Private practice with SMI patients

[bashir]

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I love treating patients with SMI, and I like doing some therapy. I hate practicing for the big box in town, and the other big box is even worse, as would be (I strongly suspect) the CMHC-type places here who only ever seen to hire NPs. I have a supportive spouse with no job at present (has been raising the kids who are finally in school) and business experience, who could probably run my private practice.

You see where this is going. Is there any way to have my cake and eat it too? I don't think I could stomach totally abandoning the SMI population in my city, but these patients don't exactly fit with private practice. To make matters worse I'm really fantasizing about a cash only practice because I am burnt out on the documentation burden which comes along with insurance.

So I'm brainstorming and trying to think outside the box. Is it possible to do a cash practice 3 days per week and take insurance one day? Maybe get the word out as a specialst in first episode psychosis, as many patients are covered by parents' insurance? These are my favorite patients to treat and the local FEP program has some NP via telehealth from another state, so I really wouldn't feel badly siphoning off patients from them. Is a hybrid practice like this even possible? Or would you be better off establishing a sliding scale that goes down to almost zero for a select number of patients? I should mention that several colleagues are equally fed up and might consider starting a group practice.

Any thoughts are welcome. I don't need to make a lot of money. I still have loans to pay off (and would probably have to abandon PSLF dream) but we have been saving aggressively for retirement and living below our means. I just want to have some job satisfaction, and corporate medicine is breaking my spirit.

 

[MedMan80]

I would say the likely solution is offering a sliding scale and even taking on some probono cases to capture some of the SMI population. I don't think insurance will allow offering of preferential treatment of their clients. I can't imagine the CMHC places not taking a psychiatrist on, their primary challenge is probably finding someone which is why they take on NP's. Such a place will give you the SMI pop plus good documentation time to not get burned out.

 

[clausewitz2]

I would caution you that the evidence in the FEP population in particular is that their outcomes are much better in a coordinated specialty care model and if you are diverting people from the local FEP program you are doing them a disservice, provided that the local program is actually implementing CSC (probably is more or less if it is getting any grant funding).

Even if the NP is remote and terrible, they will do better with the resources and framework of CSC than they will with a solo private practitioner.

Instead of making your private practice take insurance one day per week, why not reach out to whoever is running the FEP program and explore the possibility of coming on one day a week as their psychiatrist? I am sure they would like to not have to rely on an out of state NP. Much less hassle for you and also more in line with best practices in this area.

 

[Sushirolls]

I'm doing solo insurance practice. I tried when I started to have schizophrenia, but the med non-compliance, need for injectables, and if your state allows it, civil out patient commitments, I was doing a disservice for this population and have since stopped. The folks really do need some level of nursing/SW wrap around to enhance medication use and the other issues.

Don't do an insurance practice if is only part time, insurance based practices, because of the bump up in overhead, really are meant for 0.5 or higher FTE status. Cash only can be any size FTE.

 

[dl2dp2]

It really depends on what you want: do you want to treat more than 50%+ SMI as a career, or do you want to make more money and be more flexible and just retain a 10-20% commitment.

If you want 10-20%, work for a CHMC one day a week.
If you want 50%+ AND make a lot of money, it's possible but it'll be hard -- i.e. you will typically need state salary line support to sponsor a large number of Medicaid patients. I.e. you own the clinic, hire a bunch of NPs, run many cases and bill Medicaid/Medicare PLUS you get non-profit status to apply for supplemental funding from the state agency. You draw a salary as the Executive Director of the large organization which you build, and your partner works as the Director of Operations (in essence).

Even then, the total income is often lower than if you open a [successful] private practice outside of this rubric. So people who end up doing this are typically driven not by an entirely profit motive. Which is interesting because these people are often under higher scrutiny because 1. there are easy ways to defraud, and people are more tempted to do that. 2. 3rd party payers audit, especially if they know how much you are getting paid.

Think about it for a second--you can't really defraud a private cash paying patient. Service rendered. Bill paid. Then think about insurance for a second.

On rare occasions, interesting things can happen where a for-profit SMI clinic that sustains itself (and grows!) occurs, but this is VERY rare and very specific. I know of examples but I'm under NDA so can't really reveal anything on the internet.

