RVU model

[randomdoc1]

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Hi everyone, I'm trying to design some payment models for recruiting new psychiatrists and psychologists. Many seem to have a tendency to gravitate towards salary or RVU model with a benefits package over split fee. But when I calculated the total financial value say, at the VA 1.0 FTE, salary, contributions to health insurance premium, 401k (I'm aware there's a pension), vacation days, sick days, federal holidays, loan forgiveness-->I calculated that if you maxed out all your leave time per year and ended up doing say 1688 hrs of work a year, factor in the salary, monetary value of loan forgiveness, etc. The earnings you get per hour/unit of work is less than PP which would bring back (at least at my office) $260/hour. Correct me if I'm doing any math wrong, but people seem to feel more secure with the classic RVU or salary with benefit package although at some places with salary, you're working more actually for less (I'm getting numbers that are not even close to $200/hr of time your physical warm body is on the work site)?

Now back to the RVU question. Trying to familiarize myself with RVUs and was thinking, ok, what if I offer an RVU model with a benefit package (although compared to split fee it still looks like you're bringing back less even with the monetary value of the benefits factored in). On cms.gov, it says working RVU for 99213+90833 is 2.8. The CMS website also says the conversion factor is 34.89 although I see on the forums 62.5 is closer (can someone direct me to a source to how this is determined and or a site that gives conversion factor range for psychiatrists?). Then I looked up wRVU range annually for psychiatrists and I saw 3600-4000. I'm assuming this is 1.0FTE. So then at 3800 wRVU, multiply by 62.5, that gives $237,500. 3800 wRVUs divided by 2.8 means about 1357 follow ups a year, divide over 46 weeks gives 29 follow ups in a working week which is a little less than 6 follow ups a day (I'm a little confused as it feels like most FT psychiatrists are seeing more than 6 patients a day, of course some may bill 99214 or 99215 for higher complexity)? If I use the 34.89 conversion factor, it results in $132,582 in that year for 3800 wRVU. Now if that doubles to $265,164, that makes it 12 follow ups a day (working 5 days a week, 46 weeks in a year). Then you add the benefit package and it looks more like what my geographic area had been offering.

I'd welcome any feedback on how this calculation was done and would love to see other example RVU models and how this translates to what work flow in the day and week would look like!

 

[clausewitz2]

I think you may be misunderstanding why people gravitate towards a salaried gig over RVU/billing model. The advantages of W2 employment are mostly non-monetary. They involve

1) Ability to have time off without it affecting their paycheck, so that the calculation of "should I call out sick today?" is not "do I want to pay my mortgage this month?" Similarly, vacation is not consumed with repetitive thoughts about all the money they are losing by not being in the office. This kind of calculus is extremely uncomfortable for some people and makes them inclined to never ever take time off, even when they really should and can afford it.

2) Not having to think about retirement or make as much of a deliberate effort to save

3) Being able to have a slow day without it lightening their wallet

4) Less pressured to turn the crank and grind out more hours

5) Flexibility in the work day - say you need to duck out for a couple hours for a medical appointment or for family reasons or leave a bit early for a few days. Might not be officially in your contract but in most salaried positions this sort of flex is usually possible in a way that doesn't cost you anything, depending on your relationship with your immediate supervisors etc.

I say this as someone who clearly opted for the 1099 route and does not regret it but I attach a high degree of importance to control over my schedule and life.

 

[randomdoc1]

I think you may be misunderstanding why people gravitate towards a salaried gig over RVU/billing model. The advantages of W2 employment are mostly non-monetary. They involve

1) Ability to have time off without it affecting their paycheck, so that the calculation of "should I call out sick today?" is not "do I want to pay my mortgage this month?" Similarly, vacation is not consumed with repetitive thoughts about all the money they are losing by not being in the office. This kind of calculus is extremely uncomfortable for some people and makes them inclined to never ever take time off, even when they really should and can afford it.

2) Not having to think about retirement or make as much of a deliberate effort to save

3) Being able to have a slow day without it lightening their wallet

4) Less pressured to turn the crank and grind out more hours

5) Flexibility in the work day - say you need to duck out for a couple hours for a medical appointment or for family reasons or leave a bit early for a few days. Might not be officially in your contract but in most salaried positions this sort of flex is usually possible in a way that doesn't cost you anything, depending on your relationship with your immediate supervisors etc.

