maximum inpatients per attending

[LisaLou]

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I've been trying to find information on recommended maximums or even averages of inpatient psychiatric patients per physician per day. I've found some things regarding outpatient, but none regarding inpatient. Does anyone know of any such information out there? Does the APA have a stance on this? I couldn't find anything from the APA regarding this either.

 

[notdeadyet]

That's going to be so location biased as to not be particularly helpful. Is this crisis stabilization, step down, short stay, prolonged stay, or long-term hospitalization?

 

[LisaLou]

Ideally, state hospital so a mix of acute and long-term, civil commitments and forensic. However, given that I've not found any information at all, I'll take ANY inpatient info for comparison purposes.

 

[vistaril]

I've been trying to find information on recommended maximums or even averages of inpatient psychiatric patients per physician per day. I've found some things regarding outpatient, but none regarding inpatient. Does anyone know of any such information out there? Does the APA have a stance on this? I couldn't find anything from the APA regarding this either.

huh? thew question makes no sense. The minimum or maximum in the real world depends entirely on what you want to make. If you want to see 4 inpatients per day, Im sure you can....but your pay is going to reflect that. Same as if you want to see 45.

 

[notlucid]

I see 12 as inpatient psychiatrist on a usual day. Beyond that you need support and extra hours. I would imagine 20 might be maximum. On the other I am facing a salary cut for seeing less, so 16 may be the norm.

 

[learnmore]

I'd say most employed positions expect you to carry 15-20 beds with brisk turnover.

If you want to see 4 inpatients per day, Im sure you can....but your pay is going to reflect that. Same as if you want to see 45.

I think perhaps a more interesting question is whether or not an inpatient-only private practice is realistic. Assuming you aren't getting any directorship/stipend/subsidy from the hospital and you are billing the patients/insurance directly, can you actually make a good living doing this without an outpatient component? I used to think this was possible, but now I question how one gets paid without "capturing" discharged patients into outpatient follow-up.

For example, more and more people are opting for high-deductible plans. If they're admitted to the the hospital and haven't met the deductible, good luck trying to get reimbursed as a sole practitioner.

 

[LisaLou]

huh? thew question makes no sense. The minimum or maximum in the real world depends entirely on what you want to make. If you want to see 4 inpatients per day, Im sure you can....but your pay is going to reflect that. Same as if you want to see 45.

I think you misunderstood my question. There is a decent amount of literature in the outpatient world regarding how to determine a reasonable patient case load. I'm unable to find any equivalent information for the inpatient world. Depending on the content of one's contract, the number of patients seen in a day may have no relationship to one's salary. However, hospitals are naturally interested in maintaining their financial health, and so will often push for providers to see more patients. I'm looking for objective information to determine what is a reasonable inpatient case load for psychiatrist (assuming the workweek is generally intended to be about 40 hours, so we're not including taking on extra patients "after hours" or in addition to regular workload to increase salary).

 

[LisaLou]

I see 12 as inpatient psychiatrist on a usual day. Beyond that you need support and extra hours. I would imagine 20 might be maximum. On the other I am facing a salary cut for seeing less, so 16 may be the norm.

What setting are you in?

 

[vistaril]

I'd say most employed positions expect you to carry 15-20 beds with brisk turnover.



I think perhaps a more interesting question is whether or not an inpatient-only private practice is realistic. Assuming you aren't getting any directorship/stipend/subsidy from the hospital and you are billing the patients/insurance directly, can you actually make a good living doing this without an outpatient component? I used to think this was possible, but now I question how one gets paid without "capturing" discharged patients into outpatient follow-up.

For example, more and more people are opting for high-deductible plans. If they're admitted to the the hospital and haven't met the deductible, good luck trying to get reimbursed as a sole practitioner.

yes, good points

 

[vistaril]

I think you misunderstood my question. There is a decent amount of literature in the outpatient world regarding how to determine a reasonable patient case load. I'm unable to find any equivalent information for the inpatient world. Depending on the content of one's contract, the number of patients seen in a day may have no relationship to one's salary. However, hospitals are naturally interested in maintaining their financial health, and so will often push for providers to see more patients. I'm looking for objective information to determine what is a reasonable inpatient case load for psychiatrist (assuming the workweek is generally intended to be about 40 hours, so we're not including taking on extra patients "after hours" or in addition to regular workload to increase salary).

