Thoughts on a job?

[psyduck1990]

In the last year the company Traditions Behavioral Health expanded to the Geisinger Health System in Pennsylvania. They were previously only on the west coast. Was wondering what your thoughts would be on the following job. It's acute inpatient at the Geisinger Medical Center in Danville, PA seeing 22-26 (average of 25) inpatients per day during a 7am-11pm shift. The average length of stay is 8 days. No NP/PA/residents. EMR is Epic. No consult/outpatient responsibilities. 11pm-7a is covered via telepsychiatry. The days sound long, but you can work 8 of these shifts and be off the rest of the month so could live elsewhere and commute in for work. It's flexible so you could do 4 on/10off, 8 on/20 off, etc. This is considered FT and comes with good benefits.

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[robellis]

Ok what’s the income..bonuses..etc

 

[psyduck1990]

Ok what’s the income..bonuses..etc

7.5 shifts/month is 236k with up to 8k in bonus. Travel costs are reimbursed.

 

[Techmed07]

300k or walk.

 

[robellis]

7.5 shifts/month is 236k with up to 8k in bonus. Travel costs are reimbursed.

Way too low, 25 patients per day is actual insanity, it needs to be at least 275k

 

[psyduck1990]

They offer the option of working more shifts/month for higher income (i.e. 9.5 shifts/mo for 300k)

 

[Old&InTheWay]

I'm not sure I could do good work seeing 25 patients in a 16 hour day, but if you have good stamina, it's no more patients than if you were seeing 12 patients/8 hour day, 16 days a month.

As far as a schedule goes, it would be pretty sweet to work something like 4 on, 4 off, 4 on, 16 off.

 

[psyduck1990]

I'm not sure I could do good work seeing 25 patients in a 16 hour day, but if you have good stamina, it's no more patients than if you were seeing 12 patients/8 hour day, 16 days a month.

As far as a schedule goes, it would be pretty sweet to work something like 4 on, 4 off, 4 on, 16 off.

Yeah I'd like to be able to travel more so the flexible schedule with no commitments between shifts is appealing.

 

[Sushirolls]

236k for an inpatient job and that number of pts is bad deal. Unlikely you will get the days you want to work. Assume you are low on priority and get mostly weekends for shifts.

My experience also shows few docs take pride in sign in sign out and with those types of shifts you will be walking into sign out question marks or a lot of Monday discharge shifts where you get stuck doing the DC summary on people you don't know.

Coverage at 11pm means you get called until 11pm, but oh wait nursing can't reach the coverage so they call you and admin don't care and don't want to fix it. Psych admissions mostly happen between 3pm and 3am which means you are phone busy.

This job is big box fresh grad targeted poison cake.

 

[calvnandhobbs68]

Those shifts suck ass. I highly doubt they have takers for this job right now. Technically not a bad deal hourly-wise (works out to 164/hour with benefits) but holy crap having to see 25 patients for a 16 hour shift and having to be there for 16 hours means you'll have to take a whole day just to recover from that sh*tshow. You're not sleeping or resting either with a shift from 7AM-11PM, it's not like this is a night shift from 7PM-11AM where you might get to sleep for a few hours. No f'ing way you'd want to work any amount of days on more than 1-2 in a row. Dude you'd hate your life after 8 of those in a row.

@Sushirolls is right too that you're probably gonna get crappy signout and spend the whole first day trying to figure out what the hell is going on with that level of discontinuity.

I agree, tell them to come back with at least 275K or nothing. that's like 191/hr which is certainly more reasonable for what they're expecting you to do.

 

[wolfvgang22]

Once again, Sushi is right.
I cannot see that many patients per day and do quality work. I'd feel bad about the quality of care required to see (or not really see) that many patients per shift and feel bad about myself as a clinician pretty quickly. At the end of 8 days like this I'd need two weeks to recover, unless I wasn't really doing the work. Then I'd feel like crap the whole time I was on vacation knowing I didn't do my best work.
$350k minimum for me, and I still probably wouldn't do it. Money can't buy a cure for burn out or roll back compassion fatigue, I've learned.

 

[robellis]

They offer the option of working more shifts/month for higher income (i.e. 9.5 shifts/mo for 300k)

Hell no, absolutely not, this is a bad deal unless they keep the same number of shifts and you still make 280k, otherwise you’re being exploited

 

[robellis]

Those shifts suck ass. I highly doubt they have takers for this job right now. Technically not a bad deal hourly-wise (works out to 164/hour with benefits) but holy crap having to see 25 patients for a 16 hour shift and having to be there for 16 hours means you'll have to take a whole day just to recover from that sh*tshow. You're not sleeping or resting either with a shift from 7AM-11PM, it's not like this is a night shift from 7PM-11AM where you might get to sleep for a few hours. No f'ing way you'd want to work any amount of days on more than 1-2 in a row. Dude you'd hate your life after 8 of those in a row.

@Sushirolls is right too that you're probably gonna get crappy signout and spend the whole first day trying to figure out what the hell is going on with that level of discontinuity.

I agree, tell them to come back with at least 275K or nothing. that's like 191/hr which is certainly more reasonable for what they're expecting you to do.

