his hard work can be 'shared' with others doing less volume.

Interesting discussion. Although I have a lot of experience in private practice (mostly sleep, a little psych); I am a lone wolf and have usually billed individually rather than as part of a group.

If one joins a psychiatric group practice that bills as a group and has negotiated favorable insurance contracts, would this be a reason to pay something (or temporarily accept a lower % of generated revenue) to become a "partner"??

 

[billypilgrim37]

If there are people reading this thread whose reaction is, "Oh my God, what are these people talking about? The only psychiatry I know is the team-based psychiatry where you have to be surrounded by a lot of good people from a lot of disciplines to do real good for patients," it's okay, there are others of us too.

This isn't at all to disparage the folks in this thread or say you're not doing important work. I just read this stuff and it really sounds like you're talking about some entirely different than I've ever seen. I might take a few evenings a week in a buddy's office to do some cash stuff next year on top of my other job (there is very little of this where I'm at), but I will probably limit it to people who are being referred from a specific pool of therapists, so that I know they're getting good therapy. So don't think I'm being high and mighty.

 

[michaelrack]

If there are people reading this thread whose reaction is, "Oh my God, what are these people talking about? The only psychiatry I know is the team-based psychiatry where you have to be surrounded by a lot of good people from a lot of disciplines to do real good for patients," it's okay, there are others of us too.

.

I am sure that many of the people reading this thread would be interested in learning more about the business aspects of that form of practice. For example, are other professional members of the team (such as psychologists) typically employees of the practice? Do they get bonuses or any form of profit sharing?

 

[billypilgrim37]

I am sure that many of the people reading this thread would be interested in learning more about the business aspects of that form of practice. For example, are other professional members of the team (such as psychologists) typically employees of the practice? Do they get bonuses or any form of profit sharing?

Very interesting questions, ones that I don't have much of an idea about. It's really hard for me to think about services that aren't targeted at medicaid populations (not exclusively, but frequently) and that aren't somehow related to county operations. I'm just used to agencies, not larger private practices.

 

[michaelrack]

Very interesting questions, ones that I don't have much of an idea about. It's really hard for me to think about services that aren't targeted at medicaid populations (not exclusively, but frequently) and that aren't somehow related to county operations. I'm just used to agencies, not larger private practices.

I have worked for gov agencies in the past. In my current locum assignment (occasional weekend coverage of an inpatient psych unit) I see a lot of medicaid patients.

I am sure you are aware (but non-physicians reading this thread may not be) that the posters on this thread are not money-obsessed; we are talking about the business aspects of medicine here because we get so little education about it in residency. Even in non-profits/gov agencies, someone needs to be keeping an eye on the administrative and financial aspects.

Personally, as a co-owner and one of the top 2 managers of a healthcare related company with 75 employees, I participate in discussions such as these because I am interested in learning more about the business aspects of medicine (even parts of medicine that I am not directly involved with right now).

 

[judasreznor]

I have worked for gov agencies in the past. In my current locum assignment (occasional weekend coverage of an inpatient psych unit) I see a lot of medicaid patients.

I am sure you are aware (but non-physicians reading this thread may not be) that the posters on this thread are not money-obsessed; we are talking about the business aspects of medicine here because we get so little education about it in residency. Even in non-profits/gov agencies, someone needs to be keeping an eye on the administrative and financial aspects.

Personally, as a co-owner and one of the top 2 managers of a healthcare related company with 75 employees, I participate in discussions such as these because I am interested in learning more about the business aspects of medicine (even parts of medicine that I am not directly involved with right now).

Off-topic, I know, but are there significant opportunities for physicians interested in business to own companies like you do?

 

[billypilgrim37]

we are talking about the business aspects of medicine here because we get so little education about it in residency.

Sure. Hey, I don't want to be poor. I just happen to live in a locale where not a ton of psychiatry follows this model, and I do think there's a good chance that governmental pressures will force health care to look a lot more like what I see than what a lot of people see.

