Looking into a community mental health clinic job

[GUH]

I am finishing training in the Spring looking into a particular outpatient job affiliated with an academic institution. It is considered a state mental health clinic, and takes medicaid patients. I like the idea of working with residents and the location is good. The pay is a substellar but reasonable guaranteed salary.
I have not yet worked with Medicaid outpatients so I was wondering what questions I need to ask about how the clinic is run before I pursue this job further. I am very comfortable with (and enjoy) treating patients who have a low level of baseline function, substance abuse issues, psychosocial dysfunction, and lack of financial resources, so those issues don't concern me too much. I'm more wondering what kind of logistical/administrative issues that frequently come up in these kinds of clinics that I should be aware of before I agree to take a job as an attending. Things that I could think of to ask about are:

Bonuses, benefits, malpractice, time off, hours
After hours/weekend phone coverage
Midlevel supervision
noncompete/nonsolicitation
requirements and expectations for scholarly and administrative activity
Time allotted for new patients and for followups
Whether patients are ever double booked
How prior authorizations are handled, and if I'm expected to do them, what time I'm given to do them
How paperwork like disability forms and such are handled, and if I'm expected to do them, what time I'm given to do them
How patients are handled when they are late for appointments
How patients are handled when they become disruptive
How psychiatric emergencies are handled
Whether there are walk-ins, and if so, how they are handled
Community resources for ACT, therapy, and so forth
and once I have a contract, indemnification

Any obvious ones I'm missing?

(on an unrelated note, everyone during residency told me that inpatient jobs are more available but almost everything that I can find online is outpatient. odd.)

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[nexus73]

There as many more outpatient jobs than inpatient jobs.

 

[GUH]

There as many more outpatient jobs than inpatient jobs.

yeah that's what I'm seeing. Not sure why I was told that it's hard for hospitals to find inpatient psychiatrists. Most of the inpatient jobs I see posted are already filled by the time I contact the recruiter.

 

[Stagg737]

Do they have SW/CM within the clinic/building or is this typically through a local CMHC? How involved are they with patient care, social issues, etc.

Our academic center accepts Medicare/medicaid so a fair amount of our patients are the type you'd typically encounter at a CMHC. However, we don't have a SW or CM who is solely dedicated to our gen psych clinic and those needing that resource we have to work with local CMHCs which can be very frustrating. This was one of only 2 things about our CMHC site that I liked more than our academic clinic, the CMHC had significant SW/CM involvement which was really helpful.

 

[clausewitz2]

I would agree that finding out about paperwork and who is responsible for completing what is critical. If you have good CM/SW support you will only have to sign some things from time to time, if you have poor support you should push for admin time for the reams of forms you will have to complete. Same is true of nursing support; good nursing staff can make LAIs and clozapine trivial, poor or no nursing staff makes them a nightmare.

 

[LimpSpatula]

I think what you’re missing is that there’s zero reason in this market to take substellar pay for CMHC. Regardless of whether or not you have SW or case management in the building, the population will be sicker, with less resources, and less motivated for treatment than other settings. It is a tough job and you should be reimbursed as such.

 

[GUH]

I think what you’re missing is that there’s zero reason in this market to take substellar pay for CMHC. Regardless of whether or not you have SW or case management in the building, the population will be sicker, with less resources, and less motivated for treatment than other settings. It is a tough job and you should be reimbursed as such.

Yes, I definitely need to keep this in mind, although area I want to live has a reasonably low COL. To be honest I don't mind working with patients with poor motivation and severe pathology although this may be because those are the kinds patients I've mostly been working with throughout training. I'll keep my eyes peeled for better compensation but the other jobs in the area I've looked into so far aren't offering that much more.

Do they have SW/CM within the clinic/building or is this typically through a local CMHC? How involved are they with patient care, social issues, etc.

Our academic center accepts Medicare/medicaid so a fair amount of our patients are the type you'd typically encounter at a CMHC. However, we don't have a SW or CM who is solely dedicated to our gen psych clinic and those needing that resource we have to work with local CMHCs which can be very frustrating. This was one of only 2 things about our CMHC site that I liked more than our academic clinic, the CMHC had significant SW/CM involvement which was really helpful.

Thank you! I'll definitely ask about in-house SW/CM and their availability and level of involvement.

