Interventional psychiatry

[ilovecostco]

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I've searched through the depths of the internet, and come up short --

For psychiatrists who deal exclusively in ECT, TMS, ketamine infusions, what type of salary are you looking it? Is this type of practice sustainable?

 

[Sushirolls]

I've searched through the depths of the internet, and come up short --

For psychiatrists who deal exclusively in ECT, TMS, ketamine infusions, what type of salary are you looking it? Is this type of practice sustainable?

Yes, no.
Below median, median, and way above median.

Really have to break it down to volume and payor mix. So same rules as normal psychiatry apply...
But with ECT you have extra bureaucracy of needing a practice location. And having done solo for years it gets old limiting service closure to one week for vacation, so a back up colleague is nice. That then introduces their goals and desires for the practice. And are they thymatron or mecta person? Do they do more RUL or BF? Do they do age or dose titration?

What do you charge for ketamine, are they others also doing it? Do you do infusions or do you have a nurse or anesthesiologist do them?

Do you own or lease TMS machine, is there competition locally?

Cultural still has people seeing Neurostimulation as end of the line not an early treatment option. It will take time to re educate local providers.

If job is employed you'll make less than independent. So many variables to answer that question.

I had interviewed years ago with an established neurostimulation practice and they offered a laughable low salary. I instead opened up an ECT service at existing job at that time. You then have issues of politics if part of hospital will they require call and inpatient coverage? Will other psychiatrists do ECT too or be completely hands off? Will the hospital value the service or ignore it like most of psych? So many political issues when it comes to ECT sadly.

 

[Shufflin]

TMS and ketamine income depends on private practice business economics. how hard you market your clinic determines your volume determines your income. sit on your hands, you'll make pennies. bust your butt, do online marketing, youtube videos, presentations at clinics/shows, networking with doctors in the area and you'll do well. need to be an entrepreneur. i know of one ketamine clinic that had to close due to underperformance in a competitive space.

The ECT in my region are provided by larger hospital systems, one model you're an employee, the other you bill the patient's insurance.

 

[TexasPhysician]

“Interventional” employed positions typically pay no different than other typical psychiatry positions.

Typical psychiatry jobs already pay pretty well. Even offering $180/hr, I’m struggling to find any applicants.

The problem with “interventional” psychiatry would be building a well known, highly advertised high acuity referral center. You would need a place where people would maybe even fly in to see you/treatment. There isn’t a lot of money on a per-patient basis, but if you could theoretically simultaneously perform ECT while monitoring ketamine patients while techs operate a few TMS machines 8 hours/day, the $$ would be there. The getting there would be very difficult.

 

[dl2dp2]

I've searched through the depths of the internet, and come up short --

For psychiatrists who deal exclusively in ECT, TMS, ketamine infusions, what type of salary are you looking it? Is this type of practice sustainable?

I am familiar with several cash markets, and I still don't think a practice that's purely TMS and/or ketamine will have a future. Right now TMS can be very lucrative, but I have no doubt that the reimbursement will come down, and further more there's not enough of a patient stream for TMS in a general psychiatry practice. Ketamine infusion will die once nasal spray becomes more routine. There's no advantage of infusion over spray.

Think of this as being a cardiologist--you need to control the patient flow to make money. As an outpatient interventionalist, you need to do a fair bit of screening and longitudinal treatment on your own. It's best to develop a subspecialty niche over a disease entity (in this particular case, treatment-resistant depression) and focus on that IMO and add on the subspecialty services that way. Interventionalists really emerged from being a niche field focusing on PCI for acute ischemic conditions ONLY. Similarly, electrophysiologists as well for only specific niche issue. In psychiatry, child psychiatrists don't have any procedures available, and yet they can still make a lot of money doing purely evaluations and complicated psychotherapy.

So I think thinking in terms of high volume intervention based on insurance reimbursement is the wrong overarching approach. I hope this makes sense. Insurance is sort of icing on a cake. The most critical piece of running any business is that you need to drive DEMAND.

