The downside of the med check system

[NYCMS2]

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As an MS3 who is heading towards psychiatry, one of my greatest concerns about the practice of psychiatry - the 15 minute med check - is at work in this disturbing article:

http://www.nytimes.com/2013/02/03/u...ctices-and-amphetamine-addiction.html?hp&_r=0

I fear becoming "that" psychiatrist.

 

[vistaril]

As an MS3 who is heading towards psychiatry, one of my greatest concerns about the practice of psychiatry - the 15 minute med check - is at work in this disturbing article:

http://www.nytimes.com/2013/02/03/u...ctices-and-amphetamine-addiction.html?hp&_r=0

I fear becoming "that" psychiatrist.

this is hardly a new thing....has been going on for 2 decades+ now.

this is what a majority of psychiatrists practice in this country. And 15 minutes may be generous. Most med checks don't take a full 15 minutes.

 

[OldPsychDoc]

this is hardly a new thing....has been going on for 2 decades+ now.

this is what a majority of psychiatrists practice in this country. And 15 minutes may be generous. Most med checks don't take a full 15 minutes.

Even so, missing an inpatient hospitalization for psychosis, and continuing to supply a controlled med that can be psychotogenic...

I don't want to be "that psychiatrist" either!

 

[vistaril]

Even so, missing an inpatient hospitalization for psychosis, and continuing to supply a controlled med that can be psychotogenic...

I don't want to be "that psychiatrist" either!

well yeah, not every medcheck psychiatrist is of the same quality.

I do think the article made a good point of just how much adult adhd meds have exploded in the psychiatric med check era. The number of very sketchy adult adhd dx out there in the outpt psych community(and perpetual med checks and refills) is astounding.....and looking at the numbers, it is obviously not a few outpt psychiatrists either. It's common to the point it's almost becoming the norm in med mgt private practice(the numbers dont lie)....

 

[PikminOC]

"Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: "reading books — read 10!" her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, "Okay rewrite.""

So it wasn't just a doc.

 

[vistaril]

"Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: “reading books — read 10!” her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, “Okay rewrite.”"

So it wasn't just a doc.

well just skimming the article it appears to be a nurse practitioner in the group, who is likely employed by and supervised bythe psych group. She likely just follows protocol set forth by the group that employs her.

 

[BobA]

I don't know the norm for the country, but I'm glad there are many areas in psychiatry where we can avoid the 15min med check.

For med students reading this, there are enough outpatient venues that allow for longer appointment times to make the field worthwhile. (a Kaiser job promised me 60min new evals and 30min follow ups with excellent support; VA outpatient the same - although I doubt the support would've been as good). The local cash-only private practices here do 60min new evals and 30min f/u's.

There's also inpatient, partial hospital and consults where you can spend more time with patients.

 

[vistaril]

I don't know the norm for the country, but I'm glad there are many areas in psychiatry where we can avoid the 15min med check.

For med students reading this, there are enough outpatient venues that allow for longer appointment times to make the field worthwhile. (a Kaiser job promised me 60min new evals and 30min follow ups with excellent support; VA outpatient the same - although I doubt the support would've been as good). The local cash-only private practices here do 60min new evals and 30min f/u's.

There's also inpatient, partial hospital and consults where you can spend more time with patients.

support at the VA(at least the ones Im familar with) is incredible.....also, they only typically schedule you maybe 10 followups in a day, so even though they are booked in 30 minute intervals....well, do the math. It is a horribly inefficient system. Of course outpt VA has its own frustrations, but the schedule is incredible.

the downside is that if you do 30 minute followups you make less money. And you're still doing a med check. You're still seeing the patient fairly infrequently. It makes for a more enjoyable day sure. It may give you a little extra time to catch things you wouldnt have otherwise caught. But the downside is you are making a lot less money. also, many patients with deductibes would prefer the 15 min med mgt...after that if their copay is the same they may not care either way.

curious- what was the outpt kaiser job paying?

 

[vistaril]

I don't know the norm for the country, but I'm glad there are many areas in psychiatry where we can avoid the 15min med check.
.

you can avoid them in every area of the country....heck, you can do 3 day med checks if that is your thing...with 5 day evals. Nobody is preventing you from practicing however you want.

 

[F0nzie]

The 15 minute med check does not take place in all settings. The reason it exists so extensively in particular settings is due to diminishing reimbursements. A lot of places cannot generate enough revenue from a psychiatrist to support their salary, so in many cases the psychiatrist salary is subsidized. It's a sad reality. This is why the VA can afford to pay their psychiatrists 170k per year + excellent benefits for 30 minute follow ups with a 50% no-show rate and no late charges. Believe me, these psychiatrists are not supporting their own salaries by the reimbursement rates I know of.

