what about this psych business idea?

[vistaril]

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Your local micro environment perhaps is reflective of how things might be with "colabs" and "psychs" and "psych NPs" but is not reflective of the US as a whole, especially with most states as independent practice states for ARNPs.

please...I've been post-residency in 5 states. This encroachment is happening everywhere. But we've seen it really picking up steam the last couple of years.

The point is if it *hasn't* gotten to your area yet, it will. It's coming.

And most states are *not* fully independent practice states. Like 15% are. Where do you guys get all these 'facts' that are so wrong
and can be easily looked up

 

[vistaril]

Ahh, now it all makes sense. You are uncomfortable that a huge chunk of your salary comes from you providing meaningless "collaborations" to NPs (i.e. frank and naked rent-seeking exploiting regulatory loopholes) so it is important that you tell us all that this is the future and everyone else will be doing the same thing in a few years.

well it's become more the present too, but yes it will get much worse.....my point is to point out the economic realities of what's at work.

But hey if you choose to place a lot of faith that C-suite types are going to value quality of care over $, especially when there is little evidence that the quality of care is different, thats your choice. I know I wouldn't want to be on the side of the bet that hopes admins turn away from cost savings....

 

[hebel]

If I was capable of pulling off such things Id be in a lot better position honestly. Not just in my job but life in general.

Part of it is just resistant to change on my part as well. What I do has become comfortable, it is fairly easily, I'll probably make about 425k or so this year and that doesnt include 401k add on, don't pay anything for great health insurance, probably work more like 35 hrs a week M-F than 40, free dental, etc....now I have to work some weekends and see a lot of patients for that, but as crappy as some aspects of the job are there is still a resistance to change at some level too.

The other part I didn't mention is that even though I dont work much with the psych nps directly, I still give the practice like three formal collaborative agreements with that salary. So my boss isn't interesting in paying me 425k(lets say 335 for the M-F part) to see my 35 inpatients a day. Thats not going to make him money sans stipend after my salary and expenses and taxes and benefits. He makes the money on the delta on what the nps for those three collabs produce. Like one of them has a 2 days per week contract with a distant cmhc to do high volume med mgt. The cmhc of course just needs a psych np who has a collaborator, and we provide that. The cmhc is paying us more than the 110k or so she makes just for those 2 days per week.....

So thats where the money is made- the psychs themselves arent bringing in much due to their salaries. It's the psych nps and that delta between what they bring in(in clinic and through cmhc type contracts) and their small salaries where the money is made. And people like me give the practice those collaborative slots(since the owner of the practice can only use so many)....

You do you Vistaril, but reading this with your recent posts in mind, I have to say this is pretty lame man.

 

[clausewitz2]

well it's become more the present too, but yes it will get much worse.....my point is to point out the economic realities of what's at work.

But hey if you choose to place a lot of faith that C-suite types are going to value quality of care over $, especially when there is little evidence that the quality of care is different, thats your choice. I know I wouldn't want to be on the side of the bet that hopes admins turn away from cost savings....

I agree with you that the lack of evidence of differential quality is a problem and one I hope is addressed by people positioned to do that research, but you are making this argument on the basis of anecdotes from your experience.

The trouble with anecdotes is that when yours say one thing, and the anecdotes of literally everyone else on this forum say another, it becomes hard to see why anyone should accept yours as more reflective of reality. Where's the evidence your anecdotes are higher quality than those of anyone else?

I mean, everyone keeps saying that they don't trust admin types farther than they can throw them and so maybe if you are worried about this don't work in settings where you are dependent on the good will of administrators. A majority of psychiatrists are not doing inpatient work and the thing about outpatient psychiatry is that unless we are talking about CMHCs it is patients who choose who they see (or at least which practice) rather than an administrator.

Thus, the trick is making sure to appeal to and retain patients. I am sorry in your corner of Alabama the outpatient psychiatrists generally aren't very adept with the local culture and/or speak with accents people find offensive but in many parts of this country (i.e., the metropolitan areas where 60-70% of the population lives) there are outpatient psychiatrists who are in fact culturally adept at dealing with the locals and who have practices bulging to the gills.

Look at my practice thread. Look how quickly I filled with even the barest bones, half-assed marketing effort. This is the modal experience and those people I can tell you were not interested in seeing an NP; if they were there is a place across town they could have gotten in much faster.

 

[vistaril]

I agree with you that the lack of evidence of differential quality is a problem and one I hope is addressed by people positioned to do that research, but you are making this argument on the basis of anecdotes from your experience.

