In search of a work week under 40 hours

[futureapppsy2]

---

Members don't see this ad.

While it won’t always give you a sub-40 hour week, academia, especially R1 academia, can give you a ton of schedule flexibility without lowering pay, moreso than pretty much any other full-time job.

 

[chicandtoughness]

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.

The problem with becoming a psychoanalyst for the rich is that the costs to become a psychoanalyst are insane. And they’re always wondering why they can’t get numbers in their programs. Because it’s 4 years of tuition + PERSONAL ANALYSIS AIN’T CHEAP 😫

Unironically endorse working in eating disorders tbh, assuming you get the appropriate training. My waitlist is a mile long. Adolescent/child EDs are great but even adult EDs can be lucrative. Find yourself a good dietitian friend and develop a good working relationship and your schedule will be full. A lot of parents will pay OOP for these services too.

 

[R. Matey]

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 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.

Yeah, this was one of the reasons I decided against rehab training. Outside the VA and some AMCs. it seems that this merit badge carried little weight. As I said, I don't know ppl seeing 16-19 pts a day for their salary, but I believe you that it's happening somewhere. When I interviewed for positions, I had a lot of options to choose from because I have a strong CV. I get that's not true for everyone everywhere.

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?

For sure, this is why many psychologists don't accept insurance. From my view, consumers are getting wiser to it and are willing to pay OOP for good work (i.e., they get tired of being seen 1x/month for 30 minutes and thus seek out care in the community). What neither of us can say confidently is what percentage of the market this represents. You say it's only the rich. I'm telling you that isn't my experience.

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.

In some places, yes. In my area, people are trying to compete with the AMC who largely hires psychologists and pays a similar rate to the VA. As a result, demand for psychologists doing specialty work (e.g., health, neuro, peds mainly) continues to exist.

 

[WisNeuro]

For sure, this is why many psychologists don't accept insurance. From my view, consumers are getting wiser to it and are willing to pay OOP for good work (i.e., they get tired of being seen 1x/month for 30 minutes and thus seek out care in the community). What neither of us can say confidently is what percentage of the market this represents. You say it's only the rich. I'm telling you that isn't my experience.

Depends on the population. In the gero population, I can get people to see a neuropsych for an eval within weeks if they want to pay cash. 90%+ would rather wait the 4-9 months to use their insurance/Medicare. Peds evals, different story. Those with money will pay the $3k+ fees to get it done soon.

 

[R. Matey]

Depends on the population. In the gero population, I can get people to see a neuropsych for an eval within weeks if they want to pay cash. 90%+ would rather wait the 4-9 months to use their insurance/Medicare. Peds evals, different story. Those with money will pay the $3k+ fees to get it done soon.

Fair enough. I'm speaking mainly of peds and adults. I don't work too much with gero populations.

 

[WisNeuro]

Fair enough. I'm speaking mainly of peds and adults. I don't work too much with gero populations.

Meh, even with adults, at least in trauma. I know a couple psychologists who are very well trained in PTSD tx who are cash pay, and very few patients I refer there will go that route, instead opting to stay within their healthcare network and utilize the midlevel based MH clinic there. People can still make it work, but as time goes on, in general, I'm also seeing the erosion of doctoral level care in most settings with midlevel encroachment.

 

[R. Matey]

Meh, even with adults, at least in trauma. I know a couple psychologists who are very well trained in PTSD tx who are cash pay, and very few patients I refer there will go that route, instead opting to stay within their healthcare network and utilize the midlevel based MH clinic there. People can still make it work, but as time goes on, in general, I'm also seeing the erosion of doctoral level care in most settings with midlevel encroachment.

Maybe we need to revive the salary thread. Last I checked, most regular posters here are doing just fine as are the ppl I know running cash practices. I'm not saying that midlevel encroachment doesn't exist, but rather that midlevel/insurance incompetence drives a select group of people to quality care.

 

[quickpsych]

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 was surprised to learn that LMFTs are in higher demand because they can bill medicare in SNFs and can be paid less than psychologists while doing both the work of the psychologists and the LPCs/LCSWs (who themselves often have to see 15-18 patients a day to meet productivity if salaried). It made me wonder why these companies bother with us psychologists but then realized there aren't many LMFTS (and many less who would even know this kind of work is available). In other words, in the eyes of the SNF world, LMFTS = Psychologists, from a straight billing money making perspective.

