private practice type

[CaMD]

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This might be a silly question, but:

I'm wondering what the feasibility is of setting up a private practice focusing on psychotic disorders. Are there enough patients with psychotic disorders but covered by insurance (perhaps on their own, or via their families) that this is possible? Or if I want to work with this population am I limited to county facilities?

 

[kugel]

Interesting idea.
Personally, I think properly managing such patients generally takes a team. Nursing to manage labs and give injections and run education groups, social worker to keep benefits in order. However, I do think this could work if you had a few different docs who all agree on the basics of how to manage such patients (so can cover each other) and then the docs could share nurse and social worker. I had a fantasy at one point of running a clinic along with a primary care doc, plus a top-notch social worker and an unlicensed social services worker and a nurse. By sharing space and patients with the PCP and a social worker with a good business sense and amazing knowledge of systems and benefits, we thought we could make a go of it. But we never tried.

It'll be interesting to see if healthcare financing reform will cause this kind of idea to be more or less feasible.

 

[nitemagi]

Interesting idea.
Personally, I think properly managing such patients generally takes a team. Nursing to manage labs and give injections and run education groups, social worker to keep benefits in order. However, I do think this could work if you had a few different docs who all agree on the basics of how to manage such patients (so can cover each other) and then the docs could share nurse and social worker. I had a fantasy at one point of running a clinic along with a primary care doc, plus a top-notch social worker and an unlicensed social services worker and a nurse. By sharing space and patients with the PCP and a social worker with a good business sense and amazing knowledge of systems and benefits, we thought we could make a go of it. But we never tried.

It'll be interesting to see if healthcare financing reform will cause this kind of idea to be more or less feasible.

It's called the "Medical Home." The reform carves out $ for this purpose.

 

[Chimed]

I agree with Kugel here. Although I'm sure it could be done, the best model, IMO, is community mental health. I'm fortunate to have trained in a very good CMH system, so I might be biased. But for chronically psychotic patients (i.e. schizophrenics), having them on a team with a nurse practitioner, a psychiatrist, a case manager/social worker, and the resources for individual and/or group therapy is hard to make up in private practice.

 

[kugel]

I agree with Kugel here. Although I'm sure it could be done, the best model, IMO, is community mental health. I'm fortunate to have trained in a very good CMH system, so I might be biased. But for chronically psychotic patients (i.e. schizophrenics), having them on a team with a nurse practitioner, a psychiatrist, a case manager/social worker, and the resources for individual and/or group therapy is hard to make up in private practice.

I absolutely agree that this type of team is best. But CMH systems have been hit so hard in the last 10 yrs that few public MH systems have these services available anymore for the vast majority of their pop'n. Most CMH patients now have access to only the psychiatrist's services (no case mgr, no NP, no groups, etc), and it can take 3 months to get a new pt appt, and 3-4 weeks to get an appt with the pt's psychiatrist. Most counties where I've worked only have such additional services available to ~10% of the patients. And even when Case Mgt is available, there is little coordination between the services being utilized.

So, could this be done in private practice, I believe it could. There would have to be a careful detailed business model, with a lot of attention to billing everything possible for the services provided.

I've thought that one way would be to have a psycho-educational group every day at 4pm, with rotating topics on everything including illness education, meds, how to ask questions to your psychiatrist, using the bus system, hygiene, nutrition, ETOH, using your PCP, sun protection, smoking, etc. The topic of group every Thursday is crisis prevention (get these thoughts drummed in before the weekend arrives) and every Friday it's recreation. Patients are expected to show up by 3:30pm and only the first 6 (plus any hosp discharges) will be registered for the group. Upon registering, the pt's will tell the nurse if they need any refills, have problems with meds, change in symptoms/weight, get VS taken, etc. While the Soc Worker and Nurse run the group, the psychiatrist takes each patient out in turn for ~5-8 minutes to check in, provide any refills, etc. This "check-in" does NOT substitute for the regularly scheduled appt, but is additional. Patients may show up ANY time they are having a problem (no need to wait for an appt opening - just come to group), and they are directed to come to group 5 times in a row after any psych ER or medical ER visit. After any Inpt admission, they are directed to come to group 5 times in a row, and then twice per week for 3 weeks after that. There should be a lot of connection to the local NAMI, DBSA, and other advocacy/support/awareness groups. Since every patient attending the group can be billed, this system is not as economically draining as it sounds.

Sorry, just fantasizing again.

