VA versus Private Practice??

[Hope4Grad]

Hey Everyone,

I feel like I am at a developmental precipice. My issue is that I will soon have two great VA job offers on the table....but I am thinking of hanging a shingle and just going for it in private practice. I currently work at a big and famous teaching hospital and have a faculty appointment at a top 10 medical school...but I am not happy! I hate dealing with unprofessional co-workers, getting paid 87K in an expensive part of the country, working in a dingy hospital (it is dirty and as inspiring as a jail), having a boss, and working my tail off. I would rather work fewer hours but be happier. I have a 1.5 year old child and want another one, so I want flexibility in my schedule to be with my babies. I also hear you can make a ton of money in private practice. My spouse has health benefits, so I don’t need the VA health benefits. Should I just skip the VA and get cracking on my private practice? I only want to do private practice if I’ll make at least what I’d make at the VA (so that’s around 105K I think). Thoughts??

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[Doctor Eliza]

Hey Everyone,

I feel like I am at a developmental precipice. My issue is that I will soon have two great VA job offers on the table....but I am thinking of hanging a shingle and just going for it in private practice. I currently work at a big and famous teaching hospital and have a faculty appointment at a top 10 medical school...but I am not happy! I hate dealing with unprofessional co-workers, getting paid 87K in an expensive part of the country, working in a dingy hospital (it is dirty and as inspiring as a jail), having a boss, and working my tail off. I would rather work fewer hours but be happier. I have a 1.5 year old child and want another one, so I want flexibility in my schedule to be with my babies. I also hear you can make a ton of money in private practice. My spouse has health benefits, so I don’t need the VA health benefits. Should I just skip the VA and get cracking on my private practice? I only want to do private practice if I’ll make at least what I’d make at the VA (so that’s around 105K I think). Thoughts??

Remember benefits are not just health care, but also things like paid sick and vacation time and retirement savings. These are worth a significant amount of money.

I work in a group practice with a 60/40 split as an independent contractor, so it is slightly different. I’m never going to get rich this way, but it is very conducive to being a mom. I have considered going into solo practice, but I am hesitant to do all my own billing, secretarial work, and patient recruitment. It’s a trade off. I get to go to all my son’s field trips and classroom parties. If he’s sick, I have office staff cancel my day. I can pretty much do what I want when I want. Of course, it hits me in the bank account if I take off too much time. It’s pretty low stress because after I write my notes, I’m done for the day. I don’t have to worry about billing or any of that sort of thing. I love my set up....except for the money. I think I’m also in a particularly low reimbursement area.

I’m sort of rambling at this point because it is late. Let me know if you have questions. I’m also happy to answer PMs.

 

[WisNeuro]

You can make that much in PP, and much more, as long as you are good at business. Otherwise, I see people under that figure pretty often.

 

[PsyDr]

You can easily look up the fee schedule for CMS in your area. Read up on billable hours productivity from law blogs. Then you can multiply the number of hours you work times the relevant fee schedule. Then subtract your office rent, buy malpractice + office insurance (which isn't expense at all), add in some ADA compliant couches/computers/toilet paper/billing software. Throw up to 25% of your income into a SEP IRA up to $49k. Find a CPA and an attorney. Create an LLC, get an EIN, get a PO box, read up on relevant laws such as CMS opting out/balance billing, and associated lawsuits, start getting credentialed, start marketing. It's not complex, it's just hard.

I will say there are a few problems with your plan:

1) With all due respect to parents, the times when patients want to come in are usually the exact same times that kids have things going on. Outpatients generally want before work, at the start of work, or 3pm-6pm. Avoiding prime hours is not unlike a restaurant being closed for dinner. Specialty practices tend to have more flexibility in this (e.g., high dollar psychoanalysis, fertility focused psychotherapy, etc). Billing isn't exactly a 5 min/day endeavor at the end of the day. If you think you're going to work 15hrs/week and make $100k, you're likely going to fail.

2) "Not having a boss" is a trap. Google any self employed profession about the subject. You won't be working for someone, but that does not make anything easier. When down months happen, you're the one stressing about how to pay for business things including IRS quarterly payments (hint: they believe you will always make 10% more each year, even if you don't, which means you can owe more than you make very easily). When up months happen, you're the one that has to restrain your spending. When the CPA asks you, "what are your deductions?", that's on you. When a patient calls you last night at 8pm, you're the one handling it. In general, add in all the admin stuff, subtract all the structure of it all. Will you actually be diligent in doing your monthly financials when you at home?

