In search of a work week under 40 hours

[transitioning19230]

---

Members don't see this ad.

Looking to hear from people who work less than 40 hours. What do you do? I know of a few people who have accomplished this:

a. private practice with a smaller case load or forensic work where you set your hours.
a. consult/liaison work. Their workload fluctuates depending on the number of referrals, with some weeks being closer to 40-45 hours while others are closer to 30. It's generally accepted that you do what is required of you then go home. No one is filling those extra hours and it's not expected of you to work unless you have a research FTE.
b. Some academic positions: some smaller lib arts colleges even advertise a 35 hour/4.5 day work week.

 

[WisNeuro]

Private practice, work as little or as much as you want.

 

[PsyDr]

I think you should refine your question, to reflect your preferred work schedule.

You can have limited office hours, but asymmetrical workflow. For example: In forensics, court dates and locations are not scheduled in a convenient way, and can be conflicting. Or in PP, you could work zero hours one week and 80hrs the next week. Or in admissions, you could work few hours, but may be regularly called in at 2AM. Or in research, you could work like a dog in grant season, but nothing during recruitment.

 

[Sanman]

Anyone in this field can work less than 40 hours. There are adjunct professors and part-time clinicians. Now, whether any of that brings in a living wage is a different question. The unstated part of the question seems to be how do I work fewer hours and still make lots of money. In most of those cases in this field, the quickest answer that I see most often is marry a rich spouse.

 

[WisNeuro]

Anyone in this field can work less than 40 hours. There are adjunct professors and part-time clinicians. Now, whether any of that brings in a living wage is a different question. The unstated part of the question seems to be how do I work fewer hours and still make lots of money. In most of those cases in this field, the quickest answer that I see most often is marry a rich spouse.

Like all the Redditors who want to be paid like 150k for seeing 12-15 therapy patients a week?

 

[Sanman]

Like all the Redditors who want to be paid like 150k for seeing 12-15 therapy patients a week?

That's hardly an impossible goal. They just want to skip all the years of hard work (and some luck) that lead to it.

 

[WisNeuro]

That's hardy an impossible goal. They just want to skip all the years of hard work (and some luck) that lead to it.

Definitely not impossible, just have to build that cash pay patient base. But, these people also don't want to run their own practice, they want someone else to pay them that and take care of the overhead logistics.

 

[Sanman]

Definitely not impossible, just have to build that cash pay patient base. But, these people also don't want to run their own practice, they want someone else to pay them that and take care of the overhead logistics.

Other people's willingness to complain and lack of interest in improving their business or personal finance skills is something that I have truly come to appreciate. Don't want too much competition when Trump fires me and burns down the VA.

 

[PsyDr]

Like all the Redditors who want to be paid like 150k for seeing 12-15 therapy patients a week?

You could. But you have to backwards reason this. "I want to work 15hrs/week in an office by my house, where office rent is 2k/month plus NNN (or worse if you buy due to property taxes) for a total of 30k/yr, my spouse pays for my health insurance and tax preparer, I want zero in my retirement account ever, administrative tasks don't count for work hours, my costs are not affected by inflation, and I will always have a full patient load (by magic). I want 8 weeks off for holidays+sick time+vacation+conferences+family things+"time to process things", some of which I won't consider into the actual number of weeks off. For a schedule, I want to work from 9-noon, an hour lunch, and then work from 1-2pm (don't mention kids here, because people get mad about that)."

That leaves 44 weeks of potential work, with 528-660 hours of work, so you'd need to charge ~$350/hr to net $150k, less taxes.

 

[Sanman]

You could. But you have to backwards reason this. "I want to work 15hrs/week in an office by my house, where office rent is 2k/month plus NNN (or worse if you buy due to property taxes) for a total of 30k/yr, my spouse pays for my health insurance and tax preparer, I want zero in my retirement account ever, administrative tasks don't count for work hours, my costs are not affected by inflation, and I will always have a full patient load (by magic). I want 8 weeks off for holidays+sick time+vacation+conferences+family things+"time to process things", some of which I won't consider into the actual number of weeks off. For a schedule, I want to work from 9-noon, an hour lunch, and then work from 1-2pm (don't mention kids here, because people get mad about that)."

