Managing burnout/income issues

[Sanman]

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Hey All,

Being early-career I've noticed one of the large changes between training and being out in the real world is having financial pressures/declining reimbursements and managing that with burnout. Being early on, I am fee for service and it really does add to the stress of the job. When I work private practice, I notice (and so does my gf) that the stress is considerably less. However, having a comfortable office, higher reimbursements, and largely working outside of insurance all contribute to this. However, this really is not a full-time possibility for most people and filling a full-time client list requires insurance panels (though I am now seeing the upside of treating rich housewives). Working with the medicaid/medicare patients in a nursing home, I notice the lower reimbursements, lack of proper offices/clerical support, and lack of care by other staff often increase burnout. I notice colleagues seeing 7-12 patients a day on average and skipping lunch. Often a lack of coordination means it feels like banging your head against a wall. While my supervisor has suggested it gets better when you are on salary, I notice the emotional toll that the surroundings and financial pressure takes on me makes things not worth it at times. Especially if it means not having the patience to deal with family or my gf at times. I have considered moving more toward positions only doing 90801 evals and less treatment (comp and pen, SS disability evals, etc) as well as less clinical more management related roles full-time (utilization reviews, maybe director positions in a few years).

Anybody else feeling the crunch of reimbursements and having difficulty with self-care and burn-out? Anyone find solutions to taking better care of themselves despite financial pressures? Experiences, thoughts, venting,etc welcome.

 

[JeyRo]

Hey All,

Being early-career I've noticed one of the large changes between training and being out in the real world is having financial pressures/declining reimbursements and managing that with burnout. Being early on, I am fee for service and it really does add to the stress of the job. When I work private practice, I notice (and so does my gf) that the stress is considerably less. However, having a comfortable office, higher reimbursements, and largely working outside of insurance all contribute to this. However, this really is not a full-time possibility for most people and filling a full-time client list requires insurance panels (though I am now seeing the upside of treating rich housewives). Working with the medicaid/medicare patients in a nursing home, I notice the lower reimbursements, lack of proper offices/clerical support, and lack of care by other staff often increase burnout. I notice colleagues seeing 7-12 patients a day on average and skipping lunch. Often a lack of coordination means it feels like banging your head against a wall. While my supervisor has suggested it gets better when you are on salary, I notice the emotional toll that the surroundings and financial pressure takes on me makes things not worth it at times. Especially if it means not having the patience to deal with family or my gf at times. I have considered moving more toward positions only doing 90801 evals and less treatment (comp and pen, SS disability evals, etc) as well as less clinical more management related roles full-time (utilization reviews, maybe director positions in a few years).

Anybody else feeling the crunch of reimbursements and having difficulty with self-care and burn-out? Anyone find solutions to taking better care of themselves despite financial pressures? Experiences, thoughts, venting,etc welcome.

I empathize and understand completely. I'm in the VA so I get to avoid all of this (albeit with a frozen salary that's being cut over time in real dollars due to inflation), and this is what honestly intimidates me about possibly re-entering the private sector again someday.

 

[edieb]

Unless we accept reality, we cannot begin to do anything to change it. Thus, I really think a dose of reality is at hand here: You say one thing you do is SSI evaluations. Well, the rates for those are being cut, too. In addition, some states (like Mississippi) are now allowing LCSWs to complete these evaluations. Looking at the current trajectory of the field, things will NOT be improving. So your choices are either to (1) Enter another field; (2) Hope you become one of the psychologists who figure out how-to fill a cash practice or land one of the few cushy jobs left or (3) Continue to struggle

 

[LivingOffLoans]

That is a rough situation. I am not there quite yet, but may be soon. Fee-for-service seems really tough. I want to do 1:1 and group work mostly, but it seems like other than fee-for-service or private practice, there is really not a (stable) way to do so. I know there exist some 'cushy' positions like that out there, like the VA, or some outpatient hospital programs, but those are not always so easy to come by. I have toyed with looking for a low pressure job as a psychology professor at a community college (well, lower pressure than a university job anyway) just so I can have a predictable salary and still get to do something I'd enjoy in the field. But yeah, a successful private practice is the dream...

