Any idea on reimbursement for tms? I can't find much online.
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Adding components like ECT and Suboxone and try to bulk up in volume will not work. There are a decent number of cash psychiatrists in the NYC Metro who clear 500k+, for <40 hours a week. But it's more about marketing and branding, and this outcome is not guaranteed. If you are not sure how you can be on that track, you probably aren't.
For a run-of-the-mill insurance based psychopharm practice, the math is typically as follows: total billing optimistically would be ~$300 an hour (2x 99213+90836 @ Medicare rates), 35 hours a week billable, 48 weeks a year, minus an optimistic 35% overhead, nets 300-350k a year. Total work hours > 50 hours a week, with a panel of ~300 patients, 1x FTE admin. More psychotherapy = less overhead but lower revenue. Hire someone to do your job: a young locum $150 an hour + recruitment cost, clear a thin profit margin (i.e. ~50k, against a startup cost in the 100-150k range, and NOT counting practice founder's opportunity cost). Takes about a year.
You can see why people don't do this--it's an administrative mess. In a market with a decent number of wealthy patients, the provider cohort tends to bifurcate: either low overhead "boutique" solo cash practice or employed by a medical system getting immediately paid ~200k a year salary + some RVUs and save the work of practice management and buy-in. It's hard to recruit people who are interested in a traditional "partnership" based private practice model because the low profit margin and high labor cost.
In smaller markets, things are different in that 1) people can't afford to pay cash 2) few providers, room for negotiation with insurance 3) therapists are cheaper 4) overhead is lower. It's more feasible to"join" a traditional single specialty or multi-specialty group partnership practice and end up with a much higher profit once you enter equity partnership--i.e. profit margins on allied staff, such as psychologists and SWs, much higher than MDs, and usually the small number of MDs run the mental health divisions of a large multi-specialty provider group. Classically, this is the typical medical practice in the US for all other specialties.
Atypically, quite a few private psychiatrists in even small markets tend to not follow this model, but rather cut their own rates and just do cash solo. Statistically, this number is now >50% and growing. The long term implication for this is unclear.
There's nothing "clinical" in psychiatry that makes a ton of money in a very short period of time (not suboxone, not TMS, not ECT) by just doing it repetitively. We are not MOHS or Retina... I would argue that that's actually a good thing in the long run because CMS can easily cut specific procedural codes, but it's much harder to cut 99213 universally. So when supply and demand is favorable, cash practice can work for pretty much everyone.
