PP Urgent Cares

[Geodont]

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How come we don’t come across more urgent cares in private practice? Too much red tape? Too much overhead? Too few patients willing to pay cash to be methed out in a boutique psych ER?

 

[Bartelby]

My thought: these would be high liability, high stakes evaluations that reimburse less than follow ups. You could not easily control the volume, leaving you sitting around losing money much of the time and overwhelmed at other times. You would also likely need to place a lot of holds, which ERs can manage so much better than a freestanding psych urgent care. It just seems like it would pay less than standard PP while being more stressful.

 

[comp1]

Because you need an actual support system of some sort to manage acute (as opposed to chronic) psychiatric conditions. Also...most of these patients don't have insurance. It's literal adverse selection of your patient population.

 

[FlowRate]

While there's ample and appropriate debate as to how much medical workup should really be required to send a psych patient to an inpatient unit, it's really helpful to have medical services on site. For that reason and also because it's not uncommon for our patients to be sick or to occasionally even have a relevant medical differential. Also, treatment for serious suicide attempts that come in.

 

[calvnandhobbs68]

Urgent cares are predicated on the idea that most of what comes in will be stupid stuff you can see in 5-10 minutes that can be addressed with a short term prescription, very minor workup or reassurance, almost 100% of which could have just gone to their PCP anyway for a sick visit if they could or had a PCP.

That applies to almost nothing in psychiatry.

 

[Geodont]

Urgent cares are predicated on the idea that most of what comes in will be stupid stuff you can see in 5-10 minutes that can be addressed with a short term prescription, very minor workup or reassurance, almost 100% of which could have just gone to their PCP anyway for a sick visit if they could or had a PCP.

That applies to almost nothing in psychiatry.

The first part of what you’re saying is very true.
That said, the same concept of, “could have reached out to your psychiatrist, case manager, NP, counselor” applies to a lot of subthreshold symptomatic patients in psych ER settings too.

 

[dl2dp2]

How come we don’t come across more urgent cares in private practice? Too much red tape? Too much overhead? Too few patients willing to pay cash to be methed out in a boutique psych ER?

I see urgent cases in private practice all the time. Your basic assumptions aren't correct. I mean, I don't know why anyone would pay me a lot of money to see them if it isn't "urgent"...

 

[Geodont]

I see urgent cases in private practice all the time. Your basic assumptions aren't correct. I mean, I don't know why anyone would pay me a lot of money to see them if it isn't "urgent"...

I meant a psych ER or ER-like practice.

Obviously urgent matters are diffused in other settings too. Maybe a group that exclusively takes night, weekend, or vacation call for a multitude of solo or group practices is the closest variation on the theme, but very unlikely anyone would give away a slice of their PP pie like that.

 

[Sushirolls]

I suppose some doc who did C/L could possibly set up an UC clinic in the evening?

During the AM they do their niche of whatever they are trying to do as a strictly consult only practice, then keep doing the same in the evening, but with walk-ins? Made very clear from start it's a one time consult only. Be a way to generate recs to send off to PCP? Or at worst be glorified SW who helps triage patients to ideal services in the area?

 

[calvnandhobbs68]

The first part of what you’re saying is very true.
That said, the same concept of, “could have reached out to your psychiatrist, case manager, NP, counselor” applies to a lot of subthreshold symptomatic patients in psych ER settings too.

For urgent cares to be viable, they have to be busy with simple stuff that can get pushed through quickly. Again, this doesn't happen with psychiatry and would be extremely difficult to be cost effective. They don't get the revenue capture of ERs which basically charge you hundreds of dollars for just walking through the door and being in an "emergency" room.

 

[Stagg737]

That said, the same concept of, “could have reached out to your psychiatrist, case manager, NP, counselor” applies to a lot of subthreshold symptomatic patients in psych ER settings too.

Calvin has it right in the sense that the nature of what we treat is not conducive to the goals of "Urgent" treatment, which means something can be done RIGHT NOW in 10-15 minutes that can prevent a patient from needing an ER visit. No one is going to a psych UC clinic when they can call their doc, talk to them for 5 minutes and then be seen in the next few days. Conversely, if someone has a legit concern (SI with plan, I'm dizzy and I keep falling down, this rash keeps getting bigger, etc) they're either going to require a more thorough eval meaning a longer appointment, or require a medical eval which means sending them somewhere else (like an ER).

I'm curious as to what situations you think would warrant a psych UC clinic that couldn't be addressed by a triage RN/quick phone call or a more thorough eval in an ER. I can maybe think of a couple, but there's already a national crisis hotline that people call and get advice regarding "psych crises" for free. So how are you going to convince people to come in and pay for the same services?

 

[Sushirolls]

Ketamine?