 

[AcronymAllergy]

At the moment, there seem to be enough patients willing to pay OOP, in many areas, to keep cash-only therapy practices relatively full. I don't know how sustainable that is, as also in my experience, there is a significant proportion of the patient population who can't or won't pay OOP for mental health services. That said, I also don't know if the proportion of patients willing to pay OOP is growing, shrinking, or stable.

Outside of the coasts and peds, I don't think I know of any assessment-based practices (particularly neuropsych) that are cash-only. In general, neuropsychologists who make relatively good money and aren't highly efficient and volume-based in their practices (e.g., using multiple testers, having efficient and templated report writing practices) are supplementing income with medicolegal work.

Which is unfortunate, because there's a substantial and growing need for all of our services.

 

[Therapist4Chnge]

Maybe we need to revive the salary thread. Last I checked, most regular posters here are doing just fine as are the ppl I know running cash practices. I'm not saying that midlevel encroachment doesn't exist, but rather that midlevel/insurance incompetence drives a select group of people to quality care.

I think some/many are doing okay *despite* encroachment from midlevels, downward pressure on reimbursements bc of PE, slashed rates for Medicaid & Medicare, etc.

The only reason I have the flexibility I do is bc I do very niche work and have invested years in developing a solid reputation in those niche areas.

While my referral sources are not traditional commercial or govt insurances doesn’t mean I’m not impacted by these problems. I was just fortunate to find different options, but the economics of different insurance payors still has a ripple effect on most all of us.

 

[Therapist4Chnge]

At the moment, there seem to be enough patients willing to pay OOP, in many areas, to keep cash-only therapy practices relatively full. I don't know how sustainable that is, as also in my experience, there is a significant proportion of the patient population who can't or won't pay OOP for mental health services. That said, I also don't know if the proportion of patients willing to pay OOP is growing, shrinking, or stable.

Outside of the coasts and peds, I don't think I know of any assessment-based practices (particularly neuropsych) that are cash-only. In general, neuropsychologists who make relatively good money and aren't highly efficient and volume-based in their practices (e.g., using multiple testers, having efficient and templated report writing practices) are supplementing income with medicolegal work.

Which is unfortunate, because there's a substantial and growing need for all of our services.

Strong agreement.

Unfortunately, our physician colleagues continue to have a much easier path to a comfortable income, on average. Sub-par lobbying for the past 30+ years have knee-capped us. Tony Fuentes made more progress in his time at APA than most, but it was 20+ yrs too late. We are now fighting for scraps in the clinical world, forced to find multiple alternative revenue options if we don’t want to grind 48-50wks a year.

 

[PsyDr]

The problem with becoming a psychoanalyst for the rich is that the costs to become a psychoanalyst are insane. And they’re always wondering why they can’t get numbers in their programs. Because it’s 4 years of tuition + PERSONAL ANALYSIS AIN’T CHEAP 😫

Unironically endorse working in eating disorders tbh, assuming you get the appropriate training. My waitlist is a mile long. Adolescent/child EDs are great but even adult EDs can be lucrative. Find yourself a good dietitian friend and develop a good working relationship and your schedule will be full. A lot of parents will pay OOP for these services too.

My point is that the legal world is not the only area to make money. Those were just two ideas from someone who doesn't really do treatment. There are many other niches. Money is made in market gaps or inefficiencies.

The barrier to entry in psychoanalysis is a good thing, from the provider's side. It prevents market competition. Sorta like neuropsych, without the safety concerns.

Other areas:

1) Marriage therapy- Getting divorced is one of the most expensive actions someone can get into. I can't tell you how many times attorneys have asked me to negotiate between two parties getting divorced.
a. Some high net worth couple makes a pee-pee video, and all the sudden they have to work out who gets custody of the videos.
b. You know how intense borderline's relationships get? Some fools marry those people.
c. I wonder if there is a significant intersection between some software engineer people with ASD, and the rule bound nature of some of kinky practices. They probably need help, and can pay for it.
d. Someone is probably doing couples therapy with those sugar daddies/sugar babies. They have some money.
e. Gay marriage only became legal in like 2009. I wonder if the LGBTQIA population will have new marital issues, as the first legal marriage group ages.

2) Substance abuse- The American cultural process is to do something hideous, blame it on substance abuse, and then go into treatment. There has to be a market there.
a. Corporate America, med school, and law school have to be drowning in adderall and testosterone abuse. Median age of dx of hypertension is 46. Mean age of prostate cancer dx is like 67. Something is going to happen when those people can't take that anymore.
b. How many jobs would require very quiet outpatient substance abuse treatment? Lawyers? Physicians? Clergy? Cops?

