Job Options after CAP Fellowship

[Gavanshir]

Hello Psychiatry brain trust, I can't believe it has been 15 years since I joined as a premed and now I'm posting about first job offers. This forum has and continues to be been a great resource.

I will be finishing up my CAP fellowship in a few months and considering some job options. I will be moving out of state in July and plan to continue to see patients in my current state via telepsychiatry as we will likely return. My wife will be starting a fellowship so I would like to keep a flexible job schedule (telepsych) to help out with childcare. I have gotten my license in our new state but don't plan to seek employment there other than perhaps small private practice work on the side.

I have 2 job offers currently which are both places that I moonlight with:

My current program which is a community mental health center is offering me a choice between a few models:
1) Hourly outpatient telepsychiatry around $270-$290K/yr; 60 min evals and 20 min follow-ups, essentially 8-5pm but generally flexible with scheduling, not a whole lot of benefits, no match retirement plan, 2 weeks PTO.

2) Base rate + piecework (productivity): They asked me to suggest what I want my base rate to be, but threw 240K as a number during the meeting. I have no idea how to determine what the cutoff is before I hit the productivity threshold.

3) Productivity only: The rates are $100 per eval and $68 for treatment plan and $7 for FARS note (so essentially $175 per eval), $40 for med management, . These rates are the same whether I see adults or minors but the need for minors is greater right now.

Benefits of staying with my training program would be that I am very familiar with the organization, the EMR, the patient population, and already have a solid case load. Also FYI there are some who see med managements faster than 20 mins for uncomplicated cases (ie. ADHD) and some attendings that are on productivity are earning around $400-700K, granted they are seeing way too many patients per day and right now I am interested in working less, rather than more.

My 2nd employer has not yet made a solid offer but currently pay me $175/hr which I hope to negotiate to $200/hr after graduation. It is pure outpatient telepsych with 45 min evals and 15 min follow-ups. I don't have to do any treatment plans and all the other documentation that I have to do in job #1. Benefits are better and scheduling remains flexible. They pay me regardless of show-rate.

Both employers have in-house therapists, case managers and community teams that often join the appointments and I can always refer to.

I don't really need much benefits as I can go under wife's health plan, so I am considering asking to be an independent contractor and asking for a higher rate. I am also considering if working part-time for both would be more advantageous than just choosing one employer. I have also heard it's best to maintain one W-2 job and other 1099.

Has anyone been in a similar position? Anything that I am not considering? Thank you,

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[Stagg737]

Find out the productivity threshold for the second option. For the third, is that $100 per eval with an extra $68 for the treatment plan at that appointment, (so $168 for evals and $108 for f/ups) or just straight up $100 and $40? Neither sounds great, but I'd find the latter insulting.

 

[robellis]

I am actually constantly shocked by the offers people post..some of these offers you mentioned are incredibly insulting especially with you being CAP trained. 100 dollars for a new eval? 40 dollars for a follow up?? Are you serious???

 

[clozareal]

Wow $100 for a new eval and $40 for each follow-up is an extremely insulting payment model. For an average panel, this comes out to approximately $200k/year for 40 hours a week 50 weeks a year which is a lot of work for below average pay.

For CAP trained, you can at least get $200/hr. I wouldn't accept anything less. In my area, the average salary for offers I'm seeing for CAP is about $300k/yr for 1.0 FTE.

 

[Gavanshir]

Find out the productivity threshold for the second option. For the third, is that $100 per eval with an extra $68 for the treatment plan at that appointment, (so $168 for evals and $108 for f/ups) or just straight up $100 and $40? Neither sounds great, but I'd find the latter insulting.

Yes it is the former, there is also a CFARS that bills an additional $7.. so it ends up being $175 per initial eval and $40 for med management. If there is a treatment plan due at time of Med Management then med management + Tx plan review is $74.

Wow $100 for a new eval and $40 for each follow-up is an extremely insulting payment model. For an average panel, this comes out to approximately $200k/year for 40 hours a week 50 weeks a year which is a lot of work for below average pay.

For CAP trained, you can at least get $200/hr. I wouldn't accept anything less. In my area, the average salary for offers I'm seeing for CAP is about $300k/yr for 1.0 FTE.

As I had mentioned the model guarantees a base of at least $240K plus productivity. I would agree if it was just productivity and you were to maintain an average to low volume, then you may be below average. As a graduating fellow on the job market right now, these numbers are not grossly different from what is being offered in most decent locations. These are also pure telepsychiatry positions with no call requirement. Please share if you find comparable jobs with better offers so that I can use them to negotiate.

 

[clozareal]

As I had mentioned the model guarantees a base of at least $240K plus productivity. I would agree if it was just productivity and you were to maintain an average to low volume, then you may be below average. As a graduating fellow on the job market right now, these numbers are not grossly different from what is being offered in most decent locations. These are also pure telepsychiatry positions with no call requirement. Please share if you find comparable jobs with better offers so that I can use them to negotiate.

One of my co-fellows got an offer for $336k for a telepsych outpatient only position, 2 hour initial evals, 30-60 min follow-up, full benefits, no call, no weekends, malpractice coverage, all children/adolescents.

Another place in the area that's fully telehealth for children/adolescents/transitional age offers $300k for first-year salary and then productivity the year after you build up your panel (which typically goes over $300k/yr). No call, no weekends, full benefits.

The few places I'm moonlighting as a fellow for outpatient telepsych are about $150-200/hr depending on billing code.