The trouble with anecdotes is that when yours say one thing, and the anecdotes of literally everyone else on this forum say another, it becomes hard to see why anyone should accept yours as more reflective of reality. Where's the evidence your anecdotes are higher quality than those of anyone else?

I mean, everyone keeps saying that they don't trust admin types farther than they can throw them and so maybe if you are worried about this don't work in settings where you are dependent on the good will of administrators. A majority of psychiatrists are not doing inpatient work and the thing about outpatient psychiatry is that unless we are talking about CMHCs it is patients who choose who they see (or at least which practice) rather than an administrator.

Thus, the trick is making sure to appeal to and retain patients. I am sorry in your corner of Alabama the outpatient psychiatrists generally aren't very adept with the local culture and/or speak with accents people find offensive but in many parts of this country (i.e., the metropolitan areas where 60-70% of the population lives)

if you define a metropolitan area as one where 60-70% of the population lives, then where I live now is easily within that definition. IOW if you divided the country in half and called one half rural and one half metro, based on things like population density or whatever I would probably unfortunately now be in the metro half. Don't get me wrong I live in a smaller city or a larger town(however you want to define it), but it's very representative of where people live.....much moreso than NYC or whatever, and much moreso than a town of 5000 people as well. Most people in this country(and psychiatrists too) live somewhere on the density spectrum between NYC and a town of 5000 people. You guys are big into speaking as if these things are binary(huge city vs a few red lights town), but thats not reality.

but i've lived several places(some bigger and some smaller) and my point is the basic principles are true pretty much everywhere, and if these principles haven't resulted in change in one's specific area yet.......well it's coming. Thats why I find the people gloating about their specific situation so odd("I see 8 patients a day at my hospital").....that makes them a prime target to be acquired then sliced and diced. Right now I can guarantee that some hospital admin is somewhat perturbed at that line item for the psych seeing 8 patients, and it's only a matter of time before things come together and
a 'better'(from the perspective of the hospital sytem) solution is found.....and it won't be better for that psych who was gloating earlier about how he only sees 8 pts and how much leverage he thinks he has lol.....

 

[nexus73]

If I was capable of pulling off such things Id be in a lot better position honestly. Not just in my job but life in general.

Part of it is just resistant to change on my part as well. What I do has become comfortable, it is fairly easily, I'll probably make about 425k or so this year and that doesnt include 401k add on, don't pay anything for great health insurance, probably work more like 35 hrs a week M-F than 40, free dental, etc....now I have to work some weekends and see a lot of patients for that, but as crappy as some aspects of the job are there is still a resistance to change at some level too.

The other part I didn't mention is that even though I dont work much with the psych nps directly, I still give the practice like three formal collaborative agreements with that salary. So my boss isn't interesting in paying me 425k(lets say 335 for the M-F part) to see my 35 inpatients a day. Thats not going to make him money sans stipend after my salary and expenses and taxes and benefits. He makes the money on the delta on what the nps for those three collabs produce. Like one of them has a 2 days per week contract with a distant cmhc to do high volume med mgt. The cmhc of course just needs a psych np who has a collaborator, and we provide that. The cmhc is paying us more than the 110k or so she makes just for those 2 days per week.....

So thats where the money is made- the psychs themselves arent bringing in much due to their salaries. It's the psych nps and that delta between what they bring in(in clinic and through cmhc type contracts) and their small salaries where the money is made. And people like me give the practice those collaborative slots(since the owner of the practice can only use so many)....

The real travesty is you're only making $335K seeing 35 patients a day, then another $90K for supervising 3 NPs. 35 patients a day should be closer to $800K-1million dollars a year. I think your boss is screwing you.

 

[clausewitz2]

if you define a metropolitan area as one where 60-70% of the population lives, then where I live now is easily within that definition. IOW if you divided the country in half and called one half rural and one half metro, based on things like population density or whatever I would probably unfortunately now be in the metro half. Don't get me wrong I live in a smaller city or a larger town(however you want to define it), but it's very representative of where people live.....much moreso than NYC or whatever, and much moreso than a town of 5000 people as well. Most people in this country(and psychiatrists too) live somewhere on the density spectrum between NYC and a town of 5000 people. You guys are big into speaking as if these things are binary(huge city vs a few red lights town), but thats not reality.

but i've lived several places(some bigger and some smaller) and my point is the basic principles are true pretty much everywhere, and if these principles haven't resulted in change in one's specific area yet.......well it's coming. Thats why I find the people gloating about their specific situation so odd("I see 8 patients a day at my hospital").....that makes them a prime target to be acquired then sliced and diced. Right now I can guarantee that some hospital admin is somewhat perturbed at that line item for the psych seeing 8 patients, and it's only a matter of time before things come together and
a 'better'(from the perspective of the hospital sytem) solution is found.....and it won't be better for that psych who was gloating earlier about how he only sees 8 pts and how much leverage he thinks he has lol.....

