How many f/us are equal to one new patient eval?

[deleted1100659]

Sorry, younger attending, probably a bit of an obvious question. What is the typical standard, 3 f/u=1 new patient? Trying to get a sense of number of patients/productivity. Lately ive been averaging around 4 new ones a day, in addition to the f/us

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[clausewitz2]

Sorry, younger attending, probably a bit of an obvious question. What is the typical standard, 3 f/u=1 new patient? Trying to get a sense of number of patients/productivity. Lately ive been averaging around 4 new ones a day, in addition to the f/us

You'll need to clarify a bit more what you mean. Equivalent in terms of payments, in terms of RVUs, in terms of actual effort?

4 new intakes a day is miserable but hopefully this slows down when your panel is more established. At this point I refuse to do more than one a day.

 

[deleted1100659]

You'll need to clarify a bit more what you mean. Equivalent in terms of payments, in terms of RVUs, in terms of actual effort?

4 new intakes a day is miserable but hopefully this slows down when your panel is more established. At this point I refuse to do more than one a day.

Both really. Im curious to what you and others think about the effort equivalence, but yes also the standard as far as RVUs. I make a flat rate salary so im not getting any productivity bonuses.

It is quite miserable, a few people quit recently and I took on a huge amount of patients and I became significantly more busy. My schedule is always completely booked in addition to supervising midlevels

Thanks!

 

[calvnandhobbs68]

Both really. Im curious to what you and others think about the effort equivalence, but yes also the standard as far as RVUs. I make a flat rate salary so im not getting any productivity bonuses.

It is quite miserable, a few people quit recently and I took on a huge amount of patients and I became significantly more busy. My schedule is always completely booked in addition to supervising midlevels

Thanks!

Followups actually pay more and are more RVUs on a per hour basis. For instance, a 99205 (60 minute intake) is now 3.5wRVUs while 2x 99214s (30 minute followups) are 3.84wRVUs. 3x 99213s an hour is about 3.9wRVUs. If I billed straight time based 99214s, I would also make slightly more with 2 followups than 1 more eval (this isn't even basing things on billing therapy codes if you're billing on complexity, I make way more with one 99214+90833 plus one 99214 vs one 99205).

From a work standpoint, intakes are wayyy more work than a followup. From both a cognitive and actual work standpoint. So yeah probably 3 followups = 1 intake in terms of work.

4 news a day definitely sucks. I was doing 5 a day initially when my panel was empty, now I'm maxed out at 3 a day, more like 1-2 a day average.

 

[robellis]

You are seeing 4 new patients per day and your schedule is completely booked and you’re supervising your future replacements…please god please tell me you’re making 400k+

 

[wolfvgang22]

I would tell the clinic chief I can only handle 2 new evaluations per day.

If my admin said no, I would start looking for another job, saying nothing. Once you have another position in hand, you can then negotiate with your current employer if desired from a position of strength.

 

[deleted1100659]

This is why I like SDN, I assumed this was normal and I was just whining to myself until reading other people's experiences...This definitely clarifies a few things for me and will help with a few decisions going forward..

 

[robellis]

This is why I like SDN, I assumed this was normal and I was just whining to myself until reading other people's experiences...This definitely clarifies a few things for me and will help with a few decisions going forward..

What is your salary..that’s a very important piece of info

 

[Stagg737]

Imo 4 new evals should be (nearly) a full day, as in you see 4 evals + 1 or 2 follow-ups. Unless this is a psych ER or something this sounds pretty miserable.

 

[sloop]

Imo 4 new evals should be (nearly) a full day, as in you see 4 evals + 1 or 2 follow-ups. Unless this is a psych ER or something this sounds pretty miserable.

I think that it probably also depends on practice setting, population, and the complexity of the referrals you’re getting. If you’re mostly seeing young professionals who have maybe been on one antidepressant, are pretty functional, and are good historians, that is different than if you’re on an ACT team and half of your patients just got out of the hospital and are taking clozapine.

 

[hebel]

4 news per day is a lot. I generally limit it to one intake per half day.

Follow-ups, especially with therapy add-on codes are usually more productive/profitable than intake time.

 

[Sushirolls]

This video sort of conceptualizes the conversion rate of follow ups to consults. So many variables, so let's ask Mr. Owl...

