Income (in)Sanity

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st2205 said:
It's hard enough getting people within our own field to recognize and accept this, never mind a judge or jury.
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Residents don't have a good sense of what lawsuits are about. When I was a resident I had similar thoughts, but they are proven to be completely off.

No, you are not getting "sued" by your "panel" of upper middle class patients on fluoxetine because you are not picking up at 2AM because they just had a fight with their boyfriend. These concepts are just too quaint and completely not applicable if you are in a private practice. The best defense against lawsuit is patient selection. If you don't take suicidal patients you'll never have a suicide (most of the time). And if you did, and the record reflects that you've always appropriately assessed, and this is one time off thing, there's no basis for lawsuit. If a suit is filed, it'll never get to the judge or the jury. Residents have this dramatic vision of you at some deposition with lawyers throwing you questions. No most of the time it's a negotiation process between the plaintiff and your insurance company's lawyer and a bunch of paperwork. (At least, that's what PRMS told me).

If they call at 9PM for a medication side effect, it's perfectly fine to not call back till next day. You will not get sued for that. Don't be crazy. If you want to take challenging patients, and charge high fees, and be available, do that. There is no one size fits all. If you run your own practice, whether you are available 24/7 is part of the FRAME of treatment that should be customized to the patient.

People who actually need 24/7 care (i.e. DBT, severe psychosis, etc.) should not be in this kind of practice anyway, and they won't get it, because they will be working in a clinic or have a DBT therapist, and whether clinic has 24/7 coverage depends not on you, the clinician, but the faceless administrator and hospital. You have absolutely no say so this is completely irrelevant. Sure you can always get sued, but it has nothing to do with whether you take 24/7 call. Lawsuits are due to adverse events and poor documentation, and not paying attention to appropriate clinical procedures (i.e. being sloppy), as well as poor patient-doctor relationship, and sometimes just for no reason at all. They are not because of reasonable business decisions. Whether your practice offers 24/7 call coverage for a particular individual is a business decision, not a medical-legal decision.
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Merovinge said:
Heh I guess it appears you are correct. I am not going into the realm of practice anytime soon but I do think it is very silly to hold psychiatry to a different level then other fields of medicine for which there is absolutely not always an MD on call for their patients 24/7.
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My impression from other primary care providers is that it is always possible to get a medical professional on the phone if you need one. When I call the pediatrician after hours they have an answering service, and if I have a legitimate medical question they page the pediatrician who is on call that evening. My ped has his own practice but I think he partners up with a few other solo practitioners and they trade around to cover the phones. Same for ob/gyn, although I think they have an NP staffed line for calls (I've never used it so don't know for sure).

I think the question is whether psych is primary care or is it a specialty practice (in which case the 24/7 availability may not be standard of care).
 
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tr said:
My impression from other primary care providers is that it is always possible to get a medical professional on the phone if you need one.
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I know a pediatrician without 24/7 phone coverage. That seems reasonable to me anyway. If you can't wait then it's an emergency and you need to go to the ED.
 
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the standard of care is not 24/7 availability but that there is some provision (for example a weekend of after hours service) beyond office hours for things like med refills, slightly urgent but not emergent issues etc. this is ine reason why private practitioners choose to abandon the mentally ill.

it is absolutely ethical to charge patients for calls beyond 5 mins. it is in fact a very good idea to do so. you can always waive the cost if you then decide it was appropriate use of time. What you want to avoid is pts never turning up and then calling fir a refill at the last minute

also bear in mind it is really, really difficult to be successfully sued as a psychiatrist. bad care is the standard, snd even worse care is not enough for mslpractice - plaintiff has to show direct causation of damages from the crappy care. juries are loathe to blame anyone but the patient for suicide and in some states (e.g. NH) it is all but impossible to sue the psychiatrist due to the doctrine of contributory negligence. if your patients harms someone else however, expect the axe to fall on you...
 
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splik said:
the standard of care is not 24/7 availability but that there is some provision (for example a weekend of after hours service) beyond office hours for things like med refills, slightly urgent but not emergent issues etc.
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What does that look like, more concretely? Is that an MD available 6-10? An NP? Just an answering service/machine?
 
splik said:
the standard of care is not 24/7 availability but that there is some provision (for example a weekend of after hours service) beyond office hours for things like med refills, slightly urgent but not emergent issues etc. this is ine reason why private practitioners choose to abandon the mentally ill.
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Which is super annoying because private practice immunologists certainly arent all providing that as SoC
 
TorMed said:
Inpatient pays well, as does academic. Office based academic not so much.

