So can we talk money?

[Doctor Bagel]

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A bunch of the multispecialty physicians groups that I looked at around here were flat out "no public aid" for outpatient psychiatry. So assumedly it can be done.

My residency program's outpatient clinic didn't take medicaid or only grandfather in medicare people. No one takes medicaid in my area except community mental health places that are pretty much 100% medicaid.

Not only could it be done, but I think it's almost necessary to have manageable patients for an outpatient practice without community MH resources like case management.

 

[Doctor Bagel]

So tangentially related to money, I'm actually making more money than I anticipated, and I'm struggling with the spending money angle. I feel like a cliche because I'm moving to a nice apartment and buying a new car. Admittedly the new car is an upgrade from my civic to a subaru. The move was needed, and rents and mortgages aren't cheap anywhere in my city. Still, anxiety!!

 

[psych md jd]

NAS? [New Attending Syndrome]

Don't worry, in a short time your Lexus dealer will know you by name and you will have a private banker, a stockbroker, and real estate person as your new best friends.

 

[WingedOx]

I plan on letting my Ford Focus keep running until the wheels fall off. (doesn't help that where I live the idea of a "nice car" is a huge waste unless I want to fill a Lexus with bumper marks from frequent street parking... I'll wait until I get boring and move to suburbia before getting an RX350).

I'm in a fortunate situation that Ms. Ox purchased a short sale in a rapidly gentrifying area before we met. My living expenses are actually lower than during residency. But aside from the fact that my loan payments are up to a grand a month, I've been happy to live like a resident for a while.

/though it's more like a "resident who moonlights frequently"

 

[Doctor Bagel]

I plan on letting my Ford Focus keep running until the wheels fall off. (doesn't help that where I live the idea of a "nice car" is a huge waste unless I want to fill a Lexus with bumper marks from frequent street parking... I'll wait until I get boring and move to suburbia before getting an RX350).

I'm in a fortunate situation that Ms. Ox purchased a short sale in a rapidly gentrifying area before we met. My living expenses are actually lower than during residency. But aside from the fact that my loan payments are up to a grand a month, I've been happy to live like a resident for a while.

/though it's more like a "resident who moonlights frequently"

Cars are essentially indestructible these days, so I'm sure I keep keep the civic going for ages. However, I hate, hate, hate, hate, hate driving it to the mountain -- it's got some weird design thing where putting chains on it (which is a thing out here when you drive on snow in the mountains) is so freaking hard and stressful and miserable and probably takes years off my life. So new car is needed before ski season starts. Jeez, I really do sound like a doctor cliche here. Need new car so I can go skiing. We're a one car family, so still, that subaru again isn't anywhere pushing extravagant.

$1k/month loan payments sound nice. Mine are a little less than now with IBR, but that's not gong to last after they get readjusted with my new income. Putting extra money toward them depends on whether I want to go for PSLF or not. Argument against PSLF is the private practice thought ...

 

[psych2009]

I am currently in an inpatient plus outpatient major hospital system, leaving this due to disorganization in unit and clinic. Have two offers and trying to weigh both. Input will be much appreciated 🙂
Inpatient with full benefits : 50$ an rvu: 8 inpt plus 2-3 ED plus 2-3 consults a day: people working there say they can take home 250k depending on amount of work and staff. Calls paid extra but can be more than once a week.
Outpatient independent contractor: they take 30% in overhead, no benefits. Only good insurance accepted, no Medicaid , little Medicare and some cash. More than 90% collection. This is 5 miles from my home.
My Three year old's daycare might need to be changed at both places but less so than the first option.

 

[sweetlenovo88]

So tangentially related to money, I'm actually making more money than I anticipated, and I'm struggling with the spending money angle. I feel like a cliche because I'm moving to a nice apartment and buying a new car. Admittedly the new car is an upgrade from my civic to a subaru. The move was needed, and rents and mortgages aren't cheap anywhere in my city. Still, anxiety!!

Dave Ramsey

 

[Doctor Bagel]

Dave Ramsey

Eh. Nah. Could do without the religious angle in my financial advice.