Now that I think about it when you approach it from an hourly perspective even at 191/hr this is not great, I’ve seen many jobs offers at 200 or 225/hr for ER shift work and they probably won’t even see 25 patients per shift..yeah OP this job sucks especially when you mention the location

 

[dl2dp2]

It's interesting that the board judges this job so poorly. 8/20 is not too bad IMO if you are single and don't care about a steady schedule.

In terms of long-term career though, this is not a job that'll likely go anywhere... the main issue is that it's a "dead-end" job. I generally think it's a bad idea for new grads to take dead-end jobs.

 

[calvnandhobbs68]

It's interesting that the board judges this job so poorly. 8/20 is not too bad IMO if you are single and don't care about a steady schedule.

In terms of long-term career though, this is not a job that'll likely go anywhere... the main issue is that it's a "dead-end" job. I generally think it's a bad idea for new grads to take dead-end jobs.

For the right amount of money, it would suck the days your on but might be doable. 8 days on is fine but 8 days on of 16hour shifts a day seeing 25 patients a day (128 hours over 8 days)? Gross.

Not for 236k/year.

 

[psychacad]

There are too many issue here. Low pay, very high patient volume that will inevitably lead to poor patient care, shifts are too long and unlikely you will get much rest if the patient load is this high. You have less than 8 hours to recover between shifts.

It would potentially be negotiable if it weren't for the patient load. But like this, this is not doable. Don't shortchange yourself.

 

[splik]

I have done this before. Not for me. Many people like it to have the time off for their own personal pursuits or for their own projects or other work related activities. It works out as $300k full time and over $360k if you’re a contractor. I definitely recommending not being employed for these sorts of positions and been 1099 instead. This model of 16h shifts works better for things like emergency psychiatry and corrections than it does for inpt. They have frequently lost contracts for inpt because of poor feedback (it might be nice for docs who want to work fewer days but it’s bad for pts etc)

 

[Psych19]

I've been doing mostly inpatient work since I graduated from fellowship a year and a half ago. There was a brief period at the beginning of Covid last spring where another psychiatrist and I decided to merge into a single service and alternate one-week-on one-week-off. Our combined inpatient caseload would peak at 17 (plus a small amount of C&L work, typically 1-3 new consults per day). We had the help of a midlevel for about half of those patients. It was busy but manageable. We did this for about 2 months, then went back to normal.

Two thoughts:
(1) It was nice to have the time off every other week, but I learned that prefer to have a more normal schedule with shorter days. However, the thing that bothered me the most was sharing patient management with another psychiatrist. We saw eye-to-eye on most treatment decisions, but it was really challenging when we did not. And the decision to share patients was a mutual one with another psychiatrist whom I knew and trusted. I can't imagine having this arrangement with another psychiatrist without being able to vet them myself first.
(2) I can't imagine doing this with 25-26 patients. That sounds miserable. I don't care what you pay me.

 

[Trismegistus4]

Once again, Sushi is right.
I cannot see that many patients per day and do quality work. I'd feel bad about the quality of care required to see (or not really see) that many patients per shift and feel bad about myself as a clinician pretty quickly. At the end of 8 days like this I'd need two weeks to recover, unless I wasn't really doing the work. Then I'd feel like crap the whole time I was on vacation knowing I didn't do my best work.
$350k minimum for me, and I still probably wouldn't do it. Money can't buy a cure for burn out or roll back compassion fatigue, I've learned.

I have to agree with this. While one might think, logically, that if you can see 12-13 patients in an 8 hour day, you can see 25 patients in a 16 hour day, in reality there is a law of diminishing returns because of mental fatigue. For me, personally, any more than about 12 patients is too many different people with all their different problems to think about in one day, no matter how much time I might spend at work. Each additional patient increases the total time I spend getting my work done more than the last. If you graphed the number of patients per day on the x-axis and time it takes to get all your work done on the y-axis, it would be an exponential increase, not a linear one.

 

[AD04]

I agree with everyone else that you're being lowballed. You can see for yourself when you convert your work to wRVU. From what I see, you're getting less than $55 / wRVU which is below the median. Do your own calculations to arrive at a fair salary. Then propose a higher amount than fair and start the negotiation process.

The set up is interesting though as it gives your lifestyle a lot of options. I am assuming you can go home early if you finish your work and if you're following the same patients and average length of stay is over 1 week, it shouldn't be hard to finish your work way before your shift ends. If I had this schedule, I would work 6 months (16 shifts / month) and spend the next 6 months in a tropical 3rd world country living like a king.

In terms of long-term career though, this is not a job that'll likely go anywhere... the main issue is that it's a "dead-end" job. I generally think it's a bad idea for new grads to take dead-end jobs.

Why is this a dead-end job? I would assume outpatient only jobs are dead-end jobs as it is easier to transition from inpatient to outpatient than the other way around.

 

[psyduck1990]

Thanks for the feedback everyone. Will see if compensation is negotiable or if there are plans to bring on midlevel support. It's a high workload for sure but considering it's 1 week on/3 weeks off it doesn't seem worse to me than a more typical lower volume 1 week on/1 week off setup.