(What I'm saying is, this whole time, I've actually been from the FUTURE!!!)

 

[PikminOC]

Sure. Hey, I don't want to be poor. I just happen to live in a locale where not a ton of psychiatry follows this model, and I do think there's a good chance that governmental pressures will force health care to look a lot more like what I see than what a lot of people see.

(What I'm saying is, this whole time, I've actually been from the FUTURE!!!)

Now everything makes sense....

 

[michaelrack]

Sure. Hey, I don't want to be poor. I just happen to live in a locale where not a ton of psychiatry follows this model, and I do think there's a good chance that governmental pressures will force health care to look a lot more like what I see than what a lot of people see.

(What I'm saying is, this whole time, I've actually been from the FUTURE!!!)

Agree about changes coming in healthcare.

This model of psychiatry being discussed isn't particularly relevant to me either.

The point I was trying to make previously was that it's a good (or at least not evil) thing for physicians to learn more about the business of medicine/psychiatry. I am using the term "business" in a broad sense, and NOT to mean "make as much money for myself as possible". Not every doc has to have a full understanding of business, but I think it is good for the profession for some docs to know the basics of financial statements, marketing, human resource issues (including how to properly hire and fire), etc. Of course, in addition to general business knowledge, there are some areas specific to medicine including physician practice structures, contracts/relationships between physicians and other healthcare entities, and legal issues (including stark, anti-kickback statute).
Many of the above areas are relevant to physician leaders/administrators working in the non-profit sector.

20-30 years from now physicians will probably all be mid-level salaried workers, but in the transition period to the full Obama state there will be incentives and revenue sharing for physicians

 

[michaelrack]

Off-topic, I know, but are there significant opportunities for physicians interested in business to own companies like you do?

Not really.. If you wanted to duplicate what I did, there are several things you would need to do:

1. Become relatively well known in your field and in your geographic area (in my case, I had worked in both academia and private practice in sleep/psychiatry. I was a committee member for the American Academy of Sleep Medicine-AASM. I had also traveled across the country, inspecting sleep labs for the AASM. I had worked in several locations across the state of MS and was and still am a board member of the Missippippi Sleep Society. I also did and still do post publicly to blogs/discussion forums, etc)

2. Accumulate some cash (see step 5)

3. Be willing to work part-time/side jobs when $ is tight at the main job

4. Be willing to travel (although most of my company's facilites are in the Memphis/Southaven MS areas, we have a sleep sleep in Tupelo MS - about 100 miles away- that I travel to once a week)

5. Find a struggling healthcare company and loan it $ and/or personally guarantee loans (Most small business loans require personal guarantees. When you see a good opportunity and are working with good people, some you just have to go "all in" and risk it all)

and finally,

6. When the company's situation has improved and the company is profitable, be prepared to deal with tax issues (I am not saying my company is or is not at that point yet, can't be too specific. Taxes do need to be paid on principal but not interest repayment. Income-profit- is not the same as cashflow)

------------------------------------------

I have edited this several times, here is the final edit/clarification:

I erased a few things to protect the privacy of company members/owners. I am not authorized to discuss the company's current financial situation publicly

 

[vistaril]

If there are people reading this thread whose reaction is, "Oh my God, what are these people talking about? The only psychiatry I know is the team-based psychiatry where you have to be surrounded by a lot of good people from a lot of disciplines to do real good for patients," it's okay, there are others of us too..

I don't even know what this means as it doesnt make sense without more details.....the bottom line is *someone* is being billed and *someone* is being paid....if the psychiatrist is on salary, then those services he is providing are still being billed to individual patients and they are(in one way or another) what is responsible for their salary. Whether they are 98205's or 99xxx's or inpatient codes or contracts or whatever may vary from place to place, but the concept is the same. Same goes for psychologists and speech therapists or OT or whatever depending on the setting....they may work as an independent contractor and bill separately(under their codes) or they may be employees of a larger business model that bills separately for their services(assuming outpatient) and then they are on salary.

