is insurance based private practice med mgt outpt......

[vistaril]

still a potentially lucrative and enjoyable endeavor these days *IF* you do it in a reasonable(ie don't give people xanax 2 TID + Klonopin + ambien) way?

It seems like so many of the people doing outpatient private practice(who take insurance) fall into a few groups:

1) write insane(or what I consider insane) amounts of bzds and stimulants and other controlleds, usually together
2) refuse to and are constantly battling patients day after day on the issue

I'm getting intake after intake after intake these days of patients who were seen by another clinic for years and need to transfer for some legitimate reason(they weren't fired or anything, usually an insurance change or death of previous psych) who come in on psychotropic drug regimens which are crazy.....xanax 2 QID, Klonopin prn qhs, Ambien 10 qhs, and Adderall 30 TID. All together. That's an extreme example....but not really. It's like psychs here are in a competition with each other to see who can up the ante the most to capture the 'best' patients. Oh and tons of people on suboxone also on very high dose bzds and ambien and crap.

But in seeing all these patients, it gets me to thinking- what is the future of private practice outpatient psychiatry that isn't private pay therapy/boutique type work? Is there a real future there with what is going on with reimbursements?


Im not talking about cmhc or VA or other govt type jobs here. I am talking about the general outpt psych who takes insurance and does what we call 'med management'. I see patients for followup in 20 minute blocks. I know some people do 15 and a few do 30 for f/us.

Is there anyone else here who takes insurance and works in the model I'm talking about who has been able to really make it work financially and practice responsible psychiatry and have fun doing it? I know there are plenty of people who do this in academia or the VA or even a cmhc or whatnot, but that's not private practice. And I know many people are happy with their cash private practices, but that's not what I'm talking about or doing either.

I think sunlioness used to try to do this(take insurance, practice reasonably, true pp) and had a rough go of it. Anyone else do that here?

I'm trying to decide what to do longterm along with my real estate interests, and it's definately a feeling out process.

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[sunlioness]

I did do it for about a year and there were lots of reasons I didn't like it. I could never figure out how to get paid by Medicare for one.

In retrospect were I to do it again (I won't), I'd give thought to a having some sort of statement that every patient would sign off on. Something that said benzos would only be prescribed in low doses for no more than 15 days course, no more than two times per year. And that stimulants would only be prescribed for people who had a testing report from a legit psychologist showing a clear indication for one. I wonder how that would have gone? But like I said, that was only one of many reasons why it didn't work out for me.


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[vistaril]

I did do it for about a year and there were lots of reasons I didn't like it. I could never figure out how to get paid by Medicare for one.

In retrospect were I to do it again (I won't), I'd give thought to a having some sort of statement that every patient would sign off on. Something that said benzos would only be prescribed in low doses for no more than 15 days course, no more than two times per year. And that stimulants would only be prescribed for people who had a testing report from a legit psychologist showing a clear indication for one. I wonder how that would have gone? But like I said, that was only one of many reasons why it didn't work out for me.


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I wonder the same thing....I think that here such a practice would have a hard time generating patients that are going to be reasonable turnover patients. And as we know turnover is related to compensation in insurance based outpt pp world.

I also think that the govt and salaried jobs will begin to change in structure and compensation and working conditions as the feasibility of what I describe above becomes tougher. Right now I think the pendulum has definately swung towards certain types of jobs being more favorable(especially if you dont have very unique skills or arent willing to write xanax 2 TID to tons of pts) from a lifestyle and compensation standpoint, and as the tide changes that may eventually swing back.....so I woudnt close any future doors as possibilities.

 

[wolfvgang22]

I also think that the govt and salaried jobs will begin to change in structure and compensation and working conditions as the feasibility of what I describe above becomes tougher.

In what way?

 

[PikminOC]

Keep on grindin!

 

[vistaril]

In what way?

Again, I think it's highly dependent on the contracts in the area and how those play out. But I'll just give my area as an example. 15 or so years ago(well well before I started) it used to be fairly easy to get on at the VA or one of the cmhcs. Jobs were always open. But now as various aspects of those jobs have become more attractive(increases in salary to name one, although this VA still lags well behind for new hires what I've heard others here getting at other VAs and what I was offered in other places) and various aspects of non-salaried/non-govt jobs have become less attractive, it seems as if people are now shuffling from the latter jobs to the former jobs. Just in the last 2 years our VA here has probably hired 8 very veteran psychiatrists(and I can't think of any moving in the reverse direction). Same for cmhcs.

It's just common sense- most psychiatrists are capable and qualified to work in several different settings. Certainly doing outpt work at a cmhc or outpt(or inpt) work at a VA are settings where most any BE/BC psychiatrist is capable of working. As jobs in other settings become either more or less appealing, that will play a large role in how desirable these salaried/govt jobs are(ie supply/demand for these jobs). Which of course goes a long way towards determining the conditions and compensation of any job.

You still have lots of VAs that are advertising positions they can't fill. My guess is that in these areas the conditions for a psychiatrist to come in and work in another setting in that area would still be favorable....with a hospital contract for example. Or some of those may be in places where the conditions arent that favorable but just nobody wants to live period...so thats why they are open.

I would say the greatest advantage any new graduate would have is to be geographically flexible(or alternatively be geographically inflexible and need to be in a community where the circumstances happen to be favorable)