Provincial hospitals (like a state hospital) are paying over $330k plus benefits. Google waypointe psychiatric for an example. It's 90 mins from Toronto.


Sent from my iPhone using SDN mobile
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It's the same pay effectively here in the states. Saw an ad for TX inpt, 306k + 1 call =80k, 2 calls = 160k + loans
 
Blitz2006 said:
I dunno, I was all about cash as well, until last few weeks.

But some attendings have told me that with cash you have higher no-show rate, and obviously, its almost impossible to fill a 40 hour work week with cash (even in NYC). Whereas you can easily fill a 40 hour work week with insurance...
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I bill for no-shows and am cash-only. I do return some calls on weekends and holidays, but they are brief. Longer calls are billed in increments.

24/7 call is not the standard of care. I document a crisis plan, and calling me at 3am is not an appropriate response. I cannot ensure safety of patients at 3am from my home.

Some of my patients work nights and call in for refills at 3am and leave a message. Perfectly fine
 
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TexasPhysician said:
I bill for no-shows and am cash-only. I do return some calls on weekends and holidays, but they are brief. Longer calls are billed in increments.

24/7 call is not the standard of care. I document a crisis plan, and calling me at 3am is not an appropriate response. I cannot ensure safety of patients at 3am from my home.

Some of my patients work nights and call in for refills at 3am and leave a message. Perfectly fine
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Thanks for your response. Honestly I don't want to open up a private practice if I have to be on call 24/7. Out of your curiosity, at the end of your day, you turn on your voicemail, and what does it say? "If you have an emergency, dial 911 or go to your nearest emergency room"?
 
Shikima said:
It's the same pay effectively here in the states. Saw an ad for TX inpt, 306k + 1 call =80k, 2 calls = 160k + loans
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I personally think AVERAGE pay is higher in Canada. I'm Canadian so I've looked into this.

Average psych pay in Toronto is 300k-350k (40 h/week). And Toronto is the largest city in Canada, not like small town Kansas. Average psychiatrists here in big east coast cities will be lucky to hit 275k (40 h/week).

You get out into the boonies and you're looking at 400k-500k.

But remember I said AVERAGE. If you hustle and are a businessperson, then pay is higher in U.S in the big cities, such as top psychiatrists in NYC making 500-600k. But again, this is a small percentage, and are "elite" cash-only psychiatrists that work 50-60 hours/week. Not average. And the job Shikima mentioned in TX looks awesome, but I personally haven't seen many ads like that. But this is just my anecdotal observation.

But yes taxes and cost of living is also higher in Canada (especially now with Trump taking over), so its a tough call which is better financially. Trade off is free healthcare and much cheaper college education (if you have kids).

U.S > Canada when it comes to research and fellowships, and if you want to be an "expert" in your field. But if you want to be a run of the mill psychiatrist, Canada might be a better option.
Although in that other thread people are saying Kaiser in SF/LA is offering 300k, if that's the case, then perhaps in the next few years U.S will take over.
 
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TexasPhysician said:
I bill for no-shows and am cash-only. I do return some calls on weekends and holidays, but they are brief. Longer calls are billed in increments.

24/7 call is not the standard of care. I document a crisis plan, and calling me at 3am is not an appropriate response. I cannot ensure safety of patients at 3am from my home.

Some of my patients work nights and call in for refills at 3am and leave a message. Perfectly fine
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Interesting. Here in NYC if you cancel before 24 hours you don't charge patient.

"Longer calls are billed in increments". So do you have a rate per 10 minutes?
 
sluox said:
Residents don't have a good sense of what lawsuits are about. When I was a resident I had similar thoughts, but they are proven to be completely off.

No, you are not getting "sued" by your "panel" of upper middle class patients on fluoxetine because you are not picking up at 2AM because they just had a fight with their boyfriend. These concepts are just too quaint and completely not applicable if you are in a private practice. The best defense against lawsuit is patient selection. If you don't take suicidal patients you'll never have a suicide (most of the time). And if you did, and the record reflects that you've always appropriately assessed, and this is one time off thing, there's no basis for lawsuit. If a suit is filed, it'll never get to the judge or the jury. Residents have this dramatic vision of you at some deposition with lawyers throwing you questions. No most of the time it's a negotiation process between the plaintiff and your insurance company's lawyer and a bunch of paperwork. (At least, that's what PRMS told me).