But there isn't anything all that unique about the concept you described...people are still being paid for their services. The structure is just a little different and the funding(depending on the setting) may be a little different as well....but that's not particularly important or a meaningful distinction.

 

[vistaril]

Very interesting questions, ones that I don't have much of an idea about. It's really hard for me to think about services that aren't targeted at medicaid populations (not exclusively, but frequently) and that aren't somehow related to county operations. I'm just used to agencies, not larger private practices.

there isn't anything unique about such agencies....the payer source is different(ie medicaid). The employees are on salary. But what is paying the salary is all the individual billing codes submitted by you, clinical therapists, OT/PT(if that sort of stuff is in your agency as well), etc every time you see a patient.

Yes, some money is sometimes doled out in blocks to meet certain community needs(again, depending on the funding and the agency), but at these agencies that serve medicaid populations the fundamental concept of services being provided at each visit which is reimbursed at a certain rate for that specific service by that provider is still very much relevant....no different than in pp.

 

[vistaril]

Sure. Hey, I don't want to be poor. I just happen to live in a locale where not a ton of psychiatry follows this model, and I do think there's a good chance that governmental pressures will force health care to look a lot more like what I see than what a lot of people see.

(What I'm saying is, this whole time, I've actually been from the FUTURE!!!)

It sounds like you see a bunch of medicaid kids......there will be changes in the future no doubt(there always are), but the idea that those changes are going to look like your govt-has a solution for everything utopia is not going to happen imo. Now there will be continuing squeezing from hmos, ppos, etc.....no doubt. But the govt and medicare/medicaid is going to be squeezing you guys more as well.

Also, if health care for insured patients every becomes what it is now for the medicaid population(ie crappy), that will open up a lot more opportunities for boutique medicine and self pay medicine as well. I know this may come as a shock to you, but most people/patients don't associate medicaid with good care or really anything positive at all.

 

[michaelrack]

Also, if health care for insured patients every becomes what it is now for the medicaid population(ie crappy), that will open up a lot more opportunities for boutique medicine and self pay medicine as well. .

that's assuming that boutique and self pay are still legal several years from now.

 

[vistaril]

that's assuming that boutique and self pay are still legal several years from now.

oh I think it will be.....there are too many *obvious* uses where self pay is the only thing practical/possible, and I don't see state govts being able to make distinctions between those things.

 

[billypilgrim37]

It sounds like you see a bunch of medicaid kids...

Yes, and clearly we have many different experiences. I'm very glad that the environment where I practice doesn't often resemble the environment you describe, as I don't believe I would enjoy working in that sort of environment.

 

[vistaril]

Yes, and clearly we have many different experiences. I'm very glad that the environment where I practice doesn't often resemble the environment you describe, as I don't believe I would enjoy working in that sort of environment.

that's fine...but just be aware that your funding for those populations don't come from magic fairly dust. They come from one of two sources(sometimes a combination of both):

1) grinding out medicaid codes....when one of you child guys sees a medicaid kid and their family for an intake or followup, the reimbursement method(that part of it, it may not be the only source that keeps the clinic afloat) is no different than the reimbursement method the guys on this forum in pp use. Because it's medicaid, it's just crappier. That also goes for all the other providers on these teams you describe.

2) taxpayer monies in various forms to subsidize these agencies that serve medicaid population. As states across the country are hit with more and more financial issues(ballooning pensuion obligations for example), this money is going to become more and more scarce....as it should. What can't continue forever won't of course. And as monies become more and more scarce, a larger % of the funding will revert to #1 and the process of grinding.

Unfortunately, I could also add a third(medicaid fraud). The amount of fraud within medicare and medicaid is legendary of course. And not contained to any specialty. In every way possible, medicaid is the one program(not just the one health related program, the one program overall) that represents everything wrong with govt. It has a reputation for being expensive, wasteful and also resulting in substandard care....not good combinations.