 

[Sanman]

I empathize and understand completely. I'm in the VA so I get to avoid all of this (albeit with a frozen salary that's being cut over time in real dollars due to inflation), and this is what honestly intimidates me about possibly re-entering the private sector again someday.

How many patients do you see a day JeyRo? It certainly is a barrier to jumping back in as a provider somewhere. Many of the nursing homes in my area are contracting services to my company or ones like it that hire dozens/hundreds of therapists (mostly psychologists, but LCSW and LMHC as well). With the slim margins in mental health and the overhead for these (for-profit) companies, there really is not a lot left for a provider. On the plus side, if you are willing to delve into billing and clinical utilization reviews for the company or develop new avenues of practice/revenue streams, there are management jobs to be had for decent money. Once I am fully licensed, I would not mind finding a smaller competitor that focuses more on marketing higher quality to nursing care facilities with richer/better insured clientele. Alternatively, getting on staff at a not-for-profit nursing care facility (often church based) might be more amenable to a decent lifestyle.

EdieB,

There are definitely things that need to be fixed in the system and I know fee-for-service and salaried psychologists struggling to make a decent income (early career people like myself). Many can tell you that a 90806 for a medicaid pt pays less than $30 a session after the overhead is taken by a company or facility. It just does not pay to see medicaid pts. However, this is not just a psychologist problem. The medical and psychiatry providers are also getting squeezed and we have already had one person taken off the service due to being unable to bill enough to justify their salary ( and this was a Psych NP). SS disability is not the only eval out there. There are many different surgical or medical related evals that are in demand. I agree that 90801 reimbursement is going down. However, it is still better reimbursed than therapy and it is one and done. No banging your head against a wall, trying to speak to physicians that are never around/available and having to face families that struggle in a broken system. No getting burned out by volume and providing second rate services the same as everyone else. Finish the eval, go home, and enjoy family time. I'm not a greedy guy, but I don't think that something along the lines of a VA pay scale should be out of the question in the private sector without working much harder.

Livingoffloans,

I have had the same thought as I love teaching. However, getting a TT position at a cash strapped CC is just as hard these days as anything in the private practice market. At least that is true in my neck of the woods.

 

[Pragma]

I have had the same thought as I love teaching. However, getting a TT position at a cash strapped CC is just as hard these days as anything in the private practice market. At least that is true in my neck of the woods.

You may want to reconsider - the TT job market is rough, but it never hurts to apply. I personally went that route (not CC - I went to an R2), and most of the folks in my department also have thier own private practices on the side. The TT job gives you security, stimulation, and a decent paycheck. I'd say it is worth fighting for - even if it is not quite as cushy as a VA job, personally I see it as a better alternative than chasing people around to get paid, being at the mercy of the healthcare system, or being stuck in a federal government system.

 

[edieb]

How many patients do you see a day JeyRo? It certainly is a barrier to jumping back in as a provider somewhere. Many of the nursing homes in my area are contracting services to my company or ones like it that hire dozens/hundreds of therapists (mostly psychologists, but LCSW and LMHC as well). With the slim margins in mental health and the overhead for these (for-profit) companies, there really is not a lot left for a provider. On the plus side, if you are willing to delve into billing and clinical utilization reviews for the company or develop new avenues of practice/revenue streams, there are management jobs to be had for decent money. Once I am fully licensed, I would not mind finding a smaller competitor that focuses more on marketing higher quality to nursing care facilities with richer/better insured clientele. Alternatively, getting on staff at a not-for-profit nursing care facility (often church based) might be more amenable to a decent lifestyle.

EdieB,

There are definitely things that need to be fixed in the system and I know fee-for-service and salaried psychologists struggling to make a decent income (early career people like myself). Many can tell you that a 90806 for a medicaid pt pays less than $30 a session after the overhead is taken by a company or facility. It just does not pay to see medicaid pts. However, this is not just a psychologist problem. The medical and psychiatry providers are also getting squeezed and we have already had one person taken off the service due to being unable to bill enough to justify their salary ( and this was a Psych NP). SS disability is not the only eval out there. There are many different surgical or medical related evals that are in demand. I agree that 90801 reimbursement is going down. However, it is still better reimbursed than therapy and it is one and done. No banging your head against a wall, trying to speak to physicians that are never around/available and having to face families that struggle in a broken system. No getting burned out by volume and providing second rate services the same as everyone else. Finish the eval, go home, and enjoy family time. I'm not a greedy guy, but I don't think that something along the lines of a VA pay scale should be out of the question in the private sector without working much harder.