Again, though, I'm not doing anything remotely extravagant. I'm just feeling guilty and anxious about spending pretty small amounts of money that could result in substantial improvements in my quality of life. I'd been delaying lots of purchases until I finished training so it just feels like this stuff is stacking up all of the sudden.

 

[Doctor Bagel]

I am currently in an inpatient plus outpatient major hospital system, leaving this due to disorganization in unit and clinic. Have two offers and trying to weigh both. Input will be much appreciated 🙂
Inpatient with full benefits : 50$ an rvu: 8 inpt plus 2-3 ED plus 2-3 consults a day: people working there say they can take home 250k depending on amount of work and staff. Calls paid extra but can be more than once a week.
Outpatient independent contractor: they take 30% in overhead, no benefits. Only good insurance accepted, no Medicaid , little Medicare and some cash. More than 90% collection. This is 5 miles from my home.
My Three year old's daycare might need to be changed at both places but less so than the first option.

What's the volume with the outpatient?

 

[sweetlenovo88]

Eh. Nah. Could do without the religious angle in my financial advice.

Again, though, I'm not doing anything remotely extravagant. I'm just feeling guilty and anxious about spending pretty small amounts of money that could result in substantial improvements in my quality of life. I'd been delaying lots of purchases until I finished training so it just feels like this stuff is stacking up all of the sudden.

I wouldn't feel guilty if they really are small amounts of money. Just have a solid plan to get rid of your debt and keep your spending in check. I said Dave Ramsey because the show is quite inspirational when you are working your butt off paying loans. And I'm definitely not evangelical Christian. Lol

 

[Doctor Bagel]

I wouldn't feel guilty if they really are small amounts of money. Just have a solid plan to get rid of your debt and keep your spending in check. I said Dave Ramsey because the show is quite inspirational when you are working your butt off paying loans. And I'm definitely not evangelical Christian. Lol

You know, I'd love to get more nuanced financial advice from people who actually know about student loan debt, which seems to be no one. I don't have any other sources of debt, although I guess I might have this car loan soon. The whole all debt is bad thing is fairly simplistic.

I know you're opting to work a ton and really pay down debt. I'm curious what other people are electing to do? Right now I'm leaning more toward PSLF -- primary downside of this is putting off thoughts about private practice for several years. 10 year tax free forgiveness (less than 10 years for me because I paid some in residency) would be a huge windfall. I know there's talk about future caps on forgiveness, but the general feeling (not guarantee, but feeling) is that already existing debtors will be grandfathered in, keeping the current system.

I've decided I either need to do this or emphasize making a lot of money. 🙂

 

[doctorpilgrim]

I am currently in an inpatient plus outpatient major hospital system, leaving this due to disorganization in unit and clinic. Have two offers and trying to weigh both. Input will be much appreciated 🙂
Inpatient with full benefits : 50$ an rvu: 8 inpt plus 2-3 ED plus 2-3 consults a day: people working there say they can take home 250k depending on amount of work and staff. Calls paid extra but can be more than once a week.
Outpatient independent contractor: they take 30% in overhead, no benefits. Only good insurance accepted, no Medicaid , little Medicare and some cash. More than 90% collection. This is 5 miles from my home.
My Three year old's daycare might need to be changed at both places but less so than the first option.

IMHO the best part to negotiate is higher price per rvu as median rvu is more like 60. Anywhere you go if you get paid more per unit then you can always make more units as needed or desired.

 

[psych2009]

I have signed the letter of intent but not the contract yet. I will ask for 60$ an rvu. Thanks for the advice.
Dr Bagel : they say I will be full within a few weeks, I intend to work about 32-35 hours, anymore and outpatient burn out would happen. This will be pretty flexible as to number of patients etc... I intend 20 min follow ups once initial one hours are out of the way for each patient.
I like both options, so it is tough to decide. But ya no calls option is enticing with the kids situation.
And money might be better per hour in outpatient deal.