 

[dl2dp2]

Psych ER typically lose money. When it doesn’t lose money, money is usually made via inpatient billing (ie nursing etc).

One might ask the same questions: why aren’t there group psych practices have contracts with hospitals that specifically cover inpatient units? Reason is that inpatient units are not wildly profitable, if at all—this is the same for IM, by the way, which is why very very few old school IM practices covering primary care and hospital care still exists. Prevailing model is hospital employed hospitalists. Same as hospital employed inpatient psychiatrists and CL. Facility based revenues are now very much consolidated and often receive monies from public sources.

In psychiatry, margin is all in the outpatient well-insured, especially in sub-sub-specialized services (similar to every other specialty in medicine). Many inpatient/ER work is chronically understaffed and paying pricy locums to fill gaps. You could think of these locum individuals as solo practices covering hospital work, which is actually exactly what they are. These jobs are so numerous and easy to get that there’s not substantial advantage for organizing a larger umbrella practice around it. But it is interesting that there’s no clearing house around that sort of has this Uber for psych ER/inpatient shift situation.

This is somewhat changing with large national tele chains like IRIS etc. The trend is moving toward tele coverage for inpatient/ ER for cheap. But having had interaction with these organizations, the prevailing ethos is that there’s little margin. I find it fascinating that they would pay physicians $140 an hour and still have no margin. So this implies to me that there’ll be further consolidation in this space. Right now the dynamic is that even the bottom of the barrel candidates aren’t willing to work for a low hourly rates, so numbers are slowly crawling up. My prediction is that gradually all of these chains would realize that they aren’t profitable because they can’t staff at market rates with below market reimbursements, and hence would eventually be absorbed by large nonprofits that are partially publicly subsidized.

 

[Geodont]

I see urgent cases in private practice all the time. Your basic assumptions aren't correct. I mean, I don't know why anyone would pay me a lot of money to see them if it isn't "urgent"...

I meant a psych ER or ER-like practice.

Obviously urgent matters are diffused in other settings too. Maybe a group that exclusively takes night, weekend, or vacation call for a multitude of solo or group practices is the closest variation on the theme, but very unlikely anyone would give away slice of their PP pie like that.

Calvin has it right in the sense that the nature of what we treat is not conducive to the goals of "Urgent" treatment, which means something can be done RIGHT NOW in 10-15 minutes that can prevent a patient from needing an ER visit. No one is going to a psych UC clinic when they can call their doc, talk to them for 5 minutes and then be seen in the next few days. Conversely, if someone has a legit concern (SI with plan, I'm dizzy and I keep falling down, this rash keeps getting bigger, etc) they're either going to require a more thorough eval meaning a longer appointment, or require a medical eval which means sending them somewhere else (like an ER).

I'm curious as to what situations you think would warrant a psych UC clinic that couldn't be addressed by a triage RN/quick phone call or a more thorough eval in an ER. I can maybe think of a couple, but there's already a national crisis hotline that people call and get advice regarding "psych crises" for free. So how are you going to convince people to come in and pay for the same services?

In one of the highest volume ERs of my populous state, the vast majority of what comes through the pipeline are reassurance seeking, respite from interpersonal drama seeking, treatment splitting, substance seeking, socializing seeking cases. Many many complain of showing up for immediate access on the basis of either not accessing their providers on weekends or during snowstorms, not liking their providers in general and being in limbo for months until securing intake elsewhere, and very very often not liking phone/video interactions with their prescriber or therapist. There’s definitely a market for the, “don’t like tele” population out there and wants to be SEEN “whenever I’m in perceived crisis.”

 

[dl2dp2]

In one of the highest volume ERs of my populous state, the vast majority of what comes through the pipeline are reassurance seeking, respite from interpersonal drama seeking, treatment splitting, substance seeking, socializing seeking cases. Many many complain of showing up for immediate access on the basis of either not accessing their providers on weekends or during snowstorms, not liking their providers in general and being in limbo for months until securing intake elsewhere, and very very often not liking phone/video interactions with their prescriber or therapist. There’s definitely a market for the, “don’t like tele” population out there and wants to be SEEN “whenever I’m in perceived crisis.”

Yes, but how many are willing/able to pay to be seen? Money talks bull**** walks, right?

 

[Geodont]

Yes, but how many are willing/able to pay to be seen? Money talks bull**** walks, right?

Let’s just say it, bull**** walks IN!
Now there is an idealist, misguided part of me that wonders if those in-perceived-crisis-and-want-to-be-seen-NOW (as opposed to needs to be seen now) cases wouldn’t be motivated to pay every bit as much as the cosmetic derm population is.

 

[Sushirolls]

When people go to UC they aren't seeking a professional opinion typically.
They are seeking a transaction, they want something.
The only something Psych offers is IM/IV ketamine, or benzos that could be perceived as an immediate something / transaction.
Is that the 'cosmetic derm' you dreamed of?

