Patient Scheduling

[psychdesoleil]

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Hi all, I wanted to check in with others about how many patients you are seeing a day and how your schedule looked when you started your job. 3 days a week I work at a CMHC seeing 21 patients a day, which is brutal but I make it work because this is how its always been done here. I work one day a week each at hospital satellite clinics which is a new thing for the hospital. I have 20 minute follow ups and 40 minute intakes. My schedule has been completely packed with new patients. There is no template so they put anybody in any open spot. I explained that I am only there one day a week and I can only accommodate a certain amount of patients overall in order to be able to see them often enough. My supervisor, who is not a doctor, said that "you can't expect to be paid for doing nothing" (I'm salaried) and that they are going to continue to put new patients in any open spots. He also pointed out that they don't make any money when new people no show, which they do a lot. I explained that I have no control over that. He said I should be seeing patients for 15 minutes. He said that they are allowing me 20 minutes "because you are new." I then said that I think that 15 minutes is really pushing it for a follow up and that 7 or 8 new patients a day results in too much documentation and inability to obtain records, do paperwork, etc.. in a timely fashion, to which he replied "that's the doctor's life, nobody is paying for documentation." He said the allotted appointment time includes documentation. He said no psychiatrist could survive in private practice seeing 4 new patients a day + follow ups and that all new doctors are seeing a full day of intakes. Am I crazy? I'm thinking this is not the place for me

 

[sunlioness]

Give notice now.

That is ****ing bull****.


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[vistaril]

Hi all, I wanted to check in with others about how many patients you are seeing a day and how your schedule looked when you started your job. 3 days a week I work at a CMHC seeing 21 patients a day, which is brutal but I make it work because this is how its always been done here. I work one day a week each at hospital satellite clinics which is a new thing for the hospital. I have 20 minute follow ups and 40 minute intakes. My schedule has been completely packed with new patients. There is no template so they put anybody in any open spot. I explained that I am only there one day a week and I can only accommodate a certain amount of patients overall in order to be able to see them often enough. My supervisor, who is not a doctor, said that "you can't expect to be paid for doing nothing" (I'm salaried) and that they are going to continue to put new patients in any open spots. He also pointed out that they don't make any money when new people no show, which they do a lot. I explained that I have no control over that. He said I should be seeing patients for 15 minutes. He said that they are allowing me 20 minutes "because you are new." I then said that I think that 15 minutes is really pushing it for a follow up and that 7 or 8 new patients a day results in too much documentation and inability to obtain records, do paperwork, etc.. in a timely fashion, to which he replied "that's the doctor's life, nobody is paying for documentation." He said the allotted appointment time includes documentation. He said no psychiatrist could survive in private practice seeing 4 new patients a day + follow ups and that all new doctors are seeing a full day of intakes. Am I crazy? I'm thinking this is not the place for me

Im confused....what is the problem here?

your cmhc is probably billing medicaid mostly(and then probably getting a little grant money for a few uninsured smi pts). You are seeing 3 followups(AT MOST!) per hour. So the only revenue they are generating from you is 3 99214's perhaps. The medicaid reimbursement for that, if everything goes smoothly and every patient shows up, is going to be about 180 dollars or so for that hour. It is a similar situation at the other clinics.

Now how much are you getting paid per hour? I bet if you are a contract employee with no benefits, you are getting at least 135 an hour. But if you are salaried with benefits, I bet you are getting at least 100 dollars an hour(in terms of what you see in your before taxes paycheck) but I bet in that case your real/total compensation counting benefits and everything would come to about 135 an hour.

So do you see what kind of margins you are working with there from the clinics perspective?

So of course they are going to put patients in OPEN SLOTS. The only way they can pay you what they do is if your schedule is filled. They can't pay you at the rate of > 100/hr for you to do paperwork and write notes and do other things that doesn't lead to any additional reimbursement. Are you willing to give up 1-2 'paid' hours per day to shift it from clinical to non-clinical/'you' time? If not, then stop complaining.

Or go work for the VA. Because I can guarantee you with the margins on private practive outpt jobs and cmhc outpt jobs, they don't have margins to pay you a couple hundred dollars a day for some down time to document and stuff. Document whenever you have a cancellation or no show. Because outside of the VA(or maybe some academic jobs or state jobs...I dunno), you are going to be expected to be seeing patients for all of your paid time. And seeing them efficiently.

Now if you don't want all that time to be paid, then discuss it with them. But thats a you problem, not their problem.

 

[hamstergang]

Im confused....what is the problem here?

your cmhc is probably billing medicaid mostly(and then probably getting a little grant money for a few uninsured smi pts). You are seeing 3 followups(AT MOST!) per hour. So the only revenue they are generating from you is 3 99214's perhaps. The medicaid reimbursement for that, if everything goes smoothly and every patient shows up, is going to be about 180 dollars or so for that hour. It is a similar situation at the other clinics.

Now how much are you getting paid per hour? I bet if you are a contract employee with no benefits, you are getting at least 135 an hour. But if you are salaried with benefits, I bet you are getting at least 100 dollars an hour(in terms of what you see in your before taxes paycheck) but I bet in that case your real/total compensation counting benefits and everything would come to about 135 an hour.

So do you see what kind of margins you are working with there from the clinics perspective?

So of course they are going to put patients in OPEN SLOTS. The only way they can pay you what they do is if your schedule is filled. They can't pay you at the rate of > 100/hr for you to do paperwork and write notes and do other things that doesn't lead to any additional reimbursement. Are you willing to give up 1-2 'paid' hours per day to shift it from clinical to non-clinical/'you' time? If not, then stop complaining.

Or go work for the VA. Because I can guarantee you with the margins on private practive outpt jobs and cmhc outpt jobs, they don't have margins to pay you a couple hundred dollars a day for some down time to document and stuff. Document whenever you have a cancellation or no show. Because outside of the VA(or maybe some academic jobs or state jobs...I dunno), you are going to be expected to be seeing patients for all of your paid time. And seeing them efficiently.