I say this as someone who clearly opted for the 1099 route and does not regret it but I attach a high degree of importance to control over my schedule and life.

I pay everyone on a W2 already. I'm on a W2, not 1099.
1. The time off does affect your pay. You still need to be at the office a minimum number of hours a year (so let's say you exhaust all the "PTO"), you are still paid less per hour in RVU/salary.
2. Same thing, I factored in the retirement monetary value, the 5% 401k match is a joke and not worth that much.

The truth is, the PTO is really not PTO. If you work 1688 hours a year in PP, you'd easily make $350k pure money. Now at a salary position, you bring home say, your $210k salary, factor in 5% match for 401k, loan forgiveness, health insurance premium contributions. The total monetary value of all that is about $280k. But you still need to be at work 1688 hours a year. How many hours per year do you need to be in PP to make that same monetary value? It equates to 1,077 hours a year. You are working about 40 odd days extra to bring the same amount back on a salary model. It's just packaged differently.

Now, if that's what people are gravitating to despite the math. Then I'd be happy to offer the salary with benefits and I guess the rest stays retained in the clinic?

 

[clausewitz2]

I pay everyone on a W2 already. I'm on a W2, not 1099.
1. The time off does affect your pay. You still need to be at the office a minimum number of hours a year (so let's say you exhaust all the "PTO"), you are still paid less per hour in RVU/salary.
2. Same thing, I factored in the retirement monetary value, the 5% 401k match is a joke and not worth that much.

1. Sure, if you exhaust the PTO, you're having to make that calculation. But up till you use that last day, you don't have to worry about it. The moment I take a day off paid on an hourly basis, bam, that's revenue gone, even if I have worked every day of the preceding year.

2. I would say that many people are not thinking about retirement in a strictly monetary way per se and the utility they derive from the match is more a feeling of doing "something" to save for retirement than the actual cash value of what employer is contributing.

Hard-nosed homo economicus would be hard-pressed to pick the salaried gig, sure, but people who are not always making decisions based entirely on time-invariant cash value are choosing differently.

 

[randomdoc1]

1. Sure, if you exhaust the PTO, you're having to make that calculation. But up till you use that last day, you don't have to worry about it. The moment I take a day off paid on an hourly basis, bam, that's revenue gone, even if I have worked every day of the preceding year.

2. I would say that many people are not thinking about retirement in a strictly monetary way per se and the utility they derive from the match is more a feeling of doing "something" to save for retirement than the actual cash value of what employer is contributing.

Hard-nosed homo economicus would be hard-pressed to pick the salaried gig, sure, but people who are not always making decisions based entirely on time-invariant cash value are choosing differently.

Well, the interesting thing is point number one is, let's say you don't exhaust the "PTO". So you're working more, but you're not paid more which means less pay per unit of time at work.

I do find #2 quite interesting and agree. I've worked at the VA before as well and remember a colleague of mine getting so excited about "performance pay." The dollar amount was not very impressive, maybe 4 grand max for a FTE? Like really?

Hmm, the phrase time-invariant cash is intriguing. Because it's not truly time invariant. You get a finite amount of time away, you are still expected to be at the job a minimum amount of time per year and to perform a certain level of productivity. I remember even at the VA they monitored our RVUs and if they were low like a lot of no shows, one of my colleagues was moved to the DOM and his productivity went up.

 

[calvnandhobbs68]

I pay everyone on a W2 already. I'm on a W2, not 1099.
1. The time off does affect your pay. You still need to be at the office a minimum number of hours a year (so let's say you exhaust all the "PTO"), you are still paid less per hour in RVU/salary.
2. Same thing, I factored in the retirement monetary value, the 5% 401k match is a joke and not worth that much.

The truth is, the PTO is really not PTO. If you work 1688 hours a year in PP, you'd easily make $350k pure money. Now at a salary position, you bring home say, your $210k salary, factor in 5% match for 401k, loan forgiveness, health insurance premium contributions. The total monetary value of all that is about $280k. But you still need to be at work 1688 hours a year. How many hours per year do you need to be in PP to make that same monetary value? It equates to 1,077 hours a year. You are working about 40 odd days extra to bring the same amount back on a salary model. It's just packaged differently.

Now, if that's what people are gravitating to despite the math. Then I'd be happy to offer the salary with benefits and I guess the rest stays retained in the clinic?