 

[deleted1100659]

4 new ones, 5 f/us today for example. Patients are moderate to higher acuity ; underserved population. Usually a good bit of medical problems, polypharm, drug use. you know, all the fun stuff.

yes I think i may have a chat with the admin in the near future

 

[robellis]

4 new ones, 5 f/us today for example. Patients are moderate to higher acuity ; underserved population. Usually a good bit of medical problems, polypharm, drug use. you know, all the fun stuff.

yes I think i may have a chat with the admin in the near future

Why are you ignoring my question

 

[TexasPhysician]

4 new ones, 5 f/us today for example. Patients are moderate to higher acuity ; underserved population. Usually a good bit of medical problems, polypharm, drug use. you know, all the fun stuff.

yes I think i may have a chat with the admin in the near future

You are going to get vastly different averages here. In my cash practice, I’m not wanting more than 1-2/day. These are in-depth evaluations that set up the relationship for the future.

In an insurance practice with NP’s, the goal may be to get a good diagnosis (rapport not important). A good diagnosis and starting treatment plan is what is needed to pass the patient to the NP. 3+ new evals/day is expected. I think it’s ideal for psychiatrists to do at least the evals.

 

[calvnandhobbs68]

You are going to get vastly different averages here. In my cash practice, I’m not wanting more than 1-2/day. These are in-depth evaluations that set up the relationship for the future.

In an insurance practice with NP’s, the goal may be to get a good diagnosis (rapport not important). A good diagnosis and starting treatment plan is what is needed to pass the patient to the NP. 3+ new evals/day is expected. I think it’s ideal for psychiatrists to do at least the evals.

I would burn out so hard if I was doing new evals every day just to pass them off to NPs. Evals are way more exhausting than followups from a money per time standpoint, even for my most messy followup patients. At least I can just copy forward the notes for my followups.

 

[robellis]

Why in the hell would anyone do evals for an NP? That sounds like the most uninspiring burnout prone work I’ve ever heard. You form no relationships and do the busy work with none of the reward

 

[Stagg737]

I think that it probably also depends on practice setting, population, and the complexity of the referrals you’re getting. If you’re mostly seeing young professionals who have maybe been on one antidepressant, are pretty functional, and are good historians, that is different than if you’re on an ACT team and half of your patients just got out of the hospital and are taking clozapine.

Of course, which was why I gave the qualifier. OP is asking about a CMHC setting and imo 4 evals per day with those patients would be exhausting.

4 new ones, 5 f/us today for example. Patients are moderate to higher acuity ; underserved population. Usually a good bit of medical problems, polypharm, drug use. you know, all the fun stuff.

yes I think i may have a chat with the admin in the near future

Yea, that position would be a hard pass for me. Cut those evals in half or ONLY do evals and I think it's reasonable but not ideal. Unless you're making 400k+ you're getting hosed.

Why in the hell would anyone do evals for an NP? That sounds like the most uninspiring burnout prone work I’ve ever heard. You form no relationships and do the busy work with none of the reward

Sounds like a pretty profitable set-up for those with ownership in the practice. You do the evals to ensure to diagnosis and starting treatment is good, hand off f/ups to NPs (especially straightforward or stable patients) to increase billing productivity, and keep the harder follow-ups for yourself. Some quick math assuming you employ an NP who only sees 6 f/ups per day:

99214 + 90833 is about $200, times 6 patients/day is $1200 per day or $6,000 per week. If 45 weeks is a full year, that's $270k extra being brought in per year, and leaves a nice chunk after NP salary is paid. Most NPs are seeing a lot more than 6 f/ups per day (unless they're at a VA). Let's increase the number to 10 f/ups per day and say they're terrible at billing and only bring in $100/hour (a mix of 99213 and 214 without add-ons). that's still $5k per week and at 45 weeks in a year an extra $225k. Employing NPs can be very profitable, the question is whether you're willing to take on that supervision risk and finding NPs that are actually good.

 

[TexasPhysician]

Why in the hell would anyone do evals for an NP? That sounds like the most uninspiring burnout prone work I’ve ever heard. You form no relationships and do the busy work with none of the reward

Money talks. Many private practice docs do this.

 

[sloop]

Why in the hell would anyone do evals for an NP? That sounds like the most uninspiring burnout prone work I’ve ever heard. You form no relationships and do the busy work with none of the reward

Money talks. Many private practice docs do this.