Now if you don't want all that time to be paid, then discuss it with them. But thats a you problem, not their problem.

You always seem to have such a simplistic view of these things that you end up wrong, essentially. I'm now signing with an outpatient job that's 40 hours a week, not all of which as spent seeing patients. Intakes are 90 minutes and follow ups 30 minutes. Pay comestubs out to about $100 per hour of working time, plus benefits on top of that. Such jobs are possible and exist.

How could this be with your math? The psych department may not make much money and the hospital system as a whole supports it. They may receive grants to provide care. They may not force me to see more patients as they want me to actually provide good care and not give the place a bad name. Or maybe something else -- all I can be sure of is that this is more complicated than you make it sound.

 

[vistaril]

You always seem to have such a simplistic view of these things that you end up wrong, essentially. I'm now signing with an outpatient job that's 40 hours a week, not all of which as spent seeing patients. Intakes are 90 minutes and follow ups 30 minutes. Pay comestubs out to about $100 per hour of working time, plus benefits on top of that. Such jobs are possible and exist.

How could this be with your math? The psych department may not make much money and the hospital system as a whole supports it. They may receive grants to provide care. They may not force me to see more patients as they want me to actually provide good care and not give the place a bad name. Or maybe something else -- all I can be sure of is that this is more complicated than you make it sound.

we'll see....if your job is a private outpt job(you didnt mention whether it was) that pays over 200k and you will only be expected to see what....8-9 or so patients per day with a mix of intakes and f/us and all this 'not seeing patient' time, then you are right the numbers don't add up and because of that I would be suspicious of what it will really be. Because the reality is that most private businesses aren't in business to lose money.

I'm still waiting for a very wealthy individual to open up a private group and employ me as a psychiatrist at a handsome wage to see just a few patients per day and lose money for him......fingers crossed.

 

[Ψ-117]

He said no psychiatrist could survive in private practice seeing 4 new patients a day + follow ups and that all new doctors are seeing a full day of intakes.

I can believe that a new doctor getting started on their own in private practice would only have intakes for a while, until the practice is more established and the schedule begins filling with follow up appointments. But I personally haven't yet heard of a situation (until now) in which a psychiatrist in an established practice is seeing more than four intakes per day on a consistent basis, plus a bunch of follow ups. I know that some employers are fairly flexible and will allow you to see patients at your own pace but there are incentives added to your salary for more production. One that I've talked with recently said that most of their doctors do intakes in 1 hour and follow ups in 15-30 minutes, and complicated patients can be scheduled for more time if needed.

 

[wolfvgang22]

My advice: ignore Vistaril. Find another job yesterday. You are being abused.

 

[vistaril]

My advice: ignore Vistaril. Find another job yesterday. You are being abused.

dude you work at the VA. If you ever leave the VA and go out there in the private world(not just see job offers listed/posted but actually take one and work it for awhile), then you are in a better spot to comment on whether or not the OP is being abused.

 

[vistaril]

I can believe that a new doctor getting started on their own in private practice would only have intakes for a while, until the practice is more established and the schedule begins filling with follow up appointments. But I personally haven't yet heard of a situation (until now) in which a psychiatrist in an established practice is seeing more than four intakes per day on a consistent basis, plus a bunch of follow ups. I know that some employers are fairly flexible and will allow you to see patients at your own pace but there are incentives added to your salary for more production. One that I've talked with recently said that most of their doctors do intakes in 1 hour and follow ups in 15-30 minutes, and complicated patients can be scheduled for more time if needed.

depends on how many 'a bunch' of followups is. If you are seeing 4 intakes and 12 followups and both have low overhead and very efficient collections with decent payer sources then yeah that is doable I suppose.

It really just depends how much you want to make. If you want to both be an employed/salaried person and make X, then you better expect to provide clinical services where your employer collects X + overhead + something from your clinical services. The numbers are going to be a little different depending on a few things, but the concept is very simple. Again, this is for the real world(not govt jobs or VA jobs or whatever.....where salary and revenue are obviously not connected in any meaningful way).

 

[Guyton]

I have 20 minute follow ups and 40 minute intakes.

Get out or demand an appropriate standard of care.

 

[sunlioness]

Hey Vistaril, you know what my before taxes hourly rate is working in a CMHC seeing four patients an hour with no control over my schedule?

I calculated it out once. $80.

Eighty freaking dollars an hour. (And I rounded up to the nearest 10)

You know what else? I don't care if it were $200 an hour. It's MISERABLE.

We're doctors. We're a valuable resource. There are plenty of other things we could be doing besides being exploited by some suit who probably drives a Lexus and cares more about our productivity than our happiness or the health of our patients.

QUIT.


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[sunlioness]

dude you work at the VA. If you ever leave the VA and go out there in the private world(not just see job offers listed/posted but actually take one and work it for awhile), then you are in a better spot to comment on whether or not the OP is being abused.

I have.

They're being abused.

 

[Shikima]

I work at a VA now still teaching and staffing Fellow clinics and I'm earning $87/hour.

 

[Guyton]

When I started my gig at the CMHC they tried scheduling 20 patients a day. Uhm... nope. I saw 8 patients today and I am done. You are the physician. If you don't want to stand up for yourself, do it for your patients.

 

[daru1]

I guess that's the issue that vistaril isn't picking up on, there are certain minimal standards that each of us have set for good psychiatric care. Most don't want to bemoan that personal standard, for if this becomes a mass movement, we all get screwed. In this case, if this psychiatrist were to allow this to happen, what's to say they won't ask for 15 minutes for f/u and 30 minutes for new patients (when I worked at a CMHC, this is what the asked of me on the day that I quit). Collectively, we shouldn't be allowing this type of practice, nor should we encouraging others that believe that it is below their personal standard to "take it," so to speak.