3) Religious and cultural stuff- There has to be some religious sects and/or ethnicities that are ashamed of psychological issues.
a. Like 40% of 90210 is Persian. Presumably, they over represent the smart/wealthy groups that got out of the country pre coup. Sounds like a patient population of wealthy, intelligent, and educated individuals, if you know about Iranian stuff.
b. There are a ton of ethnic groups with inbreeding, that probably need culturally informed services related to the associated risks (e.g., Anabaptists).

4) Online stuff- Pure conjecture, but the number of people who need help with getting off video games or online stuff has to be unreal.
a. What happens when your kid fails out of college because they watched twitch for 19hrs straight? Relative to the lost tuition, a specialist psychologist is cheap.
b. What happens when grandpa "falls in love" with an AI girlfriend?
c. The neckbeard dudes probably need social skills training.

5) Political stuff- There HAS to be a need to treat people for being over involved in politics. Can you imagine how many spouses would pay for their spouse's treatment?

There are tons of opportunities there.

 

[R. Matey]

I think some/many are doing okay *despite* encroachment from midlevels, downward pressure on reimbursements bc of PE, slashed rates for Medicaid & Medicare, etc.

The only reason I have the flexibility I do is bc I do very niche work and have invested years in developing a solid reputation in those niche areas.

While my referral sources are not traditional commercial or govt insurances doesn’t mean I’m not impacted by these problems. I was just fortunate to find different options, but the economics of different insurance payors still has a ripple effect on most all of us.

Right. You built a reputation for quality niche work and now you are paid for it. I think this is probably how psychologists will continue to function for the foreseeable future, admitting that my take is optimistic, rather than cynical. I agree that insurers are trying to get the bottom dollar, but to use smalltown's restaurant analogy from upthread, not everyone wants McDonalds. After that, we're really just haggling over base rates.

 

[WisNeuro]

My point is that the legal world is not the only area to make money. Those were just two ideas from someone who doesn't really do treatment. There are many other niches. Money is made in market gaps or inefficiencies.

The barrier to entry in psychoanalysis is a good thing, from the provider's side. It prevents market competition. Sorta like neuropsych, without the safety concerns.

Other areas:

1) Marriage therapy- Getting divorced is one of the most expensive actions someone can get into. I can't tell you how many times attorneys have asked me to negotiate between two parties getting divorced.
a. Some high net worth couple makes a pee-pee video, and all the sudden they have to work out who gets custody of the videos.
b. You know how intense borderline's relationships get? Some fools marry those people.
c. I wonder if there is a significant intersection between some software engineer people with ASD, and the rule bound nature of some of kinky practices. They probably need help, and can pay for it.
d. Someone is probably doing couples therapy with those sugar daddies/sugar babies. They have some money.
e. Gay marriage only became legal in like 2009. I wonder if the LGBTQIA population will have new marital issues, as the first legal marriage group ages.

2) Substance abuse- The American cultural process is to do something hideous, blame it on substance abuse, and then go into treatment. There has to be a market there.
a. Corporate America, med school, and law school have to be drowning in adderall and testosterone abuse. Median age of dx of hypertension is 46. Mean age of prostate cancer dx is like 67. Something is going to happen when those people can't take that anymore.
b. How many jobs would require very quiet outpatient substance abuse treatment? Lawyers? Physicians? Clergy? Cops?

3) Religious and cultural stuff- There has to be some religious sects and/or ethnicities that are ashamed of psychological issues.
a. Like 40% of 90210 is Persian. Presumably, they over represent the smart/wealthy groups that got out of the country pre coup. Sounds like a patient population of wealthy, intelligent, and educated individuals, if you know about Iranian stuff.
b. There are a ton of ethnic groups with inbreeding, that probably need culturally informed services related to the associated risks (e.g., Anabaptists).

4) Online stuff- Pure conjecture, but the number of people who need help with getting off video games or online stuff has to be unreal.
a. What happens when your kid fails out of college because they watched twitch for 19hrs straight? Relative to the lost tuition, a specialist psychologist is cheap.
b. What happens when grandpa "falls in love" with an AI girlfriend?
c. The neckbeard dudes probably need social skills training.