If they call at 9PM for a medication side effect, it's perfectly fine to not call back till next day. You will not get sued for that. Don't be crazy. If you want to take challenging patients, and charge high fees, and be available, do that. There is no one size fits all. If you run your own practice, whether you are available 24/7 is part of the FRAME of treatment that should be customized to the patient.

People who actually need 24/7 care (i.e. DBT, severe psychosis, etc.) should not be in this kind of practice anyway, and they won't get it, because they will be working in a clinic or have a DBT therapist, and whether clinic has 24/7 coverage depends not on you, the clinician, but the faceless administrator and hospital. You have absolutely no say so this is completely irrelevant. Sure you can always get sued, but it has nothing to do with whether you take 24/7 call. Lawsuits are due to adverse events and poor documentation, and not paying attention to appropriate clinical procedures (i.e. being sloppy), as well as poor patient-doctor relationship, and sometimes just for no reason at all. They are not because of reasonable business decisions. Whether your practice offers 24/7 call coverage for a particular individual is a business decision, not a medical-legal decision.
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Great post, thanks.

I actually mentioned the 24/7 thing not from a medical-legal perspective but from a business point of view! Lol. From what I hear, if you don't answer your phone at night or on wkds patient will get frustrated and switch to another psychiatrist. But again, I'm a resident, so I'm not claiming I know this , just what I've been told by attendings
 
Blitz2006 said:
I personally think AVERAGE pay is higher in Canada. I'm Canadian so I've looked into this.

Average psych pay in Toronto is 300k-350k (40 h/week). And Toronto is the largest city in Canada, not like small town Kansas. Average psychiatrists here in big east coast cities will be lucky to hit 275k (40 h/week).

You get out into the boonies and you're looking at 400k-500k.

But remember I said AVERAGE. If you hustle and are a businessperson, then pay is higher in U.S in the big cities, such as top psychiatrists in NYC making 500-600k. But again, this is a small percentage, and are "elite" cash-only psychiatrists that work 50-60 hours/week. Not average. And the job Shikima mentioned in TX looks awesome, but I personally haven't seen many ads like that. But this is just my anecdotal observation.

But yes taxes and cost of living is also higher in Canada (especially now with Trump taking over), so its a tough call which is better financially. Trade off is free healthcare and much cheaper college education (if you have kids).

U.S > Canada when it comes to research and fellowships, and if you want to be an "expert" in your field. But if you want to be a run of the mill psychiatrist, Canada might be a better option.
Although in that other thread people are saying Kaiser in SF/LA is offering 300k, if that's the case, then perhaps in the next few years U.S will take over.
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There is no such thing as free healthcare.
 
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PistolPete said:
Thanks for your response. Honestly I don't want to open up a private practice if I have to be on call 24/7. Out of your curiosity, at the end of your day, you turn on your voicemail, and what does it say? "If you have an emergency, dial 911 or go to your nearest emergency room"?
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Yes. I do return some calls after hours, but I have a VM to text service. It's free but not perfect.
 
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DJspreadsheet said:
That's assuming a 25% no show.
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HOLY CRAPOLA! Why so high?! Gotta plug that hole. My n/s rate is 5-10%. Employ pre-registration, a graduated n/s fee, and fire repeat offenders. You will get to the point where you hope someone no-shows just to catch up on charts.
 
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PistolPete said:
What system do you use? Google voice?
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As has been mentioned before, Google Voice specifically says they are not HIPAA compliant so should not be used if you take insurance. I believe Texas Physician has a cash practice and thus this doesn't matter. Commonly misunderstood, but HIPAA only applies to practices that take insurance and use some form of electronic transmission in order to do so. HIPAA does not apply to cash only practice, as long as it really is cash only.
 
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splik said:
As has been mentioned before, Google Voice specifically says they are not HIPAA compliant so should not be used if you take insurance. I believe Texas Physician has a cash practice and thus this doesn't matter. Commonly misunderstood, but HIPAA only applies to practices that take insurance and use some form of electronic transmission in order to do so. HIPAA does not apply to cash only practice, as long as it really is cash only.
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Great, thanks! Good to know. Cash-only is sounding more and more appealing. Are cash-cash only practices required to be enrolled in electronic prescribing? Obviously it's convenient, but I'm wondering what the cost is, and if it's optional.
 
PistolPete said:
Great, thanks! Good to know. Cash-only is sounding more and more appealing. Are cash-cash only practices required to be enrolled in electronic prescribing? Obviously it's convenient, but I'm wondering what the cost is, and if it's optional.
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I'm unaware of anyone in Texas being required to do electronic prescribing, but cash-only docs are not penalized monetarily for written Rx's. Is eRx required in some states?