3) Hours worked X fee = gross revenue. At $100k/yr with a 35% overhead, you'd need to bill 1350hrs at $100/hr. That's about 6 sessions/day assuming everyone shows up, with only 2 weeks off a year, so either Christmas and a one week vacation OR a two week vacation.

 

[Ollie123]

How soon would you want/need to be making that 105k?

Its certainly a very reasonable figure to make in private practice, though may be an underestimate of total comp. Even if you take out health insurance, my retirement and other benefits adds at least 15-20k to total comp between retirement, vacation, etc.

That said...I would not expect it right away and that is doubly true if the reason for pursuing private practice is to have limited/flexible hours. The first year or two will likely be less and potentially much less. It takes time to build a reputation and a steady flow of patients even if you are working at it hard. The learning curve for some things can be steep and it can take many additional hours.

Another consideration is the hours you want to work. It is not by chance that most of my mid-day patients are medicaid or medicare. They also pay the least (medicaid MUCH less than some private insurers). I'm in an AMC so am fortunate that the payee mix doesn't (directly) impact my overall comp, but in PP it would. Folks with top-notch employer-provided insurance tend not to be available mid-day. Depending on where you are, there may not be sufficient cash-pay folks to build a practice.

This isn't to dissuade you and I'm not in PP so take all this with a grain of salt. However, I have never heard of anyone killing it in PP who also had an easy/flexible schedule - especially when initially launching. If the goal was 60-70k, it wouldn't be a question but I think if you are hoping to clear 100k+ in your first year with a light schedule...you are going to end up disappointed with either the income or the time commitment.

 

[WisNeuro]

Medicaid is essentially doing pro bono work for many services. In terms of PP, if you plan on taking insurance/medicare/Medicaid, I'd be keeping a close eye on what they are doing in DC.

 

[erg923]

Hey Everyone,

I feel like I am at a developmental precipice. My issue is that I will soon have two great VA job offers on the table....but I am thinking of hanging a shingle and just going for it in private practice. I currently work at a big and famous teaching hospital and have a faculty appointment at a top 10 medical school...but I am not happy! I hate dealing with unprofessional co-workers, getting paid 87K in an expensive part of the country, working in a dingy hospital (it is dirty and as inspiring as a jail), having a boss, and working my tail off. I would rather work fewer hours but be happier. I have a 1.5 year old child and want another one, so I want flexibility in my schedule to be with my babies. I also hear you can make a ton of money in private practice. My spouse has health benefits, so I don’t need the VA health benefits. Should I just skip the VA and get cracking on my private practice? I only want to do private practice if I’ll make at least what I’d make at the VA (so that’s around 105K I think). Thoughts??

You will work more in private practice than in most any employed job (if you want to make equivalent or more money anyway). Not sure who told you otherwise?

 

[WisNeuro]

Yeah, pretty much the only way to work less and make more in PP is to do forensic work, or go cash only and find people willing to pay a premium. The former is about having connections and the latter is about marketing skills and finding a gullible enough client base.

 

[deleted343839]

A few thoughts:

Most of the people I know who've made the move to private practice say they would do it again. But most of those people also have a spouse who is bringing in steady income and benefits. Also, the people who want more flexibility/comfort in their day to day lives usually find they have to adjust their expectations re: working conditions or income because they can't optimize both. But if you have the tolerance for income fluctuation and your personal flexibility is of higher value than the reliability of your income, then sure, give a go. Hopefully you have some local friends/colleagues in PP who can give you the lowdown.

Have you considered other options like going less than 100% FTE at your current institution and doing PP on the side? That's a way to test the waters without giving up the security of an institutional job.

The VA does not have a great reputation for handling maternity leave. Depending on how soon you are hoping to have your next child, I suggest you look into how their leave system works and maybe also ask VA colleagues whom you know and trust. If your current institution offers good maternity leave benefits I would think twice about making a move too soon.

 

[WisNeuro]

The VA does not have a great reputation for handling maternity leave. Depending on how soon you are hoping to have your next child, I suggest you look into how their leave system works and maybe also ask VA colleagues whom you know and trust. If your current institution offers good maternity leave benefits I would think twice about making a move too soon.

The US does not have a great system for maternity leave. Even outside the VA this is spotty at best. In our system, it's adequate........as long as you are a physician, it sucks for everyone else. Places with good maternity/paternity leave policies are definitely the exception in this backwards country.

 

[Pragma]

The VA does not have a great reputation for handling maternity leave. Depending on how soon you are hoping to have your next child, I suggest you look into how their leave system works and maybe also ask VA colleagues whom you know and trust. If your current institution offers good maternity leave benefits I would think twice about making a move too soon.