Thanks for the reply, but I recently began as a prescribing psychologist, leaving a V.A. staff psychologist position. From my experience, the 30 or so psych NPs I have et and the psychiatrists, prescribing is not being squeezed at all. For a medication check, I earn around $65 from Medicaid, more with better insurance. I usually can do 3-4 of these an hour. I have a waiting ilst of 4+ months and have to turn patients away and, once I finish with my waiting list, I will be cash only, only doing a little pro bono work for the poor, etc. In addition, I have offers for locum tenens positions for $150 an hour + per diem for food and they pay my rent. I get so many calls from recruiters I can't keep up.

I would never, never, never want to be a clinical psychologist who does therapy and assessment for $40 an hour at the V,A,\ again. I don't know where people get the idea that prescribing is strapped because it is definitely not,. Just look at the psychiatry boards right now --- theyre receiving offers or $200k right out of school while psychologists are hoping to find a job. I hate to be blunt, but, as far as income, clinical psychology sucks pretty bad. It hurts me to say that because I love the work, but it's true. WHen we sugar coat and spin, prospective graduate students are misled and that's not right

 

[Doctor Eliza]

Re: benefits of an rx pad. I just went to a great seminar today and met yet another child psychiatrist in my town that has a cash only practice (I.e. No insurance). I now know at least 3 of the best child psychiatrists in the area who refuse to deal with insurance. They are so in demand they can be picky.

As you might guess my bank account and I are strongly in favor of rx privileges for psychologists. Actually, I think my patients are too because it would let them get appropriate care quickly instead of being on a 6 month waiting list.

Dr. E

 

[KillerDiller]

Just thought I'd share that I misread the title of this thread as "Managing burnouts" and briefly thought it was yet another discussion about marijuana use.

 

[JeyRo]

Just thought I'd share that I misread the title of this thread as "Managing burnouts" and briefly thought it was yet another discussion about marijuana use.

Did somebody say marijuana? 🙂

(Kidding!)

 

[Pragma]

Did somebody say marijuana? 🙂

(Kidding!)

For a second there, I thought I saw a double rainbow... 🙂

 

[Sanman]

Edieb,

I'm glad you're doing well. the difference between my experience and yours might be due to the higher overhead in NY. I never meant to suggest that doctors are hurting. Simply that Medicaid/ medicare does not seem to pay enough here for us to keep a psychiatrist or NP very long. They are still doing well financially, but are not interested in managing the complex day program patients for the money. The thing is that they rarely see any pts. The review the chart and manage meds with minimal contact. It is not what I would call quality patient care. That is the pressure I speak of. The private practice I work for can bring in a nice living as it is one of the only Strict CBT practices in the NYC area. However, it really requires at least some insurance paneling (the higher paying ones) to fill a schedule full-time. I have figured out something physicians did a long time ago. Running your own practice is the best way to go. Having a few others work under you is even better. You really cannot make a decent living as an employee psychologist.

 

[edieb]

sanman,

and from what i see, psychiatrists are getting raises in the coming medicaid reimbursement schedule and psychologists are getting cut again. unfortunately, medicaid is a bellwether for insurance companies. I can afford now to cherry pick my therapy patients because i make enough managing medication...

another sign of the dismal shape psychology is in is the fact that the V.A. cannot find psychiatrists but psychologists are fighting for V.A. positions.

 

[AcronymAllergy]

sanman,

and from what i see, psychiatrists are getting raises in the coming medicaid reimbursement schedule and psychologists are getting cut again. unfortunately, medicaid is a bellwether for insurance companies. I can afford now to cherry pick my therapy patients because i make enough managing medication...

another sign of the dismal shape psychology is in is the fact that the V.A. cannot find psychiatrists but psychologists are fighting for V.A. positions.