 

[smalltownpsych]

Hi all, I wanted to check in with others about how many patients you are seeing a day and how your schedule looked when you started your job. 3 days a week I work at a CMHC seeing 21 patients a day, which is brutal but I make it work because this is how its always been done here. I work one day a week each at hospital satellite clinics which is a new thing for the hospital. I have 20 minute follow ups and 40 minute intakes. My schedule has been completely packed with new patients. There is no template so they put anybody in any open spot. I explained that I am only there one day a week and I can only accommodate a certain amount of patients overall in order to be able to see them often enough. My supervisor, who is not a doctor, said that "you can't expect to be paid for doing nothing" (I'm salaried) and that they are going to continue to put new patients in any open spots. He also pointed out that they don't make any money when new people no show, which they do a lot. I explained that I have no control over that. He said I should be seeing patients for 15 minutes. He said that they are allowing me 20 minutes "because you are new." I then said that I think that 15 minutes is really pushing it for a follow up and that 7 or 8 new patients a day results in too much documentation and inability to obtain records, do paperwork, etc.. in a timely fashion, to which he replied "that's the doctor's life, nobody is paying for documentation." He said the allotted appointment time includes documentation. He said no psychiatrist could survive in private practice seeing 4 new patients a day + follow ups and that all new doctors are seeing a full day of intakes. Am I crazy? I'm thinking this is not the place for me

That system is designed to provide substandard care. I wouldn't work for them unless they put me in charge of designing a functional system.

 

[Doctor Bagel]

So I had a parttime community job where I had 90 minute intakes (2 a day) + 30 minute follow ups. The expectation was down the road that I would do maybe one hour of my day with 20 minute follow ups and the rest 30 minute follow ups. I'd also have 30 minutes of straight documentation time. If my schedule were full and everyone showed up, which was rare, I'd see maybe 13 patients a day. This was for $100/hour plus benefits, including PTO. This was what I made without asking for me (I discovered later they probably would have paid me a bit more had I asked). Not a great job for all sorts of reasons but certainly not a job where 15 minute follow ups were the expectation. And yeah, they said they lost money on me, but they needed me to keep all their programs going because they were promising psychiatric care with their contracts. So they were making money somewhere even when they were losing it with physicians.

I guess what I'm saying then is don't listen to vistaril here unless he is indeed in the worst market for psychiatrists in the country. You can quit and find something better.

 

[nexus73]

The demands at both places sound difficult. I hope you're being paid well. Whoever is making demands at the hospital clinic sounds like they are trying to make the numbers look good for their own ambitions, e.g. If I run a profitable psychiatry clinic I'll get my performance bonus, and if I keep it up year over year I'll get promoted to manage multiple clinics, or one day I'll be the outpatient manager overseeing all of outpatient medicine at the hospital. They're not looking out for you.

 

[keifernny2]

Vote with your feet. (Or even just threatening to sometimes works).


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[vistaril]

I have.

They're being abused.

Yes, and it appears that in two of those non-govt/non-academic positions you....

1) were in your own private practice and saw up close the cold realities of running a business(what the reimbursement rate actually is per patient, what the collection rate is, etc)
2) were in the cmhc you describe above which seems an *even worse*(much worse actually) position than the OP's situation

So I would say, based on what you have shared about some of your experiences, that the OP(assuming he is making about 100 bucks an hour or more if no bennies) has a pretty good deal compared to some of the past situations you have described.

 

[vistaril]

I guess that's the issue that vistaril isn't picking up on, there are certain minimal standards that each of us have set for good psychiatric care. Most don't want to bemoan that personal standard, for if this becomes a mass movement, we all get screwed. In this case, if this psychiatrist were to allow this to happen, what's to say they won't ask for 15 minutes for f/u and 30 minutes for new patients (when I worked at a CMHC, this is what the asked of me on the day that I quit). Collectively, we shouldn't be allowing this type of practice, nor should we encouraging others that believe that it is below their personal standard to "take it," so to speak.

It's fine to feel that way....hell your own 'personal standard' for care can be to give the patient a 45 minute deep tissue massage after the apt for all I care. None of that changes the reality of what it is. Hell just in this thread we've seen more psychiatrists than not(even a few that have taken offense at my characterization here) basically say "yeah I worked a job like that(and some even worse!)" when I was in the community.......

But I'll play along.......if the 'standard of care' for all of us is/we should be be minimum 30 minutes for followups and we are using the same codes as outpt internists(who have a little higher overhead but more than make up for it with ancillary rev) and they are doing 10 minute followups, well......do the math.

 

[vistaril]

The demands at both places sound difficult. I hope you're being paid well. Whoever is making demands at the hospital clinic sounds like they are trying to make the numbers look good for their own ambitions, e.g. If I run a profitable psychiatry clinic I'll .

How dare he have such a goal! The audacity....to open a business and want the business to be profitable??!!??

 

[vistaril]

So I had a parttime community job where I had 90 minute intakes (2 a day) + 30 minute follow ups. The expectation was down the road that I would do maybe one hour of my day with 20 minute follow ups and the rest 30 minute follow ups. I'd also have 30 minutes of straight documentation time. If my schedule were full and everyone showed up, which was rare, I'd see maybe 13 patients a day. This was for $100/hour plus benefits, including PTO. This was what I made without asking for me (I discovered later they probably would have paid me a bit more had I asked). Not a great job for all sorts of reasons but certainly not a job where 15 minute follow ups were the expectation. And yeah, they said they lost money on me, but they needed me to keep all their programs going because they were promising psychiatric care with their contracts. So they were making money somewhere even when they were losing it with physicians.