 

[Extralong]

New sub-specialty: Interventional Psychiatry

So I somehow stumbled upon a medscape article (at the most recent annual APA meeting) with "Drs. Edward M. Kantor and Nolan R. Williams about the emerging new field of interventionalist psychiatry and their initiative to develop a training program" There was discussion about a new psychiatry...

forums.studentdoctor.net

Reception wasn’t too strong during this post. Maybe things have changed?

 

[NickNaylor]

The job I'm starting in ~2 weeks is all interventional psychiatry - I'm doing ECT 3 days/week and outpatient evaluations for ketamine, TMS, and ECT for the other 3 days - at an academic center. I assume this is different than what you're thinking about since it's an employed position rather than a private practice, but I will be making about $240k - a nearly negligible amount more than inpatient work alone. We have a fairly busy service as there are no other outpatient ECT programs in our geographic area and there are only ~3 other hospitals doing ECT at all. The ketamine and TMS programs are less active, but the hospital will be buying a new TMS machine and is making plans to increase the volume of ketamine administration, so clearly the institution thinks this is a profitable way forward.

Based on how this service runs, I think it would be extremely difficult to get a busy service off the ground in a private practice setting.

 

[Merovinge]

Nick, so is there no inpatient coverage at all for that position? You literally do ECT for the entire day three days a week?

 

[Sushirolls]

As some one who has started an ECT service in the past, fresh from ground up, it takes about a year. It can even be done on a M/Th or Tu/Fr schedule, too.
I can assure you the billings from that 100% Neurostimulation job, is in far excess of the $240K you are getting, and the billings are most likely subsidizing the rest of the department. I hope you get something else like a 30 work week or no weekends or something else.

 

[Shufflin]

The job I'm starting in ~2 weeks is all interventional psychiatry - I'm doing ECT 3 days/week and outpatient evaluations for ketamine, TMS, and ECT for the other 3 days - at an academic center. I assume this is different than what you're thinking about since it's an employed position rather than a private practice, but I will be making about $240k - a nearly negligible amount more than inpatient work alone. We have a fairly busy service as there are no other outpatient ECT programs in our geographic area and there are only ~3 other hospitals doing ECT at all. The ketamine and TMS programs are less active, but the hospital will be buying a new TMS machine and is making plans to increase the volume of ketamine administration, so clearly the institution thinks this is a profitable way forward.

Based on how this service runs, I think it would be extremely difficult to get a busy service off the ground in a private practice setting.

I'd be curious to know how the financial gods, with your input, decide the fate of a patient: TMS, ECT, or ketamine. That decision is financially driven I'm sure. There's no medical precedent as to which therapy to do first, second, and third in a treatment-refractory patient that I'm aware of.

 

[Sushirolls]

Discuss ECT and TMS options with risks, benefits, and remission data for each. Patient picks what's best for them.

Limited response from TMS, offer up ECT.
Non-responder to ECT, offer ketamine.
Non-responder to TMS and refuses ECT, offer ketamine.

 

[NickNaylor]

I'd be curious to know how the financial gods, with your input, decide the fate of a patient: TMS, ECT, or ketamine. That decision is financially driven I'm sure. There's no medical precedent as to which therapy to do first, second, and third in a treatment-refractory patient that I'm aware of.

All that matters from a financial perspective is what is doable by the patient. Most patients have ECT benefits through their insurance but TMS benefits are less common. I don't know about esketamine yet since it's so new, and now that esketamine is available we don't do IV infusions.

In general, if someone has true treatment-resistant depression with severe symptoms, I am going to recommend ECT in nearly all cases. I will discuss the others as options but will only go that route if that's what the patient wants or if they decline ECT for whatever reason.

 

[NickNaylor]

Nick, so is there no inpatient coverage at all for that position? You literally do ECT for the entire day three days a week?

Sorry, I missed this post earlier. Yes, I'm only doing ECT - no inpatient coverage. This isn't really what I wanted as I'm more interested in inpatient work with some interventional psychiatry rather than all interventional work, however this will be a temporary arrangement. Our hospital is in the process of expanding, and when that expansion is complete, our inpatient unit will be moving and increasing beds. When that happens, I will be doing 60-80% inpatient work with the remainder interventional work. The faculty essentially "rotate" among the different inpatient teams and the ECT service, and I will be joining that paradigm in about a year. The current unit isn't large enough to justify hiring another attending for inpatient work, but our ECT volume is large enough that a second, parallel acute service can be started and sustained, which is what I'll be doing.