I would agree that finding out about paperwork and who is responsible for completing what is critical. If you have good CM/SW support you will only have to sign some things from time to time, if you have poor support you should push for admin time for the reams of forms you will have to complete. Same is true of nursing support; good nursing staff can make LAIs and clozapine trivial, poor or no nursing staff makes them a nightmare.

Thanks! I'm sure there are nursing staff on hand but I wonder how to phrase a question to assess their helpfulness. Maybe I'll ask how many patients receive LAIs and lab draws each month at the clinic.

 

[When is graduation again?]

I'm also looking into jobs at community mental health centers. Does anyone have any knowledge on typical salaries to expect? Other forum posts have mentioned jobs in the 270k+ range. Does that apply to CMHC work as well or are the pays lower? I'm looking in the Southeast and all the jobs hide salaries

 

[robellis]

How anyone could accept a job making less than 300k as an attending physician is mind boggling unless you’re in academia with amazing benefits

 

[nexus73]

How anyone could accept a job making less than 300k as an attending physician is mind boggling unless you’re in academia with amazing benefits

or 4 day week considered full time

 

[Candidate2017]

From what I've seen, CMHCs are 9-5 and well-funded by taxes for SW/ACT/"therapists"/emergencies. Double booking, disability forms, lateness, walk-ins etc should be no different from Big Box shops or private practice, i.e., you are the attending and decide how much you want to be screwed by The Man. Hint: just say no to all of the above, in any practice environment.

And LOL at nonsolicitation agreements. No one wants to steal a Medicaid panel of two to three 99215s per hour, at $45 per visit.

 

[Jules A]

Yes, I definitely need to keep this in mind, although area I want to live has a reasonably low COL. To be honest I don't mind working with patients with poor motivation and severe pathology although this may be because those are the kinds patients I've mostly been working with throughout training. I'll keep my eyes peeled for better compensation but the other jobs in the area I've looked into so far aren't offering that much more.

Just because you like it doesn't mean you shouldn't get a good salary and even more so when it is a specialty that others tend not to prefer. Geri, corrections, eating disorders etc they should be paid at the high end. Why not attempt to negotiate for a better salary there? Do you have inside information from peers negotiating at those other places in your area? The ad ranges are fairly worthless in my experience.

 

[MedMan80]

Lots of people being negative on CMHC, but FTCA insurance is a good draw (Can't really be sued). Some CMHC make you see a therapist (and thus have the SW support) before you get access to meds. Pay wise i think in the NE you're looking at 220-250 max for probably 12-15 booked patients a day with maybe 30% no shows

 

[splik]

Lots of people being negative on CMHC, but FTCA insurance is a good draw (Can't really be sued). Some CMHC make you see a therapist (and thus have the SW support) before you get access to meds. Pay wise i think in the NE you're looking at 220-250 max for probably 12-15 booked patients a day with maybe 30% no shows

the FTCA does not apply to most CMHCs which are either run by the county, state, or privately run. If you worked for a FHQC or another federally supported facility then the FTCA comes into play. I do malpractice case reviews, and I can tell you it is very hard to successfully be sued as an outpatient psychiatrist, even if you are providing bad care in an underresources CMHC. I often find myself say "yes, it was bad, but it did not fall below the standard of care" which is low in psychiatry. It's also much harder to prove proximate causation in the outpatient setting. ERs and acute inpatient units are the higher liability settings for psychiatrists.

 

[clausewitz2]

From what I've seen, CMHCs are 9-5 and well-funded by taxes for SW/ACT/"therapists"/emergencies. Double booking, disability forms, lateness, walk-ins etc should be no different from Big Box shops or private practice, i.e., you are the attending and decide how much you want to be screwed by The Man. Hint: just say no to all of the above, in any practice environment.

And LOL at nonsolicitation agreements. No one wants to steal a Medicaid panel of two to three 99215s per hour, at $45 per visit.

Some CMHC places have negotiated rates with state and local gvmt payors that are way beyond $45 dollars for a 99215. The CMHC I worked at initially out of residency got ~200 for a 99215.

Still the economic base of many CMHCs is turning the crank on therapy using new grads with stupidly large caseloads and burning them out in two years.

 

[splik]

Still the economic base of many CMHCs is turning the crank on therapy using new grads with stupidly large caseloads and burning them out in two years.