That leaves 44 weeks of potential work, with 528-660 hours of work, so you'd need to charge ~$350/hr to net $150k, less taxes.

Telehealth is the way to go for this. Lower overhead.

 

[quickpsych]

Currently I work for a company that provides psych services/psych professionals to SNF (skilled nursing facilities) and nursing homes. For psychologists , for now, it's easy money, for the midlevels I have no idea why any of them work in this arrangement as they get worked to the bone for less). I maybe put about 3-5 hours a day in 3-4 days a week but to be honest it's not really work I'd currently at this time, for a variety of reasons. I'm considering an exit from them eventually, as I cut down my time at these facilities. I also do some side work for a small private practice that provides more boutique therapy and assessment services catering to high income families. Longer term definitely want to revisit idea of my own practice especially after seeing what's possible.

My hunch on academia is that it isn't going to be a path to long term wealth or even a decent living wage as a "full time" gig, but as part as a mix of different work across the week I'm sure it could scratch a teaching or research itch on the side.

@WisNeuro and @Sanman have offered some excellent ideas and insight into how working less than 40 hours a week might look like while also earning a decent living.

A good realization to have and to accept is that you'll trade time for money no matter what you do. Personally while I do really miss some settings I worked in where I was a full time 40 hr employee, I have tasted freedom, time, and flexibility while earning decent money so I don't think I'd go back to punching a clock or set salaried hours of a 9-5 nature. Also some prefer more variety so to speak, so for some the answer may be one role or just PP, for others it might mean having income from different roles/sources.

 

[Therapist4Chnge]

I run a private practice that is a mix of clinical assessment & intervention, record review/IMEs, and consulting (mix of educating, presenting). It depends on the week. Some weeks I work 20hr and others it’s 40+ hr. Then some weeks I have to cancel my plans and/or drop everything bc of a court deadline, last minute client request for rebuttal, etc. I love the flexibility and hourly my forensic work brings, but it’s a different kind of stress to make things work sometimes.

Not all hours are billable either. While I try and minimize my non-billable clinical hours, there are plenty for my consulting work, legal work, and speaking work hours that I can’t bill. Some of it evens out with good cancellation/reschedule policies. Other times you plan on more hours, and they disappear. I had 3 referrals for cases around Xmas, and 2 are on hold now, 1 is probably a quicker turn around. I have a few prior cases where I likely have 1-2 rebuttals to write, but dates unknown. They could be due in 3 weeks or 4 months, who knows. I’ll probably get 1-3 requests to review records this month, but 1 may be ready to send, while others are weeks to more than a month out from receiving any documents.

I’m still tweaking my mix of cases and how I spend my time. Generating enough quality legal referrals takes times, usually a number of years. I don’t do any marketing, though it would probably help in some areas. I turn down probably 30% of my legal referrals, but I prefer to be picky than have to navigate the minefields of a bad case. I also have established myself that referrals can come from ppl I don’t know bc they are familiar w my work.

Some people prefer a steady (higher) volume for lower hourly pay; I do not. I built my practice to start 80/20 clinical v all other hours, but I’m much close to 40/60 now. Hopefully I can reach 20/80 for this year.

One last thing about legal work, you can try and keep a regular flow of work, but cases will settle out of the blue, but others might have a quick turn around rebuttal, and sometimes you have a full Friday afternoon of patients and now your weekend is gone bc something popped up. I don’t see patients on Fridays, but I may have reserved the time to review notes from my counselor or f/u on outstanding invoices.