This also includes a half-day of academic time each week, so I'll be doing ECT 3 days/week and outpatient evaluations for 1.5 days/week.

 

[Merovinge]

Ah okay, the later is the same model I have seen in most places, that description makes sense. Let us know in a year how you feel about leaving the full-time interventional role

 

[TexasPhysician]

Are there current investigations into single pulse TMS for depression?

 

[philosophize]

As some one who has started an ECT service in the past, fresh from ground up, it takes about a year. It can even be done on a M/Th or Tu/Fr schedule, too.
I can assure you the billings from that 100% Neurostimulation job, is in far excess of the $240K you are getting, and the billings are most likely subsidizing the rest of the department. I hope you get something else like a 30 work week or no weekends or something else.

how did you recruit patients for your ECT practice? It might be a naïve thought, but it seems to me that getting patients might be the rate limiting step

 

[Sushirolls]

Letters to the psychiatric docs and ARNPs in huge geographic swath. Letters to the academic center a ways away that was temporarily closed to new patients (so they could refer on, which they did). Internal marketing with that health system, too get the PCPs to send those who had 3 med failures or 3 prior depressive episodes - not so much success there. Also getting psych colleagues in health system to refer, which verbally was going to be easy, but really they under utilized it. Sad, compared to where I trained and how frequent it was used.

It really is a long haul game for an ECT service to communicate to people and also change referral patterns. After a year it was steady. I've heard from my former place that they are still getting calls for ECT referrals...

 

[Sushirolls]

Sorry, I missed this post earlier. Yes, I'm only doing ECT - no inpatient coverage. This isn't really what I wanted as I'm more interested in inpatient work with some interventional psychiatry rather than all interventional work, however this will be a temporary arrangement. Our hospital is in the process of expanding, and when that expansion is complete, our inpatient unit will be moving and increasing beds. When that happens, I will be doing 60-80% inpatient work with the remainder interventional work. The faculty essentially "rotate" among the different inpatient teams and the ECT service, and I will be joining that paradigm in about a year. The current unit isn't large enough to justify hiring another attending for inpatient work, but our ECT volume is large enough that a second, parallel acute service can be started and sustained, which is what I'll be doing.

This also includes a half-day of academic time each week, so I'll be doing ECT 3 days/week and outpatient evaluations for 1.5 days/week.

Sounds like a sweet setup to me! I'd love an ECT only gig.

 

[whopper]

A major problem with TMS.
You don't get recurring patients. You get them better and then you likely don't see them again, even if they should get recurring TMSs cause their insurance won't pay for it.

Most patients won't need TMS. Of course some will, but that block of patients will be much smaller vs the conventional psych patient, but then you do the TMS and usually that's it. It's over, nothing more and it's cause of insurance, not because this is what you or the patient wants. The data does show many patients who benefit from TMS will further benefit from maintenance treatments, but they won't do it if their insurance isn't paying the $20K treatments, and they almost never do.

This makes TMS financially potentially risky. You could spend the big bucks on a TMS machine and then not be able to drum up enough business to have made it worth it. It's a reason why the attendings and I where I work didn't want to put the money into buying a machine. Further you could buy a machine and then it turns out just a few years later it's obsolete cause a much newer and better type of TMS was later available that the machine you have doesn't support.

I currently offer TMS but through a business that buys the machine and just pays me to do them without any financial risk on my part. Pro is that I get paid, there's no risk, the machine is in the same parking lot location as my office so I just have to cross the street to zap patients, then I can go back to my own office and not worry about the BS associated with running a business, especially if there's no patients to zap at the time. Con is I don't own the business, I could've made way more money had I taken the risk owned it.

Ketamine: Now there's something that makes money. The effects of it only last about 1-2 weeks so these patients will need to get another treatment over and over. I say that not flippantly and as if it's just about the money but because this is a fact. Now I have seen several improve to the point where their treatments could be decreased to about say monthly or even less. I don't do ketamine but 2 of the doctors in the office I work that I'm partners with do it. ketamine patients will be a revolving source of income. Of course have the decency to not do it more than it should be done.