 

[Candidate2017]

$350k minimum for me, and I still probably wouldn't do it. Money can't buy a cure for burn out or roll back compassion fatigue, I've learned.

I see your $350k and raise $450k+.

This board probably attracts a disproportionate share of academically trained people. But there are plenty of places and psychiatrists who are perfectly ok with what we consider terrible psychiatry: seeing 25-35+ patients, writing a few lines, and initiating the same plan and signature cocktail of meds on everyone.

 

[Old&InTheWay]

This job is big box fresh grad targeted poison cake.

When you say "big box" what do you mean exactly? Everything not private practice? You throw the expression around a lot to the point where it has become a bit meaningless. I would say it is most apt to describe big healthcare systems that operate like walmart and amazon: gobble up all the small practices then offer ****ty service/jobs. This job could certainly fit that description, but I don't have enough detail to say for sure.

 

[Trismegistus4]

I see your $350k and raise $450k+.

This board probably attracts a disproportionate share of academically trained people. But there are plenty of places and psychiatrists who are perfectly ok with what we consider terrible psychiatry: seeing 25-35+ patients, writing a few lines, and initiating the same plan and signature cocktail of meds on everyone.

Amen to that. If you are still in med school or residency you wouldn't believe what some people in the private world get away with--things that are drilled into you in training as being sure to get you fired/sued/delicensed. One fellow psychiatrist within my organization does notes that are 100% copy-and-paste/drag-and-drop/pre-populated boilerplate. You would have absolutely zero indication from reading them that this person ever even laid eyes on the patient.

 

[robellis]

Amen to that. If you are still in med school or residency you wouldn't believe what some people in the private world get away with--things that are drilled into you in training as being sure to get you fired/sued/delicensed. One fellow psychiatrist within my organization does notes that are 100% copy-and-paste/drag-and-drop/pre-populated boilerplate. You would have absolutely zero indication from reading them that this person ever even laid eyes on the patient.

But he can still bill for them?

 

[Trismegistus4]

But he can still bill for them?

You can try to bill for anything. Whether you will get audited someday is another matter.

 

[robellis]

You can try to bill for anything. Whether you will get audited someday is another matter.

But I’m assuming someone would say something to him (like the coders at your hospital) if there was an issue?

 

[Trismegistus4]

But I’m assuming someone would say something to him (like the coders at your hospital) if there was an issue?

I'm thinking all the boilerplate/pre-populated fields are calculated to meet the requirements for billing.

 

[clausewitz2]

Billers do not care about the things we care about.

True story. Covered once for someone else in an IOP. Looked over previous notes to have some sense of what I would walk into that day as I got zero hand-off. None of the notes were longer than three lines. My favorite was:

'Feeling better today. No mania or psychosis. Increase lithium to'

Not a typo. The note just ended there. The entire plan in the note subsequent was 'continue meds', so literally had no idea what dose they were taking. Some people really just DGAF.

 

[calvnandhobbs68]

Billers do not care about the things we care about.

True story. Covered once for someone else in an IOP. Looked over previous notes to have some sense of what I would walk into that day as I got zero hand-off. None of the notes were longer than three lines. My favorite was:

'Feeling better today. No mania or psychosis. Increase lithium to'

Not a typo. The note just ended there. The entire plan in the note subsequent was 'continue meds', so literally had no idea what dose they were taking. Some people really just DGAF.

Yep. Everyone should take a look at what's actually required for billing specific codes. It's really more of a copy and paste thing than anything else, although this might change this year with the bigger emphasis on medical decision making to dictate the final billing code (so encouraging more to be actually put in the assessment/plan instead of making sure you check off 2+ ROS, 2+ vital signs, 7+ items on your MSE, etc). You can get away with total **** notes and they're still billable, just look at most of the orthopedic surgery outpatient notes lol.

For the notes that are purely billed based on time, you can write whatever the F you want, as long as you put down you spent 20, 30, 40 minutes with the patient or whatever. The insurance company won't even look at the note really unless you get audited.

The reason people write good notes is because they either: care about patient continuity/handoffs, want to remind themselves of what's going on with the patient over time, want to make sure they're covered in case of a lawsuit or want to make sure they're covered in case of an audit from an insurance company (where you can literally lose thousands of dollars if your notes clearly don't support a certain level of coding).

 

[Merovinge]

Thanks for the feedback everyone. Will see if compensation is negotiable or if there are plans to bring on midlevel support. It's a high workload for sure but considering it's 1 week on/3 weeks off it doesn't seem worse to me than a more typical lower volume 1 week on/1 week off setup.

I think the pay is low but the structure is not unreal if you are single and looking for this type of setup. I know a number of docs well into their 50's and 60's who see this number of inpatient's/day and in much less than 16 hours. It's not for me now, but if I were single and wanting to travel or grind (you could easily add a second job on days not working this one), I would consider it. If it paid say $275k for 8 days/month and it fit your lifestyle for the time being (i.e. you know you can handle working long days), I wouldn't find it outlandish.

 

[jbomba]

How do we find those inpatient jobs that allow us to just leave when we're done rounding? Anything we need to look for? Do we make this known to recruiters? Is it something we can negotiate?