It’s actually easier for me to schedule legal work now bc I limited my clinical work slots, but reducing clinical work can add to cash flow variability. Clinical work can settle into patterns for payment, but if you want to do more legal work, you better have a healthy biz account already bc payments can takes weeks longer than expected. I’m currently waiting on $35k+ across 3-4 legal cases from outstanding invoices. Even with retainers, hours can add up quickly while you wait weeks for the prior invoices. Having $35k+ out for clinical work is much more tolerable bc you get $300 here, $1,000 there, etc.

 

[PsyDr]

Telehealth is the way to go for this. Lower overhead.

So long as you can sell your services better than the national names in the market. Otherwise, it's selling sand at the beach.

 

[Therapist4Chnge]

The telehealth space will be cannibalized by private equity, if not already saturated by them. They invest in startups who contract cheap labor, and it drives down payments and is a liability nightmare for the contractors. Maybe ~6 years ago I had 2-3 try to recruit me bc of my tech background to help them develop their models and processes, but even back then I saw the giant red flags.

There should be some niches and low-volume spaces where telehealth makes sense for clinicians, but then you are competing against those large groups on price. Trying to pair a high hourly with telehealth is not likely to be successful bc people who are willing to spend $250-$300+/session usually want it in-person. Accepting <$100 per session as a contractor isn’t a good option for a range of reasons.

You can still carve out a high hourly rate and make a 30-40hr/wk model work, but it will probably be very locale dependent and require some very niche areas of expertise related to legal work.

 

[Sanman]

The telehealth space will be cannibalized by private equity, if not already saturated by them. They invest in startups who contract cheap labor, and it drives down payments and is a liability nightmare for the contractors. Maybe ~6 years ago I had 2-3 try to recruit me bc of my tech background to help them develop their models and processes, but even back then I saw the giant red flags.

There should be some niches and low-volume spaces where telehealth makes sense for clinicians, but then you are competing against those large groups on price. Trying to pair a high hourly with telehealth is not likely to be successful bc people who are willing to spend $250-$300+/session usually want it in-person. Accepting <$100 per session as a contractor isn’t a good option for a range of reasons.

You can still carve out a high hourly rate and make a 30-40hr/wk model work, but it will probably be very locale dependent and require some very niche areas of expertise related to legal work.

Unfortunately, private equity is cannibalizing eveything. They already took over the nursing home market, regular office-based psychotherapy (Lifestance Health just went public and Summit Partners unloaded a boatload of shares) and are going after telehealth as well. At the end of the day, staying small and offering higher quality services is likely going to be more important regardless of how you practice. The large mills are going to corner the high volume, lesser quality insurance work. Hell, Optum already bought one of the largest group practices by me.

 

[chicandtoughness]

Are you only interested in direct patient care?

If not, come work on the other side in utilization review 😉

80k for 3-4 hours of work daily on my end.

 

[cara susanna]

Are you only interested in direct patient care?

If not, come work on the other side in utilization review 😉

80k for 3-4 hours of work daily on my end.

What is utilization review?

 

[AcronymAllergy]

What is utilization review?

If it's what I've typically seen described, then it involves working for an insurance company and reviewing the necessity/reasonableness of care by other MH providers.

 

[WisNeuro]

What is utilization review?

Something that is hard, but not impossible, to do with integrity.

 

[PsyDr]

IMO, there is money to be made in niches of pediatrics, and adult psychotherapy. I've never met an independently wealthy person who was happy. And most parents will spend their last dollar to help their child.

 

[R. Matey]

If it's what I've typically seen described, then it involves working for an insurance company and reviewing the necessity/reasonableness of care by other MH providers.

Mostly staffed by mid-level clinicians from what I've seen but YMMV

 

[smalltownpsych]

Private practice here and I have 32 hours a week scheduled. Since I run the business, I often have other work that adds to that total. For me, it is about working hard and as efficiently as possible. If I went to 40, I would make a little more, but available energy for effort is another limitation that people don’t always consider. Think of a 24 hour restaurant as opposed to one that just services the dinner hour, which one is more likely to provide quality food. Since we don’t take insurance, people are going to expect us to be on our game and provide excellent service.