And of course it is vanishingly rare for CMHCs to provide anything close to therapy for patients (with the possible exception of first episode/early psychosis programs which often have additional funding). There is a reason they have called them "case managers" and not therapists for over 40 years and why they don't usually hire psychologists except possibly in leadership/administrative roles.

 

[SmallBird]

How anyone could accept a job making less than 300k as an attending physician is mind boggling unless you’re in academia with amazing benefits

The MGMA data suggests that many of us do.

 

[psyguru]

I work at an FQHC part-time (one day...soon to be half-day a week per my choice due to my forensic practice). The pay is hourly with no benefits but I was told it was in the top 10%. I don't think the pay would be as high if I was full-time. I would look around and negotiate if possible.

Anyhow, I would recommend not being compelled to supervise a mid-level for a low amount. I was offered two paid hours a week to supervise an NP and basically turned it down (I would rather invoice an attorney as an expert witness for 0.6 hours for the same amount without the headache). I could have negotiated it up to 4 hours maybe a week (close to $4k a month) but even that is not worth it for me. There are two ways of looking at compensation for mid-level supervision. Some may think being given a few hours a week off at the same pay is adequate and this is the wrong way of looking at it IMHO (i.e. $1k-$2k a month). The other way of looking at it is that you are in effect "renting your license" and also allowing a clinic to essentially get someone that can do your work at half pay (plus compelling an MD to supervise one for $1-2k a month). As such, your supervision should be valued as such. My opinion is that you should be entitled to more than 1-2k when the organization pockets half an MD salary basically. Also, I feel you should be paid more to carve out additional time to do at least a half-decent job in supervising an NP.

 

[clausewitz2]

And of course it is vanishingly rare for CMHCs to provide anything close to therapy for patients (with the possible exception of first episode/early psychosis programs which often have additional funding). There is a reason they have called them "case managers" and not therapists for over 40 years and why they don't usually hire psychologists except possibly in leadership/administrative roles.

The places I have worked generally assign a "therapist" separate from a "case manager" or "service coordinator." It is still the case that any therapist with any actual nous seems to quit and go into private practice as soon as they are licensed and the modal client is being seen perhaps once a month, which is hard to describe as therapy. Weekly therapy I have only seen happen at either of these agencies as part of an IOP or as you said a FEP program that has a totally different funding model and has to meet state model fidelity requirements.

 

[Stagg737]

The places I have worked generally assign a "therapist" separate from a "case manager" or "service coordinator." It is still the case that any therapist with any actual nous seems to quit and go into private practice as soon as they are licensed and the modal client is being seen perhaps once a month, which is hard to describe as therapy. Weekly therapy I have only seen happen at either of these agencies as part of an IOP or as you said a FEP program that has a totally different funding model and has to meet state model fidelity requirements.

Where I was at the frequency of therapy actually seemed decent (weekly to Q2weeks), though Idk how great the quality actually was. The problem with that CMHC was that it was near impossible to get someone into therapy d/t the need. When we started PGY-3 there is was a 4-5 month wait to start therapy. When I left, they weren't accepting any new patients d/t the high load.

How anyone could accept a job making less than 300k as an attending physician is mind boggling unless you’re in academia with amazing benefits

I mean, I've never heard of any CMHC that offers a 300k salary and rarely above 250k from what I've seen for standard FT loads. Admittedly I haven't looked very hard into CMHCs, but that's the general trend I see from the positions I get from recruiters and various sites.

 

[nexus73]

the FTCA does not apply to most CMHCs which are either run by the county, state, or privately run. If you worked for a FHQC or another federally supported facility then the FTCA comes into play. I do malpractice case reviews, and I can tell you it is very hard to successfully be sued as an outpatient psychiatrist, even if you are providing bad care in an underresources CMHC. I often find myself say "yes, it was bad, but it did not fall below the standard of care" which is low in psychiatry. It's also much harder to prove proximate causation in the outpatient setting. ERs and acute inpatient units are the higher liability settings for psychiatrists.

Any examples of bad care that didn’t fall below standard of care. I’d be interested in this in a separate thread even.

 

[Candidate2017]

Some CMHC places have negotiated rates with state and local gvmt payors that are way beyond $45 dollars for a 99215. The CMHC I worked at initially out of residency got ~200 for a 99215.