Haha right I think you just underestimate how many physicians just DON'T CARE about this kind of stuff. That's why you have so many people taking a job in academics after they graduate from residency and then bitching about how little they get paid when they could go join/open a PP 20 minutes away and make 2x as much. Doctors are notoriously terrible at finances in general and you have very few people who even know how to calculate/estimate RVUs/split fees.

I totally get what you're saying but I think most physicians just don't bother doing the math. They're just like "eh that looks like a good deal and I don't have to worry about buying my own benefits/malpractice/retirement, sounds good".

 

[randomdoc1]

Haha right I think you just underestimate how many physicians just DON'T CARE about this kind of stuff. That's why you have so many people taking a job in academics after they graduate from residency and then bitching about how little they get paid when they could go join/open a PP 20 minutes away and make 2x as much. Doctors are notoriously terrible at finances in general and you have very few people who even know how to calculate/estimate RVUs/split fees.

I totally get what you're saying but I think most physicians just don't bother doing the math. They're just like "eh that looks like a good deal and I don't have to worry about buying my own benefits/malpractice/retirement, sounds good".

*facepalm* lol. That's what I'm thinking too. I know I'm not delusional! The numbers don't lie. But ok, salary model it is and I guess more for me? Shrug.

 

[calvnandhobbs68]

*facepalm* lol. That's what I'm thinking too. I know I'm not delusional! The numbers don't lie. But ok, salary model it is and I guess more for me? Shrug.

Well and lets be honest, for years 1-2 in many places you probably do make more with a guaranteed base salary. Like there were places offering me guaranteed 275-300K for at least year 1-2. Those first couple years you're building a patient panel and so while you aren't going to go hungry, you also aren't probably going to make as much while you're ramping up productivity, especially when you find out your first couple paychecks are rather meager while you wait for insurances/patients to pay up. I think many people don't look past that first couple years to figure out that financially its better for them in the long run to get more of a cut from their built patient panel once they're pretty full.

Something you could try that people might gravitate towards is a short "lead in" period where they get paid a lower hourly rate upfront for the first few months while you wait for collections to catch up, then switch to pure collections/productivity and reconcile their collections with the money you've already given them. That way people aren't getting a paycheck of like $1000 the first month while they wait for collections to catch up.

Also people with large student loan burdens will gravitate towards places that qualify for PSLF, which are usually places like academics and CMHCs which are almost all salary based, so that's what they're used to seeing. However, they also tend to miss the calculation that if you're making 300K in PP and 200K in a CMHC, that 100K/year difference (even after taxes) makes up the student loan burden pretty quickly over the 6-7 years you have to do for PSLF after residency.

People hate uncertainty and pure production based is definitely a lot more uncertain than base salary or even base salary + worse production.

 

[randomdoc1]

lol. I didn't even factor the differences in patient population. So different between the settings. I know some folks have a stronger stomach for it than I do. But even the more chill colleagues, their anxiety is palpable when they land in a nice on paper gig but it ends up being mostly high acuity cases, polypharm disaster to clean up, borderline city with everyone on benzos, etc. And with the more complex cases and more severe axis II, the regular complaints to upper management about you for making completely reasonable medical decisions. Yikes, and the messages, tons and tons of messages and it seems like each healthcare system is so variable on how they compensate for that, if at all.

 

[clausewitz2]

Those first couple years you're building a patient panel and so while you aren't going to go hungry, you also aren't probably going to make as much while you're ramping up productivity, especially when you find out your first couple paychecks are rather meager while you wait for insurances/patients to pay up.

I remember making a grand total of 600 for my first month of PP for three days of work per week. I remember the sinking feeling in the pit of my stomach and an overwhelming sensation of dread and regret for not having gone for a more sure thing. Looking at the workweek ahead and seeing like 7 patient encounters was incredibly disheartening. I had two other gigs and remember being incredibly grateful and wondering if it was too late to up my hours at one of them.

a year later I realized I would be doing better financially by dropping one of those gigs and seeing six more patients a week in PP, so I did.

 

[Psychresy]

I remember making a grand total of 600 for my first month of PP for three days of work per week. I remember the sinking feeling in the pit of my stomach and an overwhelming sensation of dread and regret for not having gone for a more sure thing. Looking at the workweek ahead and seeing like 7 patient encounters was incredibly disheartening. I had two other gigs and remember being incredibly grateful and wondering if it was too late to up my hours at one of them.

a year later I realized I would be doing better financially by dropping one of those gigs and seeing six more patients a week in PP, so I did.