I guess what I'm saying then is don't listen to vistaril here unless he is indeed in the worst market for psychiatrists in the country. You can quit and find something better.

this argument(that psychiatrists are loss leaders) seems to be a popular one for people who are somewhat aware of the numbers, and I'm not saying it doesn't happen occasionally, but it's not the norm.

 

[vistaril]

I work at a VA now still teaching and staffing Fellow clinics and I'm earning $87/hour.

ugh that sorta sucks....so your entire salary is like 175k?

 

[smalltownpsych]

All of the CMHCs will be run by midlevels before long. It's a race to the bottom. They already edged psychologists out of most of them a long time ago. First with LCSW then with LPCs. Soon it will be the just the nurses writing the scripts.

 

[Guyton]

All of the CMHCs will be run by midlevels before long

Yes, this has occurred with me in several of my contracts. When I left my most recent gig, I was replaced by a PA who is going to be supervised by a Family Practice doc- brilliant. The thing is, the medical directors usually call me three to six months later asking if I would come back after the mid-level has strung half the patient's out on stimulants and benzos. Then I ask for 20% more money and I go to work cleaning up the mess they created with their 15 minute schedule. I am not threatened by the flood of "advanced care providers" with their online degree and one thousand hours of clinical training. However, the patients are.

 

[MacDonaldTriad]

What Guyton says x 10.

This fear of mid-levels taking over is relative. Two thirds of psychotropic sales are written by family practice physicians who had a psych rotation as a medical student and a one month rotation on a psych service during training. Even more frightening is the fact that family medicine training and neurology training are the only two disciplines in medicine that require any psych training even if it is just a month. A few more mid-levels writing psychotropics poorly isn’t going to rock anybody’s world. There are already plenty of people doing it.

 

[smalltownpsych]

What Guyton says x 10.

This fear of mid-levels taking over is relative. Two thirds of psychotropic sales are written by family practice physicians who had a psych rotation as a medical student and a one month rotation on a psych service during training. Even more frightening is the fact that family medicine training and neurology training are the only two disciplines in medicine that require any psych training even if it is just a month. A few more mid-levels writing psychotropics poorly isn’t going to rock anybody’s world. There are already plenty of people doing it.

True about majority of medications being written by non-specialists, but I think you are missing the point about the CMHCs though. Right now I would think that the majority of those have psychiatrists and the majority of these patients are more complex and the family docs aren't wanting to treat them. I also completely agree with Guyton on this. I am not saying that the NPs and PAs are going to threaten the field of psychiatry, rather that it is a degradation of care for the more vulnerable patients and communities.

 

[splik]

What Guyton says x 10.

This fear of mid-levels taking over is relative. Two thirds of psychotropic sales are written by family practice physicians who had a psych rotation as a medical student and a one month rotation on a psych service during training. Even more frightening is the fact that family medicine training and neurology training are the only two disciplines in medicine that require any psych training even if it is just a month. A few more mid-levels writing psychotropics poorly isn’t going to rock anybody’s world. There are already plenty of people doing it.

family medicine does not require a psychiatry rotation - none of FM programs here have a mandatory psychiatry rotation. They have "behavioral medicine" and attend Balint group and the like but not psychiatry.

 

[Shikima]

ugh that sorta sucks....so your entire salary is like 175k?

It's a means to an end. Always work smarter, not harder.

 

[MacDonaldTriad]

Splik is right, but it makes my point. Small Town is also right, but not all public systems fail to recognize psychiatrists as a necessary quality assurance standard. Sometimes I think it is the for profit structures that compromise in this the fastest.

 

[WingedOx]

family medicine does not require a psychiatry rotation - none of FM programs here have a mandatory psychiatry rotation. They have "behavioral medicine" and attend Balint group and the like but not psychiatry.

How much exposure the FM residents get seems program dependent. We had FM residents floating around with us on the consult and inpatient (and they all seemed to really like the experience) but even then they weren't really being taught how to appropriately prescribe in the settings that they'll ultimately work in.

 

[MLT2MT2DO]

It's fine to feel that way....hell your own 'personal standard' for care can be to give the patient a 45 minute deep tissue massage after the apt for all I care. None of that changes the reality of what it is. Hell just in this thread we've seen more psychiatrists than not(even a few that have taken offense at my characterization here) basically say "yeah I worked a job like that(and some even worse!)" when I was in the community.......

But I'll play along.......if the 'standard of care' for all of us is/we should be be minimum 30 minutes for followups and we are using the same codes as outpt internists(who have a little higher overhead but more than make up for it with ancillary rev) and they are doing 10 minute followups, well......do the math.

Weren't you the same guy posting like a 18 months ago how you couldn't find appropriate employment since nobody would allow you to do 2 hour intakes?

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[Guyton]

... it is a degradation of care for the more vulnerable patients and communities.

That is what bothers me the most. CMHCs provide care for the most ill, yet often resort to staffing with the least qualified. However, I do not malign public systems. The shortcomings of many CMHCs is as much a failure of private system greed and social apathy toward the sick- especially the mentally ill . When the most educated and capable have the least incentive to provide complex care in clinically austere environments, the system cannot succeed in its mission. I see this in other areas of medicine as well. This failing is especially poignant in emergency medicine. Here you find the most highly trained physicians with a rolodex of specialists on call basically directing traffic in the level one trauma centers. Meanwhile, the rural community hospital emergency department is staffed with a physicians assistant and a CT machine that is only operational half the time.

A drastic reorganization of social priorities will be required to make a meaningful change in the delivery of healthcare. In the meantime, physicians are ill equipped to effect progress toward improved access, value, and quality of care. So, we do what we do. We care for people in the system we have, not the system we want. However, it is incumbent on physicians to also take care of ourselves. It is ironic that, as a profession, we are so good at taking care of our patients, yet suffer from alarmingly high levels of burnout across the board. Acquiescing to administration's demands for higher throughput is not going to alleviate the problem. We are obligated to collaborate with those decision makers, not collude. Physicians should know that high value care is not high profit care. Maybe some of us missed that in our training.