 

[Splenda88]

The job I'm starting in ~2 weeks is all interventional psychiatry - I'm doing ECT 3 days/week and outpatient evaluations for ketamine, TMS, and ECT for the other 3 days - at an academic center. I assume this is different than what you're thinking about since it's an employed position rather than a private practice, but I will be making about $240k - a nearly negligible amount more than inpatient work alone. We have a fairly busy service as there are no other outpatient ECT programs in our geographic area and there are only ~3 other hospitals doing ECT at all. The ketamine and TMS programs are less active, but the hospital will be buying a new TMS machine and is making plans to increase the volume of ketamine administration, so clearly the institution thinks this is a profitable way forward.

Based on how this service runs, I think it would be extremely difficult to get a busy service off the ground in a private practice setting.

Is that for <30 hrs/wk?

 

[NickNaylor]

Is that for <30 hrs/wk?

No, it’s a full-time position, though it does include a half-day each week for academic time.

 

[WisNeuro]

There have been some articles very recently about 'deep' repetitive TMS vs standard for severe depression. Anyone by chance have that study that the news reports are referring to? It's behind a paywall that I do not currently have access to, seems relevant to the current discussion.

 

[Splenda88]

No, it’s a full-time position, though it does include a half-day each week for academic time.

Is that a fair market value in TX?

 

[Sushirolls]

what the hell has FMV got to do with anything? He's being paid pretty well assuming this is an academic medical center. FMV is used by administrators to artificially keep physician salaries low. Now, it is true, particularly in other fields like surgery, that hospitals have to be mindful of FMV because if they are paying physicians more than they are worth for their work they might be violating stark law. but psychiatrists are usually overpaid compared with any other specialty (i.e. the demand/need for us makes it necessary for hospitals to pay competitively even though psychiatrists often dont generate much [or in some cases any] money). Don't fall for the fair market value trap. It's just as bad as people tying compensation to MGMA percentiles based of questionable date and low sample sizes.

We are not overpaid at most hospitals. If anything they continue to underpay, and wait for the next fresh grad or ARNP to come along. Or they still just don't value psychiatry and care less about what happens to the department. Psych departments can make money, depends on how they are being run.

But otherwise, I agree with your sentiments on FMV has an element of pay suppression to it.

 

[whopper]

There have been some articles very recently about 'deep' repetitive TMS vs standard for severe depression. Anyone by chance have that study that the news reports are referring to? It's behind a paywall that I do not currently have access to, seems relevant to the current discussion.

I am aware of the study but don't have a link.

But reiterating something I mentioned above, it doesn't matter if doing something is better for the patient if the patient can't afford it and the insurance won't pay for it. Repetitive deep TMS, unless paid for won't get off the ground unless insurance pays for it, and it doesn't at this time nor likely will for at least several years. Whenever a new study comes out showing a new thing could work expect to wait 5-10 years before insurance pays for it.

It's not simply about you being altruistic and offering something a patient can't afford. You likely won't be able to afford a recurring $20K treatment out of your pocket. This isn't like seeing a patient that you truly know doesn't have the money for the office-visit, is struggling, has been respectful, and offering to see them for free office visit that sets you back over $100. This is $20K we're talking about.

 

[downwithDTB]

If the article you're referring is the one below, in fact, the primary outcome was that deep TMS was NOT more effective than shallow TMS in inducing remission from MDD.

The secondary outcomes are exploratory, they were not subjected to multiple comparison testing, and they should NOT be used to make the claim that deep TMS is more effective, rather they need to be prospectively validated as primary outcomes.

Funny how the primary outcome is completely overshadowed by an exploratory finding that makes an exciting headline and some docs don't even bother to read the abstract...

Efficacy of repetitive transcranial magnetic stimulation using a figure-8-coil or an H1-Coil in treatment of major depressive disorder; A randomized clinical trial

Repetitive transcranial magnetic stimulation (rTMS) is an evidence-based treatment option for major depressive disorder (MDD). However, comparisons of…

www.sciencedirect.com

 

[NickNaylor]

Is that a fair market value in TX?