 

[Doctor Bagel]

I have signed the letter of intent but not the contract yet. I will ask for 60$ an rvu. Thanks for the advice.
Dr Bagel : they say I will be full within a few weeks, I intend to work about 32-35 hours, anymore and outpatient burn out would happen. This will be pretty flexible as to number of patients etc... I intend 20 min follow ups once initial one hours are out of the way for each patient.
I like both options, so it is tough to decide. But ya no calls option is enticing with the kids situation.
And money might be better per hour in outpatient deal.

So 32 hours of patient care, not including documentation and administrative time? What's the pressure for intakes? How realistic are the 20 minute follows up with this population and the clinic's administrative staff? No shows?

So potentially pretty full days with the outpatient job but less after hours versus less busy days in inpatient but more after hours. Income maybe more for outpatient when you exclude calls? The inpatient day sounds somewhat busy, too, though, if there are 2 to 3 consults (new consults?) on top of the other work.

 

[psych2009]

Clinic is owned by a psychologist and she asked me dumb q while interviewing as if I was a medical student. It didn't bother me much somehow.
She says there is plenty of work, no shows are charged full fee. And that I would make 225 to 250 k. She didn't comment on follow up min or hourly rate. I asked her how much it is but she said it is variable.
Inpatient gig, consults vary on a daily basis, I hear most people work 6 to 7 hours non stop. ( ok maybe they eat lunch in 15 min).

 

[sweetlenovo88]

Clinic is owned by a psychologist and she asked me dumb q while interviewing as if I was a medical student. It didn't bother me much somehow.
She says there is plenty of work, no shows are charged full fee. And that I would make 225 to 250 k. She didn't comment on follow up min or hourly rate. I asked her how much it is but she said it is variable.
Inpatient gig, consults vary on a daily basis, I hear most people work 6 to 7 hours non stop. ( ok maybe they eat lunch in 15 min).

So the psychologist is taking 30% of all the billing? I am working for a psychologist owned clinic 2 days a week now. I wonder how many patients they will want you too see per day and how many hours you end up working for the pay.

 

[WingedOx]

Cars are essentially indestructible these days, so I'm sure I keep keep the civic going for ages. However, I hate, hate, hate, hate, hate driving it to the mountain -- it's got some weird design thing where putting chains on it (which is a thing out here when you drive on snow in the mountains) is so freaking hard and stressful and miserable and probably takes years off my life. So new car is needed before ski season starts. Jeez, I really do sound like a doctor cliche here. Need new car so I can go skiing. We're a one car family, so still, that subaru again isn't anywhere pushing extravagant.

$1k/month loan payments sound nice. Mine are a little less than now with IBR, but that's not gong to last after they get readjusted with my new income. Putting extra money toward them depends on whether I want to go for PSLF or not. Argument against PSLF is the private practice thought ...

I love where I'm at and have an insanely good job for this point in my life, but yeah, there's no skiing that's worth anything in this part of the Midwest. Sad, because ski racing was my HS varsity sport. If I move anywhere in the future, it's going to have some mountains.

My loans are in private hands so PSLF was never an option, but I'm in better shape than most when it comes to interest.

My residency program's outpatient clinic didn't take medicaid or only grandfather in medicare people. No one takes medicaid in my area except community mental health places that are pretty much 100% medicaid.

Not only could it be done, but I think it's almost necessary to have manageable patients for an outpatient practice without community MH resources like case management.

Isn't your area basically OSHU + Providence and that's about it?

Our area is kind of different because community MH resources are poor and shrinking rapidly (thanks Rahm/Obama) and we have entire geographic swaths of the city where if you're not taking medicaid, you really don't have any patients. Ironically enough my clinics were probably 60% medicaid with the rest university employees and city employees with whom we had a large HMO contract. We didn't have much SW help either. It was frustrating at times but in hindsight it made me a better psychiatrist.

Of course our state privatized medicaid within the last couple years... it's created chaos for our chronically ill patients who were well established with us.

 

[psych2009]

Ya she is taking 30% and it includes all the staff billing rent etc. I don't know how good a deal it is but the collection rate is above 90s she says.can set own hours and there are other MDs too. Couldn't talk to any of them.