Larger entities can also subsidize their psychiatrist's salary ie. Kaiser, and large multispecialty groups. Working for the county, State, academics, also subsidizes salaries with public funding. You are more likely to be able to negotiate 30 minute checks in these settings.

Hospital practice settings such as CL psychiatry where 15 or even 30 minute visits are next to impossible due to the inefficiencies of walking around the hospital and extensive nature of evaluations do not have any job openings. I have noticed in my search that many hospitals have psychiatric nurse practitioners handling all the floor consults and have no interest in hiring a CL psychiatrist.

In an insurance based private outpatient practice however, you're completely on your own. The smaller your practice is, the greater your overhead burden will be. The Medicare formula which sets the rates for reimbursement which insurance companies also follow, is also making it increasingly more difficult to survive in independent practice (not just psychiatrists). As reimbursement rates are cut or fail to keep up with inflation, larger entities are able to offer higher hourly wages as they are better able spread out the overhead burden. If this trend continues you will see psychiatrists making a shift away from private practice.

If you want to make your life easier in private practice, drop your insurance panels and charge cash. Set up your practice so that you see patients for 1 hour follow ups for med/therapy. Just know, you'll have to work hard to find these patients and you will not have a steady stream of income for quite some time.

Unfortunately, in an economic downturn Psychiatry is the first to get cut out from spending and in an economic upswing it's the last to get funded. The extreme shortage of psychiatrists and need for psychiatric treatment is giving us the leverage we currently have for employers willing to hire us at a loss *cough except Cedar Sinai*. And it is really good leverage-- you will not have problems finding a work. Either way, do what's best for the patient and find a work environment that will support it.

 

[vistaril]

The 15 minute med check does not take place in all settings. The reason it exists so extensively in particular settings is due to diminishing reimbursements. A lot of places cannot generate enough revenue from a psychiatrist to support their salary, so in many cases the psychiatrist salary is subsidized. It's a sad reality. This is why the VA can afford to pay their psychiatrists 170k per year + excellent benefits for 30 minute follow ups with a 50% no-show rate and no late charges. Believe me, these psychiatrists are not supporting their own salaries by the reimbursement rates I know of.

Larger entities can also subsidize their psychiatrist's salary ie. Kaiser, and large multispecialty groups. Working for the county, State, academics, also subsidizes salaries with public funding. You are more likely to be able to negotiate 30 minute checks in these settings.

Hospital practice settings such as CL psychiatry where 15 or even 30 minute visits are next to impossible due to the inefficiencies of walking around the hospital and extensive nature of evaluations do not have any job openings. I have noticed in my search that many hospitals have psychiatric nurse practitioners handling all the floor consults and have no interest in hiring a CL psychiatrist.

In an insurance based private outpatient practice however, you're completely on your own. The smaller your practice is, the greater your overhead burden will be. The Medicare formula which sets the rates for reimbursement which insurance companies also follow, is also making it increasingly more difficult to survive in independent practice (not just psychiatrists). As reimbursement rates are cut or fail to keep up with inflation, larger entities are able to offer higher hourly wages as they are better able spread out the overhead burden. If this trend continues you will see psychiatrists making a shift away from private practice.

If you want to make your life easier in private practice, drop your insurance panels and charge cash. Set up your practice so that you see patients for 1 hour follow ups for med/therapy. Just know, you'll have to work hard to find these patients and you will not have a steady stream of income for quite some time.

Unfortunately, in an economic downturn Psychiatry is the first to get cut out from spending and in an economic upswing it's the last to get funded. The extreme shortage of psychiatrists and need for psychiatric treatment is giving us the leverage we currently have for employers willing to hire us at a loss *cough except Cedar Sinai*. And it is really good leverage-- you will not have problems finding a work. Either way, do what's best for the patient and find a work environment that will support it.

agree with much of this post.

Note that not all VA outpt positions pay 170k+....some are starting more at 155k. But yeah, there is no way a psychiatrist at the VA 'earns' that salary if they were 90805's or whatever. Furthermore, it's not really relevant because the VA doesn't charge most patients anyways. Not linking salary and billing/patients in any real sense is a good thing for the VA psychiatrist(or VA outpt internist for that matter) because it would not be a pretty sight if it were done...taxpayers are getting screwed by every facet of the VA(it's not just a psych thing)

 

[Doctor Bagel]

The 15 minute med check does not take place in all settings. The reason it exists so extensively in particular settings is due to diminishing reimbursements. A lot of places cannot generate enough revenue from a psychiatrist to support their salary, so in many cases the psychiatrist salary is subsidized. It's a sad reality. This is why the VA can afford to pay their psychiatrists 170k per year + excellent benefits for 30 minute follow ups with a 50% no-show rate and no late charges. Believe me, these psychiatrists are not supporting their own salaries by the reimbursement rates I know of.