 

[smalltownpsych]

That is what bothers me the most. CMHCs provide care for the most ill, yet often resort to staffing with the least qualified. However, I do not malign public systems. The shortcomings of many CMHCs is as much a failure of private system greed and social apathy toward the sick- especially the mentally ill . When the most educated and capable have the least incentive to provide complex care in clinically austere environments, the system cannot succeed in its mission. I see this in other areas of medicine as well. This failing is especially poignant in emergency medicine. Here you find the most highly trained physicians with a rolodex of specialists on call basically directing traffic in the level one trauma centers. Meanwhile, the rural community hospital emergency department is staffed with a physicians assistant and a CT machine that is only operational half the time.

A drastic reorganization of social priorities will be required to make a meaningful change in the delivery of healthcare. In the meantime, physicians are ill equipped to effect progress toward improved access, value, and quality of care. So, we do what we do. We care for people in the system we have, not the system we want. However, it is incumbent on physicians to also take care of ourselves. It is ironic that, as a profession, we are so good at taking care of our patients, yet suffer from alarmingly high levels of burnout across the board. Acquiescing to administration's demands for higher throughput is not going to alleviate the problem. We are obligated to collaborate with those decision makers, not collude. Physicians should know that high value care is not high profit care. Maybe some of us missed that in our training.

Our rural facility is fortunate in that our ED is staffed by a rotation four EM docs and I think our CT works most of the time or at least I haven't heard too many complaints. We are a private non-profit and the board of directors includes the four members of the medical executive board so the physicians (and even one psychologist) get a bit of a say in how it is run. Meanwhile, our community mental health system is abysmal as it has been contracted out to a company located in another part of the state and they employ one PMHNP and one LPC in training who gets supervision from the remote location. I think they might have one or two case managers. This is to service a population of about 20k people. Base rates of the various mental illnesses gives a pretty good idea of how woefully inadequate that is. You are absolutely right in that it is more about what we incentify and how things are structured.

 

[Information Underload]

Im confused....what is the problem here?

your cmhc is probably billing medicaid mostly(and then probably getting a little grant money for a few uninsured smi pts). You are seeing 3 followups(AT MOST!) per hour. So the only revenue they are generating from you is 3 99214's perhaps. The medicaid reimbursement for that, if everything goes smoothly and every patient shows up, is going to be about 180 dollars or so for that hour. It is a similar situation at the other clinics. .

This depends on the state. There are states that reimburse much more competitively for level 4s--even more than Medicare and nearly double what you are quoting. Granted, that is still less than private insurance. And if you're confused about what the problem is in cranking out patients every 15-minutes, well, psychiatry has some quality-control issues.

I should also add that the 90833 has made the 30-40 minute follow-up much more economically viable.

 

[Guyton]

we are using the same codes as outpt internists

I am going to go beyond the obvious conflation fallacy in that statement and explain how an internist can see 10 patients an hour while maintaining an appropriate standard of care. When I see someone as an internist, I don't need 30 minutes to know whether their diabetes, hypertension, and hyperlipidemia are well controlled. I have easily obtained objective data to rely on. Furthermore, I am blessed with a depth and breadth of specialists and sub-specialists accepting and eager for referrals for that "zebra" that occasionally walks through the door. That is not the case with the depressed, anxious, insomniac with intractable back pain I see as a psychiatrist. To begin with, the more equivocal conditions prevalent in psychiatry take more time to evaluate. Then, once I have a grip on what the diagnosis is, I don't exactly have a host of "somatic symptom disorder with predominant pain" specialists one speed dial to refer to. Furthermore, if I am seeing the patient at the CMHC, it is often impossible to even get the patient in with primary care because they can't afford the copay, if they are lucky enough to be insured at all. And, if the patient is blessed with primary care access, I release them when they are stable and doing well to their PCP for follow-up so I can get to one of the multiple patients sitting in the state hospital waiting for discharge because they can't get an outpatient psychiatric appointment. IM and Psych are Apples and Oranges my friend.

 

[vistaril]

All of the CMHCs will be run by midlevels before long. It's a race to the bottom. They already edged psychologists out of most of them a long time ago. First with LCSW then with LPCs. Soon it will be the just the nurses writing the scripts.

bing ****ing o

 

[vistaril]

I am going to go beyond the obvious conflation fallacy in that statement and explain how an internist can see 10 patients an hour while maintaining an appropriate standard of care. When I see someone as an internist, I don't need 30 minutes to know whether their diabetes, hypertension, and hyperlipidemia are well controlled. I have easily obtained objective d
yoata to rely on. Furthermore, I am blessed with a depth and breadth of specialists and sub-specialists accepting and eager for referrals for that "zebra" that occasionally walks through the door. That is not the case with the depressed, anxious, insomniac with intractable back pain I see as a psychiatrist. To begin with, the more equivocal conditions prevalent in psychiatry take more time to evaluate. Then, once I have a grip on what the diagnosis is, I don't exactly have a host of "somatic symptom disorder with predominant pain" specialists one speed dial to refer to. Furthermore, if I am seeing the patient at the CMHC, it is often impossible to even get the patient in with primary care because they can't afford the copay, if they are lucky enough to be insured at all. And, if the patient is blessed with primary care access, I release them when they are stable and doing well to their PCP for follow-up so I can get to one of the multiple patients sitting in the state hospital waiting for discharge because they can't get an outpatient psychiatric appointment. IM and Psych are Apples and Oranges my friend.

you aren't getting what I am saying. I have *no interest* in having a debate whether psychiatrists need 1 minute, 5 minutes, 20 minutes, 30 minutes, or 3 hours per patient to do followups appropriately. That is a meaningless argument and I have little interest in it. Because whether or not one 'maintains appropriate standard of care' isn't the point in this thread. You guys are looking at it completely wrong. Maybe I feel that psychiatrists need a full damn hour for every followup. That doesn't matter.