 

[sweetlenovo88]

Interesting if you do this please keep me updated

 

[Blitz2006]

Slightly off topic, but kinda on topic.

Whats the deal with ECT reimbursements? One attending tells me you can bill $500 for an ECT, but another says the psychiatrist only takes home $40 and is not worth it.

I'm struggling to see why a psychiatrist would wake up at 6am to do it if they are bringing back only $40/pop.

Somone is not telling the truth here!

 

[splik]

well it depends on the insurance, whether a hospital or private clinic, and the model of payment for the psychiatrist. If working in a hospital medicare currently pays $113.84 for an ECT. If in a private clinic $172.53. Medicaid will pay much less and private insurance will pay more. But the only way you can bill $500 if the psychiatrist is also doing the anesthesia. Technically psychiatrists can also do and bill for the anesthesia for ECT but I can't imagine a situation where this would be reasonable.

also bear in mind medicare is notorious for not paying what is billed. bear in the mind the vast majority of ECT in the US is on medicare patients. In fact there is an astronomical difference is the chance of someone getting ECT at the age of 64 vs. 65 and it is only explained by medicare coverage. also remember what is billed isn't necessarily what the psychiatrist takes home because their are additional costs associated with ECT.

 

[WingedOx]

Here's a question I don't know because I've never asked: Is the ECT machine a single fixed cost when it's purchased or is it like Lasik where a royalty is paid to the company every time the laser is zapped? (or something in between where the tech support is paid for incrementally?)

 

[doctorpilgrim]

Ect machine is approx 12k one time cost with maintenance contract for 10 years. One ect is less than 2 rvu.

 

[Blitz2006]

Stupid resident question time.

How much is 1 rvu?

 

[TexasPhysician]

Stupid resident question time.

How much is 1 rvu?

How much what?

 

[Blitz2006]

is RVU time dependent or $ dependent or procedure dependent (which i figure does not apply in psych).

As in, is 1 RVU = 30 min or $50 or 1 ECT....newbie question.

 

[Blitz2006]

Ect machine is approx 12k one time cost with maintenance contract for 10 years. One ect is less than 2 rvu.

So based on this, I presume buying an ECT machine and having it in your outpatient clinic setting is a 'good investment' , as its $172/pop as per splik's post (for private insurance).

 

[WingedOx]

For the vast majority of things you'll do as an attending psychiatrist (not counting procedures), your RVU for each encounter will depend on the encounter code you put in. (99213, 99214, +/-90833). This will most of the time correlate with time spent with the patient, but it will depend on your documentation.

 

[splik]

RVU = relative value units. This was something developed by Bill Hsaoi's group at Harvard to curtail costs to medicare in as fair a way as possible. Prior the 1970s medicare would pretty much pay whatever people billed (if seen as "reasonable"). Its a very elegant solution on the one hand, but its hugely problematic and ignores the entire problem of fee for service

RVUs have 3 components - work (time, effort, stress on doctor), practice expense (office space, supplies, non-clinical personnel) and professional liability insurance (i.e. more risky the procedure) and thus all adds up to the RVUs assigned to a procedure (CPT code). This is one of the reasons that psychiatrists are paid much less than other specialities because we tend to use time based codes, whereas other specialties can crank out people much faster and bill the same codes. Also many of the CPT codes and RVUs assigned (which self-servingly is done by the AMA) have not been changed since the 1970s or 80s! This is the reason why gastroenterologists get paid so much. Because the RVUs assigned to an EGD or colonoscopy assume it takes 60 minutes when today it takes 3-10 minutes! You can't do this with psychotherapy because it's entirely time based for example. One issue has been psychiatrists have not been involved in this committee until recently, whereas the dermatologists, cardiologists and other specialists have been. As a result they have been defrauding the system and earning lots of money, whereas primary care specialties and psychiatry have been losing out.

CMS sets how much an RVU is worth each year, currently is $32.80, this figure has continued to fall, and only stopped falling dramatically further this year because government repealed SGR (finally).