 

[whopper]

Agree with all of the above. Psychosis patients as a whole tend to have a lot of problems and aren't great candidates for the type of treatment where they show up on their own, tell their problems, and the doctors treat. Many of them have poor compliance, insight, comorbid problems, and require case managers.

There are psychotic patients who do fit will in the type of setting where a team is not needed, but they are the exception, not the norm.

 

[michaelrack]

Are there enough patients with psychotic disorders but covered by insurance (perhaps on their own, or via their families) that this is possible?

no.

It's hard to have a profitable private psychiatry practice when the majority of (adult) patients have medicare and/or medicaid.

I would advise you to have a regular private practice and work several half-days a week also at the local comm mhc.

Or, if you are really interesed in that population, you could work full time at the comm mh center.

 

[CaMD]

Thank you, everyone, for the thoughtful responses. I agree it's a population that needs lots of support, and ideally a whole team of people working w them, not just a doc. Just thought it was worth asking if anyone had seen it work since this is the population I most like to work with, but hearing about PP set-ups has been making me jealous. 🙂

Perhaps I will target getting a job w a community mental health center and then having a little PP on the side for $. Or if this medical home concept really gets off the ground I can help establish one for this population.

Kugel I love your idea of having psych-ed and drop-in hours. Maybe that's something I can integrate into my practice in the future.

 

[kugel]

Kugel I love your idea of having psych-ed and drop-in hours. Maybe that's something I can integrate into my practice in the future.

That'll be $50, please.
Your insurance does not cover business advice. When you signed the Consent to Treatment in SDN (here termed "agreement to terms of service") you also signed the clause that said you would promptly pay any charges that are not covered by your insurance.

Don't try to sue me over sending a bill collector after you.
You also signed the Agreement to Mandatory Arbitration, wherein a professional arbiter is chosen by me. In this case, I choose me.

 

[CaMD]

a professional arbiter is chosen by me. In this case, I choose me.

👍

 

[sunlioness]

Just thought it was worth asking if anyone had seen it work since this is the population I most like to work with, but hearing about PP set-ups has been making me jealous. 🙂

Don't be jealous. Been there, done that, got the t-shirt. Private practice is totally over-rated.

That'll be $50, please.
Your insurance does not cover business advice. When you signed the Consent to Treatment in SDN (here termed "agreement to terms of service") you also signed the clause that said you would promptly pay any charges that are not covered by your insurance.

Don't try to sue me over sending a bill collector after you.
You also signed the Agreement to Mandatory Arbitration, wherein a professional arbiter is chosen by me. In this case, I choose me.

Awesome. 👍

 

[Chimed]

Don't be jealous. Been there, done that, got the t-shirt. Private practice is totally over-rated.

Why? What is the difference between what you're doing now?

 

[sunlioness]

I don't have to pay rent. I don't have to argue with insurance companies nearly so frequently. I have way less paperwork. I have a support staff I don't have to pay for and manage. I know when my next paycheck is coming and what the number on it will say. I don't have to be on call 24/7.

Of course people who like PP will have a rejoinder for every one of those things. It all just really comes down to what suits your personality. I have to admit that setting my own schedule was kind of nice, but then I went and scheduled myself for several evenings per week because I felt bad for my patients who worked. 😕

 

[Chimed]

I don't have to pay rent. I don't have to argue with insurance companies nearly so frequently. I have way less paperwork. I have a support staff I don't have to pay for and manage. I know when my next paycheck is coming and what the number on it will say. I don't have to be on call 24/7.

Of course people who like PP will have a rejoinder for every one of those things. It all just really comes down to what suits your personality. I have to admit that setting my own schedule was kind of nice, but then I went and scheduled myself for several evenings per week because I felt bad for my patients who worked. 😕

Thanks. How much control do you have over your own schedule compared to before? I'm sure every situation is different.

 

[sunlioness]

I'm doing inpatient at the moment, so it's 8ish to around 4-5ish, M-F.

I'm actually leaving this job (and this state) to go back to doing outpatient for a health system elsewhere and I'm not 100% sure how flexible my schedule will be there. It's also 8ish - 5ish, M-F. No evenings, no weekends.

 

[OldPsychDoc]

I don't have to pay rent. I don't have to argue with insurance companies nearly so frequently. I have way less paperwork. I have a support staff I don't have to pay for and manage. I know when my next paycheck is coming and what the number on it will say. I don't have to be on call 24/7.

Like. 👍