I am roughly defining metropolitan area as an MSA with greater than 500k population. If we limit ourselves only to MSAs with > 1 million population we already have a bare majority of the US population. Only one of these is in Alabama, specifically Birmingham-Hoover. If you live outside of this area in AL you are in an unusually sparsely populated part of the country relative to the experience of most people living in the United States.

I'd still love to hear where you practiced in PA since it is so very different from the environment on the ground now.

 

[SmallBird]

if you define a metropolitan area as one where 60-70% of the population lives, then where I live now is easily within that definition. IOW if you divided the country in half and called one half rural and one half metro, based on things like population density or whatever I would probably unfortunately now be in the metro half. Don't get me wrong I live in a smaller city or a larger town(however you want to define it), but it's very representative of where people live.....much moreso than NYC or whatever, and much moreso than a town of 5000 people as well. Most people in this country(and psychiatrists too) live somewhere on the density spectrum between NYC and a town of 5000 people. You guys are big into speaking as if these things are binary(huge city vs a few red lights town), but thats not reality.

but i've lived several places(some bigger and some smaller) and my point is the basic principles are true pretty much everywhere, and if these principles haven't resulted in change in one's specific area yet.......well it's coming. Thats why I find the people gloating about their specific situation so odd("I see 8 patients a day at my hospital").....that makes them a prime target to be acquired then sliced and diced. Right now I can guarantee that some hospital admin is somewhat perturbed at that line item for the psych seeing 8 patients, and it's only a matter of time before things come together and
a 'better'(from the perspective of the hospital sytem) solution is found.....and it won't be better for that psych who was gloating earlier about how he only sees 8 pts and how much leverage he thinks he has lol.....

I'll stay optimistic. You told me the same thing in 2012. I promise if I'm replaced by a better solution by 2030 Ill let you know.

 

[hamstergang]

And most states are *not* fully independent practice states. Like 15% are. Where do you guys get all these 'facts' that are so wrong
and can be easily looked up

Yes, let's look up facts.

State Practice Environment

It’s essential that NPs and policy makers have a clear understanding of how their state laws and regulations impact their practice. AANP’s interactive State Practice Environment map provides an overview of NP licensure for all 50 states, Washington, D.C. and U.S. territories. For details about the…

www.aanp.org

I've searched a number of other sources and all are closer to 50% than 15%. What's your source?

 

[vistaril]

I am roughly defining metropolitan area as an MSA with greater than 500k population. If we limit ourselves only to MSAs with > 1 million population we already have a bare majority of the US population. Only one of these is in Alabama, specifically Birmingham-Hoover. If you live outside of this area in AL you are in an unusually sparsely populated part of the country relative to the experience of most people living in the United States.

I'd still love to hear where you practiced in PA since it is so very different from the environment on the ground now.

well thats where I happen to live, so I don't live in a sparsely populated area relative to the rest of the country. But whatever....the point is that most people in the US live in places like this, and places like I have lived in before. It was mostly the same crap when I lived in atlanta; just busier interstates(although 280 here can be a nightmare too)....

In fact, outside of a few places and outside of unique really small towns, the whole damn US is pretty much one big box store now. We all shop at amazon, we all watch netflix, we all go to some little local coffee shop that we swear is the best and oh so unique but it's really just the same as the one two states over that someone elses swears is the 'best' little independent coffee shop in town....yawn.

In pennsylvania I lived somewhere on the fringe of what would be called a suburb of pittsburgh vs what would be considered an exurb. I actually moved because my work was poached there....in fact thats one of the reasons why I have lived in so many different states- I take a job, get comfortable, do what is considered solid work without any issues, and then BOOM....usual BS. Thats not what happened at every place(once it was personal/family reasons), but it's definately been a trend.....

This time in taking a job I just said I'll skip a step ahead and take a job with a place that has already gone through that so I won't be left holding the bag.....so far it's worked ok as Im still working there.

 

[clausewitz2]

well thats where I happen to live, so I don't live in a sparsely populated area relative to the rest of the country. But whatever....the point is that most people in the US live in places like this, and places like I have lived in before. It was mostly the same crap when I lived in atlanta; just busier interstates(although 280 here can be a nightmare too)....