To be honest if you're not learning about this sort of stuff then you should be doing your own reading on the topic otherwise you will not be able to effectively bargain for your salary if going for a salaried job, or know how to maximise earnings if going into insurance based private practice.

 

[Blitz2006]

that is the medicare reimbursement i put not private and medicare assigns 5.26 RVUs to 90870 (ECT) in a non-facility. 3.18 RVUs for facility (at least last figures I have)

Where do you get these figures? Is it on the medicare website?

My residency program teaches us jack on this stuff....

So now that psychiatrists sit on this committee, do you think CPT/RVU will change for the better in our favor, as derm/cards has had their glory years?

 

[splik]

get the APA's CPT coding book

 

[notdeadyet]

So based on this, I presume buying an ECT machine and having it in your outpatient clinic setting is a 'good investment' , as its $172/pop as per splik's post (for private insurance).

Don't discount anesthesia. You need folks sedated and their airway protected while you're inducing the seizure.

Psychiatrists do ECT with the assistance of an anesthesiologist or a nurse anesthetist. I guess you could try to do it solo but you'd be practicing outside the standard of care. You'd stand a good chance of getting killed in a civil suit.

ECT is typically safe, but if you've done it for any length of time, you've had a patient not react well to the anesthesia. Sitting alone in an outpatient clinic when this happens is not good and can produce events that might be outside your skill-set. Also, most places require monitoring the patient post-procedure.

The money for the box is the least of the investment. These issues are why ECT is usually done at academic places or via the county institutions.

 

[Blitz2006]

Right, I realize this. I wasn't planning on doing ECT solo! But I figured it can't be hard to recruit a CRNA for a couple hours in the AM to do ECT in an outpatient setting? Or maybe it is?

 

[TexasPhysician]

And RVU's don't necessarily correlate to $.

For instance: The local academic center faculty bill all new evals at 90192 as it has more RVU's than 99204. Faculty get bonuses based on RVU's. Oddly enough 99204 codes there pay better than 90792.

 

[TexasPhysician]

Right, I realize this. I wasn't planning on doing ECT solo! But I figured it can't be hard to recruit a CRNA for a couple hours in the AM to do ECT in an outpatient setting? Or maybe it is?

You would likely need significant volume of patients. You are likely to have to pay anesthesia staff by the hour, and they are likely to want to know the # of hours in advance. If you can't fill their time, you still have to pay them.

ECT is mostly done at academic centers (already have anesthesia staff) and large inpatient centers (lower risk of no-shows and high volume).

In private practice, you need a lot of patients to have enough ECT volume, guarantee anesthesia time/pay, rent the space, pay a nurse, and be worth your time ($$$).

 

[masterofmonkeys]

I just found out that my institution sets pay based on MGMA annual salaries. My concern is that as we know a substantial chunk of psychiatrists do not work 1 FTE but more like 0.6 or 0.8. I know nothing about MGMA but ifthey aren't automatically correcting for hours, this seems like this could depress wages significantly. And would explain why their pay is...100k less than median. 100k less. No joke.

 

[Leo Aquarius]

Tell your institution to get a clue. I'm asking all of us to negotiate fair and competitive salaries (if you go that route), and not settle for anything less. This way we can put the pressure on lame institutions that forget that MGMA ignores hours worked.

 

[sunlioness]

My new job resulted in a pay cut and a move to a higher cost of living area. I feel bad being freaked out by that. All things considered, it's a nice salary. I mean compared to the general population. Low for psychiatry though. And I'm still paying off school loans. I'm still a bit freaked out by the whole thing. Fortunately I already bought the new car.


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[Shikima]

My new job resulted in a pay cut and a move to a higher cost of living area. I feel bad being freaked out by that. All things considered, it's a nice salary. I mean compared to the general population. Low for psychiatry though. And I'm still paying off school loans. I'm still a bit freaked out by the whole thing. Fortunately I already bought the new car.


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Unfortunately? With the new place, any loan forgiveness options through Feds and/or state?

 

[sunlioness]

Nope. I don't believe so.