I will also play devil’s advocate and say that not everybody is that interested in the treatment side of psychiatry. One of the things that I love about my fellowship (forensics) is that it’s almost 100% diagnostic. The things about psychiatry that interest me most are phenomenology and diagnosis. Rapport and longitudinal treatment can also be rewarding and I think I’m pretty good at those, too, but they just don’t excite me like the diagnostic part. Assuming the patients got good care and I wasn’t exposing myself to too much liability by doing it, this arrangement sounds pretty great to me. I get to see a patient, diagnose them, and initiate treatment, but I don’t have to get the annoying after hours calls to refill meds or complaints that things aren’t working, etc. Sounds like a decent arrangement. But I’m also the type of person who likes working in the ED.

This being said, I don’t necessarily think that this model is a great recipe for excellent care and I think it could carry a decent amount of liability. Those are the main reasons I probably wouldn’t do it, but the actual practice arrangement doesn’t sound bad.

 

[hebel]

I will also play devil’s advocate and say that not everybody is that interested in the treatment side of psychiatry. One of the things that I love about my fellowship (forensics) is that it’s almost 100% diagnostic. The things about psychiatry that interest me most are phenomenology and diagnosis. Rapport and longitudinal treatment can also be rewarding and I think I’m pretty good at those, too, but they just don’t excite me like the diagnostic part. Assuming the patients got good care and I wasn’t exposing myself to too much liability by doing it, this arrangement sounds pretty great to me. I get to see a patient, diagnose them, and initiate treatment, but I don’t have to get the annoying after hours calls to refill meds or complaints that things aren’t working, etc. Sounds like a decent arrangement. But I’m also the type of person who likes working in the ED.

This being said, I don’t necessarily think that this model is a great recipe for excellent care and I think it could carry a decent amount of liability. Those are the main reasons I probably wouldn’t do it, but the actual practice arrangement doesn’t sound bad.

Any recommended readings or resources for diagnosis?

 

[sloop]

Any recommended readings or resources for diagnosis?

I would recommend the following books. The first is mostly a propaedeutic on psychiatric formulation. The second is essentially a textbook on phenomenology. Of course, if we’re talking about diagnosis a la DSM-5, you can just read that, but I think these are probably more valuable in terms of understanding psychopathology in a more nuanced way.

McHugh, P. R., & Slavney, P. R. (1998). The perspectives of psychiatry (2nd ed.). Johns Hopkins University Press.

Oyebode, F. (2015). Sims' symptoms in the mind: Textbook of descriptive psychopathology. Elsevier/Saunders.

 

[calvnandhobbs68]

Money talks. Many private practice docs do this.

Yeah I mean it's way different if you own the practice and you're generating actual revenue from this rather than just being told that's your job in some clinic. It'd still be exhausting for me personally but at least you're getting something out of it. Same way even with a lot of PCP offices where you end up "following up" with NPs/PAs after you initially see the PCP for the first couple visits.

I will also play devil’s advocate and say that not everybody is that interested in the treatment side of psychiatry. One of the things that I love about my fellowship (forensics) is that it’s almost 100% diagnostic. The things about psychiatry that interest me most are phenomenology and diagnosis. Rapport and longitudinal treatment can also be rewarding and I think I’m pretty good at those, too, but they just don’t excite me like the diagnostic part. Assuming the patients got good care and I wasn’t exposing myself to too much liability by doing it, this arrangement sounds pretty great to me. I get to see a patient, diagnose them, and initiate treatment, but I don’t have to get the annoying after hours calls to refill meds or complaints that things aren’t working, etc. Sounds like a decent arrangement. But I’m also the type of person who likes working in the ED.

This being said, I don’t necessarily think that this model is a great recipe for excellent care and I think it could carry a decent amount of liability. Those are the main reasons I probably wouldn’t do it, but the actual practice arrangement doesn’t sound bad.

Problem is that in this scenario you are ending up carrying all the liability because I'd be assuming you're also "collaborating" with all those NPs. Not that this isn't the setup in a lot of outpatient offices in various specialities but it's way different than a forensic eval or disability eval or something where you're truly hands off outside of whatever your eval is for. Neuropsych evaluations are the same way, where you truly just do the evaluation, write the report and hand the patient back to their outpatient clinic.