 

[R. Matey]

IMO, there is money to be made in niches of pediatrics, and adult psychotherapy. I've never met an independently wealthy person who was happy. And most parents will spend their last dollar to help their child.

This matches what I've seen locally. There is a subsection of people willing to pay for more than McTherapy from PE, but the competition for those patients is fierce.

 

[Sanman]

This matches what I've seen locally. There is a subsection of people willing to pay for more than McTherapy from PE, but the competition for those patients is fierce.

The competition can be fierce because there are fewer people that can afford those services. I like restaurant analogy. A master sushi chef is not in competition with a master BBQ Pitmaster. Neither is he really in competition with grocery store sushi, the mall hibachi place, or McDonalds. The question becomes can you identify the correct niche, recieve the correct training, and make it work.

Offering generic therapy for every issue is unlikely to be the answer. Same way a diner has a ton options on the menu, but none of them are really great.

 

[R. Matey]

Offering generic therapy for every issue is unlikely to be the answer. Same way a diner has a ton options on the menu, but none of them are really great.

Really curious about what constitutes generic therapy in your view.

 

[chicandtoughness]

What is utilization review?

If it's what I've typically seen described, then it involves working for an insurance company and reviewing the necessity/reasonableness of care by other MH providers.

There's two sides to UR. The first is the insurance side, where yes, you work as an insurance reviewer to approve or deny authorizations (requests for services). The second is the facility side, where I work. I audit patient charts (typical caseload is 80 or so patients, I was holding 120 for a time but it's come down significantly since then) for timely documentation and quality intervention, and then I call the insurance companies to argue for authorization approval. It's actually pretty satisfying work, I get to advocate for my patients on the daily and practice case conceptualization/patient presentation on the fly. UR only exists as a job for HLOCs (inpatient/RTC/PHP/IOP) and not for outpatient services, so that's where you'll have to look for positions.

And I get to tell providers that the therapy they are doing is ridiculous and to please stop doing EMDR for eating disorders because in no book is that an EBM or reasonably covered by insurance at the facility level.

 

[Therapist4Chnge]

And I get to tell providers that the therapy they are doing is ridiculous and to please stop doing EMDR for eating disorders because in no book is an than EBM or reasonably covered by insurance at the facility level.

Just in case people need a reminder.

 

[AcronymAllergy]

There's two sides to UR. The first is the insurance side, where yes, you work as an insurance reviewer to approve or deny authorizations (requests for services). The second is the facility side, where I work. I audit patient charts (typical caseload is 80 or so patients, I was holding 120 for a time but it's come down significantly since then) for timely documentation and quality intervention, and then I call the insurance companies to argue for authorization approval. It's actually pretty satisfying work, I get to advocate for my patients on the daily and practice case conceptualization/patient presentation on the fly. UR only exists as a job for HLOCs (inpatient/RTC/PHP/IOP) and not for outpatient services, so that's where you'll have to look for positions.

And I get to tell providers that the therapy they are doing is ridiculous and to please stop doing EMDR for eating disorders because in no book is an than EBM or reasonably covered by insurance at the facility level.

I think your refusal to accept the universal applicability of EMDR requires some EMDR to fix.

 

[Sanman]

Really curious about what constitutes generic therapy in your view.

It really comes down to what is readily available using your insurance if we are talking about a cash practice (and especially a telehealth cash practice). Brief CBT/psychodynamic/EMDR for mild depression, anxiety, and the kitchen sink are probably not going to be the easiest sell via telehealth for $250/hr. However, a teen eating disorder specialist, ERP for OCD, or many other niches might not be easily accessible everywhere and could lend itself to a telehealth practice with a skilled provider.

 

[Sanman]

I think your refusal to accept the universal applicability of EMDR requires some EMDR to fix.

