ominous development going forward in psych market....

[vistaril]

As if our field(for us MDs) needs more bad news.

In my area I heard a hospital has shifted their contract to cover their inpatient units. Not a huge # of beds...we're talking average census of maybe high 20s. But since this hospital is close to where my son goes to elementary school and my house, I figured I would look into who has the new contract and who is covering it.

I actually know of the new np grad who is doing it, so I as her "who is this dr x that is signing your notes? I've never heard of him"

He's in freaking arizona or nevada(can't remember). She is there in person covering the unit in the morning- interviewing the patients, getting nursing report, writing the notes/orders, etc. Then he beams in from 2500-3000ish miles away on zoom for like 10 minutes around lunch with her to see the patients and supervise her work.

The np also only works m-f, so on the weekends his little zoom bit from thousands of miles away is the only provider the pts see.

Many hospitals are seeing that since things have evolved to have the psychiatrist fairly removed from the day to day work on many psych units, may as well just go one step further and open it up to telepsych inpatient coverage for the supervision part. Open up the bidding and that allows for lower and lower stipends....

The group out west that 'won' this contract was probably like "well the stipend is super low, but hell we'll pay an np 110k or so to be there everyday, have one of us zoom in over lunch for ten minutes, sign off and voila... "

So I looked into it more and it's going the other way here too....one of the groups here is covering an inpatient psych unit in Connecticut or rhode island I found out. Again same model- hire a local np to be there in person and do notes,orders, talk to nurses/patients and then just zoom in briefly at lunch or at the end of the day to 'see' the patients and sign the nps notes.

Unfortunately, I think this is only going to become more and more common since it is a way to drive down what it costs hospitals to staff a unit in more competition for the contracts, stipend......

I asked the np if she knew what stipend is attached to that unit and she threw out a number that made me sad and angry.......and even more pessimistic going forward.

---

Members don't see this ad.

 

[lejeunesage]

On the other hand, there are jobs like this: Medical Director of Behavioral Health at Talas Harbor at Kindred

This is the independent contract model you see with the largest inpatient rehab companies. If you find such a gig, take it. You get the stipend from the management company, easily 100K+ yearly. You send your billings directly to the insurance companies (through a billing company that takes a 6-7% cut), and you keep all your collections.

That can add up to a compensation package north of 400K.
You're welcome.

 

[calvnandhobbs68]

I think this is gonna be a big risk vs big reward type of situation though for these groups right now. They're heavily banking on the telemedicine regulations continuing to be as relaxed as they are right now. I think that's a big thing to be banking on. I highly suspect a lot of the telemedicine regulations once the public health emergency is declared over will start requiring some type of in person assessment frequency but who knows.

 

[psychacad]

I mentioned this in another thread. I've come across this kind of model in a state where NPs can practice independently. The pay for the MD supervisor is dismal, but it's "supposed" to be a handful of hours a week of rounding.

Any MD who's willing to take a job like that is asking for trouble. The liability here is huge.

I don't think the existence of these jobs prove anything. These places are mostly very desperate and understaffed and are looking for any MDs to take on liability that they can't find on site. If anything, it only illustrates that they cannot depend on NPs for care.

 

[vistaril]

I mentioned this in another thread. I've come across this kind of model in a state where NPs can practice independently. The pay for the MD supervisor is dismal, but it's "supposed" to be a handful of hours a week of rounding.

Any MD who's willing to take a job like that is asking for trouble. The liability here is huge.

I don't think the existence of these jobs prove anything. These places are mostly very desperate and understaffed and are looking for any MDs to take on liability that they can't find on site. If anything, it only illustrates that they cannot depend on NPs for care.

but this is/are states where NPs *cant* practice independently. Even in the states where they can't practice independently, lets not act like they arent
a huge problem. Unfortunately there are plenty of docs who are happy to 'just sign off' for what amounts to a tank of gas lol....

As for the second part of your post.....yeah, let's keep telling ourselves that. That should fix the problem

 

[vistaril]

I think this is gonna be a big risk vs big reward type of situation though for these groups right now. They're heavily banking on the telemedicine regulations continuing to be as relaxed as they are right now. I think that's a big thing to be banking on. I highly suspect a lot of the telemedicine regulations once the public health emergency is declared over will start requiring some type of in person assessment frequency but who knows.

The np is there in person now. But you bring up a good point- at some inpatient sites now it is *all* telepsych. Maybe one day a week in person with the np.

And this trend was happening *before* Covid. All for cost reasons. The idea that hospitals and the powers that be are going to just give up those cost savings and efficiencies because the pandemic is over is wishful thinking.