 

[Geodont]

When people go to UC they aren't seeking a professional opinion typically.
They are seeking a transaction, they want something.
The only something Psych offers is IM/IV ketamine, or benzos that could be perceived as an immediate something / transaction.
Is that the 'cosmetic derm' you dreamed of?

I think they are often seeking professional answers in UCs. Some are purely seeking transactions.
In my parts, medics dole out IM ketamine like red velvet cupcakes with cream cheese frosting. Not my idea of cosmetic derm for sure, but the reward factor is there- whether it’s ketamine or someone to imminently listen in-person about your household drama.

 

[Sushirolls]

So, you thinking you'll open one up?

 

[Geodont]

So, you thinking you'll open one up?

Not unless my SDN colleagues provide their seal of endorsement.

It’s satisfying however to consider PP models that stray from the usual constructs.

 

[Candidate2017]

Let’s just say it, bull**** walks IN!
Now there is an idealist, misguided part of me that wonders if those in-perceived-crisis-and-want-to-be-seen-NOW (as opposed to needs to be seen now) cases wouldn’t be motivated to pay every bit as much as the cosmetic derm population is.

B.S. will definitely walk in. I don't know about you, but $55 or whatever B.S. Medicaid is paying for a 60 minute new eval is not worth it. Which is why hospitals have the EM doc, resident, midlevel, SW or whoever else that's already there as a fixed labor cost evaluate the "walk in" psych patients.

The patients who can pay to be seen right now likely already have a semi-competent cash psychiatrist who has enforced boundaries as to what to do in an "emergency" in between their appointments.

 

[Geodont]

B.S. will definitely walk in. I don't know about you, but $55 or whatever B.S. Medicaid is paying for a 60 minute new eval is not worth it. Which is why hospitals have the EM doc, resident, midlevel, SW or whoever else that's already there as a fixed labor cost evaluate the "walk in" psych patients.

The patients who can pay to be seen right now likely already have a semi-competent cash psychiatrist who has enforced boundaries as to what to do in an "emergency" in between their appointments.

Those boundaries often turn into weekend or late night invitations to the wrong level of care.

 

[dl2dp2]

Those boundaries often turn into weekend or late night invitations to the wrong level of care.

Not really. Have you actually practiced outpatient psychiatry?

I see sick sick borderline patients all day and nobody really wants to constantly call their shrink on weekends or randomly show up to ERs at midnight. Maybe it happens at the start of the referral but when you do psychiatry right people get better and learn from their mistakes and gain better impulse control skills. When they don’t learn you end treatment.

If someone calls you constantly you say you have to see them twice a week and you do real TFP or schema therapy. If they can’t afford you you send them to an IOP. The end. I don’t really see where this cash urgent care fits into this.

 

[Geodont]

Not really. Have you actually practiced outpatient psychiatry?

I see sick sick borderline patients all day and nobody really wants to constantly call their shrink on weekends or randomly show up to ERs at midnight. Maybe it happens at the start of the referral but when you do psychiatry right people get better and learn from their mistakes and gain better impulse control skills. When they don’t learn you end treatment.

If someone calls you constantly you say you have to see them twice a week and you do real TFP or schema therapy. If they can’t afford you you send them to an IOP. The end. I don’t really see where this cash urgent care fits into this.

I have practiced outpatient psychiatry. A whole lot of emergency psychiatry too. Both with indigent and monied populations. Not everyone agrees to increase the frequency of care for the BPD flares you reference. Nor is IOP access so plentiful everywhere. BPD routinely churns the wheels at some psych ERs with 5000+ annual visits. At best I can speculate that there may be geographic nuances in ER psych demographics and education to the public about the appropriate threshold to seek that level of care.

 

[dl2dp2]

I have practiced outpatient psychiatry. A whole lot of emergency psychiatry too. Both with indigent and monied populations. Not everyone agrees to increase the frequency of care for the BPD flares you reference. Nor is IOP access so plentiful everywhere. BPD routinely churns the wheels at some psych ERs with 5000+ annual visits. At best I can speculate that there may be geographic nuances in ER psych demographics and education to the public about the appropriate threshold to seek that level of care.

i think you have some interesting ideas but might want to flush it out more precisely. You want a subscription based service for DBT-style coaching outside of the ER in lieu of ER. Some startup companies are working on these types of things…

Or do you want to create a similar service for psychosis? Again some companies are working on that right now.

Or do you want to create a company to do outpatient coverage for private psychiatrists? I think there’s less value add there as private psychiatrists typically have a large enough coverage pool and often don’t take calls off hours.

Or is it that you want to create an IOP because there is not enough of them?