I think the VA can have difficulty (depending on the location) attracting physicians as a whole, yes, and psychiatrists especially. I'd imagine a big part of the demand for physicians is because of the firm grasp on supply the AMA has implemented, and this is something from which psychology could certainly learn.

Edit: As for prescribing privileges, given how torn even our own field seems to be about that, I don't know that it's going to be sweeping the nation anytime soon (not that anyone was suggesting this, of course). However, with all the funding cuts state mental health agencies are/have been taking, I could also see a point of "critical mass" being reached relatively soon where many, many individuals with SMI aren't able to receive care. If psychology wants to push for widespread Rx, that would probably be the time to do it.

At the same time, now that it's been actively going in Louisiana for a few years now, if we're going to purport ourselves to be equally-viable prescribers to psychiatrists (or at least to midlevel providers such as psych NPs), we need to start gathering and presenting the data to support that assertion.

 

[MBellows]

For a second there, I thought I saw a double rainbow... 🙂

Ugh! Fall allergy issues and this line of comments almost led me into a medical disaster from trying to laugh and not being able to breathe. Thanks guys...

As for helping with burnout. Mindfulness meditation can do wonders, but it won't fix the fact that the economy still sucks and the medical system is broken to ****. I saw a post earlier this week about a public policy program coming up with a psych focus, maybe in 30 years if we haven't been replaced by a black neurowand, that will have helped some.

 

[paramour]

Meh, our psychiatrists complain just as much and we can't keep them around. They're "overworked" as is with 15-minute med checks and now limits are to be placed (by Medicaid) on the number of meds patients can receive unless they extend the time psychiatrists see patients (which I don't see happening...).

 

[cara susanna]

Ugh! Fall allergy issues and this line of comments almost led me into a medical disaster from trying to laugh and not being able to breathe. Thanks guys...

As for helping with burnout. Mindfulness meditation can do wonders, but it won't fix the fact that the economy still sucks and the medical system is broken to ****. I saw a post earlier this week about a public policy program coming up with a psych focus, maybe in 30 years if we haven't been replaced by a black neurowand, that will have helped some.

Mindfulness should help you be able to accept those facts as well as the uncomfortable thoughts and emotions that they inspire, though. 😉

 

[AcronymAllergy]

I'm in an r1 TT position in a medical school. I don't make that much less than the neurologists of similar level in my department. I am never on call or on service. I do a clinic day once a week, assessment only. I am in no danger of not meeting the financial targets for that portion of my job. The word RVU is never uttered in reference to me. I think there is risk to my position. If I don't make tenure if will be unpleasant. And funding is increasingly scarce. But so far so good. I think Edieb is right in one respect. People want drugs even in cases where it absolutely should not be the first line treatment (eg PTSD). So even in cases where our services are clearly the best choice, where we are clearly the best experts, we are ignored in favor of drug treatments from whatever prescriber can make a buck by writing the script and we are often second choice to hand holding social workers who don't have he educational background to so anything interesting. Thus, having a prescription pad is a ticket to steady cash, regardless of efficacy. There is demand for that pill. I suppose you could argue that we are undervalued or perhaps the prescription pad is way overvalued. I'm sure Edieb that you can attest to the fact that the nurses et al that you have worked with that have the pad are not generally in the educational/intellectual ballpark of clinical psychs.. The task, writing the script, is also easy, and the assessments are facile and not well executed. Basically it's not high quality care that we are moving toward as a country.

But lots of people make much more money than I do. Turn on the tv and check out reality television, any actor in a semi successful show, a bajillion sales people with minimal education, etc. . And this is also true of most physicians. Starting salaries for most physician specialties are way over estimated here or are not considered in context. There are easier ways to make a dollar than working your ass off as a physician. So why so it? When you have the skill level/intellectual capacity to be a top flight researcher or a cutting edge specialty physician, and you make the choice to do so, that choice is generally not about money. Sure you want to be at comfortable level, but the point is to fill a different need.