 

[robellis]

Billers do not care about the things we care about.

True story. Covered once for someone else in an IOP. Looked over previous notes to have some sense of what I would walk into that day as I got zero hand-off. None of the notes were longer than three lines. My favorite was:

'Feeling better today. No mania or psychosis. Increase lithium to'

Not a typo. The note just ended there. The entire plan in the note subsequent was 'continue meds', so literally had no idea what dose they were taking. Some people really just DGAF.

LOL

 

[robellis]

How do we find those inpatient jobs that allow us to just leave when we're done rounding? Anything we need to look for? Do we make this known to recruiters? Is it something we can negotiate?

You tell them that you’re leaving and they can call you if they have any questions, if they have a problem with it they can find someone else to work there, key point: you are in demand so you call the shots, don’t ever forget that

 

[sloh]

You can try to bill for anything. Whether you will get audited someday is another matter.

Probably won’t get audited unless the physician is an outlier based off comparative billing

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[Trismegistus4]

But I’m assuming someone would say something to him (like the coders at your hospital) if there was an issue?

Yep. Everyone should take a look at what's actually required for billing specific codes. It's really more of a copy and paste thing than anything else, although this might change this year with the bigger emphasis on medical decision making to dictate the final billing code (so encouraging more to be actually put in the assessment/plan instead of making sure you check off 2+ ROS, 2+ vital signs, 7+ items on your MSE, etc). You can get away with total **** notes and they're still billable, just look at most of the orthopedic surgery outpatient notes lol.

For the notes that are purely billed based on time, you can write whatever the F you want, as long as you put down you spent 20, 30, 40 minutes with the patient or whatever. The insurance company won't even look at the note really unless you get audited.

The reason people write good notes is because they either: care about patient continuity/handoffs, want to remind themselves of what's going on with the patient over time, want to make sure they're covered in case of a lawsuit or want to make sure they're covered in case of an audit from an insurance company (where you can literally lose thousands of dollars if your notes clearly don't support a certain level of coding).

I think the key to what I meant about this person's notes not giving any clue that they (I hate using "they," but I want to be as anonymous as possible) saw the patient is not that each individual note doesn't say "I did X, Y, and Z," because they do, but that when you compare their notes across different days and different patients, you see that they all say the exact same thing. The first day this person comes on service, they cobble together a paragraph for the subjective section of their SOAP note that is clearly just made up of a bunch of drag-and-drop phrases and sentences, which are the same across multiple patients. Each day after that, they just copy forward the exact same subjective section, verbatim, without changing it at all. The result is that 1) the subjective section of each patient's progress note sounds pretty much the same as all the others, and 2) you don't get the sense on each subsequent day that they did anything at all.

Granted, it seemed like in residency doing that kind of thing was drilled into us as being likely to get you in trouble if you got sued, not likely to get you audited. I think a key point here is that insurance doesn't care about that "subjective" section. They don't look at it. It's just that for us, the narrative you put there is important; that's the section that really gives you an idea of what went on with the patient that day. The problem here is that this person is writing "I discussed X and Y with the patient. Patient reports he feels A about his B and C. Patient will work on D, and in the meantime I informed patient of E and F" and then copying forward that exact same paragraph every day with no modification--the dreaded "documenting that you did things you didn't do." But I guess insurance doesn't care about that.

Of course, given that the speed with which this person completes rounds, they can't possibly be spending more than 5-6 minutes with new patients and 2-3 minutes with follow ups, yet despite this, they are dropping a 35 minute face-to-face time statement into each progress note and billing a 99233 on every follow-up every day, they may eventually get audited for being an outlier based on comparative billing.

And yes, I'm somewhat venting here about this person essentially getting away with treating this job like it's a part-time job while I'm there all day.

 

[robellis]

I think the key to what I meant about this person's notes not giving any clue that they (I hate using "they," but I want to be as anonymous as possible) saw the patient is not that each individual note doesn't say "I did X, Y, and Z," because they do, but that when you compare their notes across different days and different patients, you see that they all say the exact same thing. The first day this person comes on service, they cobble together a paragraph for the subjective section of their SOAP note that is clearly just made up of a bunch of drag-and-drop phrases and sentences, which are the same across multiple patients. Each day after that, they just copy forward the exact same subjective section, verbatim, without changing it at all. The result is that 1) the subjective section of each patient's progress note sounds pretty much the same as all the others, and 2) you don't get the sense on each subsequent day that they did anything at all.

Granted, it seemed like in residency doing that kind of thing was drilled into us as being likely to get you in trouble if you got sued, not likely to get you audited. I think a key point here is that insurance doesn't care about that "subjective" section. They don't look at it. It's just that for us, the narrative you put there is important; that's the section that really gives you an idea of what went on with the patient that day. The problem here is that this person is writing "I discussed X and Y with the patient. Patient reports he feels A about his B and C. Patient will work on D, and in the meantime I informed patient of E and F" and then copying forward that exact same paragraph every day with no modification--the dreaded "documenting that you did things you didn't do." But I guess insurance doesn't care about that.