In fact, outside of a few places and outside of unique really small towns, the whole damn US is pretty much one big box store now. We all shop at amazon, we all watch netflix, we all go to some little local coffee shop that we swear is the best and oh so unique but it's really just the same as the one two states over that someone elses swears is the 'best' little independent coffee shop in town....yawn.

In pennsylvania I lived somewhere on the fringe of what would be called a suburb of pittsburgh vs what would be considered an exurb. I actually moved because my work was poached there....in fact thats one of the reasons why I have lived in so many different states- I take a job, get comfortable, do what is considered solid work without any issues, and then BOOM....usual BS. Thats not what happened at every place(once it was personal/family reasons), but it's definately been a trend.....

This time in taking a job I just said I'll skip a step ahead and take a job with a place that has already gone through that so I won't be left holding the bag.....so far it's worked ok as Im still working there.

Well, glad you landed okay. It's strange because I am actually in the Pittsburgh metro and there are several psychiatrist jobs that keep getting posted over and over that seem challenging to fill; it is more an issue of our scarcity than the scarcity of the jobs.

 

[Stagg737]

Well yes, but you are making the assumption that we are trying to solve a different problem. While it is true that the reality is psychiatrists who prefer inpatient psychiatry have the option to exit and go outpatient and charge cash, let's suppose that this option is not available. Vistaril is asking the question what is the most optimal way to contract management a group of inpatient psychiatrists either on the provider side or on the payer/client side.

Fair point, I was just saying that for the reimbursement rates previously mentioned it's not hard to walk away and find something paying (significantly) better.

Don't agree with this at all. I think there probably are settings where psychs are superior, but I doubt most.....I would have to see some evidence that in a typical outpt med mgt practice psychs are better than psych nps,and I've never seen such....

Come hang out in our clinics for a week and see some of our new evals. Ever seen a patient come in on 3 (different) antipsychotics, 3 (different) benzos, 2 stimulants, and 3-4 other serotonergic meds who was also taking opiates? I have. [ETA: looked the patient up again and they're also on Flexeril and Ambien] Want to take a guess at what the letters after their previous prescriber's names were? They weren't MD or DO...

Things I see from NPs on a regular basis that I don't regularly see from psychiatrists:
- Patients on >2 SSRI/SNRI medications, some for the same indications
- Patients started on 2 different antipsychotics with another added at the next appointment
- Patient with a history of 10+ failed trials without getting up to a therapeutic dose or for a adequate trial time
- Patients on high doses of benzos and stimulants who are also either on opiates or suboxone (more common, but I also see this too often with patients coming from PCPs)

Some of the treatments I've seen or notes I've read are very in line with what the poopologist mentioned earlier in terms of how incompetent NPs in the area are, and I'm not in an FPA state. I don't disagree that many patients don't know the difference and that plenty don't care. I also don't disagree that there are plenty of psychiatrists providing relatively poor care d/t volume, many of whom could probably provide very good care if their patient loads were reasonable.

please...I've been post-residency in 5 states. This encroachment is happening everywhere. But we've seen it really picking up steam the last couple of years.

The point is if it *hasn't* gotten to your area yet, it will. It's coming.

And most states are *not* fully independent practice states. Like 15% are. Where do you guys get all these 'facts' that are so wrong
and can be easily looked up

As Hamstergang said above, NPs have FPA in 28 states and PAs actually have independent practice rights in ND. Another source:

28 states with full practice authority for NPs - Becker's Hospital Review | Healthcare News & Analysis

While states like California continue to debate the scope of practice for nurse practitioners, many others have opted to allow NPs to practice without physician supervision.

www.beckershospitalreview.com

Encroachment is happening all over, but even in places with that encroachment there are still employers who value quality of care. They're not going to be paying $400k+, but a "normal" Full-time position for a psychiatrist typically leaves plenty of time for a side-hustle to hit that.

Don't get me wrong I live in a smaller city or a larger town(however you want to define it), but it's very representative of where people live.....much moreso than NYC or whatever, and much moreso than a town of 5000 people as well. Most people in this country(and psychiatrists too) live somewhere on the density spectrum between NYC and a town of 5000 people. You guys are big into speaking as if these things are binary(huge city vs a few red lights town), but thats not reality.

I'm in a city of ~500k in the midwest with metro area over 1M. There are certainly a few units in our city where high volume with lower quality of care is the norm. There's also a few facilities that have not followed that trend despite the opportunity. I also get a ton of job offers sent to me right now with a huge variation in job duties and compensation. It sounds like you've had really poor luck, but that experience is not universal.