The US does not have a great system for maternity leave. Even outside the VA this is spotty at best. In our system, it's adequate........as long as you are a physician, it sucks for everyone else. Places with good maternity/paternity leave policies are definitely the exception in this backwards country.

I'd suggest investing in a short term disability plan prior to having another child, if you are going to remain at the VA. FMLA translates to "FML" on the back end. Best to avoid that if possible.

Also, you should give consideration to how much paid leave you get at the VA, and as mentioned before, if a part time option might be available. I've seen these things be incredibly flexible for parents in the VA system. You can abruptly take a sick day to take care of your kid at the VA without losing any income. If you have to cancel patients in private practice, that is a direct income loss.

 

[PsyDr]

Addition:

To be clear, you can kill it in PP if you're minimally business savvy and willing to do the work. The general advice is to find an unmet market need, and meet it. There are many ways to do this.

Working 14hrs days @ $100hr @ 100% productivity (which really means 16hr days), 5 days a week with 2 weeks off, grosses ~$350k. Not hard to make a nest egg to slow down on in that scenario. Working 3hrs/day @ $100hr, 365 grosses about 100k.

 

[cara susanna]

Can you find a part time VA psychologist job? They're rare but they do exist. That might be a happy medium.

 

[AcronymAllergy]

Can you find a part time VA psychologist job? They're rare but they do exist. That might be a happy medium.

Adding to this, if it's a high-need/hard-to-fill position, even if it's listed as F/T, they might be willing to negotiate P/T.

 

[Doctor Eliza]

The VA may have a bad maternity leave policy, but it is superior to what happens in private practice. I had complications that required me to be hospitalized for a month, plus I wanted to take some time off to recover from my c-section and be home with my premature baby. It was a major financial hit.

I also wanted to add pertaining to finances: you almost never get a raise in PP. a major insurer just raised our rates, which was great, but they had been paying the same rate for the past 25 years! Cost of living keeps increasing, but reimbursement doesn’t reflect that.

Okay, one last “Debbie Downer” thing about PP is the relative lack of prestige. I didn’t think that would bother me, but it does a little. In an organization, you have the opportunity to rise up through the ranks, get promotions, supervise others, etc. just something to think about.

Negatives aside, PP is working for me during this stage of my life. It might be right for you too, but go in with your eyes open. Good luck!

 

[foreverbull]

A lot of good advice here, so I won’t repeat it all, but PP is no easy endeavor. You have to know the demographics of your client base well, what they need, and whether you are offering something unique in your area. You might break even in your first 6 months to a year and slowly build from there if your skill set isn’t in high demand or there’s oversaturation in your area.

If you take insurance, good luck making $100k from PP without working many hours (especially if you’re renting an office full time, doing your own billing, and have high expenses), and people strongly prefer late afternoon/evening hours unless they are privileged enough to own their own businesses or have flexible schedules themselves. All considerations people don’t think about when they hear “private practice” as an option.

It’s certainly doable, but will require a serious time and money investment initially, patience, and having a skill set that clients in your area want. It’s not as easy as people make it out to be. It would be much easier to dip a toe in by starting with one or two evenings of seeing clients and minimizing expenses the first year, the working your way up. This way minimizes possible business losses in the first year.

Ultimately you will probably need to make $150k+ or so just to cover the additional benefits you’re going to lose in your other job—-insurance, retirement, paid time off, etc plus the business expenses you now have in your own practice that you didn’t have when you were employed by someone else (can run anywhere from $10k all the way up to $30k+/year for full time private practice). When you take any time time off and go on vacation, you not only pay for the vacation, but immediately lose monthly income. Doesn’t look quite as appealing for some when they take this into account.

Make sure you consult with folks who’ve done it if you proceed. It is helpful to get their input.

 

[Sanman]

Hold on, do you want to literally "hang a shingle" or would you be open to joining an existing group practice?


Going to the VA will help with the time off and the pay, but unprofessional coworkers, dingy facilities, and a boss will still be there. The pace will likely be a lot slower, but add in a lot of pointless bureaucracy instead (I get to do a bunch of mandatory Mission Act training this week, woohoo!). That said, it is one of the better paying W-2 gigs in the clinical world, IMO.


In a group practice, you are unlikely to make quite as much without a specialty practice area. That said, the facilities and clients are likely to be better off and if you are an independent contractor it will likely give you more flexibility. That said, you will be trading time for money, You won't be making VA money unless you are working a lot. However, you might be able to work less now and more down the line without switching positions. It will likely be easier to find a practice near your home, so easy commute.