Of course, given that the speed with which this person completes rounds, they can't possibly be spending more than 5-6 minutes with new patients and 2-3 minutes with follow ups, yet despite this, they are dropping a 35 minute face-to-phase time statement into each progress note and billing a 99233 on every follow-up every day, they may eventually get audited for being an outlier based on comparative billing.

And yes, I'm somewhat venting here about this person essentially getting away with treating this job like it's a part-time job while I'm there all day.

5 minutes with a new patient? Damn that’s “efficient” I bet he’s making bank all right

 

[sloh]

I think the key to what I meant about this person's notes not giving any clue that they (I hate using "they," but I want to be as anonymous as possible) saw the patient is not that each individual note doesn't say "I did X, Y, and Z," because they do, but that when you compare their notes across different days and different patients, you see that they all say the exact same thing. The first day this person comes on service, they cobble together a paragraph for the subjective section of their SOAP note that is clearly just made up of a bunch of drag-and-drop phrases and sentences, which are the same across multiple patients. Each day after that, they just copy forward the exact same subjective section, verbatim, without changing it at all. The result is that 1) the subjective section of each patient's progress note sounds pretty much the same as all the others, and 2) you don't get the sense on each subsequent day that they did anything at all.

Granted, it seemed like in residency doing that kind of thing was drilled into us as being likely to get you in trouble if you got sued, not likely to get you audited. I think a key point here is that insurance doesn't care about that "subjective" section. They don't look at it. It's just that for us, the narrative you put there is important; that's the section that really gives you an idea of what went on with the patient that day. The problem here is that this person is writing "I discussed X and Y with the patient. Patient reports he feels A about his B and C. Patient will work on D, and in the meantime I informed patient of E and F" and then copying forward that exact same paragraph every day with no modification--the dreaded "documenting that you did things you didn't do." But I guess insurance doesn't care about that.

Of course, given that the speed with which this person completes rounds, they can't possibly be spending more than 5-6 minutes with new patients and 2-3 minutes with follow ups, yet despite this, they are dropping a 35 minute face-to-phase time statement into each progress note and billing a 99233 on every follow-up every day, they may eventually get audited for being an outlier based on comparative billing.

And yes, I'm somewhat venting here about this person essentially getting away with treating this job like it's a part-time job while I'm there all day.

I'm actually curious if insurance/auditors read or care about the subjective at all. Can anyone chime in here?

 

[AD04]

@Trismegistus4

Yesterday, I was talking to someone a year above mine from residency and he talked about how one of the psychiatrist he works with sees a ton of patients and make $1 million / year -- bills 99213 mostly without add-on codes. To make that money with such low billing, that psychiatrist have to see 50 patients a day. I have no clue how someone can provide quality care and document well for 50 patients / day. So my assumption is that both quality of care and documentation are substandard.

It's about risk and reward. Your peer is taking a big risk and getting rewarded for it. Maybe he'll have to pay the penalty down the road. Maybe never.

If I were you, I'll speak with him and find out about his experience. How long he'll been billing the way he has been. If he was audited and if there were any penalties. Based on his experience, you may be a bit more aggressive in your billing without having to get in trouble.

But at the end of the day, you have to do what you're comfortable with. I personally cannot sleep easily knowing I half-assed my care and billed without the supporting information in my documentation.

 

[Merovinge]

@Trismegistus4

Yesterday, I was talking to someone a year above mine from residency and he talked about how one of the psychiatrist he works with sees a ton of patients and make $1 million / year -- bills 99213 mostly without add-on codes. To make that money with such low billing, that psychiatrist have to see 50 patients a day. I have no clue how someone can provide quality care and document well for 50 patients / day. So my assumption is that both quality of care and documentation are substandard.

It's about risk and reward. Your peer is taking a big risk and getting rewarded for it. Maybe he'll have to pay the penalty down the road. Maybe never.

If I were you, I'll speak with him and find out about his experience. How long he'll been billing the way he has been. If he was audited and if there were any penalties. Based on his experience, you may be a bit more aggressive in your billing without having to get in trouble.

But at the end of the day, you have to do what you're comfortable with. I personally cannot sleep easily knowing I half-assed my care and billed without the supporting information in my documentation.

I find 50 pts/day in psych utterly preposterous, maybe even more so than most as a CAP where 30 minutes feels tight for many of my follow-ups. However, I will say many docs across numerous specialties are seeing 50 pts/day and in some fields the codes are more 99214 for most. Few examples I personally know of, there are many more.

Pediatrician who has 3 staff, 2 RNs alternating patients, 1 receptionist managing pt flow, RNs help cover calls with any downtime, most of these are in the 213 (some 212 as peds) rare 214s.

Specialty surgeon using scribe, RN for assistance with some procedures, in part of larger office with staff to cover calls/patient flow. Routinely in the 40's of patients, the majority of which are 214's given the specialist nature of the field, can hit 50 pts on rare days.

These are not necessarily huge outliers and actually no one I know finds these practices to be obscene, so I do find it interesting how much more psychiatrists hold each other to actually spending time with patients than other fields of medicine. I find it refreshing. I also understand why so many psychiatrists are cash only to provide the appropriate care but still be able to make similar reimbursement per hour.

