So much this! I see this in new grads so much. Which I guess I'm the outlier? Money is important. But whenever there is something offered that pays very high, it makes me very suspicious no matter how good the offer looks. There's a reason I decided to not join the local big boxes. Although they need us more than we need them, longevity would be an issue. The culture, quality of life and especially patient selection. There's another aspect to this career that is hard to put a monetary value on. Many young grads jump at the money for various reasons, I understand. Now we're several years out and the burn out is obvious while I'm content. Especially especially the patient selection. I can't imagine day after day going through multiple arguments about benzos, stims, wacky ketamine referrals, severe axis II, and all sorts of...whatever. My colleague is working with an emotionally draining patient who did atrocious things to a kitten and now the family is demanding she give him a diagnosis he does not have when he's clearly antisocial.
Curious about fellow brethren here: when your office gets new calls for psychiatry patients, are the bulk of them about stims, benzos, fired from somewhere, high acuity/super complex, some combination of all of the above, with high preponderance for the first two? As a physician in general, how I wish the first two were not 80% of our calls. Our region ranks super high when it comes to the prescription drug epidemic. Most of the high paying job descriptions have zero patient selectivity. I cannot emphasize enough that it's way better to wait a bit longer for a more manageable patient than take on anyone who can end up very difficult to maintain an outpatient relationship with. It can be super time consuming, exhausting in all degrees and imho not financially worth it. Had one such case that called everywhere I worked at (met her in the resident clinic during training) and tried to get an appointment as an "established" patient. At my own PP when she kept getting told I'm not taking new patients and she realized she'd never get an appointment with me, she sent harassing long emails about how she won't go anywhere else and she may kill herself. When that didn't work she and her spouse and other family left several fake google reviews on the google my business page. Was fortunate enough to have a major SEO figure working for us, she still is, and we got them taken down. And it's my own issues and counter transference, but it's just so much better to work with patients that believe in the science, are motivated, and really about getting after the underlying problem. Although this generally recruits for a less ill, higher functioning population with more mature psychological defenses to begin with. But at this clinic I say, the only criteria is that you are truly on board with getting better, we don't care about anything else.
Maybe we've gotten too spoiled here or maybe we're doing the right thing after all. But there's something nice about being in a work environment where you really enjoy your patients, your colleagues and the atmosphere. We unfortunately have less experience in the more severe chronically ill. But the nice thing with having students doing their training is that we can take on some cases with more variety and try to keep the those skills sharp and we've carved out time for a peer consult meeting that is recurring and what we call an academic "book club" now! Anyways, it seems like a good set up for a nice balance of longevity and good pay. This office will never pay like some mega big box (but it is still pretty damn nice) but our case census isn't full of high acuity or complex cases either. The big money is paid for a reason. There truly is no free lunch lol.
The most lucrative model includes patients who are desperate to see you be it some sort of acuity, strong therapeutic relationship, drug seeking, any reason. And you bill higher complexity med checks, back to back. The other end of the spectrum is longer visits that may have less pay per minute. There are some cash models that can be worked to offset this. But I'll be transparent. It would take me forever to build a cash only practice. I actually prefer not to for various reasons but one is that I think it affects the dynamic and makes it feel more salesy versus having insurance be a healthy boundary. Local colleagues who are thinking of making their own PP considered cash only and I don't recommend it. That was how one colleague started and after a couple years, she's decided to sign on with one insurance panel and will see how it goes. Now in this region if you start as a PP solo practitioner, it seems to have gotten harder to get paneled. This same colleague was denied being paneled on some of the higher paying ones unless she accepted Medicaid which was not the case when I started. Although I wonder if it makes a difference since I was already seeing patients under a different entity and some insurance companies worry about their members losing continuity of care. If you have good insurance rates and because psychiatrists are so desperately needed, it's still reasonably attainable, you can easily get $150s-$160s for 99213+90833. Some insurances pay $200s for that and with good networking, you can find the employers that use these insurances and BOOM you got a powerful multiplier. Now with the changes in billing, we can easily hit 99214. But yes, that sliver of time makes a DIFFERENCE. Lets say you miss out on a 99213+90833 each day at 5 days a week. In a 48 week work year that's at least $36000. That's why attendance policies are so important.
How long did it take me to build a full practice? 3 years with being on most insurance panels. But that's factoring in terrible patient recruiting with the employer I was under and I'm selective when it comes to patients. Now if I doled out benzos and stims, yes, 3-4 months sounds about right. After being with my first employer in PP for 2 years, I branched off, took the patients with. Took me less than a year to fill up with good patients for whatever space was left. So if you have strong patient recruitment and networking and are on insurance panels (a lot), starting from zero I'd guess it takes 1-1.5 years to build up a full time practice if you're shooting for 30 min visits. Also, if your name is new, it would take longer than a more established psychiatrist. Definitely highly recommend working somewhere that has promised income so you can grow into the PP. I did work at the VA while recruiting PP patients and for a stretch of time was doing tons of hours of clinical work in preparation to run full PP with as many established patients to run with to minimize income loss.
Sorry, one last caveat. We are in need but this is still a free market and there is competition. The well insured, easy to work with patients often know they are desirable patients and can go anywhere (or at least have their PCP refill for awhile). Let's say you have a professional working patient, good commercial insurance and on a simple regimen of SSRI + atypical. Refilling her scripts can keep her coming back, but if you offer a thorough visit, she feels listened to, she sees good evidence based results and the add on therapy is good, you've got someone coming back to you for a long time. Getting complacent can lead a practice to have to recruit new patients more often and the intakes are less lucrative than follow ups. This patient knows she can also see an NP who'd be sufficient to manage her case and she may find she has a better visit experience with the NP. I've had some psychologists join and most have stayed on board so far. But the ones who had the hardest time staying full, as I got to know them, imho were also not very impressive as providers. You don't have to be a sell out. But the better you perform, the better the outcome if that makes sense.
) for visits with 2+ problems. Good to know you were able to get your worth with biweekly 99214+90838!