How come you weren't initially getting paid?

I've had a couple mentors in my program tell me if I take an insurance or two I should be completely filled within a few months. What's all this couple of years to fill talk?

 

[randomdoc1]

How come you weren't initially getting paid?

I've had a couple mentors in my program tell me if I take an insurance or two I should be completely filled within a few months. What's all this couple of years to fill talk?

Payment is rendered in complete fulfillment once both patient and insurance pay up. Which on average takes 30-45 days and that's considered a fast turnaround time. That's the part that most new providers to practice, they have a hard time grasping and start to have second thoughts. I'm burnt out doing nearly IOP level psychological reassurance the first 3 months of every new provider. Salary it is .... but ... they're basically volunteering for themselves to profit less and me more! Take the money you guys deserve dude.

That's why an accurate depiction is that gross income you see the first 14 months AND factor in which dates of service it is for. Like say, you worked with a full caseload, all follow ups, a calendar year and all the remittances came in. THAT is the income. People get thrown off by the time lapse. If us providers don't take that money, and say someone goes to a big company with a salary, that leftover money, it'll go to the health system to....I dunno, pay more hospital administrators in a department that is already overstaffed? That's our money man.

to the quote below, that's so interesting. Because we preach not being dictated by our anxieties, emotion regulation, wise mind, look at the facts. All that vitamin CBT and DBT goodness. But this is an interesting depiction of making financial decisions based on psychological comfort.

People hate uncertainty and pure production based is definitely a lot more uncertain than base salary or even base salary + worse production.

 

[Psychresy]

Payment is rendered in complete fulfillment once both patient and insurance pay up. Which on average takes 30-45 days and that's considered a fast turnaround time. That's the part that most new providers to practice, they have a hard time grasping and start to have second thoughts. I'm burnt out doing nearly IOP level psychological reassurance the first 3 months of every new provider. Salary it is .... but ... they're basically volunteering for themselves to profit less and me more! Take the money you guys deserve dude.

That's why an accurate depiction is that gross income you see the first 14 months AND factor in which dates of service it is for. Like say, you worked with a full caseload, all follow ups, a calendar year and all the remittances came in. THAT is the income. People get thrown off by the time lapse. If us providers don't take that money, and say someone goes to a big company with a salary, that leftover money, it'll go to the health system to....I dunno, pay more hospital administrators in a department that is already overstaffed? That's our money man.

Good points, thanks for the clarification. I'm planning to do PP 3 days a week when I finish and have been thinking about potential salary so I can add on extra jobs as needed that first year or two. The uncertainty of not knowing makes planning hard.

In talking to a couple private docs at my program, they've stated I should be able to generate 320-400ish dollars per hour in revenue doing two 99214 and a 90833 per hour, or accounting for no shows, simply seeing 16 patients per day. They've alluded to being able to keep overhead to 15-20% if running a lean practice. Based on loose calculations on those figures, it seems bringing in 350k/yr would be reasonable for 24 clinical hours/48 patients a week. How does that sound to you?

 

[randomdoc1]

Good points, thanks for the clarification. I'm planning to do PP 3 days a week when I finish and have been thinking about potential salary so I can add on extra jobs as needed that first year or two. The uncertainty of not knowing makes planning hard.

In talking to a couple private docs at my program, they've stated I should be able to generate 320-400ish dollars per hour in revenue doing two 99214 and a 90833 per hour, or accounting for no shows, simply seeing 16 patients per day. They've alluded to being able to keep overhead to 15-20% if running a lean practice. Based on loose calculations on those figures, it seems bringing in 350k/yr would be reasonable for 24 clinical hours/48 patients a week. How does that sound to you?

for fee schedules i've seen around $75 for 90833 or so and $80 or high $70s for 99213, about $110-120 for 99214. So let's say you get 50/50 99213 and 99214, then that's avg of reimbursement of $175 per follow up. 48 follow ups per week and say you work 46 weeks, that's gross reimbursement $386,000 then you keep 85% it's $328,440. So there's some variability depending on 1) your individual fee schedule and 2) proportion of complexity of cases. But yes, your numbers are right. Good job 😉. Someone who gets it! I've encouraged potential new providers to please work part time PP and part time big box. Compare the two side by side, the ones who did, verdict was completely towards PP as they saw the income potential and how big boxes look nice in the start with a salary and lighter case load. Then they add more, then more, and your time gets tighter and tighter as that income increase slows in rate at least in proportion to how your work load is escalating. I did part time PP and part time hospital system and that was my experience over the course of two years so I could make an informed decision about which way to jump.