Things were bad enough before when we had to compete against all the sharks in our area for good contracts. Now we are literally competing against outfits 2500 miles away who are emailing hospital admins with suggestions on how to save them money and ease their coverage dilemnas....

And I know what they are doing...they are going on practicematch and sites like that and looking for where the salaried positions are posted. If someone say....45 minutes out of little rock, arkansas has an 18 bed unit that they are advertising on practice match for, the people reading that know they've had trouble filling it and they are sh****** themselves worried about how much it will cost to fill. Maybe have to even spend a bunch on locums worst case. But these sharks in other states figure they can hire a local psych np(growing on trees now everywhere btw) and just get one of their guys to get an arkansas license and voila.....make a pitch to the admins there on how you can make their life 10000x easier with respect to this problem and it's
win-win......

Who loses? The honest psych who lives in the little rock area and was just looking for fair pay and some sort of modesty rewarding practice setting......the ground was just pulled out from under him by an outfit who doesn't give a damn taking advantage of both zoom and the abundance of psych nps to blow him out of the water

 

[vistaril]

On the other hand, there are jobs like this: Medical Director of Behavioral Health at Talas Harbor at Kindred

This is the independent contract model you see with the largest inpatient rehab companies. If you find such a gig, take it. You get the stipend from the management company, easily 100K+ yearly. You send your billings directly to the insurance companies (through a billing company that takes a 6-7% cut), and you keep all your collections.

That can add up to a compensation package north of 400K.
You're welcome.

if the juice is really worth the squeeze with some of these arraingments(a big if), you can be sure that eventually(and by eventually I mean pretty damn soon) the shark groups will find out and undercut it. Then once have the contract with the facility it's just a matter of carving it up for the nps and finding someone in the group to sign off. You're welcome.

 

[lejeunesage]

if the juice is really worth the squeeze with some of these arraingments(a big if), you can be sure that eventually(and by eventually I mean pretty damn soon) the shark groups will find out and undercut it. Then once have the contract with the facility it's just a matter of carving it up for the nps and finding someone in the group to sign off. You're welcome.

It appears that pessimism is your coping mechanism. Very well, then. Suit yourself.

All I meant to show, drawing on what has worked for me, was that there are and will remain plenty of lucrative jobs available, especially if you're willing/able to relocate.

There will always be examples of arrangements that would be detrimental to you, should they become the norm.
But individual examples tell you nothing about what proportion of hospitals would choose the model you mentioned over the traditional, in-person, MD-led model.

"In my area, I heard a hospital" does not a pattern make. You've found 2 hospitals that use this NP + teleMD model. In other words, n=2.

How do you know that your sample is representative?
How do you know whether these hospitals prefer this model or were driven to it by necessity?
How do you know that there won't still be plenty of great opportunities for you when you graduate?

And even if the landscape is changing, wouldn't your energies be better spent trying to figure out how you can maximize your potential rather than lamenting things you can't control. The fact remains that there are well-paying jobs available, and this will continue to be the case for a long time to come. Perhaps you should reach out to the people offering such opportunities and ask what you should can be doing right now to look attractive to them?

 

[AD04]

Weren't you the same guy who kept posting you can't make much in psychiatry and now you're making decent money? There's always going to be employers who will go with the cheapest option. But there are also employers who will go with the quality option. You presented one case study. On the flip side, I specifically included a clause in my contract that I can refuse to supervise NPs. We don't have any NPs in my department. The medical director refuses to hire NPs due to bad experience in the past.

There are physicians out there who will underbid and take on less money and supervise NPs. That's fine. Because those type of employers who want cheap supervising physicians are not places you would want to work for in the first place. If you feel NPs are unstoppable and will be the new wave in the future, why not set up your own practice and start employing them yourself and profit from them?

 

[Sushirolls]

this.....

That said, as someone who has never been a solo practice owner for any extent, this thread has been depressing(but interesting). To see all this work put into it for so little money.

I'm pretty convinced that the only way to really make money in outpt psych in most places(especially places like here where the code reimbursements are so low) is to just hire psych nps and keep the delta as your profit. I know I could make money by paying psych nps 110k and making sure they are mostly booked with medicare patients. Get 3-4 of them use your collabs on them, and then keep the delta as your profit.....

It's not anyone's idea of a rewarding practice, but it's the best shot you have to make actual money I think.

Vistaril asserted this on the "practice in progress" thread back in May 2020. Perhaps its time Inpatient be added to his/her list of venues of how money is made in Psychiatry? No longer is it just outpatient, but now inpatient, too.