Larger entities can also subsidize their psychiatrist's salary ie. Kaiser, and large multispecialty groups. Working for the county, State, academics, also subsidizes salaries with public funding. You are more likely to be able to negotiate 30 minute checks in these settings.

Hospital practice settings such as CL psychiatry where 15 or even 30 minute visits are next to impossible due to the inefficiencies of walking around the hospital and extensive nature of evaluations do not have any job openings. I have noticed in my search that many hospitals have psychiatric nurse practitioners handling all the floor consults and have no interest in hiring a CL psychiatrist.

In an insurance based private outpatient practice however, you're completely on your own. The smaller your practice is, the greater your overhead burden will be. The Medicare formula which sets the rates for reimbursement which insurance companies also follow, is also making it increasingly more difficult to survive in independent practice (not just psychiatrists). As reimbursement rates are cut or fail to keep up with inflation, larger entities are able to offer higher hourly wages as they are better able spread out the overhead burden. If this trend continues you will see psychiatrists making a shift away from private practice.

If you want to make your life easier in private practice, drop your insurance panels and charge cash. Set up your practice so that you see patients for 1 hour follow ups for med/therapy. Just know, you'll have to work hard to find these patients and you will not have a steady stream of income for quite some time.

Unfortunately, in an economic downturn Psychiatry is the first to get cut out from spending and in an economic upswing it's the last to get funded. The extreme shortage of psychiatrists and need for psychiatric treatment is giving us the leverage we currently have for employers willing to hire us at a loss *cough except Cedar Sinai*. And it is really good leverage-- you will not have problems finding a work. Either way, do what's best for the patient and find a work environment that will support it.

I would guess that closed systems like the VA and Kaiser also save money because having psychiatrists on staff can reduce hospitalizations and help with patients' overall health. So while billing doesn't pay their salary, I suspect they earn it just the same.

As for Medicare compensation, who cares about that? No one in my community even takes Medicare because their compensation is so ridiculous. And providers here are able to establish profitable private practices without a ton of effort. Maybe it depends on where you work. Or maybe more avenues for private practice are available than you think.

 

[Doctor Bagel]

Even so, missing an inpatient hospitalization for psychosis, and continuing to supply a controlled med that can be psychotogenic...

I don't want to be "that psychiatrist" either!

It sounds pretty egregious when you read the story, but I think you could easily miss a hospitalization in another hospital system if no one reports it to you. How would you know unless the patient, his family or the providers at the other hospital tell you? It's certainly imaginable that none of them would. I can also see how a charismatic, smart, addicted guy could fool a lot of people.

 

[vistaril]

I would guess that closed systems like the VA and Kaiser also save money because having psychiatrists on staff can reduce hospitalizations and help with patients' overall health. So while billing doesn't pay their salary, I suspect they earn it just the same.
QUOTE]

dont lump kaiser and the VA together....the VA is completely detached from any semblance of the market. There are full time outpt psychiatrists at the VA who only see 1300 patient visits a year....mostly followups too. Again, there is no market lesson there other than the VA is not efficient.

At kaiser the psychiatrist may very well earn their salary. Yeah, it's a closed system...but they are going to set a workload that is tied to compensation through pt visits.

 

[F0nzie]

As for Medicare compensation, who cares about that? No one in my community even takes Medicare because their compensation is so ridiculous. And providers here are able to establish profitable private practices without a ton of effort. Maybe it depends on where you work. Or maybe more avenues for private practice are available than you think.

I was not referring to psychiatrists that accept Medicare. I do not know any private psychiatrist in town that accepts Medicare patients. That's a separate issue. I was referring to the issue of "price fixing" and the fact that insurance companies adjust their rates based on the rates that Medicare sets. Insurance will reimburse about 20% more than Medicare. If Medicare cuts rates for certain procedures, insurance companies will reduce the rates to reflect the changes. If rates stay stagnant, insurance companies won't budge.

I would argue with you over your statement that starting your own insurance based private practice can be done without a ton of effort. When insurance companies are paying between $60-80 per follow up, you better be seeing at least 3 patients an hour(to account for your overhead so that you can have an "average or below average salary" assuming you have exceptional staff and a high collections rate). Not to mention the fact that you'll need to manage all the other complicated aspects of the business including payroll, hiring staff (secretarial + bulling), training the staff, paying their benefits, getting on panels, etc. When you fill you schedule full-time you'll have a nice caseload of 1000 patients that you will be on call for. Good luck getting any sleep.