 

[vistaril]

This depends on the state. There are states that reimburse much more competitively for level 4s--even more than Medicare and nearly double what you are quoting. Granted, that is still less than private insurance. And if you're confused about what the problem is in cranking out patients every 15-minutes, well, psychiatry has some quality-control issues.

I should also add that the 90833 has made the 30-40 minute follow-up much more economically viable.

I don't think a lot of you guys actually know what private insurance pays. I've worked post-residency in outpt settings in 2 different states and explored opportunities(enough to know what the major players there pay) in 4 others(in three different regions of the country), and while my current state does pay abysmally bad in terms of private insurers, most of the others pay pretty damn bad as well(sometimes there is one outlier plan that pays decently, but what % of your patients are going to be it usually).

Also keep in mind that 19 states in this country(out of 50) still have mental health carveout insurance payers in place to some degrees......and these almost always results in us collecting far less money than if not. Yes, it's supposedly against obamacare....many of the larger players in these states obviously know this and don't give a rip.

 

[dl2dp2]

Hi all, I wanted to check in with others about how many patients you are seeing a day and how your schedule looked when you started your job. 3 days a week I work at a CMHC seeing 21 patients a day, which is brutal but I make it work because this is how its always been done here. I work one day a week each at hospital satellite clinics which is a new thing for the hospital. I have 20 minute follow ups and 40 minute intakes. My schedule has been completely packed with new patients. There is no template so they put anybody in any open spot. I explained that I am only there one day a week and I can only accommodate a certain amount of patients overall in order to be able to see them often enough. My supervisor, who is not a doctor, said that "you can't expect to be paid for doing nothing" (I'm salaried) and that they are going to continue to put new patients in any open spots. He also pointed out that they don't make any money when new people no show, which they do a lot. I explained that I have no control over that. He said I should be seeing patients for 15 minutes. He said that they are allowing me 20 minutes "because you are new." I then said that I think that 15 minutes is really pushing it for a follow up and that 7 or 8 new patients a day results in too much documentation and inability to obtain records, do paperwork, etc.. in a timely fashion, to which he replied "that's the doctor's life, nobody is paying for documentation." He said the allotted appointment time includes documentation. He said no psychiatrist could survive in private practice seeing 4 new patients a day + follow ups and that all new doctors are seeing a full day of intakes. Am I crazy? I'm thinking this is not the place for me

Lol this thread.

You have either (1) Vis being all hey you don't make no $ stop whining or (2) everyone else telling you to quit ==> (3) bemoan the crisis state of the American public mental health system

Nobody has offer some concrete advice on how to deal with this situation when you don't want to get screwed and you don't want to quit.

Here is what I think you should do:
- clinical requirements proceed over everything else => do not schedule patients less frequently because it was demanded by the administration
- do not see patients who are not on your schedule, no exceptions
- do not follow patients who you don't know well
- do not see no shows, no exceptions
- clock in/ clock out
- do not directly confront administrators who are one level up
- work less, not more
- start showing up LATE to work and leave EARLY, especially on days when you are the only MD on site
- cancel clinic hours as frequently as possible
- reject patients from intake who are "too ill" for your clinic
- since you are paid a fixed salary, the less you work the more you get paid on a per hour basis
- patients who are not yours are not your liabilities
- it sounds like your medical director is not on your side, in this case, there's no use in continuing to act adversarial. meet with him as little as possible.
- tell the ANXILLARY staff that you are full, and cancel patients you've never seen before on your own if you need to. Medical director should not be involved in your daily patient scheduling. You are an ATTENDING MD.
- if your immediate supervisor gives you a bad performance evaluation, do nothing

This can last for a long time and you can basically start to cruise like this for years and they will never fire you. I would also obviously start exploring different opportunities in your community in the meantime. When the opportunity presents itself, you can then leverage for a higher salary.

Once you get used to this, you can strategize different things
- your "real" supervisor should not be a non-MD. for example, this discussion should be happening with the chair of psychiatry or service chief of psychiatry at the hospital, even though said person may have no involvement with this clinic whatsoever ===> THIS IS THE PERSON who you should building relationships. If and when you are looking for a new job, whose review weighs more? Some random non-MD who may quit in a few years anyway, or the Chief of Service at the hospital?
- likely the non-MD supervisor will leave before you do, if you follow my steps above
- in that case you can then take his job and make the clinic better
- however--> you will run into the issue posed by Vis, which is too little money for too many patients. Assuming however that you know what you are doing, you'll be able to leverage for block grants/other state/federal support, IF you are this type of "go-getter" person. This would involve a lot of "non-clinical" work, such as writing grants, meeting with "stakeholders", negotiating with Medicaid/other insurance, designing systems, hiring/firing, etc.
===> successfully converted a poor CHMC into a more functioning VA/Kaiser-esque system.

More likely than not, however, you would have easily found a half dozen better jobs by then and get a glowing letter from the Chief, even though you barely worked at the CHMC.

This is called "PASSING". It's in the Harvard Business Review. Look it up.
https://hbr.org/2015/04/why-some-men-pretend-to-work-80-hour-weeks

 

[dl2dp2]

I don't think a lot of you guys actually know what private insurance pays. I've worked post-residency in outpt settings in 2 different states and explored opportunities(enough to know what the major players there pay) in 4 others(in three different regions of the country), and while my current state does pay abysmally bad in terms of private insurers, most of the others pay pretty damn bad as well(sometimes there is one outlier plan that pays decently, but what % of your patients are going to be it usually).