My free EMR allows non-controlled substances to be eRx for free. I prefer writing scripts, so I've never investigated costs for just controlled meds.
 
TexasPhysician said:
I'm unaware of anyone in Texas being required to do electronic prescribing, but cash-only docs are not penalized monetarily for written Rx's. Is eRx required in some states?

My free EMR allows non-controlled substances to be eRx for free. I prefer writing scripts, so I've never investigated costs for just controlled meds.
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Which EMR do you use? Do you like it?
 
PistolPete said:
I don't see how anyone can do a proper med management check in under 10 minutes. Legally you could do a med management visit in 1 minute, sure, but it would probably be unethical and malpractice.
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Why couldn't someone do a med check in under 10 minutes? It's actually fairly quick for patients who are stable, once you have experience and finally come up with your own, "scripts" for these things. This doesn't mean you do EVERY med check in under 10 minutes. When a patient is doing well and tolerating their medication(s) well, there really isn't a whole lot to talk about if you're not also doing therapy with them. Maybe some chatter to maintain rapport? That's not billable, though.
 
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HooahDOc said:
Why couldn't someone do a med check in under 10 minutes? It's actually fairly quick for patients who are stable, once you have experience and finally come up with your own, "scripts" for these things. This doesn't mean you do EVERY med check in under 10 minutes. When a patient is doing well and tolerating their medication(s) well, there really isn't a whole lot to talk about if you're not also doing therapy with them. Maybe some chatter to maintain rapport? That's not billable, though.
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Hmm, yea I suppose. I'm just personally against the whole "grind out by seeing 4 patients and hour" type of thing.
 
So here's another "ethical" question for cash-only people.

How often do you see stable, med management patients? once a month? once every 2 months? once every 2 weeks?

And what rate do you charge them for a 15 min med management apt? Obviously not the same as a 45 minute therapy session....right?
 
Blitz2006 said:
So here's another "ethical" question for cash-only people.

How often do you see stable, med management patients? once a month? once every 2 months? once every 2 weeks?

And what rate do you charge them for a 15 min med management apt? Obviously not the same as a 45 minute therapy session....right?
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Stable med management up to q3 months. I do not do specified therapy appointments. All FU's are 30 minutes. Even q3 med management patients can use brief therapy, rapport building, or education.
 
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HooahDOc said:
How do you bill for, "rapport building" or, "education"?
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$$/time is $$/time if you have a cash practice. Just like lawyers or many other professionals, you are paying for time, as it should be.
 
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HooahDOc said:
How do you bill for, "rapport building" or, "education"?
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Part of the 15 min package while refilling scripts. Seeing if anything new has happened, changes to health, updating med list, making sure they're taking care of themselves by eating 3 squares and sleeping 8 hours.
 
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TexasPhysician said:
Via credit card before appointments.
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Actually on that topic, what do you use to run the CC and how much do you pay for it? Not planning on a PP anytime soon but seems good to know what folks are doing.
 
Are there any inpatient only jobs out there where you carry max 10-12 pts and that's that? Most ppl I know do combo inpt/outpt jobs.

What's the salary range on an inpatient only job?
 
ahmedqman said:
Are there any inpatient only jobs out there where you carry max 10-12 pts and that's that? Most ppl I know do combo inpt/outpt jobs.

What's the salary range on an inpatient only job?
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Certainly jobs with only inpatients but usually more like 15-17 pts rather than 10-12 if you want to make the standard 200-250k depending on location.
 
15-17 is a lot for inpt i would expect a helluva lot more than 200-250k for that BS. my friend too a job with 12 inpts pays 200k+ w/ 2 residents to do the work and plenty of time to do forensic evals on the side. i sm looking at 200ish job running a 14bed unit with an NP carrying 5 of the patients and a longish LoS. one private group told me than 14 or less is standard for a 9-5gig. even kaiser inpt jobs are like 12-14inpts and pay 270+.

inpt is not popular amongst psychiatrists and generates a lot more RVUs than outpt work. it is not that dofficult to find a cush inpt gig if one is not tied a narrow geographical area
 
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splik said:
As has been mentioned before, Google Voice specifically says they are not HIPAA compliant so should not be used if you take insurance. I believe Texas Physician has a cash practice and thus this doesn't matter. Commonly misunderstood, but HIPAA only applies to practices that take insurance and use some form of electronic transmission in order to do so. HIPAA does not apply to cash only practice, as long as it really is cash only.
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I'm pretty sure the misunderstanding is the other way around. Cash-only practices still have to comply with the privacy sections of HIPAA.
 