Its her countertransference. Definitely a course of EMDR to fix that.

 

[R. Matey]

It really comes down to what is readily available using your insurance if we are talking about a cash practice (and especially a telehealth cash practice). Brief CBT/psychodynamic/EMDR for mild depression, anxiety, and the kitchen sink are probably not going to be the easiest sell via telehealth for $250/hr. However, a teen eating disorder specialist, ERP for OCD, or many other niches might not be easily accessible everywhere and could lend itself to a telehealth practice with a skilled provider.

I was wondering if you and I were using the different words for the same thing. What you're calling specialty work, I would call quality work and I think we're both agreed that it's rare. For instance, supportive + CBT-lite + ACT-lite - (any meaningful case conceptualization) is what I would call incompetent practice whereas I think you're referring to this as generalist practice. Even for depression, few practitioners seem to understand how to work with core beliefs in a manner that impacts them. Heck, most of the time when I've introduced automatic thought tracking, patients were surprised.

 

[Sanman]

I was wondering if you and I were using the different words for the same thing. What you're calling specialty work, I would call quality work and I think we're both agreed that it's rare. For instance, supportive + CBT-lite + ACT-lite - (any meaningful case conceptualization) is what I would call incompetent practice whereas I think you're referring to this as generalist practice. Even for depression, few practitioners seem to understand how to work with core beliefs in a manner that impacts them. Heck, most of the time when I've introduced automatic thought tracking, patients were surprised.

Here is the difference, it is difficult to advertise that you are better at CBT than the next guy. It is easy to advertise that you specialize in XYZ thing that is uncommon, especially compared to mid-levels. I'm not saying that it cannot be done. However, it requires more word of mouth, a much longer time to develop a reputation, and a bit more luck.

 

[borne_before]

IMO, there is money to be made in niches of pediatrics, and adult psychotherapy. I've never met an independently wealthy person who was happy. And most parents will spend their last dollar to help their child.

The amount of play therapists abusing this fact drives me crazy.

 

[R. Matey]

Here is the difference, it is difficult to advertise that you are better at CBT than the next guy. It is easy to advertise that you specialize in XYZ thing that is uncommon, especially compared to mid-levels. I'm not saying that it cannot be done. However, it requires more word of mouth, a much longer time to develop a reputation, and a but more luck.

Sure, but now we're just talking about advertising where words only really matter if they get you money.

 

[Sanman]

Sure, but now we're just talking about advertising where words only really matter if they get you money.

This is where we differ. When it comes to any luxury good that people are willing to pay for, advertising matters. A $10 Casio is a more accurate tool for telling the time than a Rolex. Yet nearly no one will pay $10k for a Casio. Great for me as a consumer of Casio. Bad for Casio.

If you are accepting insurance or no one knows who you are, being the best therapist in the world makes no difference because you will make no more money than a mediocre therapist. I have treated wealthy and even famous people. That they were wealthy or famous made no difference to me as they paid me with Medicare (actually it was a bigger pain than usual). Despite them being thrilled with my services and even referring me to others my expertise was worth little. Don't underestimate the importance of good advertising.

 

[oliversacks4thewin]

The amount of play therapists abusing this fact drives me crazy.

How often I have to essentially explain to parents that they paid for what amounted to a very expensive baby-sitter/daycare and how there was no adherence to actual theory or treatment practice found in the literature for play therapy modalities blows my mind too.

 

[R. Matey]

If you are accepting insurance or no one knows who you are, being the best therapist in the world makes no difference because you will make no more money than a mediocre therapist. I have treated wealthy and even famous people. That they were wealthy or famous made no difference to me as they paid me with Medicare (actually it was a bigger pain than usual). Despite them being thrilled with my services and even referring me to others my expertise was worth little. Don't underestimate the importance of good advertising.