 

[Sushirolls]

if the juice is really worth the squeeze with some of these arraingments(a big if), you can be sure that eventually(and by eventually I mean pretty damn soon) the shark groups will find out and undercut it. Then once have the contract with the facility it's just a matter of carving it up for the nps and finding someone in the group to sign off. You're welcome.

Big Box shops, some of the insurance companies, and even academia now are on the fast track towards destroying medicine, but if we're lucky a two tier system will emerge to keep the old ways. I wish, hope that in coming years, the expanding use and embracing of midlevels will be deemed an industry disruption, a necessary change, like what Starlink will be for rural ISPs - where I am the narrow minded self interested road block to change who has enlightenment to this. But what I see routinely in my clinic is that its not the case. I almost have job security undoing the diagnostic or prescription messes that ARNPs have led their previous patients down. I've got letters recently from insurance companies that reflect their race to the bottom, to essentially make being paneled with them untenable. Patients will suffer most, then followed by physicians and their career options.

Cash only Psychiatry may be a lone sentry keeping the temple flame.

So Vistaril, do you plan to hold out or ride the slide to the chasm? What do you plan to do with your career?

 

[dl2dp2]

I asked the np if she knew what stipend is attached to that unit and she threw out a number that made me sad and angry.......and even more pessimistic going forward.

A couple of interesting vignettes, since we are sharing them today:

1. Was chatting with the owner of a for-profit inpatient site, and he told me that they are having a really hard time recruiting "medical directors" to sign NP charts and do things NPs can't legally do (i.e. involuntary paperwork, med over objection, etc). Instead of hiring independent inpatient staff MDs, they decided to hire NPs for a 50% haircut, but because they can't get a full-time medical director, they end up became profit-neutral because they have to pay more for 1099 medical directors. The productivity level of the NP is also lower, which causes slower turnover, which as I am sure you know is BAD for inpatient units bottom lines.

This conversation convinced me that it's NOT THAT EASY to replace staff MDs with NPs, telemedicine or not. This scenario is also happening at public/non-profit facilities, though not as dramatically since they often have salaried lined staff they can violate without immediate consequence.

2. NP + remote MD supervisor model seems to provide clearly inferior care, not the least of which is because the MD supervisor tends to be a bottom barrel candidate as you said. The owner mentioned to me also that they are having problems with ordinances from regulators (i.e. JACHO, etc) for very basic quality metrics. These are not sophisticated things: we are talking seeing the patient X hours after admission, not having > 2 antipsychotics, etc. The NPs just don't have very good work ethic.

3. Telemedicine is presenting UNIQUE opportunities. Because of certain things I read on this board I recently increased my fees and am now being paid an amount that I don't even believe that I could be paid for, all via video. I suspect in the medium term, high prestige psychiatrists will get paid even MORE in a more bifurcated market because a well-resourced national client/patient cohort will compete for a limited number of psychiatrists' hours. I also think a booming consulting practice model is on the offing--imagine if you are a "medical director" and have a reputation of turning around NP practices from unprofitable to profitable. I predict top psychiatry hourly comps for consulting, either clinical or administrative, will soon match or exceed that of a BIG LAW corporate lawyer ($2000+/billable hour).

 

[Sushirolls]

3. Telemedicine is presenting UNIQUE opportunities. Because of certain things I read on this board I recently increased my fees and am now being paid an amount that I don't even believe that I could be paid for, all via video. I suspect in the medium term, high prestige psychiatrists will get paid even MORE in a more bifurcated market because a well-resourced national client/patient cohort will compete for a limited number of psychiatrists' hours. I also think a booming consulting practice model is on the offing--imagine if you are a "medical director" and have a reputation of turning around NP practices from unprofitable to profitable. I predict top psychiatry hourly comps for consulting, either clinical or administrative, will soon match or exceed that of a BIG LAW corporate lawyer ($2000+/hour).

Except that Big Box shops are consolidating. There are like 3-4 main for profit psych/addiction hospitals. Perhaps you secret sauce one place as consultant, they then extrapolate that out all their others - not sustainable. One such company emerged because one doc was doing just that for another company. They continue to struggle with staffing too....

I've seen one non-profit health system pull in consultants, and they gave recommendations the hospital wanted to hear... not real solutions. And nothing changed, but the fees were high!

I don't see this as a viable niche.

 

[dl2dp2]

I've seen one non-profit health system pull in consultants, and they gave recommendations the hospital wanted to hear... not real solutions. And nothing changed, but the fees were high!

I don't see this as a viable niche.