 

[billypilgrim37]

As I said, we have different experiences, and I'm well aware of where the money comes from. I am rotating at the managed care company that handles most of the medicaid population in this area, and you might not appreciate the extent to which some of these companies are willing to put money into programs that will decrease the need for inpatient care (which is of course the most expensive thing that happens around here). Avoiding inpatient stays is pretty much the only thing that saves money in psychiatry, but for the most part, the best way to avoid inpatient stays is to deliver the most appropriate outpatient levels of care.

In our large system, plenty of our clinics lose money in terms of direct reimbursement, but may receive indirect funds from the county, the child protective services, the school systems, juvenile probation, etc. And some of our clinics just flat out lose money. One of our most prominent clinics loses between 300k and 400k a year. It just does. The money doesn't come from anywhere else. The department just eats it for a variety of unique reasons. Our system still runs in the black overall despite this, which is a marvel of management.

Also, I'm much more concerned about child psychiatry than adult, and you might be surprised about the extent to which even the most conservative governments relatively spare and/or support services for children. At least this is still true up here in the blue states. I don't know what it's like where you are.

Will we have to continue to be increasingly strict conservators of public funds? Sure. Can we figure out ways to still deliver quality services to lower SES populations? Well, either the answer is no, and I should either join a private practice or go back to school to do something else I enjoy, or the answer is yes, and there is desperate need for psychiatric leadership to help make this happen. I'm banking on the latter. I will make a little less money than you doing this kind of work, but I'll make about thrice what my and my wife's families made growing up (in today's dollars), so I'm happy.

I think we just have very divergent interests and perspectives based on the systems and locales where we have trained, and I think we like very different things about psychiatry. I keep saying that I believe the future of managed care, for better or worse, is going to make practice look increasingly like what I see. I might be entirely wrong, and most people on this forum probably disagree with me. That's okay. I've been wrong before.

 

[OldPsychDoc]

...
Will we have to continue to be increasingly strict conservators of public funds? Sure. Can we figure out ways to still deliver quality services to lower SES populations? Well, either the answer is no, and I should either join a private practice or go back to school to do something else I enjoy, or the answer is yes, and there is desperate need for psychiatric leadership to help make this happen. I'm banking on the latter. I will make a little less money than you doing this kind of work, but I'll make about thrice what my and my wife's families made growing up (in today's dollars), so I'm happy.

👍👍

I think we just have very divergent interests and perspectives based on the systems and locales where we have trained, and I think we like very different things about psychiatry. I keep saying that I believe the future of managed care, for better or worse, is going to make practice look increasingly like what I see. I might be entirely wrong, and most people on this forum probably disagree with me. That's okay. I've been wrong before.

I'm not "most people".

 

[vistaril]

I think you make a number of reasonable points, but I don't think a lot of states have even come close to experiencing what they will experience in the next decade and two decades with respect to having to tighten things in every area. States are still employing tens and hundreds of thousands of employees under guaranteed defined benefit pension plans(as they come into the system new now) at optimistic rates of return.

I don't really know where I will work next year...I'm more interested in smi populations than high functioning outpatients with private insurance, but am troubled by the financial future of this work. I'll probably still take a job in that area(or at least part of my work in that area), and I feel conflicted about this for a number of reasons.

I wish I was more interested in therapy, specifically a cash pay practice. Or high functioning outpatients. I feel like people who operate under that model(including I guess some practitioners who take only non-govt insurance) are in a way the most altruistic of all psychiatrists. When an analyst sees a high functioning cash pay pt for dynamic therapy(or anything really), the beauty of that transaction is that I am not forced to subsidize it. If I take a part time job at a community mental health center, me and my patients benefit(I get paid and they get subdisidized treatment) but the taxpayer, who never entered into any sort of agreement, is screwed over by having to pay for it.

The issue of whether care is bundled or whether an agency model(or whatever you want to call it) becomes more common in the community really isn't as applicable as whether the system is self supporting, or at least close to it. what cannot continue indefinately won't.