Thanks, I'll file that away. We're in the wrong career if money is the sole metric of success. Personally, I'm interested in providing good care and I don't meet many starving psychologists. Also good care and advertising aren't exactly mutually exclusive.

 

[Sanman]

Thanks, I'll file that away. We're in the wrong career if money is the sole metric of success. Personally, I'm interested in providing good care and I don't meet many starving psychologists. Also good care and advertising aren't exactly mutually exclusive.

I don't meet many starving psychologists but I do meet many that are overworked and underpaid. I agree that being a good psychologist and running a successful business are not mutually exclusive. However, if you end up having to work for private equity or a major healthcare conglomerate, good care and high volume productivity targets can be mutually exclusive. If you don't manage the business well, that may be all that is left for you.

 

[R. Matey]

I don't meet many starving psychologists but I do meet many that are overworked and underpaid. I agree that being a good psychologist and running a successful business are not mutually exclusive. However, if you end up having to work for private equity or a major healthcare conglomerate, good care and high volume productivity targets can be mutually exclusive. If you don't manage the business well, that may be all that is left for you.

Maybe regional variance then. Except the UCC, I haven't met psychologists who were overworked and underpaid. one of those maybe, but not both. I don't deny that it happens though. Many in the helping professions are too nice and naive to the realities of business, which allows them to be easily taken advantage of by PE or other such bad actors. For example, I regularly get spam email from private companies asking me to come do things I have no training in, like veteran's benefits evaluations, or sign up for x and y giant private practice conglomerate with "earning potential" up to $300k (lol). I'm not dumb enough to fall for such naked extortion, but obviously these ads are working for someone.

 

[WisNeuro]

Maybe regional variance then. Except the UCC, I haven't met psychologists who were overworked and underpaid. one of those maybe, but not both. I don't deny that it happens though. Many in the helping professions are too nice and naive to the realities of business, which allows them to be easily taken advantage of by PE or other such bad actors. For example, I regularly get spam email from private companies asking me to come do things I have no training in, like veteran's benefits evaluations, or sign up for x and y giant private practice conglomerate with "earning potential" up to $300k (lol). I'm not dumb enough to fall for such naked extortion, but obviously these ads are working for someone.

What, you can't do a full PTSD evaluation, with completed documentation, in 30 minutes?

 

[Sanman]

Its her countertransference. Definitely a course of EMDR to fix that.

@chicandtoughness, you should know angry face emojis are a symptom of lack of adequate eye movements.

 

[Sanman]

Maybe regional variance then. Except the UCC, I haven't met psychologists who were overworked and underpaid. one of those maybe, but not both. I don't deny that it happens though. Many in the helping professions are too nice and naive to the realities of business, which allows them to be easily taken advantage of by PE or other such bad actors. For example, I regularly get spam email from private companies asking me to come do things I have no training in, like veteran's benefits evaluations, or sign up for x and y giant private practice conglomerate with "earning potential" up to $300k (lol). I'm not dumb enough to fall for such naked extortion, but obviously these ads are working for someone.

It isn't regional. It's the part of the field you work in. Geriatrics has been a target of PE for a long time. In fact one of the PE firms that bought Lifestance Health owned the largest geriatric behavioral health provider before bankrupting and closing it (MedOptions). Hundreds of folks lost their job with no warning. Now, Lifestance is the largest outpatient behavioral health company in the U.S. However, it is now happening on all areas of the field. Check out Embark Behavioral Health (pediatrics), BlueSprig Pediatrics (autism), and many others.

If you think getting a 40-50 percent split of your work is not underpaid, then we have a different definition of underpaid.

 

[R. Matey]

It isn't regional. It's the part of the field you work in. Geriatrics has been a target of PE for a long time. In fact one of the PE firms that bought Lifestance Health owned the largest geriatric behavioral health provider before bankrupting and closing it (MedOptions). Hundreds of folks lost their job with no warning. Now, Lifestance is the largest outpatient behavioral health company in the U.S. However, it is now happening on all areas of the field. Check out Embark Behavioral Health (pediatrics), BlueSprig Pediatrics (autism), and many others.