Now if you were to join an existing private practice where you are alleviated of all administrative responsibilities and have 4 or 5 other doctors take call for you, with a stream of patients nicely added to your schedule and all you have to do is show up that's a totally different story.

 

[kindasorta]

Sorry, but I have yet to hear of a PP solo practitioner having a problem making ends meet or being awoken every night to a ringing phone.

 

[michaelrack]

Not to mention the fact that you'll need to manage all the other complicated aspects of the business including payroll, hiring staff (secretarial + bulling), training the staff, paying their benefits, getting on panels, etc.

.

It's not that complicated. Alot of this can be contracted out (though the doc still needs to keep an eye on things). For example, a doc can hire a billing service for a % of collections. Your accountant can help you with payroll; their are also companies that you can hire for this. If a doc has only 1 employee (as many solo psychiatrists do), it's probably more economical to have an accountant guide you in payroll matters, rather than hiring a payroll service.

 

[vistaril]

Sorry, but I have yet to hear of a PP solo practitioner having a problem making ends meet or being awoken every night to a ringing phone.

sunlionness on this very forum wasn't making much money in such a setting and had to take a salaried position as a result.

 

[kindasorta]

sunlionness on this very forum wasn't making much money in such a setting and had to take a salaried position as a result.

If I recall correctly, she also said she had no business-sense, or something to that effect.

 

[vistaril]

It's not that complicated. Alot of this can be contracted out (though the doc still needs to keep an eye on things). For example, a doc can hire a billing service for a % of collections. \QUOTE]

true...you can contract things out and work on %'s. But that cuts further into already tight margins.

 

[F0nzie]

As the great philosopher Eminem would say: "Would the real solo insurance-based private practice psychiatrist on this forum please stand up... please stand up".

 

[vistaril]

If I recall correctly, she also said she had no business-sense, or something to that effect.

her saying that was also(at least partly) her way of saying she wasn't going to give up certain standards of care. She gave numerous real world examples of the day to day difficulties in running an insuranced based med mgt outpt psych practice.

you guys who think these perfect patients are going to line up at your office to have you increase their wellbutrin from 300 to 450 in a nice tidy med check while you shake their hand and your staff only consuming 27% overhead promptly processes their ideal insurance makes them a follow up appt to do it all again in 4 weeks are not in reality.

 

[vistaril]

As the great philosopher Eminem would say: "Would the real solo insurance-based private practice psychiatrist on this forum please stand up... please stand up".

exactly.

to be fair though, there are tons of 3-7 person groups out there that do ok and make it work.....but most of them are doing serious grinding

 

[xlithiumx]

exactly.

to be fair though, there are tons of 3-7 person groups out there that do ok and make it work.....but most of them are doing serious grinding

Please say grinding more frequently, it is so patient centered.

 

[BobA]

curious- what was the outpt kaiser job paying?

I don't want to give away too many details, but I will say that the base pay was slightly above average for the area. People told me that with the bonuses it could be quite lucrative (up to 250K).

Really the Kaiser job was great in every way with only one problem - it seemed like Kaiser patients had more limited access to psychotherapy than someone with a private plan might have. For certain patients (not everyone) - I really feel they need a therapist +/- med management. I dislike having patients essentially expecting me to fix their marriage or job with a pill, and always like it better when I feel confident they have a therapist the could engage to help solve these problems. Of course, I would've taken it even with this misgivings if my family didn't want to go somewhere else.

 

[vistaril]

I don't want to give away too many details, but I will say that the base pay was slightly above average for the area. People told me that with the bonuses it could be quite lucrative (up to 250K).

Really the Kaiser job was great in every way with only one problem - it seemed like Kaiser patients had more limited access to psychotherapy than someone with a private plan might have. For certain patients (not everyone) - I really feel they need a therapist +/- med management. I dislike having patients essentially expecting me to fix their marriage or job with a pill, and always like it better when I feel confident they have a therapist the could engage to help solve these problems. Of course, I would've taken it even with this misgivings if my family didn't want to go somewhere else.

if the base was at least 200(you cant really trust bonuses) and it was all 9 to 5 outpatient M-F and they gave you 30 minute followups and had good support staff, then that's a damn good job. Of course I don't what area it is.

The limited access to therapy isn't as big a deal as you think when you realize a lot of patients with a private plan have limited practial access...for a variety of reasons.

there are certainly crappier jobs....I know of several people on salary making just shy of 200k who are actually expected to do low level grinding(4 an hour in some cases).