 

[bashir]

Thanks for the replies. I particularly needed to hear that part-time insurance practice doesn't make fiscal sense, and when it comes to taking insurance you're in or you're out. It may be my ego talking but I have read a lot of the CSC manuals that are made freely available by SAHMSA online, and I feel like I can do a better job as a solo practitioner wearing the several hats of the CSC team than the local alternative is currently doing, yet you are correct that it's at least worth exploring contracting myself out to the grant funded CSC team in town.

I'm going to keep agitating for changes to make my current job more tolerable for the time being, but it's much easier to do that with a back up plan in mind. And to answer your question, Sluox, I really don't know. My professional identity is wrapped up in treating an SMI population and I'm not sure how I would feel about doing just a token amount of that. I love it but I also love spending time with my young family and financial stability. Thanks, all, for your input.

 

[Sushirolls]

I recall one for profit community mental health center in Cleveland, OH. Residents back in the day would moonlight there, and they were actually one of the more functional CMHC agencies. Over the years they started dropping the psychiatrists in favor or ARNPs. So it can be done. Just tried to find the website with quick google search can't. Maybe it sold out?

Another idea if your really want to do SMI and private practice, move to middle of nowhere, open up your practice and reach out to the local critical care access hospital and county health departments and try to see if they have any funding for you. Basically, you'll be the only person for miles around and a lot of folks won't want to travel to the big metro, so you'll get everything. Another thought.

 

[clausewitz2]

Thanks for the replies. I particularly needed to hear that part-time insurance practice doesn't make fiscal sense, and when it comes to taking insurance you're in or you're out. It may be my ego talking but I have read a lot of the CSC manuals that are made freely available by SAHMSA online, and I feel like I can do a better job as a solo practitioner wearing the several hats of the CSC team than the local alternative is currently doing, yet you are correct that it's at least worth exploring contracting myself out to the grant funded CSC team in town.

I am sure that you could probably quickly learn to do any of the roles of a CSC team individually just as well if not better than anyone else but where will you find the time to do all of them to the established standard? Are you going to be getting people signed up for GED classes or doing cognitive remediation training with them? Do you plan to administer LAIs in office yourself? Are you going to sit down with them and help them apply for student loans? Who is going to pay you for doing the necessary case management? Are you going to be doing weekly hour-long psychotherapy with all of them?

There is a reason staffing ratios have to be low to be model-adherent. A team with a full complement of 5-6 people not infrequently might only have 50-75 clients total. If you are doing one day a week you can match CSC standards by your lonesome for like 5, maybe 10 if you plan to make that a very long day indeed.

The CSC model is effective but very resource-intensive. They are almost never sustainable in traditional fee-for-service models paid by insurance (way too many unbillable hours). There is a reason grant or negotiated case-rate funding is the name of the game in this area.

I'm going to keep agitating for changes to make my current job more tolerable for the time being, but it's much easier to do that with a back up plan in mind. And to answer your question, Sluox, I really don't know. My professional identity is wrapped up in treating an SMI population and I'm not sure how I would feel about doing just a token amount of that. I love it but I also love spending time with my young family and financial stability. Thanks, all, for your input.

So do FEP work part-time and make sure to be active in relevant state/regional mental health circles and become known for that FEP work. It is a small world yet and not hard to make the kinds of connections and recognition that might assuage that desire to have an SMI-treating identity.

The work requires a light touch and I think in some respects meshes better with private practice sensibilities than the veteran chronic SMI warrior mentality so I am not trying to be discouraging, just pointing out there are easier and probably more effective ways to do this.

 

[PsyDr]

I would consider the implications of being on call 24/7 for an SMI population, and talk that through with my spouse.

 

[clausewitz2]

I would consider the implications of being on call 24/7 for an SMI population, and talk that through with my spouse.

Very much this as well. If you are properly doing CSC, the crisis phone will be carried by you by your lonesome. "Go the ED if there is an emergency" doesn't really cut it. The burden is much more manageable when you are trading off every week with someone else.

 

[Monocles]

Can't comment on the "meaningfulness" or "work satisfaction" component of a cash-only SMI practice, but from a financial perspective you'll bleed yourself dry. I would try to figure out the opportunity cost of having your clinic be SMI-focused and try to figure out a theoretical income loss based on hours and days. Then take a look and see if the number is worth it to you personally.