Agree with pretty much everything above, particularly the parts related to medication. It's honestly frightening some of the medications I'll see thrown at people (including children) for problems that could be chocked up to adjustment, and/or that would either likely go away on their own, or could be handled with a brief stint of psychotherapy. Trouble is, when your insurance company and/or your schedule is more accommodating of a once-every-three-months med check rather than a once-weekly therapy appointment for two or three months, does the latter ever really stand a chance except in those cases where medications have failed?

That being said, we (psychologists) can also be fairly horrid at marketing our own services. Heck, when's the last time you saw a commercial for some CBT?

 

[Pragma]

Agree with pretty much everything above, particularly the parts related to medication. It's honestly frightening some of the medications I'll see thrown at people (including children) for problems that could be chocked up to adjustment, and/or that would either likely go away on their own, or could be handled with a brief stint of psychotherapy. Trouble is, when your insurance company and/or your schedule is more accommodating of a once-every-three-months med check rather than a once-weekly therapy appointment for two or three months, does the latter ever really stand a chance except in those cases where medications have failed?

That being said, we (psychologists) can also be fairly horrid at marketing our own services. Heck, when's the last time you saw a commercial for some CBT?

Motion seconded.

Also, thanks Jon Snow for making a statement against physician envy. It's a horrible fad 🙂

 

[Therapist4Chnge]

I'm in an r1 TT position in a medical school. I don't make that much less than the neurologists of similar level in my department. I am never on call or on service. I do a clinic day once a week, assessment only. I am in no danger of not meeting the financial targets for that portion of my job. The word RVU is never uttered in reference to me. I think there is risk to my position. If I don't make tenure if will be unpleasant. And funding is increasingly scarce. But so far so good.

I'm at an R1 clinical-track position in a medical school, and I'd echo everything JS wrote about income and productivity expectations. We differ in that the vast majority of my time is clinical (consultation and assessment), so my funding is more closely tied to seeing patients. My time is split between in-patient & out-patient settings, with research being an extension of my clinical work. I theoretically can buy out clinical time to do grant-funded research, but the $ is far better to stick with out-pt neuropsych assessments. Lastly, and most importantly...my uni football team > his uni football team. 😀

There is demand for that pill. I suppose you could argue that we are undervalued or perhaps the prescription pad is way overvalued. I'm sure Edieb that you can attest to the fact that the nurses et al that you have worked with that have the pad are not generally in the educational/intellectual ballpark of clinical psychs..

I definitely agree that much of the work of psychologists is undervalued, but we have mostly ourselves to blame. Prescribing offers easier and more steady $, but the actual work is not nearly a intellectually stimulating (to me). I will have my RxP privileges by 2013, but that is strictly a backup plan unless the field really takes a downturn.

There are still opportunities to make money working in psychology, you just need to do it in areas of demand/growth. Forensic assessment is doing very well. There have been some nice opportunities in Primary Care and Integrative Health that have opened up for psychologists, but they all require fellowship training in the area to be competitive*. Neuropsych work can be a good area to work, but I think it is very location and population dependent. NYC, LA, CHI, SF, etc...those places are flooded with people (often not fellowship trained) willing to do neuropsych assessments, so that limits earning potential once you factor in cost of living expenses. For people willing to live in the Midwest, South, and/or outside of major metro areas...I think the opportunities are better.

*This also assumes APA-acred program and internship completion, which is a growing area of differentiation these days.

 

[Pragma]

I'm at an R1 clinical-track position in a medical school, and I'd echo everything JS wrote about income and productivity expectations. We differ in that the vast majority of my time is clinical (consultation and assessment), so my funding is more closely tied to seeing patients. My time is split between in-patient & out-patient settings, with research being an extension of my clinical work. I theoretically can buy out clinical time to do grant-funded research, but the $ is far better to stick with out-pt neuropsych assessments.

What do you mean by the $ is better? Just curious. When you get soft money like grants, there isn't usually a salary incentive - they just go by paying a percentage of what you make to buy-out the time, right? Or are you referring to RVUs somehow in terms of how much time it takes to do clinical work vs. what you get back if you were to buy-out for a grant?