splik said:
15-17 is a lot for inpt i would expect a helluva lot more than 200-250k for that BS. my friend too a job with 12 inpts pays 200k+ w/ 2 residents to do the work and plenty of time to do forensic evals on the side. i sm looking at 200ish job running a 14bed unit with an NP carrying 5 of the patients and a longish LoS. one private group told me than 14 or less is standard for a 9-5gig. even kaiser inpt jobs are like 12-14inpts and pay 270+.

inpt is not popular amongst psychiatrists and generates a lot more RVUs than outpt work. it is not that dofficult to find a cush inpt gig if one is not tied a narrow geographical area
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Agreed. 15-17 per day, depending on how many weekends, I expect $325-375K. Unless the hospital is providing garbage care (e.g. psychiatrist seeing 15-17 in 3 hours then going to private practice in the afternoon, in which case I'd never work there...couldn't sleep a night).
 
splik said:
no HIPPA only applies to insurance based practices. read the laws.
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Done. It doesn't seem to differentiate between insurance-based and cash-only practices. Cash-only practices may still have to transmit patient information to others, like reporting an injury. Also, I'm not sure how it's done outside of the east coast, but most cash-only private practices here use a billing management company, which would make them liable also.
 
slappy said:
Done. It doesn't seem to differentiate between insurance-based and cash-only practices. Cash-only practices may still have to transmit patient information to others, like reporting an injury. Also, I'm not sure how it's done outside of the east coast, but most cash-only private practices here use a billing management company, which would make them liable also.
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As required by Congress in HIPAA, the Privacy Rule covers:

  • Health plans
  • Health care clearinghouses
  • Health care providers who conduct certain financial and administrative transactions electronically. These electronic transactions are those for which standards have been adopted by the Secretary under HIPAA, such as electronic billing and fund transfers.
If you bill without using codes, you're probably fine. I'll have to look into it later, but the rules were built around insurance billing, not direct billing, a situation in which actual diagnosis and treatment data had to be exchanged.
 
Cash practices should not have to follow HIPAA unless they are doing something really odd.

States have their own medical board privacy laws which need to be followed by everyone, but these laws are typically more common sense.
 
Mad Jack said:
As required by Congress in HIPAA, the Privacy Rule covers:

  • Health plans
  • Health care clearinghouses
  • Health care providers who conduct certain financial and administrative transactions electronically. These electronic transactions are those for which standards have been adopted by the Secretary under HIPAA, such as electronic billing and fund transfers.
If you bill without using codes, you're probably fine. I'll have to look into it later, but the rules were built around insurance billing, not direct billing, a situation in which actual diagnosis and treatment data had to be exchanged.
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You don't even have to bill without codes to not be a HIPAA covered provider. You can still provide your patient with a paper bill to send to their PPO for reimbursement. That's not an electronic transmission of data. You're not receiving reimbursement from an insurers just cash so no need to worry about electronic fund transfers (and no credit card transactions don't count either as that is a fund transfer with a banking institution not a health care organization).
 
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splik said:
no HIPPA only applies to insurance based practices. read the laws.
Click to expand...

slappy said:
Done. It doesn't seem to differentiate between insurance-based and cash-only practices. Cash-only practices may still have to transmit patient information to others, like reporting an injury. Also, I'm not sure how it's done outside of the east coast, but most cash-only private practices here use a billing management company, which would make them liable also.
Click to expand...

I thought it was more specifically that HIPAA only applies to practices that take medicare/medicaid?
 
splik said:
15-17 is a lot for inpt i would expect a helluva lot more than 200-250k for that BS. my friend too a job with 12 inpts pays 200k+ w/ 2 residents to do the work and plenty of time to do forensic evals on the side. i sm looking at 200ish job running a 14bed unit with an NP carrying 5 of the patients and a longish LoS. one private group told me than 14 or less is standard for a 9-5gig. even kaiser inpt jobs are like 12-14inpts and pay 270+.

inpt is not popular amongst psychiatrists and generates a lot more RVUs than outpt work. it is not that dofficult to find a cush inpt gig if one is not tied a narrow geographical area
Click to expand...

I think those are all fairly standard numbers too but conversely if one is tied to a specific city that's fairly desirable than seeing 12/day for 225k M-F may or may not be imminently doable.

Separately, your job sounds great, long LOS really feels more rewarding to me for inpatient settings and this would give you other time to pursue other things psychiatrically or otherwise.
 
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