I once got a peek at a CMHC's new intake rate and my jaw dropped. It was multiples of any private insurance rate. That's because they (1) spend lots of money lobbying the government and (2) the huge payment also covers wraparound services, I believe. There is zero chance a private practice will get anything close to these rates from a Medicaid panel.

 

[deleted456421]

How anyone could accept a job making less than 300k as an attending physician is mind boggling unless you’re in academia with amazing benefits

Some of the jobs I've inquired about are shocking. Just spoke to a recruiter about an inpatient job within a massive healthcare system affiliated with a brand name university. Although it's in one of the worst, most violent cities in the Northeast, they were only offering $275k for 40 hours weekly + once weekly overnight phone call + q6 week weekend rounding + massive midlevel supervision (no extra pay for the call or rounding or supervision). What really made me angry was the fact they couldn't guarantee the unit or the "advanced practice providers" I'd be working with. Benefits were mediocre at best. They quickly ended the call after I mentioned my current salary, which is good but nothing stellar per other posters here.

 

[GUH]

Just because you like it doesn't mean you shouldn't get a good salary and even more so when it is a specialty that others tend not to prefer. Geri, corrections, eating disorders etc they should be paid at the high end. Why not attempt to negotiate for a better salary there? Do you have inside information from peers negotiating at those other places in your area? The ad ranges are fairly worthless in my experience.

I definitely do not have inside information. From the information I'm gathering from responses here, in addition to seeking out the specifics of the job, it sounds like I should consider asking for a higher salary. I didn't know that salary negotiation was common for academia.

 

[splik]

I definitely do not have inside information. From the information I'm gathering from responses here, in addition to seeking out the specifics of the job, it sounds like I should consider asking for a higher salary. I didn't know that salary negotiation was common for academia.

It depends on the institution. I can tell you there is no salary negotiation where I am and that is true of most top academic centers, and most of the public institutions (where there is often public reporting of salaries and there would be mutiny if there were significant differences between existing and incoming faculty). But there are plenty of academic and pseudoacademic jobs (which is what the job you are describing is) where you definitely can negotiate salary. It never hurts to ask. Always ask for something. It is good practice if nothing else. See my other threads about this (here and here) and also read Never Split the Difference. Negotiations include lots of things beyond money, which may actually more more important than the money.

 

[comp1]

If you're looking for an inpatient job, don't look for ads. Call the local hospitals (private, county, VA, jail, prison, etc) and ask.

 

[Splenda88]

How anyone could accept a job making less than 300k as an attending physician is mind boggling unless you’re in academia with amazing benefits

Do you mean all physicians or only psych? Many docs (IM/FM/Peds/ID/Endo etc...) dont make over 300k/yr. However, I agree with the general sentiment. No doc should agree to work FT for <250k/yr.

 

[comp1]

Average full time salary is $275k. There's a heck of a lot of psychiatrists (most?) with a full time salary under $300k. Medscape: Medscape Access

 

[milesed]

I'd ask about how patient med problems are handled between appointments- side effects, etc.
Are patients required to see a therapist in order to see you for meds?
Coverage for and from you when prescribers are out
How and when raises are determined
Bonuses
Are licenses, DEA, malpractice paid for?

 

[When is graduation again?]

For all residents interested in this topic, I've had a few meetings with recruiters and employers. So far, the going rate in my region in the mid-Atlantic is about $185-200 per hour as a locums for a community jobs with no call. Employers have been reaching out less than a week after applying for jobs and are very willing to negotiate, so it's definitely a psychiatrists market right now.

 

[nashki]

I definitely do not have inside information. From the information I'm gathering from responses here, in addition to seeking out the specifics of the job, it sounds like I should consider asking for a higher salary. I didn't know that salary negotiation was common for academia.

Did you end up taking the job?

I'm looking at my first job post-training as well and have been looking at CMHCs and county jobs as well. I'm strongly considering a specific county job in CA. Its outpatient fulltime (some telepsych), 36ish patient encounter hours and rest for administrative stuff, some teaching (residents and med students).

Curious if anyone has experiences with county jobs and how they compare to CMHCs. Any pros, cons, things you wish you'd known, redflags, etc?