Here's a tip in PP. Collect what is owed at time of service. I found having a card on file and getting verbal consent and charging day of is a perfect model. No arguing over what is owed, transaction already completed. But you need to know in advance how much their copay is. Many have a high deductible plan and will balk at $150-$200 a visit. In those cases if you render service, insurance will pay $0, you send bill to patient, I've found at least 90% of the time they will ignore your bill. So I got into the habit of talking to my patients that their insurance policy has a fixed rate and asks I collect x amount for x service. Then patients can decide if they want to come at all, just come less often, etc. So you don't waste your time.

 

[Psychresy]

for fee schedules i've seen around $75 for 90833 or so and $80 or high $70s for 99213, about $110-120 for 99214. So let's say you get 50/50 99213 and 99214, then that's avg of reimbursement of $175 per follow up. 48 follow ups per week and say you work 46 weeks, that's gross reimbursement $386,000 then you keep 85% it's $328,440. So there's some variability depending on 1) your individual fee schedule and 2) proportion of complexity of cases. But yes, your numbers are right. Good job 😉. Someone who gets it! I've encouraged potential new providers to please work part time PP and part time big box. Compare the two side by side, the ones who did, verdict was completely towards PP as they saw the income potential and how big boxes look nice in the start with a salary and lighter case load. Then they add more, then more, and your time gets tighter and tighter as that income increase slows in rate at least in proportion to how your work load is escalating. I did part time PP and part time hospital system and that was my experience over the course of two years so I could make an informed decision about which way to jump.

Here's a tip in PP. Collect what is owed at time of service. I found having a card on file and getting verbal consent and charging day of is a perfect model. No arguing over what is owed, transaction already completed. But you need to know in advance how much their copay is. Many have a high deductible plan and will balk at $150-$200 a visit. In those cases if you render service, insurance will pay $0, you send bill to patient, I've found at least 90% of the time they will ignore your bill. So I got into the habit of talking to my patients that their insurance policy has a fixed rate and asks I collect x amount for x service. Then patients can decide if they want to come at all, just come less often, etc. So you don't waste your time.

Great, glad to hear my thinking has been on the right track. The one thing I'm curious of is that split betwen 213s/214s. At least in my residency clinic, I'm seeing probably 90% 99214s. It seems everyone has at least two chronic problems we could document along with the med management component. In your experience is the "real world" split actually closer to 50/50 between these two codes? Also will you do a 90833 with all of your patients?

 

[randomdoc1]

Great, glad to hear my thinking has been on the right track. The one thing I'm curious of is that split betwen 213s/214s. At least in my residency clinic, I'm seeing probably 90% 99214s. It seems everyone has at least two chronic problems we could document along with the med management component. In your experience is the "real world" split actually closer to 50/50 between these two codes? Also will you do a 90833 with all of your patients?

Yes, I do 90833 with all my patients. I haven't reviewed the new coding criteria yet, but do hear it's much easier to hit a 99214. But the patient population in PP tends to be much lower acuity than what we see in residency. The easier 99214s is all pretty new in the billing world relatively speaking. Rumor had it when I first got out of residency in 2016, insurances have systems in place that can flag a provider for potential audit. And if your proportion or absolute volume of 99214s crosses a threshold, you may get audited. I don't know if this was ever true, or if it was, it still would be. Audits can be nasty and payors seem to vary depending on their criteria for doing what's called a "clawback" (so they take back a large chunk of $). Like I had one insurance that audited every patient I had with their insurance although I never billed a 99214 but nothing came of the audit. But with United and BCBS there's rumors that they can work very hard to find something off, no matter how trivial, and they do the clawback. Theoretically, if you rendered the medically necessary service, billed in good faith, and documented well, you should be protected from the audit. And I like to think that's why I never had anything end up in a clawback.