Also keep in mind that 19 states in this country(out of 50) still have mental health carveout insurance payers in place to some degrees......and these almost always results in us collecting far less money than if not. Yes, it's supposedly against obamacare....many of the larger players in these states obviously know this and don't give a rip.

Absolutely right. Which is why 50% of private practice psychiatrists don't take insurance. At all. Period.

Although TO BE FAIR---with the add-ons, often the total $ paid back is really NOT bad, especially if you bill ~20 min f/u appts 99214+90833. The main issue with insurance taking is the astronomical overhead, not necessarily the reimbursement rates.

I also think that the "primary care" psychiatrist roles will go to midlevels at CHMC. Especially with all the mobile tech stuff, basically the typical CHMC patient will be in some form of umbrella/wraparound care that's handled by a specialized team. The MD will be the hired consultant/program manager and not use the typical billing codes and basically do table rounds on 1000 clinic patients and get paid out through a federal block grant system (i.e. "medical home"). That's my prediction.

If the Obama care model gets pushed to its bitter end, you basically have health insurance that looks very similar to car insurance. However, since different services cost differently, there will always be a mechanism for whoever wants to to pay for more expensive service. i.e. if you drive a cadillac, you'll pay for fixing it, even if your car insurance has a certain max coverage or high deductible. BUT, there might be additional business opportunities there, because MDs don't want to deal with working the system.

 

[vistaril]

Absolutely right. Which is why 50% of private practice psychiatrists don't take insurance. At all. Period.

And a lot of us arent interested in those sorts of setups. Yes I know thats a me problem and not a universal one, but I think it sucks.

 

[wolfvgang22]

The point of the whole thread is whether psychedesoleil should just take what he or she is getting, and if it is better elsewhere.
The answer is simple. Yes, there are better jobs elsewhere, and yes, you should move on. Just because it is common to get screwed doesn't mean you have to be. Don't settle for an abusive relationship, even if others do.

 

[dl2dp2]

The point of the whole thread is whether psychedesoleil should just take what he or she is getting, and if it is better elsewhere.
The answer is simple. Yes, there are better jobs elsewhere, and yes, you should move on. Just because it is common to get screwed doesn't mean you have to be. Don't settle for an abusive relationship, even if others do.

I don't entirely agree. People often FEEL that they are getting "screwed" but really it's just a reflection of the certain systemic issues. i.e. *everyone* is getting screwed. So you can either leave or you can try to change things because everyone else is equally dying for things to change. I don't think waiting for the right opportunity and developing the right relationship while working in a suboptimal context is necessarily "settling". It takes time to find a "good" job, and how do you cope with a "bad" one in the meanwhile? And how do you know for sure the next one is better? I'm not saying that there is only one answer. There are many other pathways than passing at a CHMC, but I don't think telling the OP "oh just leave" is helpful. He/she needs to know how to work less and not burn out while getting better evals and optimally position for the next job.

I know for a fact that you CAN run Medicaid based CHMC (in this case, for substance abuse, yeah try wrapping your head around that one) that's 1) profitable 2) good care. Several players in this space are getting huge and a few will possibly be going public in the next few years.

If you are built to be a community psychiatrist and want a "job", then yes, quit and find a better one. If you have ambition to make things better, I don't think it's impossible.

 

[wolfvgang22]

Lol this thread.

You have either (1) Vis being all hey you don't make no $ stop whining or (2) everyone else telling you to quit ==> (3) bemoan the crisis state of the American public mental health system

Nobody has offer some concrete advice on how to deal with this situation when you don't want to get screwed and you don't want to quit.

Here is what I think you should do:
- clinical requirements proceed over everything else => do not schedule patients less frequently because it was demanded by the administration
- do not see patients who are not on your schedule, no exceptions
- do not follow patients who you don't know well
- do not see no shows, no exceptions
- clock in/ clock out
- do not directly confront administrators who are one level up
- work less, not more
- start showing up LATE to work and leave EARLY, especially on days when you are the only MD on site
- cancel clinic hours as frequently as possible
- reject patients from intake who are "too ill" for your clinic
- since you are paid a fixed salary, the less you work the more you get paid on a per hour basis
- patients who are not yours are not your liabilities
- it sounds like your medical director is not on your side, in this case, there's no use in continuing to act adversarial. meet with him as little as possible.
- tell the ANXILLARY staff that you are full, and cancel patients you've never seen before on your own if you need to. Medical director should not be involved in your daily patient scheduling. You are an ATTENDING MD.
- if your immediate supervisor gives you a bad performance evaluation, do nothing

This can last for a long time and you can basically start to cruise like this for years and they will never fire you. I would also obviously start exploring different opportunities in your community in the meantime. When the opportunity presents itself, you can then leverage for a higher salary.

Once you get used to this, you can strategize different things
- your "real" supervisor should not be a non-MD. for example, this discussion should be happening with the chair of psychiatry or service chief of psychiatry at the hospital, even though said person may have no involvement with this clinic whatsoever ===> THIS IS THE PERSON who you should building relationships. If and when you are looking for a new job, whose review weighs more? Some random non-MD who may quit in a few years anyway, or the Chief of Service at the hospital?
- likely the non-MD supervisor will leave before you do, if you follow my steps above
- in that case you can then take his job and make the clinic better
- however--> you will run into the issue posed by Vis, which is too little money for too many patients. Assuming however that you know what you are doing, you'll be able to leverage for block grants/other state/federal support, IF you are this type of "go-getter" person. This would involve a lot of "non-clinical" work, such as writing grants, meeting with "stakeholders", negotiating with Medicaid/other insurance, designing systems, hiring/firing, etc.
===> successfully converted a poor CHMC into a more functioning VA/Kaiser-esque system.

More likely than not, however, you would have easily found a half dozen better jobs by then and get a glowing letter from the Chief, even though you barely worked at the CHMC.