If you think getting a 40-50 percent split of your work is not underpaid, then we have a different definition of underpaid.

Maybe that's the difference. I don't associate with Lifestance psychologists nor do I know anyone who refers to them. Lifestance is a joke around here, ngl. Hindenburg took a short position on them last year. Seems like a good idea.

 

[WisNeuro]

Maybe that's the difference. I don't associate with Lifestance psychologists nor do I know anyone who refers to them. Lifestance is a joke around here, ngl. Hindenburg took a short position on them last year. Seems like a good idea.

Also a joke around here. They are constantly trying to recruit "Testing Psychologists." They've tried to recruit me several times via LinkedIn. Once I drop my salary demands and refuse to take any compensation in company stock, they stop responding.

 

[Sanman]

Maybe that's the difference. I don't associate with Lifestance psychologists nor do I know anyone who refers to them. Lifestance is a joke around here, ngl.

Here is the thing, it isn't a joke and has nothing to do with who you associate with personally. They are large enough to affect salaries and reimbursements for everyone. In the bubble of small cash practices this may not matter. However, even academic hospitals and the VA set salaries based on the competition. So do insurance companies when setting rates.

Currently, only psychologists can practice in SNFs per medicare directives. These companies are pushing for midlevel encroachment. As someone that trains geropsychologists that often end up working for these folks early career due to a lack of better options, it is bad for the field. Cancer is cancer even if you personally don't suffer from it.

 

[borne_before]

How often I have to essentially explain to parents that they paid for what amounted to a very expensive baby-sitter/daycare and how there was no adherence to actual theory or treatment practice found in the literature for play therapy modalities blows my mind too.

I briefly worked in a developmental pediatrician ran private practice that had a large private pay psychology assessment/intervention branch. It killed me when a mom, who worked as a lab tech, was basically paying $175 dollars per week for the last five year for play therapy kept bringing her kid in.

But parents are rational actors. I know I am one. But that feeling of "i'm doing everything for my kid" is hella easy to exploit.

 

[PsyDr]

1) I was thinking about anorexia/ bulimia in adolescents. Or substance abuse in adolescents. Or PMR in athletes and nervous test takers.
2) Learn Mandarin. Treat "princess sickness".
3) My initial analyst required 3X/week, cash pay. I sat there and wondered who had a work schedule that would allow them to take off 3hrs +commute each week. Turns out that the majority of his clientele did not work.

 

[clausewitz2]

3) My initial analyst required 3X/week, cash pay. I sat there and wondered who had a work schedule that would allow them to take off 3hrs +commute each week. Turns out that the majority of his clientele did not work.

It's a bit like the old John Cleese line about how banking hours cater to two classes of people: bank robbers and the unemployed.

 

[R. Matey]

Here is the thing, it isn't a joke and has nothing to do with who you associate with personally. They are large enough to affect salaries and reimbursements for everyone. In the bubble of small cash practices this may not matter. However, even academic hospitals and the VA set salaries based on the competition. So do insurance companies when setting rates.

Currently, only psychologists can practice in SNFs per medicare directives. These companies are pushing for midlevel encroachment. As someone that trains geropsychologists that often end up working for these folks early career due to a lack of better options, it is bad for the field. Cancer is cancer even if you personally don't suffer from it.

I am sympathetic to midlevel encroachment in SNFs. I didn't actually know about gero specifically, but have heard similar things about rehab psych outside the VA. I can see the potential problems for certain specialties and do acknowledge that as a problem.