Jon Snow, a question for you - how common are TT positions in medical school settings? At least where I did my fellowship, there was no tenure. Everyone was on a year-to-year contract. That was part of why I decided I preferred to go to an R2 - I like job security and didn't want my job to be contingent on soft money. The pay isn't generally as high as one would get with a position like yours or T4C's, but you also have a lot more time on your hands. I can easily do private practice or consulting on top of my job because of all of the flexibility - I'd imagine my annual take-home is less than a medical center gig, but probably not by a lot, at least starting out.

Not that I would want to go back to a medical school necessarily, but I'd imagine that getting tenure in those settings would make them even more attractive for the cream of the crop candidates.

The other things I wonder about, comparatively for a situation like T4C or JS, is what types of grants people are going for. At least in my experience, most psychologists I know at medical schools usually were consulting on huge grants run by other people, starting up with a K award (in the case of people with research gigs like JS), or playing a small role in a huge multisite trial of some kind. T4C, how realistic is it in a position like yours to go for your own R01 down the line? I'd imagine that would make more sense for JS or someone else with a primary research emphasis - but even then sometimes I wonder if psychologists are more often running their own studies or being a Co-PI or consultant.

At least for me, the balance of being able to have a) tenure, b) potential to get R01s but not extreme pressure to, and c) scheduling flexibility are what led me to go for an R2 job.

 

[Therapist4Chnge]

What do you mean by the $ is better? Just curious. When you get soft money like grants, there isn't usually a salary incentive - they just go by paying a percentage of what you make to buy-out the time, right? Or are you referring to RVUs somehow in terms of how much time it takes to do clinical work vs. what you get back if you were to buy-out for a grant?

In most places research time buy-outs would work as you described, though my compensation package pulls from multiple buckets of funding. The most lucrative bucket (and the largest % of my work) involves out-pt neuropsych evals.

T4C, how realistic is it in a position like yours to go for your own R01 down the line? I'd imagine that would make more sense for JS or someone else with a primary research emphasis - but even then sometimes I wonder if psychologists are more often running their own studies or being a Co-PI or consultant.

Landing a large research grant helps me when I come up for review and consideration for promotion to Associate Prof, but monetarily it is a harder sell. I can still publish and present as a co-PI or consultant, which when aggregated can accomplish the same thing as doing my own research work (in regard to consideration for promotion) because I'm classified as "clinical" faculty. I'm going to take a few years and collaborate, though I'm pretty sure research will never be more than 10-20% of what I do.

 

[Pragma]

Pragma, I don't know how common they are. And I agree that the money is probably not that different. I have a K and I am a co I on an ro1 and a foundation grant. To get tenure I have to have my own r01s. Though effectively tenure or no, these positions are soft money. No big grants = no job. And with funding how it is, this means you are pretty much looking at maintaining consistent publishing in top tier journals, great networking presence, and serious effort in following grant mechanisms and trends in funding.

In most places research time buy-outs would work as you described, though my compensation package pulls from multiple buckets of funding. The most lucrative bucket (and the largest % of my work) involves out-pt neuropsych evals.



Landing a large research grant helps me when I come up for review and consideration for promotion to Associate Prof, but monetarily it is a harder sell. I can still publish and present as a co-PI or consultant, which when aggregated can accomplish the same thing as doing my own research work (in regard to consideration for promotion) because I'm classified as "clinical" faculty. I'm going to take a few years and collaborate, though I'm pretty sure research will never be more than 10-20% of what I do.

Thanks both of you for sharing. It seems to me that there are ups and downs to any of these positions depending on what is important to you. Although in a research gig at a medical school is not tenured in the job security sense, I doubt that is an issue if you have a pretty prolific paradigm.

As for me - I am just fine taking the reduced prestige for less pressure. I do hope to land an R01 or two within 5 years, but it sometimes is harder to make the case when you are at an R2 (e.g., cost sharing issues, etc). The nice thing about it is that at least I'll get credit for trying - my job will still be around if I don't get that level of funding.

However, the downside is that I have to do a fair amount of PP or consulting in order to get my salary in the same range.