you are looking at this in a bizarre way. Of course the number of patients seen in a day have a relationship to one's salary......that might not be reflected in the actual contract in terms of RVUS or whatever, but it is most certainly reflected in the base salary. If Kaiser hires an inpatient psych, the base salary(assuming there is no RVU model) is going to be a lot higher for a position that caps at 27 vs 14. That's common sense. When we are on salary, our salary is always related to how much revenue we are generating....and how much revenue we are generating is related to how many inpatients we see(and what type)

A better question you could ask(if you are talking about salaried inpatient jobs) is: What is a reasonable inpatient case load for a inpatient job that pays X and expects Y turnover? Then we could actually look at what the revenue projections would be based on codes and get some idea of how that would translate to a salary. Because salary and the number of inpatient codes you generate are related in such a way that it is possible to guess at one when the other is unknown.

 

[wolfvgang22]

I've been trying to find information on recommended maximums or even averages of inpatient psychiatric patients per physician per day. I've found some things regarding outpatient, but none regarding inpatient. Does anyone know of any such information out there? Does the APA have a stance on this? I couldn't find anything from the APA regarding this either.

As an employee psychiatrist, I will see 9 to 12 patients per day, with 12 the upper limit, and accept no less than $200,000 yearly salary if its 9 patients a day straight out of residency. No more than 2 admits a day, the others are follow ups. This would be at a typical county hospital. If anybody is willing to work more than that for less money, I think they are getting ripped off. As a psychiatrist you have value, leverage from your skills to get paid, and relative rarity as a professional. Don't forget that. As long as you are geographically flexible you can do very well.
You might decide to give an employer a deal if you really like the location and other opportunities, like time to teach or do research, etc if you want.

If you want to do private practice you can make a lot more money with more work. You may also work as an independent contractor for a hospital, and make more or less doing that.

 

[vistaril]

As an employee psychiatrist, I will see 9 to 12 patients per day, with 12 the upper limit, and accept no less than $200,000 yearly salary if its 9 patients a day straight out of residency. No more than 2 admits a day, the others are follow ups. This would be at a typical county hospital. If anybody is willing to work more than that for less money, I think they are getting ripped off. As a psychiatrist you have value, leverage from your skills to get paid, and relative rarity as a professional. Don't forget that. As long as you are geographically flexible you can do very well.
You might decide to give an employer a deal if you really like the location and other opportunities, like time to teach or do research, etc if you want.

If you want to do private practice you can make a lot more money with more work. You may also work as an independent contractor for a hospital, and make more or less doing that.

I think the key is being geographically flexible. Many of us simply don't have that option for various reasons. Seeing 9 inpatients a day(and not having a ton of other responsibilities) for 200k salary would be a dream for me so unrealistic that I would be admitted to a psych hospital if I went there. My guess is that there are inpatient VA jobs that are sorta similar to that; at least I've heard of them. But the VA is not where many want to work for other reasons. I would *LOVE* for my area to have the sort of inpatient jobs which are becoming more popular now across the country and I interviewed at in some other states- basically you are salaried and see 15-18 a day inpatients and make about 220k base. That would be ideal beyond belief. The inpatient option here would be an inpatient/outpt hybrid that pays about 235k guaranteed for first year(then you have to meet certain collection numbers to get that) and you would be expected to see about 20 inpatients in the morning then a full outpt case load after 1130 am or so. You aren't working for the hospital really but for a large group that has an exclusive contract with the hospital systems. I wasn't interested in that......

But geography is the key. If you go to an area where you have some leverage, you can do soooooo much better.

 

[OldPsychDoc]

20 a day, with PA. Approx. $250k.

 

[Merovinge]

Not sure if Child inpatient numbers help but I've been hearing roughly 250k$ for 17 pt cap/day, fairly high turnover acute care stay.

 

[wolfvgang22]

I might take less money if I have mid levels, or residents do a lot of the scut work in exchange for education.
Geography is not the only thing that matters, negotiation skill also matters. A good psychiatrist is a superior negotiator.

 

[Armadillos]

20 a day, with PA. Approx. $250k.

In this sort of setup what's the split of the day to day work and documentation like between the attending and PA?

 

[vistaril]

I might take less money if I have mid levels, or residents do a lot of the scut work in exchange for education.
Geography is not the only thing that matters, negotiation skill also matters. A good psychiatrist is a superior negotiator.