 

[sloh]

I find 50 pts/day in psych utterly preposterous, maybe even more so than most as a CAP where 30 minutes feels tight for many of my follow-ups. However, I will say many docs across numerous specialties are seeing 50 pts/day and in some fields the codes are more 99214 for most. Few examples I personally know of, there are many more.

Pediatrician who has 3 staff, 2 RNs alternating patients, 1 receptionist managing pt flow, RNs help cover calls with any downtime, most of these are in the 213 (some 212 as peds) rare 214s.

Specialty surgeon using scribe, RN for assistance with some procedures, in part of larger office with staff to cover calls/patient flow. Routinely in the 40's of patients, the majority of which are 214's given the specialist nature of the field, can hit 50 pts on rare days.

These are not necessarily huge outliers and actually no one I know finds these practices to be obscene, so I do find it interesting how much more psychiatrists hold each other to actually spending time with patients than other fields of medicine. I find it refreshing. I also understand why so many psychiatrists are cash only to provide the appropriate care but still be able to make similar reimbursement per hour.

Do you feel like inpatient lends itself to more efficient visits compared to outpatient where you have to schedule patients into time slots?

 

[robellis]

I find 50 pts/day in psych utterly preposterous, maybe even more so than most as a CAP where 30 minutes feels tight for many of my follow-ups. However, I will say many docs across numerous specialties are seeing 50 pts/day and in some fields the codes are more 99214 for most. Few examples I personally know of, there are many more.

Pediatrician who has 3 staff, 2 RNs alternating patients, 1 receptionist managing pt flow, RNs help cover calls with any downtime, most of these are in the 213 (some 212 as peds) rare 214s.

Specialty surgeon using scribe, RN for assistance with some procedures, in part of larger office with staff to cover calls/patient flow. Routinely in the 40's of patients, the majority of which are 214's given the specialist nature of the field, can hit 50 pts on rare days.

These are not necessarily huge outliers and actually no one I know finds these practices to be obscene, so I do find it interesting how much more psychiatrists hold each other to actually spending time with patients than other fields of medicine. I find it refreshing. I also understand why so many psychiatrists are cash only to provide the appropriate care but still be able to make similar reimbursement per hour.

Go to the optho forum, they have several retinal surgeon there talking about seeing 40+ patients per day and sometimes up to 70 per day, they’re also clearing 1M+ easily over there

 

[clausewitz2]

Go to the optho forum, they have several retinal surgeon there talking about seeing 40+ patients per day and sometimes up to 70 per day, they’re also clearing 1M+ easily over there

Ophtho: where you operate in ten minutes sitting down and you don't have to wear shoes.

 

[robellis]

Ophtho: where you operate in ten minutes sitting down and you don't have to wear shoes.

This is in clinic not surgeries

 

[Stagg737]

Way too low, 25 patients per day is actual insanity, it needs to be at least 275k

I'm not sure I could do good work seeing 25 patients in a 16 hour day, but if you have good stamina, it's no more patients than if you were seeing 12 patients/8 hour day, 16 days a month.

As far as a schedule goes, it would be pretty sweet to work something like 4 on, 4 off, 4 on, 16 off.

Agree that pay is too low, but 25 is not necessarily outrageous. What's the average LOS? There's a unit near us where average LOS is ~6 months. So seeing 25 f/ups in a day for patients who you're not really making significant med changes and just managing occasional behavioral outbursts isn't unreasonable. Also depends on the support staff. If you've got a great support team you can do it if there's very few admits and discharges (like 1 per day). Would still be a grind, but still possible to provide decent care in the right situation which is probably pretty rare.

Billers do not care about the things we care about.

True story. Covered once for someone else in an IOP. Looked over previous notes to have some sense of what I would walk into that day as I got zero hand-off. None of the notes were longer than three lines. My favorite was:

'Feeling better today. No mania or psychosis. Increase lithium to'

Not a typo. The note just ended there. The entire plan in the note subsequent was 'continue meds', so literally had no idea what dose they were taking. Some people really just DGAF.

I'll one up that. I have an attending at a CMHC whose whole notes are regularly "Patient stable, continue meds". The couple times his patients were transferred to me I nearly pulled my hair out because I was basically doing a whole new eval.

I'm actually curious if insurance/auditors read or care about the subjective at all. Can anyone chime in here?

A previous attending had a partner who got audited and hit hard d/t not meeting criteria in subjective for the level he was billing. My attending basically used a boilerplate for part of the subjective to meet insurance criteria with an additional sentence or two of actual relevant content.

I have no clue how someone can provide quality care and document well for 50 patients / day. So my assumption is that both quality of care and documentation are substandard.

Have everyone be stable follow-ups on 1-2 meds who are just there for refills. In med school there was one day after a long holiday where our team (attending + two M4 sub-i's) saw a lot more patients than this because almost everyone was stable and just there for refills. Most were ADHD and subjective read like "Symptoms well-controlled with current meds. Denies side effects. Denies problems with sleep or decreased appetite. Denies SI/HI/AVH." with most of the note seeming to be copy/pasted (med students were basically writing subjective portions and attending came in after and checked everything else). I'm not going to say this was quality care or that documentation was good, but all the basic bases were covered. A normal day in that clinic was 8-7 and had ~45 patients scheduled.