Of course. I'm pulling this out of my ass... for now. My point is that there's a lot of money sloshing around in the system right now, most of which is not being captured by MDs. You need a degree of creativity to make it happen. I actually had an earlier conversation with CEO of an addiction chain about this type of model, and I'm convinced (especially coupled with my experience) that the well-off clients are more interested in the prestige and design of the program than the location of the clinicians. I.e. I can much more reasonably fabricate a for-profit voluntary inpatient facility by recruiting "the best of the best" clinicians to staff the program.

This is also likely the case for a variety of other things (i.e. IOPs, outpatient, etc). If I'm a banker's kid in Little Rock, I'd rather go see someone at McLean. Now I can!! With infinite money printing, there are way more bankers kids with bad BPD in Little Rock than psychiatrists at McLean, who are already full as is in hypersatured Boston market. What do you think will happen? They will charge more, of course. Which makes them seem even more desirable.

 

[Sushirolls]

Now this concept is more viable.

 

[dl2dp2]

Now this concept is more viable.

I also think this will trickle down to those of us who are not quite as "high prestige".

McLean charges $2000 an hour. The bankers kid sees someone at McLean. The doctor's kid in Boston who used to see the guy at McLean can't afford $2000 an hour, calls me, and I charge him $500 an hour. I used to only be able to charge $250 an hour cause everyone who lives around me are ... not doctors. The long-run effect of this telemedicine thing is quite unpredictable, IMO.

 

[Sushirolls]

But also furthers my proclamations of a two tiered system further developing. The cash market, and the Big Box shop market.

To further expand on your ideas, I predict one large academia in the coming years to differentiate themselves, to pivot, and fire all their midlevels. To then declare, 'we are physician only' and market the heck out of it. I believe Cleveland Clinic and Mayo Clinic could pull that off, but of the two, logistics in each community supports viability more with Mayo over Cleveland - but that's a longer story.

I would like to see a traditional academic center like the University of [pick one] do it, but I doubt they'll have the courage to do it. A private entity is more likely.

Some of the for profit DO schools that if they expanded into hospital acquistions, they might be able to pull it off.

 

[dl2dp2]

But also furthers my proclamations of a two tiered system further developing. The cash market, and the Big Box shop market.

To further expand on your ideas, I predict one large academia in the coming years to differentiate themselves, to pivot, and fire all their midlevels. To then declare, 'we are physician only' and market the heck out of it. I believe Cleveland Clinic and Mayo Clinic could pull that off, but of the two, logistics in each community supports viablity more with Mayo over Cleveland - but that's a longer story.

Yup!! 100% spot on.

 

[Candidate2017]

I actually know of the new np grad who is doing it, so I as her "who is this dr x that is signing your notes? I've never heard of him"

He's in freaking arizona or nevada(can't remember). She is there in person covering the unit in the morning- interviewing the patients, getting nursing report, writing the notes/orders, etc. Then he beams in from 2500-3000ish miles away on zoom for like 10 minutes around lunch with her to see the patients and supervise her work.

This sounds vaguely like residency if you replaced "NP grad" with "resident".

 

[hebel]

My place has trouble keeping the inpatient services staffed. They would love to use NPs to fill in the gaps, but with things like legals and court hearings they end up being more of a logistical pain than their worth (even to the bean counters). This may be specific to my state, however.

 

[Stagg737]

But also furthers my proclamations of a two tiered system further developing. The cash market, and the Big Box shop market.

To further expand on your ideas, I predict one large academia in the coming years to differentiate themselves, to pivot, and fire all their midlevels. To then declare, 'we are physician only' and market the heck out of it. I believe Cleveland Clinic and Mayo Clinic could pull that off, but of the two, logistics in each community supports viability more with Mayo over Cleveland - but that's a longer story.

I would like to see a traditional academic center like the University of [pick one] do it, but I doubt they'll have the courage to do it. A private entity is more likely.

Some of the for profit DO schools that if they expanded into hospital acquistions, they might be able to pull it off.

I doubt Mayo or CC would do this. Mayo is crawling with NPs and CC has a very "wholistic" approach in terms of staffing. I do think some private institutions with a little prestige that don't have NP programs associated like UChicago, Rice, or Emory could pull it off. I think the question is would they really want to make an enemy of the nursing lobby?

 

[PikminOC]

I mentioned this in another thread. I've come across this kind of model in a state where NPs can practice independently. The pay for the MD supervisor is dismal, but it's "supposed" to be a handful of hours a week of rounding.

Any MD who's willing to take a job like that is asking for trouble. The liability here is huge.

I don't think the existence of these jobs prove anything. These places are mostly very desperate and understaffed and are looking for any MDs to take on liability that they can't find on site. If anything, it only illustrates that they cannot depend on NPs for care.

Lots of older docs don't care about the liability