5) Political stuff- There HAS to be a need to treat people for being over involved in politics. Can you imagine how many spouses would pay for their spouse's treatment?

There are tons of opportunities there.

Ha! I didn't even put it together, but I think that nearly every lawyer I've tested in the last few years has been on testosterone,

 

[WisNeuro]

Right. You built a reputation for quality niche work and now you are paid for it. I think this is probably how psychologists will continue to function for the foreseeable future, admitting that my take is optimistic, rather than cynical. I agree that insurers are trying to get the bottom dollar, but to use smalltown's restaurant analogy from upthread, not everyone wants McDonalds. After that, we're really just haggling over base rates.

I'm optimistic for niche providers, but I think generalist therapists are ****ed.

 

[R. Matey]

I'm optimistic for niche providers, but I think generalist therapists are ****ed.

I think we're closing the gap on the terms 'quality' and 'niche' so I'm inclined to agree. If a psychologist can't show that they're better than a mid, than yeah...

 

[Therapist4Chnge]

Impaired Provider evals or treatment are a great option for psychologists, PsyDr mentioned this above. You don’t need to be a neuropsych or rehab psych for all of them, particularly substance abuse cases, but you do need a solid grasp on assessment measures. Learning the related research and state-specific considerations can be picked up pretty quickly.

Admittedly, impaired provider work gets into that grey area of clinical v legal, which is why I always split the two. I preferred to do the evaluation portion and refer out for treatment because it’s straight-forward. I will still take an intervention referral AFTER impairment is established, but usually only acquired brain injury bc substance abuse work isn’t interesting to me.

The reason to split the two pieces should be obvious, but if there is disagreement over the eval, you don’t want to mess w the invention piece. Also, you can get a “voluntary” eval turn into a contentious one. I had a physician practice of various surgeons reach out about a fellow partner who was willing at first, but then it got ugly. My piece was clear, but it would have been trickier if I was also doing the intervention piece.

Not a cakewalk, but I think it’s interesting work that is cash pay and easily $2500-$5000+ for an eval.

 

[Sanman]

I was surprised to learn that LMFTs are in higher demand because they can bill medicare in SNFs and can be paid less than psychologists while doing both the work of the psychologists and the LPCs/LCSWs (who themselves often have to see 15-18 patients a day to meet productivity if salaried). It made me wonder why these companies bother with us psychologists but then realized there aren't many LMFTS (and many less who would even know this kind of work is available). In other words, in the eyes of the SNF world, LMFTS = Psychologists, from a straight billing money making perspective.

I was not aware of that change, but I have not been keeping up on these things as closely recently. I know LMFTs and LMHCs just earned the ability to bill medicare in January 2024. It looks like they can both bill medicare part B independently in a SNF now while social workers cannot due to the consolidated billing rule. I imagine this will push salaries down further over time and limit us more to intake and assessment in those areas.

 

[Sanman]

I think we're closing the gap on the terms 'quality' and 'niche' so I'm inclined to agree. If a psychologist can't show that they're better than a mid, than yeah...

If a psychologist can't show they are better than a midlevel *in an area that people are willing to pay cash*. Because insurance really doesn't care who is better.

 

[AcronymAllergy]

Ha! I didn't even put it together, but I think that nearly every lawyer I've tested in the last few years has been on testosterone,

The number of guys at my gym, some of whom I'm sure are lawyers, who talk about taking T has to be 80+%. It's the Adderall of the (primarily 30+ y/o) fitness world and has basically become a legal and easier to get/use replacement for steroids (although folks are much more open about the latter now than they were 20-30 years ago as well). Although Adderall can be reasonably tough to get, because you know us stick-in-the-mud MH providers, so medical marijuana may be a better analogy.

 

[WisNeuro]

The number of guys at my gym, some of whom I'm sure are lawyers, who talk about taking T has to be 80+%. It's the Adderall of the (primarily 30+ y/o) fitness world and has basically become a legal and easier to get/use replacement for steroids (although folks are much more open about the latter now than they were 20-30 years ago as well). Although Adderall can be reasonably tough to get, because you know us stick-in-the-mud MH providers, so medical marijuana may be a better analogy.

Are they getting their PCPs to Rx even with normal labs?

 

[Sanman]

Are they getting their PCPs to Rx even with normal labs?

Is it their PCP or one of these telehealth doc boxes?

 

[borne_before]

I just worry that as the cash pay model gets more adoption, it will (a) undermine psychology's authority in the eyes of working people more (although we are our own threat to that), and (b) make us a luxury good.