At the same time, I refuse to be cynical about our field. Call me naive all you want, but I believe that we provide a quality service that can be well marketed provided we advocate for ourselves. Having been a midlevel myself, I know that I am far more qualified than former R. Matey and any of his midlevel friends. Will this matter to everyone? No. There's always going to be a subsection of people who are going to try to get by on what is cheapest whether it is beneficial or not. These are the people who buy the latest iPhone and take it home to their rental. But nearly every day I see a OOP referral float by on the state org listserv. Most psychologists I know running PPs are full or nearly full. Most psychologists in salaried jobs that I know are making > $110K unless we're talking about the UCC.

Also, you are aware that Lifestance is not a W-2 model, no? So unsure how hospital salaries would be affected by a reimbursement model. The reason they are a joke is because it's widely understood that they are a predatory private practice. Their marketshare has fallen by ~70% since COVID and are ranked in the bottom tier of healthcare companies.

Also, midlevels are facing downward pressures themselves. In my state, post-degree trainees cannot bill Medicare. The average salary is somewhere in the low to mid $70k, which is barely a living wage (many of them would honestly be better off as teachers and nurses). Unsurprisingly, more than half of my graduating class of counselors, have left the field to do other things.

 

[Sanman]

I am sympathetic to midlevel encroachment in SNFs. I didn't actually know about gero specifically, but have heard similar things about rehab psych outside the VA. I can see the potential problems for certain specialties and do acknowledge that as a problem.

At the same time, I refuse to be cynical about our field. Call me naive all you want, but I believe that we provide a quality service that can be well marketed provided we advocate for ourselves. Having been a midlevel myself, I know that I am far more qualified than former R. Matey and any of his midlevel friends. Will this matter to everyone? No. There's always going to be a subsection of people who are going to try to get by on what is cheapest whether it is beneficial or not. These are the people who buy the latest iPhone and take it home to their rental. But nearly every day I see a OOP referral float by on the state org listserv. Most psychologists I know running PPs are full or nearly full. Most psychologists in salaried jobs that I know are making > $110K unless we're talking about the UCC.

Also, you are aware that Lifestance is not a W-2 model, no? So unsure how hospital salaries would be affected by a reimbursement model. The reason they are a joke is because it's widely understood that they are a predatory private practice. Their marketshare has fallen by 80% since COVID and are ranked in the bottom tier of healthcare companies.

Also, midlevels are facing downward pressures themselves. In my state, post-degree trainees cannot bill Medicare. The average salary is somewhere in the low to mid $70k, which is barely a living wage (many of them would honestly be better off as teachers and nurses). Unsurprisingly, more than half of my graduating class of counselors, have left the field to do other things.

Gero and rehab intersect outside of acute, dedicated rehab hospitals and the VA as SNFs/nursing homes also provide the bulk of sub-acute rehab services. These companies are offering less than $40 session compensation. They advertise a $125k salary and then have an RVU requirement that pressures folks to see 16-19 patients per day for 20 min sessions so they can bill out $250-300k per provider. I don't consider that a good wage despite beating your $110k threshold.

Lifestance Health generally pays a percentage (around 55%) of agreed fee (I am seeing $103/session thrown around reddit), which is not the fee they collect from insurance companies. I am aware that they are not a w-2 model. That said, even w-2 jobs are based on an RVU model because no one is hiring a provider that is revenue negative except maybe the VA ( even they compensate based on prevailing areas wages, this is how so many VA psychology departments secured special salary rates a couple of years ago). So, if Lifestance accepts a lower reimbursement from an insurer to pump up their quarterly numbers and makes it up by ripping off their providers and then local AMC and lowly Sanman in solo PP nearby also have to negotiate with the same insurer, guess what number the insurer throws out?

Midlevels are facing downward pressures and, guess what, local hospital systems are eliminating psychologist positions and only hiring midlevels for psychotherapy because they bill out at 75% our rates, but accept 55% of our pay. I'll give credit to @PsyDr for banging the drum of 'a rising tide lifts all boats' long before me. That said, a falling tide can beach a boat with a good captain as well. I am not saying it is all doom and gloom, but we can't all cater to only the rich.