Do you feel like inpatient lends itself to more efficient visits compared to outpatient where you have to schedule patients into time slots?

Depends on the patient population, EMR, and support staff. For me inpatient is more efficient because I can work on my own schedule and spend little time with some patients and more with others. If I have an outpatient requiring 45+ minutes of attention but they're only scheduled for 30 minutes it can screw up a whole day. Plus having great social workers on an inpatient unit can mean dramatic differences in efficiency.

 

[Stagg737]

Those shifts suck ass. I highly doubt they have takers for this job right now. Technically not a bad deal hourly-wise (works out to 164/hour with benefits) but holy crap having to see 25 patients for a 16 hour shift and having to be there for 16 hours means you'll have to take a whole day just to recover from that sh*tshow. You're not sleeping or resting either with a shift from 7AM-11PM, it's not like this is a night shift from 7PM-11AM where you might get to sleep for a few hours. No f'ing way you'd want to work any amount of days on more than 1-2 in a row. Dude you'd hate your life after 8 of those in a row.

@Sushirolls is right too that you're probably gonna get crappy signout and spend the whole first day trying to figure out what the hell is going on with that level of discontinuity.

I agree, tell them to come back with at least 275K or nothing. that's like 191/hr which is certainly more reasonable for what they're expecting you to do.

Once again, Sushi is right.
I cannot see that many patients per day and do quality work. I'd feel bad about the quality of care required to see (or not really see) that many patients per shift and feel bad about myself as a clinician pretty quickly. At the end of 8 days like this I'd need two weeks to recover, unless I wasn't really doing the work. Then I'd feel like crap the whole time I was on vacation knowing I didn't do my best work.
$350k minimum for me, and I still probably wouldn't do it. Money can't buy a cure for burn out or roll back compassion fatigue, I've learned.

Again, depends on more specifics. What's the churn rate/average LOS of patients? How good is support staff? Is the EMR good (for example Epic with dictation available) or is this Meditech from 2010? How often does this hospital accept personality disorders and substance problems vs. legit primary Axis I problems? I do agree that in many places this job would be awful, and that the pay is not worth it in any setting. In the right circumstances, it could be a pretty nice position though.

I think the bigger issue would be continuity of care vs. # of days in a row worked. I actually wouldn't mind this schedule in the right setting if it were 2 blocks of 4 days per month. Day 1 would suck each time, but after figuring out the patients the next few days wouldn't be as bad. In the right patient population, without high churn/low LOS, with a decent EMR (dictation available), I think this could be a pretty nice set up for some people. Having 20+ days off per month to spend with family or pursue other interests might be worth the grind for the right pay. I don't think I'd mind that schedule (again, for the right pay in the right setting).

 

[sloh]

Again, depends on more specifics. What's the churn rate/average LOS of patients? How good is support staff? Is the EMR good (for example Epic with dictation available) or is this Meditech from 2010? How often does this hospital accept personality disorders and substance problems vs. legit primary Axis I problems? I do agree that in many places this job would be awful, and that the pay is not worth it in any setting. In the right circumstances, it could be a pretty nice position though.

I think the bigger issue would be continuity of care vs. # of days in a row worked. I actually wouldn't mind this schedule in the right setting if it were 2 blocks of 4 days per month. Day 1 would suck each time, but after figuring out the patients the next few days wouldn't be as bad. In the right patient population, without high churn/low LOS, with a decent EMR (dictation available), I think this could be a pretty nice set up for some people. Having 20+ days off per month to spend with family or pursue other interests might be worth the grind for the right pay. I don't think I'd mind that schedule (again, for the right pay in the right setting).

Forgive my ignorance but what are the implications on efficiency wrt substance and personality problems compared to primary axis 1 problems?

 

[AD04]

Have everyone be stable follow-ups on 1-2 meds who are just there for refills. In med school there was one day after a long holiday where our team (attending + two M4 sub-i's) saw a lot more patients than this because almost everyone was stable and just there for refills. Most were ADHD and subjective read like "Symptoms well-controlled with current meds. Denies side effects. Denies problems with sleep or decreased appetite. Denies SI/HI/AVH." with most of the note seeming to be copy/pasted (med students were basically writing subjective portions and attending came in after and checked everything else). I'm not going to say this was quality care or that documentation was good, but all the basic bases were covered. A normal day in that clinic was 8-7 and had ~45 patients scheduled.

The 50 patients / day included geriatrics.

Stimulant pill mill will come under the scrutiny of DEA. My peer was in a place that saw 6 ADHD patients / hr. That only lasted a year before that got shut down.

And the attending you mentioned had two sub-interns to help. This guy had none.

A previous attending had a partner who got audited and hit hard d/t not meeting criteria in subjective for the level he was billing. My attending basically used a boilerplate for part of the subjective to meet insurance criteria with an additional sentence or two of actual relevant content.

What a newb. That's why you should go by examination and MDM, so subjective won't have to matter.