 

[R. Matey]

If a psychologist can't show they are better than a midlevel *in an area that people are willing to pay cash*. Because insurance really doesn't care who is better.

Eh, some insurers are better than others. We can either live in fear of insurance companies or choose to market ourselves accordingly.

 

[smalltownpsych]

One way I challenge some of these trends is by supervising midlevels in our practice and promoting higher quality service from them, thus making cash pay make sense for them as well.

 

[Sanman]

Eh, some insurers are better than others. We can either live in fear of insurance companies or choose to market ourselves accordingly.

I don't live in fear of them. I am simply saying that if you begin your negotiation with an insurance company with 'I provide better quality services than a midlevel', they are not going to care. In coming to a consensus on the previous statement, this is where we disagreed previously. As others have mentioned, folks are not willing to pay for all services out of pocket.

Now, if you provide a covered service not available by other providers in your area, single case agreements exist. This is why these legalities and differences matter. Better to have the laws on your side.

 

[AcronymAllergy]

Are they getting their PCPs to Rx even with normal labs?

I haven't asked, but I wouldn't be surprised. I can't imagine that many men have low testosterone levels on labs. Although I guess it depends on what level their doctor is using for "low."

 

[Therapist4Chnge]

Good timing. A new consult this wk asked me if he should get his tested, which surprised me bc he is in his 20s & presented as athletic & fit. Manual laborer, recent back injury, multi-level herniations w nerve involvement, new onset depression, now sedentary, not allowed on the worksite, etc. New onset reported sexual dysfunction. Increased conflict w gf. You can guess what I think is going on, but his friends think it’s “low-t”….

 

[Therapist4Chnge]

I haven't asked, but I wouldn't be surprised. I can't imagine that many men have low testosterone levels on labs. Although I guess it depends on what level their doctor is using for "low."

Bingo.

Back when I did my lab training for RxP there was only one reference range, and it was based on an older male sample. Now we know the ranges need to be grouped by age. Time of day for testing is a big factor too. I can definitely see how the data could be manipulated to demonstrate a low-t level to get TRT approved.

 

[R. Matey]

I don't live in fear of them. I am simply saying that if you begin your negotiation with an insurance company with 'I provide better quality services than a midlevel', they are not going to care. In coming to a consensus on the previous statement, this is where we disagreed previously. As others have mentioned, folks are not willing to pay for all services out of pocket.

Im not saying you do. The bottom line is that we have different estimates of the cash and insurance market based on our experiences. It’s not worth arguing about further.

 

[Spydra]

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.

What kind of special skills did you have to acquire to be able to do utilization review? This sounds very interesting. I've worked in inpatient settings but haven't heard of this.

I was surprised to learn that LMFTs are in higher demand because they can bill medicare in SNFs and can be paid less than psychologists while doing both the work of the psychologists and the LPCs/LCSWs (who themselves often have to see 15-18 patients a day to meet productivity if salaried). It made me wonder why these companies bother with us psychologists but then realized there aren't many LMFTS (and many less who would even know this kind of work is available). In other words, in the eyes of the SNF world, LMFTS = Psychologists, from a straight billing money making perspective.

And when our field dropped the guidelines for the Master's level license they wish to role out, I made this very point repeatedly. That in so many spaces now, LMFTs are preferred and employers don't care that psychologists have superior training and expertise. All they care about is paying less. And I was repeatedly gaslit. I'm only an ECP living the reality of applying for jobs and being turned down with the statement of "we'd prefer an LMFT but we'll keep your application on file."

 

[WisNeuro]

And when our field dropped the guidelines for the Master's level license they wish to role out, I made this very point repeatedly. That in so many spaces now, LMFTs are preferred and employers don't care that psychologists have superior training and expertise. All they care about is paying less. And I was repeatedly gaslit. I'm only an ECP living the reality of applying for jobs and being turned down with the statement of "we'd prefer an LMFT but we'll keep your application on file."

Nearly all of the hospital/system jobs here for therapy positions list masters, social work, MFT, and psychology in their job postings. And, based on what I'm seeing for records, it's about one doctoral level therapist for every 20 midlevels.

 

[Sanman]

Im not saying you do. The bottom line is that we have different estimates of the cash and insurance market based on our experiences. It’s not worth arguing about further.