The contracts(and who owns the contracts and for how much longer) in many areas are what they are. I've managed to obtain a better setup than some in my situation here have due to hard work and creativity.....but that only goes so far. I think over time I will be able to carve things out a little better with those same things. But if I was a hundred fifty or so miles north of here I would be in a setup 3x as good with little effort.

 

[OldPsychDoc]

In this sort of setup what's the split of the day to day work and documentation like between the attending and PA?

Responsible for 10 each, but attending sees all admissions and discharges, (or a day with more complicated work in which he's involved--e.g. family meeting, change in status, etc. on PA's pts.) Attending cosigns note if that's done by PA on pts he sees, but the PA usually sees & documents independently on their subsequent day visits.

 

[vistaril]

Another issue(which may not be relevant for many now depending on where you live but things could change) is hospital systems that have the following setup: inpatient unit grants exclusive(or puts in rules to make it exclusive even if it isnt explicitly so) priv to one particular psychiatric group. Within that contract between the hospital system and the group, they can bill their own codes and the hospital system doesn't get a dime of the collections. However, they have to see the uninsured inpatients amongst their group as well. Whether or not there is a stipend or not for this service would depend on the percentage of the uninsured patients there. But again, if the balks the hospital can always threaten to give the contract to someone else.

Sounds fair right? No salary of any kind but the individual psychiatrists can bill themselves and eat what they kill. But wait......

it's fair if you have an ownership stake of the group, but what if you don't? Then you are effectively blocked out of that hospital as either a provider who can bill independently or a potential employee of the hospital system. So what do you do if you want to work community inpatient? Well the only solution is to go to the group that has the inpatient contracts and ask to work for them....not the hospital system.

That's the community inpatient setup in two places I've lived. You have no leverage as a wannabe inpatient psych doc. It would be far more advantageous to be in a setting where there is no eat what you kill contract awarded to a big group because then you could at least have a salaried position at the hospital(which from the numbers Ive seen is much better in terms of patient load than the salaried positions working for the people who have the contracts from the hospital).

Of course another possibility is to get the damn contract yourself.....but we are talking about hundreds of beds across multiple units. That's not the sort of thing one fairly new grad(or even a couple providers) can just pull off quickly.

I would not be surprised to see this happening more across the country as we move forward.

 

[vistaril]

Over in the anesthesia forum you will see this same thing has been going on for awhile. Bigger dollar amounts of course across the board for everyone, but same principle.

 

[LisaLou]

A better question you could ask(if you are talking about salaried inpatient jobs) is: What is a reasonable inpatient case load for a inpatient job that pays X and expects Y turnover? Then we could actually look at what the revenue projections would be based on codes and get some idea of how that would translate to a salary. Because salary and the number of inpatient codes you generate are related in such a way that it is possible to guess at one when the other is unknown.

Perhaps I have still not explained myself well. Yes, of course at some level salary is tied to case load, but I am focusing on quality of care. If I am caring for one inpatient in the course of my eight hour day, the quality of care will presumably be superb. If I am caring for three hundred inpatients in the course of my eight hour day, that is clearly an unacceptable quality of care. There is some point at which the number of patients cared for in a typical workday would be considered unreasonable due to the quality of care that could be rendered. It is this concept that I'm seeking some sort of ethical standard or objective data for. I'm actually pretty surprised that with all the hospital regulations (JCAHO etc.) that there is not some sort of "cap" in existence. If you wanted to look at the financial aspect, even some cost-effectiveness analysis would be helpful (which I know has been done for nurse to patient ratios).

 

[vistaril]

Perhaps I have still not explained myself well. Yes, of course at some level salary is tied to case load, but I am focusing on quality of care. If I am caring for one inpatient in the course of my eight hour day, the quality of care will presumably be superb. If I am caring for three hundred inpatients in the course of my eight hour day, that is clearly an unacceptable quality of care. There is some point at which the number of patients cared for in a typical workday would be considered unreasonable due to the quality of care that could be rendered. It is this concept that I'm seeking some sort of ethical standard or objective data for. I'm actually pretty surprised that with all the hospital regulations (JCAHO etc.) that there is not some sort of "cap" in existence. If you wanted to look at the financial aspect, even some cost-effectiveness analysis would be helpful (which I know has been done for nurse to patient ratios).

here is what you wrote though: "However, hospitals are naturally interested in maintaining their financial health, and so will often push for providers to see more patients"

by writing this, you act as if there is some set reasonable salary for the job title of inpatient psychiatrist, and that hospitals are trying to toy with this in some ways to maximize their own profits. Hospitals simply want their providers(be they psychiatrists or whatever) to make more money in collections than the total cost of their employment. Period. Yes I know there are sometimes addl issues such as generating ancillary revenue and the like, but let's just keep things simple. So an inpatient psychiatrist isn't 'worth' anything.....it just depends on what revenue they generate for their employer.