I personally would not accept anything lower than $300k for 1.0 FTE given the multiple opportunities I've seen in my area to make at least that if not more.

 

[hamstergang]

Location and setting matter, so I don't necessarily see anything wrong with these numbers other than the productivity-only model. If it's $100 for an eval that's expected to take 1 hour, or $40 for a 20 minute follow up, that puts you far below the other options.

I do outpatient CAP myself. I don't care quite so much about the pay, but having good administrative staff and case management support is absolutely vital to preventing each day in the office from being a major headache.

 

[Merovinge]

I find 15-20 minute f/u's really untenable for CAP unless you are seeing patients that honestly don't need to be seeing a CAP (steady dosed SSRIs, stable ADHD etc). I type exceptionally fast and was known to be on the ruthless end of efficient in training and I still have a cramped day when all my patients come with 30 minute f/us. There is just too much going on with schools, IEPs, family dynamics, ensuring appropriate psychotherapy, comorbid medical concerns, SI, etc. to jam into such short visits IMO. I would really worry about taking my first job out of training like that, 30 min f/u really is the standard of care for f/u in CAP from many of my peers across the country.

 

[alina_s]

20 minute follow ups for child psych would be brutal if back to back. With kids I know, I may spend only 20 minutes face to face, but need the 30 minute appointment to order meds, labs, start the note, allow me to do the full visit when the family is late...3 patients/hour is rough with adults.

$100 for an intake is quite low. I was paid $90 per disability eval when I was still a resident in 2010, with no treatment planning or coordination.

 

[Yoyomama88]

Agree wouldn't touch this job with a 10 foot pole

 

[hebel]

You plan/want to stay at whatever job you chose for more than a year, correct?

 

[calvnandhobbs68]

For the second job, are you saying 45 evals and 15 min followups for kids as well? That’s bordering on impossible. 15 min visits are what pediatricians get for sick visits. By the time you’ve sent in electronic scripts and stuff, you only have 10 minutes for the actual appointment. I don’t think you can count on that many stable kids who just need their Prozac or vyvanse refilled and one bad visit will throw you behind 2-3 appointments for the whole day.

For the first job, Id say either need to get better benefits or a better reimbursement structure. Also nix the 20min followups. 60 min evals aren’t ideal for child but are way more doable than 45min. If they gave you some more PTO or health insurance or something might be a better job.

Also I’m going to add have you been doing telepsych regularly before now? I’ve found that these encounters can actually take LONGER than in person, especially if you’re working with an FQHC population who doesn’t have the best internet access. Dealing with phones freezing, people not knowing how to connect to appointments, people figuring out how to turn video on, etc etc.

 

[Gavanshir]

You plan/want to stay at whatever job you chose for more than a year, correct?

Probably yes, but also not necessarily? Telepsych often makes it a lot easier to walk out and seek other opportunities.

 

[hebel]

Probably yes, but also not necessarily? Telepsych often makes it a lot easier to walk out and seek other opportunities.

Just checking, because personally I would have different priorities if looking for a one year gig:

- see if you can get a signing bonus (and general incentives) to basically inflate your salary for the course of the one year contract.

- make sure the non-compete weak or absent.

- I like outpatient, but wouldn't want to spend a year doing a bunch of new intakes to build a panel before leaving once I started to get established. Maybe look at some inpatient options? If you're confident you'll stick around then this doesn't matter and your outpatient telepsych plans makes sense.

 

[Stagg737]

Also I’m going to add have you been doing telepsych regularly before now? I’ve found that these encounters can actually take LONGER than in person, especially if you’re working with an FQHC population who doesn’t have the best internet access. Dealing with phones freezing, people not knowing how to connect to appointments, people figuring out how to turn video on, etc etc.

I've found this to be a huge issue. I've had more than a few appointments that have been converted to telephone appointments part way through because the patient lost connection and didn't know how to be back into the meeting. I've had f/ups last an hour because we spent 40 minutes just trying to deal with the technologic aspect of things. Some days are great and appointments go very smoothly. Some days I want to punch a hole through my monitor because technology is awful. Very much dependent on the patients' understanding of technology and internet service.

Oh, and lets not forget the patients who expect to have their appointment while driving down the highway or going for a run, let alone those doing "other things" that are inappropriate during the encounter.

 

[Gavanshir]

I agree, but I have to say I have gained a TON of telepsychiatry experience throughout my training. I had been moonlighting via telepsych prior to Covid but this year my CAP-2 year has been all telehealth thus far while I have maintained my moonlighting work via telepsychiatry afterhours. I would say I have found a nice balance of how to conduct these types of appointments while handling the unpredictable challenges.

 

[Gavanshir]

Thoughts on this one? I'm CAP trained just coming out of fellowship.

100% Telepsych, 100% Outpatient, mix of adults and minors, no call or weekends (unless I choose to).
45 min intakes and 20 min follow-ups
$190/hour for full-time: ~395K/year
4 weeks of vacation
403b with match
Health & Dental
Malpractice with tail included
Qualifies for PSLF

I'm going to ask for 60 min intakes and 25 min follow-ups, CME and to cover my board exam and license renewal fees.. anything else?

 

[Techmed07]

Wow

 

[Monocles]

One of my co-fellows got an offer for $336k for a telepsych outpatient only position, 2 hour initial evals, 30-60 min follow-up, full benefits, no call, no weekends, malpractice coverage, all children/adolescents.

Holy ****! What area is this and are they still hiring??