I'm not sure that we are particularly far apart. It simply has to do with what segment of the population you are exposed to regularly. I previously worked in a cash only PP in NY. If you took that county and where I currently reside, you would think the average household income in this country is $125-150k. If you took a poll of the veteran population I work with, you would think it is $40-50k.

The truth is somewhere in the middle. However, basic economics tells me that you need over $100k in income to cover most basic expenses. So, some level of affluence is required.

 

[quickpsych]

What kind of special skills did you have to acquire to be able to do utilization review? This sounds very interesting. I've worked in inpatient settings but haven't heard of this.

I'm going to go out on, what is a probably, an obvious limb and say there's probably no special skills needed to do utilization review since the nature of it is usually in how to cut costs, save money, and not pay for services. I imagine those pay rolling utilization review staff probably want midlevels (which my understanding is the person you replied to who does URs is) and someone who can be trained into the role. I imagine most competitive psychologists (and also their medical counterparts like physicians and psychiatrists) are not going to take a job doing utilization review as the more you know the less you probably want to be involved with denying people coverage and care.

And when our field dropped the guidelines for the Master's level license they wish to role out, I made this very point repeatedly. That in so many spaces now, LMFTs are preferred and employers don't care that psychologists have superior training and expertise. All they care about is paying less. And I was repeatedly gaslit. I'm only an ECP living the reality of applying for jobs and being turned down with the statement of "we'd prefer an LMFT but we'll keep your application on file."

If you look at US Bureaus of Labor statistics, the median earning of an LMFT is nearly 40% less than psychologists so indeed true a lot of the companies (ie private equity firms that own these companies) are looking at $$$ and not much else. Again this also goes to my above point about utilization review jobs; less is more. How many companies are run by psychologists or psychiatrists vs run by MBAs and midlevels? It's not necessarily the employers don't care that psychologists are better trained and have more expertise and experience...it's that LMFTS and midlevels are cheaper, are more likely to not know what they don't know and go along with what the company says, and are more promotable because they'll cost less to do more and be less likely to bring up pesky problems like quality over quantity.

In your case, yes they'll prefer an LMFT but (and esp if it involves Medicare A and B billing) they'll eventually hire a psychologist if it takes too long to fill the spot because money isn't being made on an empty spot and LPCs/LCSWs can't bill all that LMFTS and psychologists can. So if they want to fill that job, they'll have to pay more for a psychologist.

 

[chicandtoughness]

I'm going to go out on, what is a probably, an obvious limb and say there's probably no special skills needed to do utilization review since the nature of it is usually in how to cut costs, save money, and not pay for services. I imagine those pay rolling utilization review staff probably want midlevels (which my understanding is the person you replied to who does URs is) and someone who can be trained into the role. I imagine most competitive psychologists (and also their medical counterparts like physicians and psychiatrists) are not going to take a job doing utilization review as the more you know the less you probably want to be involved with denying people coverage and care.

I work on the opposite side of utilization review (aka the side fighting for coverage and care, not the one denying it). I can’t speak to insurance side UR. On facility side, best way to get into UR is to have done UR before, everyone is kind of weird about hiring people who they have to train in the process. If you can quickly skim a chart and prep a patient presentation in 5 minutes or less, you can do the job. It’s not so much about what you know and more about who you know. It’s a strangely small world, even more so when you get down into specialty UR like ED and SUD where everyone knows everyone else.

The majority of UR folks are midlevels because UR pays so much better than what you could earn anywhere else (as an employee), but I also know my fair share of psychologists who are burnt out on patient care and choose to do this work as well. They tend to be our supervisors, though no additional income is given based on your license at any level of the ladder.

Also not surprised you hadn’t heard of it despite working inpatient. General rule of ethical care is to not let insurance coverage dictate treatment planning. Some facilities have their UR work completely separate from clinical staff; if you’re not hearing from someone about denials, you probably have a good UR team who can get the days. (Inpatient tends to also be easier since most insurance policies are fine with a short lil 3-7 day stay.) Other facilities have more hands on UR teams, like mine, who can actively shape patient care. I do trainings regularly on good clinical practice, audit documentation, and make suggestions on treatment planning to set us up for more days of coverage.

 

[coffee&CBT]

Is it their PCP or one of these telehealth doc boxes?

In my experience with a few Veterans in their 30s recently, they have normal labs and VA PCPs won't prescribe so they utilize the online "doctors" to get it. They're convinced it will solve their mood/motivation problems