Opening your own practice will take time and money. You will likely be trading years of lost income now for possible additional income down the road. Do you have a business plan, a marketing budget, a transition plan for the early years, the ability to go months with minimal income until you get things rolling? Do you want to deal with everything PSYDR mentioned? IMO, that is best left to down the road after you have funds in place to be less concerned with missing a paycheck. You can always become a contractor somewhere for the cash and build your own practice slowly while working there.

 

[WisNeuro]

Going to the VA will help with the time off and the pay, but unprofessional coworkers, dingy facilities, and a boss will still be there. The pace will likely be a lot slower, but add in a lot of pointless bureaucracy instead (I get to do a bunch of mandatory Mission Act training this week, woohoo!). That said, it is one of the better paying W-2 gigs in the clinical world, IMO.

Starting out, definitely, after about 3-5 years, not really.

 

[Pragma]

Starting out, definitely, after about 3-5 years, not really.

Agree, high floor, low ceiling.

 

[WisNeuro]

Agree, high floor, low ceiling.

It's like the RBANS confrontation naming of jobs.

 

[Pragma]

It's like the RBANS confrontation naming of jobs.

Isn't that more high floor, high ceiling?

 

[Sanman]

Starting out, definitely, after about 3-5 years, not really.

Agree it evens out the longer you are there, but I was referring to the OP's current 87k salary. That said, it really depends on specialty. Many geriatrics positions pay less than VA due to the high percentage of medicare.

 

[WisNeuro]

Agree it evens out the longer you are there, but I was referring to the OP's current 87k salary. That said, it really depends on specialty. Many geriatrics positions pay less than VA due to the high percentage of medicare.

All depends on negotiation. I work with mostly gero, albeit in a specialty, and make a good amount into 6 figures. All depend son what someone is willing to accept for compensation.

 

[Sanman]

All depends on negotiation. I work with mostly gero, albeit in a specialty, and make a good amount into 6 figures. All depend son what someone is willing to accept for compensation.

And the type of work they are doing. Therapy vs assessment split makes a difference

 

[cara susanna]

The VA may have a bad maternity leave policy, but it is superior to what happens in private practice. I had complications that required me to be hospitalized for a month, plus I wanted to take some time off to recover from my c-section and be home with my premature baby. It was a major financial hit.

I also wanted to add pertaining to finances: you almost never get a raise in PP. a major insurer just raised our rates, which was great, but they had been paying the same rate for the past 25 years! Cost of living keeps increasing, but reimbursement doesn’t reflect that.

Okay, one last “Debbie Downer” thing about PP is the relative lack of prestige. I didn’t think that would bother me, but it does a little. In an organization, you have the opportunity to rise up through the ranks, get promotions, supervise others, etc. just something to think about.

Negatives aside, PP is working for me during this stage of my life. It might be right for you too, but go in with your eyes open. Good luck!

I've been at four different VAs now and I've never seen or heard about anyone have problems with taking maternity leave.

 

[WisNeuro]

I've been at four different VAs now and I've never seen or heard about anyone have problems with taking maternity leave.

Except that there is no real maternity leave policy, it's simply using your accrued sick leave, or FMLA.

 

[deleted343839]

I've been at four different VAs now and I've never seen or heard about anyone have problems with taking maternity leave.

Except that there is no real maternity leave policy, it's simply using your accrued sick leave, or FMLA.

I know a VA staff psychologist who was permanently reassigned to another clinic after taking a standard 12-week maternity leave. They have to hold a job for you, but not necessarily the same job.

 

[Pragma]

I know a VA staff psychologist who was permanently reassigned to another clinic after taking a standard 12-week maternity leave. They have to hold a job for you, but not necessarily the same job.

That’s awful. 12 weeks isn’t that long. Certainly some circumstances can make it tough on a clinic, but that sounds extreme.

I wonder why the VA does not have a short term disability plan. That buys you at least 6-8 weeks paid time off. It’s been standard at my wife’s employers to at least offer that. Some have even added weeks as a matter of policy/good will. But even then, it’s a financial struggle if you want additional leave.

Taking 3 months off unpaid is not realistic for most people. If it is then please count yourself as privileged!

 

[AbnormalPsych]

I know a VA staff psychologist who was permanently reassigned to another clinic after taking a standard 12-week maternity leave. They have to hold a job for you, but not necessarily the same job.

This is awful. I'm saddened to not be surprised by this. I hate how VA treats staff. Part of why I left.