 

[Trismegistus4]

5 minutes with a new patient? Damn that’s “efficient” I bet he’s making bank all right

Given the structure of the job, it's not so much that they are making bank, but rather leaving at noon every day.

@Trismegistus4

Yesterday, I was talking to someone a year above mine from residency and he talked about how one of the psychiatrist he works with sees a ton of patients and make $1 million / year -- bills 99213 mostly without add-on codes. To make that money with such low billing, that psychiatrist have to see 50 patients a day. I have no clue how someone can provide quality care and document well for 50 patients / day. So my assumption is that both quality of care and documentation are substandard.

It's about risk and reward. Your peer is taking a big risk and getting rewarded for it. Maybe he'll have to pay the penalty down the road. Maybe never.

If I were you, I'll speak with him and find out about his experience. How long he'll been billing the way he has been. If he was audited and if there were any penalties. Based on his experience, you may be a bit more aggressive in your billing without having to get in trouble.

But at the end of the day, you have to do what you're comfortable with. I personally cannot sleep easily knowing I half-assed my care and billed without the supporting information in my documentation.

I agree with your last paragraph here. But to my eyes, the person I'm referring to seems less shrewd or "efficient" and more just incompetent, like they don't even know they are doing anything wrong and wouldn't understand if someone tried to explain it to them. So I wouldn't find it particularly helpful to talk to them about their experience.

Agree that pay is too low, but 25 is not necessarily outrageous. What's the average LOS? There's a unit near us where average LOS is ~6 months. So seeing 25 f/ups in a day for patients who you're not really making significant med changes and just managing occasional behavioral outbursts isn't unreasonable. Also depends on the support staff. If you've got a great support team you can do it if there's very few admits and discharges (like 1 per day). Would still be a grind, but still possible to provide decent care in the right situation which is probably pretty rare.

Again, depends on more specifics. What's the churn rate/average LOS of patients? How good is support staff? Is the EMR good (for example Epic with dictation available) or is this Meditech from 2010? How often does this hospital accept personality disorders and substance problems vs. legit primary Axis I problems? I do agree that in many places this job would be awful, and that the pay is not worth it in any setting. In the right circumstances, it could be a pretty nice position though.

I think the bigger issue would be continuity of care vs. # of days in a row worked. I actually wouldn't mind this schedule in the right setting if it were 2 blocks of 4 days per month. Day 1 would suck each time, but after figuring out the patients the next few days wouldn't be as bad. In the right patient population, without high churn/low LOS, with a decent EMR (dictation available), I think this could be a pretty nice set up for some people. Having 20+ days off per month to spend with family or pursue other interests might be worth the grind for the right pay. I don't think I'd mind that schedule (again, for the right pay in the right setting).

I see your point. My reaction to this job was based more on the idea that it's a typical private/community hospital setting, such that 25 patients per day could mean 6-7 admissions and 18-19 follow-ups/discharges. If it's a setting where the average LOS is 6 months, and thus most patients don't change at all from day to day, most days you have zero admissions, and if you do have any it's only one... that's still a long day in my book, but at only 8 days per month, I could see that being a worthwhile tradeoff for some people.

I think the point about likely poor sign-out and thus spending your first day just trying to figure out what the heck is going on is a valid one, but with a long average LOS, you're likely to at least know most of the patients from your previous time on.

 

[Stagg737]

Forgive my ignorance but what are the implications on efficiency wrt substance and personality problems compared to primary axis 1 problems?

Others may have different experiences, but typically patients admitted for detox/intoxication or significant personality disorders (especially cluster B) tend to be much more needy and require greater attention that may or may not be relevant to their care. They'll self-harm, threaten others, manipulate, throw tantrums, etc but often won't gain any sustainable improvement from [acute inpatient] treatment. This is not always the case, but when I have a patient like this I can usually guess their diagnoses before even reviewing the chart. The patients who are severely depressed or psychotic I've found are generally easier to manage from a behavioral perspective and usually need to be there. Mania can also be very difficult, but depends on the individual.

The 50 patients / day included geriatrics.

Stimulant pill mill will come under the scrutiny of DEA. My peer was in a place that saw 6 ADHD patients / hr. That only lasted a year before that got shut down.

And the attending you mentioned had two sub-interns to help. This guy had none.

50 patients with no help and geri psych sounds insane. I feel like half the time geri patients take 5+ minutes just to figure out why they're even there. I actually wouldn't really consider that practice a pill mill. The attending required very thorough evaluation before treating with stimulants, often required patients to also be in therapy, and had staff with a protocol/procedure that ran like a well-oiled machine. I've never felt as legitimately efficient or organized outside of this rotation. He also had the advantage of taking 1-2 new patients per month and having 75%+ of his patients with years of stability and only needing refills or very minor adjustments. I could never practice this way, but this was probably the only time I've seen someone with a packed schedule (in addition to long days) where the care did seem to be fairly solid and not sub-standard.

What a newb. That's why you should go by examination and MDM, so subjective won't have to matter.

I know, idk how his subjective sections were so inadequate that an audit actually punished him for it, but I'd imagine it was something along the lines of examples Clausewitz and I gave earlier.