 

[calvnandhobbs68]

Yes, I do 90833 with all my patients. I haven't reviewed the new coding criteria yet, but do hear it's much easier to hit a 99214. But the patient population in PP tends to be much lower acuity than what we see in residency. The easier 99214s is all pretty new in the billing world relatively speaking. Rumor had it when I first got out of residency in 2016, insurances have systems in place that can flag a provider for potential audit. And if your proportion or absolute volume of 99214s crosses a threshold, you may get audited. I don't know if this was ever true, or if it was, it still would be. Audits can be nasty and payors seem to vary depending on their criteria for doing what's called a "clawback" (so they take back a large chunk of $). Like I had one insurance that audited every patient I had with their insurance although I never billed a 99214 but nothing came of the audit. But with United and BCBS there's rumors that they can work very hard to find something off, no matter how trivial, and they do the clawback. Theoretically, if you rendered the medically necessary service, billed in good faith, and documented well, you should be protected from the audit. And I like to think that's why I never had anything end up in a clawback.

Its super hard to figure out what insurance is going to do in an audit regardless it seems. Each insurance company also has specific criteria for what they want for a 90833 and so I've also heard of people getting burned for not doing the 90833s "correctly" when they bill a ton of 90833s and get audited.

I bill like 95% 99214s right now since it's incredibly easy to hit 99214 with 2021 guidelines (you can literally hit it with MDD increasing Lexapro 10 to 20mg (unstable chronic condition with med management)) and yeah basically any 99213s I bill I'm also doing a 90833 with it unless we were truly in and out in 10 minutes. I'm probably about 50/50 99214 + 90833 vs 99214 only for the rest right now.

 

[Bartelby]

Very interesting thread! I agree PP seems to have the potential to be more lucrative. But to play devil's advocate, I think if you pay a VA salary for PP work (rather than something where the person is keeping a lot of what they produce) you will have a hard time finding a psychiatrist. While the VA pays less for the same amount of hours worked even factoring in retirement/benefits/etc., you would need to compete with:

-Sovereign immunity from lawsuits
-No worries about billing (aside from checking off a few boxes for each encounter)
-A very high likelihood that the practice will be open for decades and that a small handful of partners cannot suddenly make major changes to the role
-Access to basically every medical journal, UpToDate and a vast array of other online resources
-The ability to hop into new roles within the system when your interests change
-The ability to teach medical students and residents
-The ability to advance into leadership (if that's your thing), get involved in facility-based research, etc.
-The ability to smile, kick back and surf SDN (or whatever) when patients no-show with no worries that it will affect your bottom line
-An absolutely guaranteed salary (even if the economy tanks or the reimbursement landscape changes)
-A relatively chill caseload where you rarely feel the pressure to stay late or plow quickly through work (none of this "well show up at 8a, see 2-3 patients per hour until 5p and voila! You are earning a time and half what the VA pays!")
-Access to a range of colleagues who can cross-cover and help you keep up to date in your practice

I know I'm painting a rosy picture and I could easily make a list just as compelling for perks of private practice, but a lot of soft factors come into play that everyone weighs differently even if they can't fully articulate why any of it matters. I think if you have a PP typically people expect the take home pay is going to be meaningfully higher to compensate for some of the losses from working outside of a major system (or other perks such as flexibility etc).

 

[randomdoc1]

Very interesting thread! I agree PP seems to have the potential to be more lucrative. But to play devil's advocate, I think if you pay a VA salary for PP work (rather than something where the person is keeping a lot of what they produce) you will have a hard time finding a psychiatrist.

I shall take you up on your challenge! Well, if I want to be a super evil capitalist villain, you can probably find very risk averse providers who'd be willing to stay on the salary model with minute yearly increases. And I understand it's my own issue to deal with, but that still doesn't sit well with me.

-Sovereign immunity from lawsuits
-No worries about billing (aside from checking off a few boxes for each encounter)
-A very high likelihood that the practice will be open for decades and that a small handful of partners cannot suddenly make major changes to the role
-Access to basically every medical journal, UpToDate and a vast array of other online resources
-The ability to hop into new roles within the system when your interests change
-The ability to teach medical students and residents
-The ability to advance into leadership (if that's your thing), get involved in facility-based research, etc.
-The ability to smile, kick back and surf SDN (or whatever) when patients no-show with no worries that it will affect your bottom line
-An absolutely guaranteed salary (even if the economy tanks or the reimbursement landscape changes)
-A relatively chill caseload where you rarely feel the pressure to stay late or plow quickly through work (none of this "well show up at 8a, see 2-3 patients per hour until 5p and voila! You are earning a time and half what the VA pays!")
-Access to a range of colleagues who can cross-cover and help you keep up to date in your practice