Also if the midlevels start screwing up and throwing everyone on antipsychotics or benzos, you now have to be the one to clean up the mess when they get "re-referred" back to you. So for this to be minimally exhausting you'd have to be pretty confident in your NPs/PAs.

 

[sloop]

Yeah I mean it's way different if you own the practice and you're generating actual revenue from this rather than just being told that's your job in some clinic. It'd still be exhausting for me personally but at least you're getting something out of it. Same way even with a lot of PCP offices where you end up "following up" with NPs/PAs after you initially see the PCP for the first couple visits.



Problem is that in this scenario you are ending up carrying all the liability because I'd be assuming you're also "collaborating" with all those NPs. Not that this isn't the setup in a lot of outpatient offices in various specialities but it's way different than a forensic eval or disability eval or something where you're truly hands off outside of whatever your eval is for. Neuropsych evaluations are the same way, where you truly just do the evaluation, write the report and hand the patient back to their outpatient clinic.

Also if the midlevels start screwing up and throwing everyone on antipsychotics or benzos, you now have to be the one to clean up the mess when they get "re-referred" back to you. So for this to be minimally exhausting you'd have to be pretty confident in your NPs/PAs.

Yep, definitely aware of these issues with such a practice, which is pretty much where I was coming from in my second paragraph. I was just saying that, in its ideal (unrealistic) form, it could be something certain types of psychiatrists could enjoy.

Maybe I’ll just stick to doing the malpractice/standard of care reports for when the NPs in these practices do exactly what you’re describing.

 

[liquidshadow22]

Of course, which was why I gave the qualifier. OP is asking about a CMHC setting and imo 4 evals per day with those patients would be exhausting.




Yea, that position would be a hard pass for me. Cut those evals in half or ONLY do evals and I think it's reasonable but not ideal. Unless you're making 400k+ you're getting hosed.




Sounds like a pretty profitable set-up for those with ownership in the practice. You do the evals to ensure to diagnosis and starting treatment is good, hand off f/ups to NPs (especially straightforward or stable patients) to increase billing productivity, and keep the harder follow-ups for yourself. Some quick math assuming you employ an NP who only sees 6 f/ups per day:

99214 + 90833 is about $200, times 6 patients/day is $1200 per day or $6,000 per week. If 45 weeks is a full year, that's $270k extra being brought in per year, and leaves a nice chunk after NP salary is paid. Most NPs are seeing a lot more than 6 f/ups per day (unless they're at a VA). Let's increase the number to 10 f/ups per day and say they're terrible at billing and only bring in $100/hour (a mix of 99213 and 214 without add-ons). that's still $5k per week and at 45 weeks in a year an extra $225k. Employing NPs can be very profitable, the question is whether you're willing to take on that supervision risk and finding NPs that are actually good.

What are np typically paid on hourly basis or collections %?

 

[Stagg737]

What are np typically paid on hourly basis or collections %?

Idk if there's a decent source for typical amounts, as it can vary a lot. I've heard of NPs making $200k+ per year and others making $80-90k. I know either CMS or insurances used to reimburse NPs at 85% the amount of physicians for the same codes, but idk if that's true anymore. I have no idea for hourly, probably 50-80% of physicians, but I just pulled those numbers out of my butt, so take it with a grain of salt, lol.

 

[robellis]

Idk if there's a decent source for typical amounts, as it can vary a lot. I've heard of NPs making $200k+ per year and others making $80-90k. I know either CMS or insurances used to reimburse NPs at 85% the amount of physicians for the same codes, but idk if that's true anymore. I have no idea for hourly, probably 50-80% of physicians, but I just pulled those numbers out of my b***, so take it with a grain of salt, lol.

What does b*** stand for?

 

[Candidate2017]

4 new ones, 5 f/us today for example. Patients are moderate to higher acuity ; underserved population. Usually a good bit of medical problems, polypharm, drug use. you know, all the fun stuff.

yes I think i may have a chat with the admin in the near future

But do you really think admin cares?

As you say, several psychiatrists have already left. I assume they didn't quit out of the blue, and likely tried multiple times to get admin to address whatever grievances they had before they realized they were wasting their breath.

The bright side is that slogging through a complicated panel with 4 new a day will make you very efficient in your next gig.