I don't know, maybe. It's kind of a moot point because I'm fine with the salary. Could I get paid more in the local area? Sure, probably, but I would also be responsible for seeing many more patients and doing a lot more call. I'm also interested in teaching and education work which wouldn't be an option at those locations.

I'm supplementing with ER work, so my gross pay will be $300k+, which is more money than my parents made when I was growing up and we had a fantastic lifestyle. "Fair market value" or no, I'm happy with the salary and don't feel like I'm being exploited, so from my perspective it's irrelevant.

 

[WisNeuro]

Funny how the primary outcome is completely overshadowed by an exploratory finding that makes an exciting headline and some docs don't even bother to read the abstract...

Efficacy of repetitive transcranial magnetic stimulation using a figure-8-coil or an H1-Coil in treatment of major depressive disorder; A randomized clinical trial

Repetitive transcranial magnetic stimulation (rTMS) is an evidence-based treatment option for major depressive disorder (MDD). However, comparisons of…

www.sciencedirect.com

This is pretty much the norm in healthcare these days. My response whenever I hear about some new "breakthrough" is always "let me see the actual study," and almost always disappointed in what the research actually showed.

 

[Extralong]

Whither TMS: A One-Trick Pony or the Beginning of a Neuroscientific Revolution?
Published Online:1 Nov 2019

AbstractPsychiatry has been at the forefront of advancing clinical transcranial magnetic stimulation (TMS) since the mid-1990s, shortly after the invention of modern TMS in 1985 by Barker. Clinical TMS for psychiatric applications is advancing rapidly, with novel methods and innovations for treating depression, as well as a new clinical indication in obsessive-compulsive disorder. This review summarizes the recent findings and peers into the near future of this fertile and rapidly changing field. It is possible that many, perhaps even most, psychiatrists will be incorporating some form of brain stimulation into their practice within the next decade. The author summarizes the reasons for this optimistic view.

Psychiatry Online

ajp.psychiatryonline.org

Thoughts?

 

[TexasPhysician]

Whither TMS: A One-Trick Pony or the Beginning of a Neuroscientific Revolution?
Published Online:1 Nov 2019

AbstractPsychiatry has been at the forefront of advancing clinical transcranial magnetic stimulation (TMS) since the mid-1990s, shortly after the invention of modern TMS in 1985 by Barker. Clinical TMS for psychiatric applications is advancing rapidly, with novel methods and innovations for treating depression, as well as a new clinical indication in obsessive-compulsive disorder. This review summarizes the recent findings and peers into the near future of this fertile and rapidly changing field. It is possible that many, perhaps even most, psychiatrists will be incorporating some form of brain stimulation into their practice within the next decade. The author summarizes the reasons for this optimistic view.

Psychiatry Online

ajp.psychiatryonline.org

Thoughts?

Yet to be impressed by TMS

 

[NickNaylor]

Whither TMS: A One-Trick Pony or the Beginning of a Neuroscientific Revolution?
Published Online:1 Nov 2019

AbstractPsychiatry has been at the forefront of advancing clinical transcranial magnetic stimulation (TMS) since the mid-1990s, shortly after the invention of modern TMS in 1985 by Barker. Clinical TMS for psychiatric applications is advancing rapidly, with novel methods and innovations for treating depression, as well as a new clinical indication in obsessive-compulsive disorder. This review summarizes the recent findings and peers into the near future of this fertile and rapidly changing field. It is possible that many, perhaps even most, psychiatrists will be incorporating some form of brain stimulation into their practice within the next decade. The author summarizes the reasons for this optimistic view.

Psychiatry Online

ajp.psychiatryonline.org

Thoughts?

As currently practiced, it is roughly equivalent to antidepressants in terms of efficacy, it is very resource-intensive (both time and money), and can be difficult to get approved through insurance. I have yet to refer anyone for TMS in our interventional clinic because, usually when hearing the outcome data and the time/money involved (even with insurance, patients are going to pay a copay that adds up quickly due to the number of treatments), they opt for other treatments.

 

[NickNaylor]

I should add that there is some very interesting research related to TMS that may dramatically improve its efficacy in the future, but for now I'm not all that impressed.