-true, we can't protect as well as the VA. But we do a killer job of risk management and being preventative and actively involving patient and loved ones.
-already have the billing part fulfilled ; D. I've learned medical billing and collections and proudly boast a 99+% collection rate. I'm the clinic's billing company and talk about the retained revenue!
-able to provide that access with our finances thanks to smart billing and collections
-true, we do not have too many other new roles
-having medical students and residents is something very much in the pipeline but assessing interest of the providers first
-true, we don't have research opportunities and the primary leadership we have (or maybe most places in general?) involves managing people and I don't see any volunteers right now so I guess we're all happy for the time being?
-yes, no shows can still have an impact. Although our rate is super low, in 11 follow ups a day, maybe 1, if that and they pay their fee
-I see the point with the guaranteed salary if in rare unusual circumstances something turned up. Hope it won't but that means I'm in the risk pool too. Although interesting with onset of covid, many MDs had pay cuts due to cancellations of all things elective but psychiatry in general has thrived and our office just exploded with productivity. Plus we saved on rent. We multiplied our provider numbers and got away with a tiny suite for awhile.
-there can be a chill caseload with decent income. Of course, I can't promise 600k a year at 6 follow ups a day, but I think our rate can compete with other regional employers : )
-we are definitely working on getting more like minded folks on board

I find this thread interesting too and validating, all the posts. That and, I'm working with a recruiter. We're scoping out the different salary and RVU models of other practices and believe I can draft up a nice job description and smoother first year. It's been a good learning experience in the HR realm that ultimately, although more work up front for me in terms of labor (but not a financial loss at all), the return will hopefully be a growing practice with good folks and good lifestyle towards a win win situation.

 

[calvnandhobbs68]

Very interesting thread! I agree PP seems to have the potential to be more lucrative. But to play devil's advocate, I think if you pay a VA salary for PP work (rather than something where the person is keeping a lot of what they produce) you will have a hard time finding a psychiatrist. While the VA pays less for the same amount of hours worked even factoring in retirement/benefits/etc., you would need to compete with:

-Sovereign immunity from lawsuits
-No worries about billing (aside from checking off a few boxes for each encounter)
-A very high likelihood that the practice will be open for decades and that a small handful of partners cannot suddenly make major changes to the role
-Access to basically every medical journal, UpToDate and a vast array of other online resources
-The ability to hop into new roles within the system when your interests change
-The ability to teach medical students and residents
-The ability to advance into leadership (if that's your thing), get involved in facility-based research, etc.
-The ability to smile, kick back and surf SDN (or whatever) when patients no-show with no worries that it will affect your bottom line
-An absolutely guaranteed salary (even if the economy tanks or the reimbursement landscape changes)
-A relatively chill caseload where you rarely feel the pressure to stay late or plow quickly through work (none of this "well show up at 8a, see 2-3 patients per hour until 5p and voila! You are earning a time and half what the VA pays!")
-Access to a range of colleagues who can cross-cover and help you keep up to date in your practice

I know I'm painting a rosy picture and I could easily make a list just as compelling for perks of private practice, but a lot of soft factors come into play that everyone weighs differently even if they can't fully articulate why any of it matters. I think if you have a PP typically people expect the take home pay is going to be meaningfully higher to compensate for some of the losses from working outside of a major system (or other perks such as flexibility etc).

Lol now for some downsides of the VA:
- You can never fire/terminate with your patients, a decent proportion of which are personality disordered/outright malingering to try to get service connected
- You have basically no control over selecting patient inflow
- There's a strong monetary incentive on the patient side to attempt to feign psychiatric symptoms or stay in the sick/disabled role for service connection....so you have a decent proportion of people who just don't want to get better
- You have ever increasing amounts of paperwork to do every year (when I was at the VA a couple years ago in residency, they just rolled out the whole new ridiculous suicide risk assessment thing you had to do on EVERYONE EVERY TIME)
- The feds are constantly expecting you to fix their veteran suicide problem with "increased access to mental healthcare!" or "give everyone this new form and make sure you tell me 3 ways you're trying to keep this person from killing themselves every time you see them"
- No incentive for doing any more work
- You very likely have to deal with inept/lazy support staff that you still have to cozy up to/not make mad because they're almost impossible to fire
- If you want to change anything in your system it has to go through 20 layers of bureaucracy and very likely some nurse or some non-clinical staff is higher in your chain of command

I could go on but I won't 😉 VA definitely works for some people but generally not the type of people that would even be remotely interested in private practice. It's like literally the opposite of it haha.