I think you need to lay out in more detail what services exactly that you are providing where there’s a gap and there’s money to be made in that gap. As of right now I’m not hearing that. There’s no money to be made to practice hospital based psychiatry as a private group.

 

[randomdoc1]

Wow, such an interesting thread. Purely from a financial standpoint, it will be easy to hemorrhage money on this one. Often times patients who have higher needs, I definitely see a correlation with finances whether they don't have insurance and/or money to pay. Even in standard PP, I check the week prior to make sure upcoming appointments all have active insurance and/or established payment agreement. And even in that situation, the self pay have a very high incidence of not having money at that same and you have to stay very on top of collecting. If you establish as an urgent care, I also wonder if there is some sort of statute like ERs have. ERs cannot turn anyone away, regardless of financial situation. And when someone walks through your door and there's a major clinical situation, you may be in a medical legal bind and it is already a population that is more likely to struggle with boundaries. Maybe another model is a 2nd opinion/consult model? Sometimes even establishing care with the patient temporarily with a firm end date and ensuring they have established care to return to. Some patients like having a second set of eyes to look at things and some providers do not mind it either. I definitely would not go down the walk ins route.

 

[SmallBird]

There are lots of psych 'urgent cares' in our state. They are not privately owned, but there clearly is a large number of patients who want to be seen same day at a place other than an ER. One can find reasons to think that they should either be in actual ERs or just go back to their PCPs but for whatever reason it's a very attractive option for patients. Most patients have anxiety. They come in, are assessed, receive psychoeducation, care coordination, and if a follow up is secured may be started on medications recognizing that most psychiatric medications that are reasonable to start in this setting aren't particularly effective for crisis stabilization. I believe one way these settings are helpful is that it provides a low cost environment for brief containment so patients can regress to a less acute mean in a few hours and feel safe to return home and engage in regular outpatient care.

I don't see it being viable from a private practice perspective at all, as we have a nurse, a tech, and ability to get labs etc like most medical urgent cares.

 

[calvnandhobbs68]

There are lots of psych 'urgent cares' in our state. They are not privately owned, but there clearly is a large number of patients who want to be seen same day at a place other than an ER. One can find reasons to think that they should either be in actual ERs or just go back to their PCPs but for whatever reason it's a very attractive option for patients. Most patients have anxiety. They come in, are assessed, receive psychoeducation, care coordination, and if a follow up is secured may be started on medications recognizing that most psychiatric medications that are reasonable to start in this setting aren't particularly effective for crisis stabilization. I believe one way these settings are helpful is that it provides a low cost environment for brief containment so patients can regress to a less acute mean in a few hours and feel safe to return home and engage in regular outpatient care.

I don't see it being viable from a private practice perspective at all, as we have a nurse, a tech, and ability to get labs etc like most medical urgent cares.

This is the key here. Many of us are familiar with crisis/observation models but again these are not stand alone money making endeavors (many of these are publicly or hospital funded to divert from higher cost ER care) and most of this can be done by a social worker. No medical urgent care keeps patients there "for a few hours"...if they're there longer than 30 minutes it's already been too long.

I absolutely think there are large numbers of patients who want to be seen same day at other places than an ER. That's the whole idea behind crisis services. Crisis services are not stand alone financially viable services.

 

[Geodont]

What if you call it a reassurance center? All jest aside, what I probably see the most in psych ERs and psych consults to medical ERs is, “I want instant in-person access to brief therapeutic interventions.” Plenty of these folks abuse the threshold for recruiting crisis services (resulting in them feeling ultimately unheard) or else there are those who feel embarrassed to have CS show up at their door. It’s true that most (on the indigent spectrum of the market especially) don’t care if it’s a physician or SWer seeing them (but don’t psychiatrists hire tons of LCSWs for their PP’s?). I know many who bank on them. The take home is, red tape is the biggest issue. Even reimbursement can probably be mitigated with sufficient marketing and in the right catchment area.

 

[ObsequiousAplomb]

What if you call it a reassurance center? All jest aside, what I probably see the most in psych ERs and psych consults to medical ERs is, “I want instant in-person access to brief therapeutic interventions.” Plenty of these folks abuse the threshold for recruiting crisis services (resulting in them feeling ultimately unheard) or else there are those who feel embarrassed to have CS show up at their door. It’s true that most (on the indigent spectrum of the market especially) don’t care if it’s a physician or SWer seeing them (but don’t psychiatrists hire tons of LCSWs for their PP’s?). I know many who bank on them. The take home is, red tape is the biggest issue. Even reimbursement can probably be mitigated with sufficient marketing and in the right catchment area.

Is it therapeutic to provide that immediate, in-person reassurance to people who don't meet. Crisis criteria? Sounds to me like that would foster unhealthy coping skills.