Ugh. Infuriating. Not my new employer. The system. The Man is getting me down.


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[WingedOx]

My new job resulted in a pay cut and a move to a higher cost of living area. I feel bad being freaked out by that. All things considered, it's a nice salary. I mean compared to the general population. Low for psychiatry though. And I'm still paying off school loans. I'm still a bit freaked out by the whole thing. Fortunately I already bought the new car.


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You in Philly proper or the 'Burbs?

 

[sunlioness]

Burbs. Work in DelCo. Live in ChesCo.


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[Doctor Bagel]

On the car issue -- I pulled up to the parking lot for my community MH gig, and I've got one of the oldest cars there. I parked right next to a Mercedes. I'm sure everyone assumes that's the doctor's car rather than my beat up civic.

 

[F0nzie]

On the car issue -- I pulled up to the parking lot for my community MH gig, and I've got one of the oldest cars there. I parked right next to a Mercedes. I'm sure everyone assumes that's the doctor's car rather than my beat up civic.

The lead case managers drive the BMWs and Mercedes at my clinic. I still have a 2007 Prius that I'm trying to drive into the ground. Damn thing keeps going! >_<.

 

[sunlioness]

It cracks me up that Priuses beep when they back up . . . On the inside.


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[dl2dp2]

The lead case managers drive the BMWs and Mercedes at my clinic. I still have a 2007 Prius that I'm trying to drive into the ground. Damn thing keeps going! >_<.

U r doing the right thing. Cars are not worth it. Unless it's a Maserati. Which you will have one day. if you want.

 

[Yellow mellow]

Bump

 

[WingedOx]

Burbs. Work in DelCo. Live in ChesCo.


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hmm, yeah, DelCo is diverse to say the least. You could be anywhere from Media to Chester...

The lead case managers drive the BMWs and Mercedes at my clinic. I still have a 2007 Prius that I'm trying to drive into the ground. Damn thing keeps going! >_<.

I've got a 2007 generic American 4 door that after 6+ years of me driving in the city now looks like something from Mad Max... yet still less than 70,000 miles or so on it or so due to 4 years of a really short commute in residency. I'm wondering how it's going to hold up now that I'm making the city to 'burb commute every morning.

 

[Trismegistus4]

Hey sunlioness, I was wondering if you'd be willing to share what you know about incomes in Southeastern PA. (I went to send you a PM, but your profile says you're bad at responding to them and to post a question instead. 🙂) I am from there and had been looking for jobs farther south for the weather, but after not finding anything ideal, I've been starting to think about returning home. But I've heard pay in the East Coast cities is not as good. I've been offered $220k/year in non-horrible places to live, and I think if I could make that much in Philadelphia I'd be happy, but much less, forget it.

 

[sunlioness]

Hey sunlioness, I was wondering if you'd be willing to share what you know about incomes in Southeastern PA. (I went to send you a PM, but your profile says you're bad at responding to them and to post a question instead. 🙂) I am from there and had been looking for jobs farther south for the weather, but after not finding anything ideal, I've been starting to think about returning home. But I've heard pay in the East Coast cities is not as good. I've been offered $220k/year in non-horrible places to live, and I think if I could make that much in Philadelphia I'd be happy, but much less, forget it.

I'm making much less. Salaries locally are on the low side. I did some digging around when I went to move back. I could make more if I were willing to work two weeks of straight nights on inpatient/emergency/CL. Those jobs were offering around $200K. Two weeks straight nights. two weeks off. No vacation time (because two weeks off). But that just sounded like sheer unadulterated hell. I think two places ran that gig by me, including the place I ultimately ended up. But I took a lower paying outpatient 8-5 type gig instead.

Where are you from? Feel free to pm if you want to chat further. I'm mostly bad at answering people who want to know how to switch from medicine to psych. That's most of what I get. Those people need to search the forums. My experience is ten years out of date now anyway. Heh.

Oh and not sure if you'd be willing to consider a place like Lancaster. I got contacted by a recruiter about a job there, but I just didn't want to be there. Not sure what they were offering.


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