As for these safety issues...I've met psychs who can safely see 45 a day, and I've met psychs who can't see 10 a day safely. It's so variable between psychs as for any average to be meaningless imo.

 

[LisaLou]

here is what you wrote though: "However, hospitals are naturally interested in maintaining their financial health, and so will often push for providers to see more patients"

by writing this, you act as if there is some set reasonable salary for the job title of inpatient psychiatrist, and that hospitals are trying to toy with this in some ways to maximize their own profits. Hospitals simply want their providers(be they psychiatrists or whatever) to make more money in collections than the total cost of their employment. Period. Yes I know there are sometimes addl issues such as generating ancillary revenue and the like, but let's just keep things simple. So an inpatient psychiatrist isn't 'worth' anything.....it just depends on what revenue they generate for their employer.

Reading back through, I can see how it would be confusing. However, this hospital's patient population is largely non-revenue-generating. The hospital is funded by the state. I doubt any psychiatrist in existence could see enough patients here to generate the revenue to cover his/her salary. So when we look at what is a reasonable caseload it really is more a matter of how many patients can a psychiatrist care for while still providing good care. It certainly varies widely and is difficult to answer, and looking at it from a perspective of how many patients would you need to see IF you were billing for all or most of them may be one way of determining this. Of course, this comparison is further complicated by the fact that the patient population is quite different from a typical acute care facility. Also, when I mentioned that hospitals may push providers to see more patients for financial reasons, in this scenario the benefit to the hospital's financial health would be by hiring fewer providers to see the set number of patients in the facility rather than by generating more revenue.

 

[vistaril]

Reading back through, I can see how it would be confusing. However, this hospital's patient population is largely non-revenue-generating. The hospital is funded by the state. I doubt any psychiatrist in existence could see enough patients here to generate the revenue to cover his/her salary. So when we look at what is a reasonable caseload it really is more a matter of how many patients can a psychiatrist care for while still providing good care. It certainly varies widely and is difficult to answer, and looking at it from a perspective of how many patients would you need to see IF you were billing for all or most of them may be one way of determining this. Of course, this comparison is further complicated by the fact that the patient population is quite different from a typical acute care facility. Also, when I mentioned that hospitals may push providers to see more patients for financial reasons, in this scenario the benefit to the hospital's financial health would be by hiring fewer providers to see the set number of patients in the facility rather than by generating more revenue.

oh ok gotcha. Well in cases like this, I think it's important to remember that tax dollars and funding is EXTREMELY LIMITED and must be treated as sacred. So I'm not sure that in a situation where money is being confiscated from us against our will that the main issue should be 'good care'. IMO, we should instead look at it like 'something is better than nothing' and that any funding is a plus for our mental health system. IOW, you take the money you happen to get and be thankful for it and deliver the care that you can with that money....however little it is. Not determine a figure needed for 'good care' and then just confiscate whatever that amount is.

You can probably tell I am not a fan of big govt 🙂

 

[Bartelby]

IMO, we should instead look at it like 'something is better than nothing' and that any funding is a plus for our mental health system. IOW, you take the money you happen to get and be thankful for it and deliver the care that you can with that money....however little it is. Not determine a figure needed for 'good care' and then just confiscate whatever that amount is.

Except you need to meet the community's standard of care. Deciding that you are going to gratefully provide substandard care for, say, 40 inpatients per day leaves you in the position to be personally responsible for the adverse outcomes that result from practicing in that way.

 

[vistaril]

Except you need to meet the community's standard of care. Deciding that you are going to gratefully provide substandard care for, say, 40 inpatients per day leaves you in the position to be personally responsible for the adverse outcomes that result from practicing in that way.

yep....and if one doesn't think they can do it, they shouldn't take the job. The solution isn't to hold taxpayers hostage for more money to satisfy some standard of care for uninsured.

I personally think(especially if I had a psych np working with me and good support system and good emr) that I could do 30-35pretty easily safely....if I didnt have outpt responsibilities of course. I know a few psychs who are more efficient than me though and still maintain standard of care, and I know a lot who aren't as efficient and would struggle with those numbers.