This is called "PASSING". It's in the Harvard Business Review. Look it up.
https://hbr.org/2015/04/why-some-men-pretend-to-work-80-hour-weeks

Lol this thread.

You have either (1) Vis being all hey you don't make no $ stop whining or (2) everyone else telling you to quit ==> (3) bemoan the crisis state of the American public mental health system

Nobody has offer some concrete advice on how to deal with this situation when you don't want to get screwed and you don't want to quit.

Here is what I think you should do:
- clinical requirements proceed over everything else => do not schedule patients less frequently because it was demanded by the administration
- do not see patients who are not on your schedule, no exceptions
- do not follow patients who you don't know well
- do not see no shows, no exceptions
- clock in/ clock out
- do not directly confront administrators who are one level up
- work less, not more
- start showing up LATE to work and leave EARLY, especially on days when you are the only MD on site
- cancel clinic hours as frequently as possible
- reject patients from intake who are "too ill" for your clinic
- since you are paid a fixed salary, the less you work the more you get paid on a per hour basis
- patients who are not yours are not your liabilities
- it sounds like your medical director is not on your side, in this case, there's no use in continuing to act adversarial. meet with him as little as possible.
- tell the ANXILLARY staff that you are full, and cancel patients you've never seen before on your own if you need to. Medical director should not be involved in your daily patient scheduling. You are an ATTENDING MD.
- if your immediate supervisor gives you a bad performance evaluation, do nothing

This can last for a long time and you can basically start to cruise like this for years and they will never fire you. I would also obviously start exploring different opportunities in your community in the meantime. When the opportunity presents itself, you can then leverage for a higher salary.

Once you get used to this, you can strategize different things
- your "real" supervisor should not be a non-MD. for example, this discussion should be happening with the chair of psychiatry or service chief of psychiatry at the hospital, even though said person may have no involvement with this clinic whatsoever ===> THIS IS THE PERSON who you should building relationships. If and when you are looking for a new job, whose review weighs more? Some random non-MD who may quit in a few years anyway, or the Chief of Service at the hospital?
- likely the non-MD supervisor will leave before you do, if you follow my steps above
- in that case you can then take his job and make the clinic better
- however--> you will run into the issue posed by Vis, which is too little money for too many patients. Assuming however that you know what you are doing, you'll be able to leverage for block grants/other state/federal support, IF you are this type of "go-getter" person. This would involve a lot of "non-clinical" work, such as writing grants, meeting with "stakeholders", negotiating with Medicaid/other insurance, designing systems, hiring/firing, etc.
===> successfully converted a poor CHMC into a more functioning VA/Kaiser-esque system.

More likely than not, however, you would have easily found a half dozen better jobs by then and get a glowing letter from the Chief, even though you barely worked at the CHMC.

This is called "PASSING". It's in the Harvard Business Review. Look it up.
https://hbr.org/2015/04/why-some-men-pretend-to-work-80-hour-weeks

Dude...these are unwritten guerilla warfare rules, and you wrote them down... 🤣
Be prepared there is a small possibility of actually being fired if you do all of this, though. You have to not give a f*** to do some of this.

 

[dl2dp2]

And a lot of us arent interested in those sorts of setups. Yes I know thats a me problem and not a universal one, but I think it sucks.

You are being a bit too pessimistic. I don't think the low apparent reimbursement is necessarily an impediment for designing your perfect job, even if it's facility based. My impression vaguely being on the market is that larger treatment programs are aggressively negotiating with payors for specific segments of the market, using any and all tactics, including traditional advocacy/grass roots, and also patient based advocacy routes. So just like hospital billing and actual billing are totally different, apparent 99213 billing from your dinky little practice is different from that at a major medical center, or even a large group practice. When you have 1000 enrollees who are high utilizers on your roster, you bet your regional insurance manager will care if you call and threaten to drop them all and release them to the local Psych ED.

This has resulted in a very favorable facility (RVU) based environment. I had this experience where the recruiter asked me what's my expected salary range for a semi-academic job, and I quoted a number, and she called me back with a number that's 30-40% bigger--I basically didn't know what to do with it. And this is in a desirable part of the Northwest. I think another thread someone said anyone on the market should not do an RVU job with less than 275-300 expected FTE, and I think that's about right.

Private practice jobs are what you make of it. You could make > 500k, or work part time and make <100k. That's also been hashed over in the forum ad nausea.

 

[vistaril]

You are being a bit too pessimistic. I don't think the low apparent reimbursement is necessarily an impediment for designing your perfect job, even if it's facility based. My impression vaguely being on the market is that larger treatment programs are aggressively negotiating with payors for specific segments of the market, using any and all tactics, including traditional advocacy/grass roots, and also patient based advocacy routes. So just like hospital billing and actual billing are totally different, apparent 99213 billing from your dinky little practice is different from that at a major medical center, or even a large group practice. When you have 1000 enrollees who are high utilizers on your roster, you bet your regional insurance manager will care if you call and threaten to drop them all and release them to the local Psych ED.

This has resulted in a very favorable facility (RVU) based environment. I had this experience where the recruiter asked me what's my expected salary range for a semi-academic job, and I quoted a number, and she called me back with a number that's 30-40% bigger--I basically didn't know what to do with it. And this is in a desirable part of the Northwest. I think another thread someone said anyone on the market should not do an RVU job with less than 275-300 expected FTE, and I think that's about right.
.

I would take a FTE non-malignant job here that pays half of that with benefits.

 

[Shikima]

The point of the whole thread is whether psychedesoleil should just take what he or she is getting, and if it is better elsewhere.
The answer is simple. Yes, there are better jobs elsewhere, and yes, you should move on. Just because it is common to get screwed doesn't mean you have to be. Don't settle for an abusive relationship, even if others do.

We need a Co-dependency no more book for bad jobs.

 

[WingedOx]

We need a Co-dependency no more book for bad jobs.