What hospitals pay locums compared

[nexus73]

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I overheard a rumor at my hospital recently that the 1 week (7 day week x 12 hours per day) cost for a locums psychiatrist is $30K, paid to the locums company. If the doc gets $200/hour it’s $16,800. Over $13,000 to the locums company. For one week.

 

[oldiebutgoodie1211]

I overheard a rumor at my hospital recently that the 1 week (7 day week x 12 hours per day) cost for a locums psychiatrist is $30K, paid to the locums company. If the doc gets $200/hour it’s $16,800. Over $13,000 to the locums company. For one week.

I doubt they are paying for 12 hours per day it’s more like 8?

 

[BiscoDisco]

I overheard a rumor at my hospital recently that the 1 week (7 day week x 12 hours per day) cost for a locums psychiatrist is $30K, paid to the locums company. If the doc gets $200/hour it’s $16,800. Over $13,000 to the locums company. For one week.

Well that would be awesome. work 6 months a year and make 430k....

 

[Merovinge]

I doubt they are paying for 12 hours per day it’s more like 8?

For a higher census inpatient unit it can make a lot more sense to pay 1 doc to work 7-7 then 2 doctors to work from 9-5. Lots of administrative "savings" in this manner and plenty of psychiatric hospitalist jobs that do this with 7 on 7 off scheduling.

 

[cookymonster]

When I cold called psych hospitals directly, one of them told me they paid Staff Care $240 an hour (can't remember exactly what they paid the doc, might have been $180 an hour).

Somehow when I tried finding work on my own without the help of an agency, the hourly rates I was quoted were usually abysmal (HCA offered me $126 an hour for weekend inpatient work). I am not sure why it is such an inefficient system that relies so much on middlemen.

There are sites (nomad health, lucidity direct) that are supposed to cut out the agencies, but they have very few listings.

 

[Sushirolls]

Because they want to remind you, that you are widget who means nothing. A large corporate entity that does staffing means more than you.

 

[Psychresy]

How would this go if one were to avoid the huge conglomerates like HCA and contact psych units directly? I recall a poster on here saying that's how he secured his highest rated.

 

[dl2dp2]

When I cold called psych hospitals directly, one of them told me they paid Staff Care $240 an hour (can't remember exactly what they paid the doc, might have been $180 an hour).

Somehow when I tried finding work on my own without the help of an agency, the hourly rates I was quoted were usually abysmal (HCA offered me $126 an hour for weekend inpatient work). I am not sure why it is such an inefficient system that relies so much on middlemen.

There are sites (nomad health, lucidity direct) that are supposed to cut out the agencies, but they have very few listings.

This phenomenon is not limited to locum. There are many full-time jobs that have higher salaries via agency than when you reach out directly. While this might defy logic at first glance, what actually happens is that people you reach out to (i.e. unit chief) don't have the decisional capacity to deploy the money, and people who have the decisional capacity (hospital executives) don't have any idea of the market rate of a particular kind of clinician. So they want the agency to help them price the clinician.

This is why the most desirable jobs often don't even circulate at all, and the most desirable of all jobs involves equity ownership.

 

[cookymonster]

This phenomenon is not limited to locum. There are many full-time jobs that have higher salaries via agency than when you reach out directly. While this might defy logic at first glance, what actually happens is that people you reach out to (i.e. unit chief) don't have the decisional capacity to deploy the money, and people who have the decisional capacity (hospital executives) don't have any idea of the market rate of a particular kind of clinician. So they want the agency to help them price the clinician.

This is why the most desirable jobs often don't even circulate at all, and the most desirable of all jobs involves equity ownership.

Seems like there are much cheaper ways to do this. Isn't this why they pay for MGMA data? Or they could just do what we do, go online and see what jobs pay.

 

[dl2dp2]

Seems like there are much cheaper ways to do this. Isn't this why they pay for MGMA data? Or they could just do what we do, go online and see what jobs pay.

You are overestimating the amount of time hospital executives actually have to deal with hiring a rank and file psychiatrist, or even worse, a locum. They have a million other things to deal with like the Joint Commission, nurses unions, insurance companies, government regulators, HR, lawsuits, quality metrics, blah blah. They would much prefer the procedure of evaluation to become outsourced and a standard practice, rather than individually evaluated, especially for things like locum, which generally has astronomical turnover.

It'd be wholly unsurprising that when you try to directly request info/negotiate with a mid level admin (who's often a nurse or an LCSW) you either get a completely unrealistic low ball number or no call back at all.

Also of note: successful PP psychiatrists with equity ownership often easily outearn hospital admins who might be 5 levels above them at a large system. To a certain extent this is also a reason why top non-research clinicians in our field are generally not direct hires in large systems.

 

[asdf123g]

Also of note: successful PP psychiatrists with equity ownership often easily outearn hospital admins who might be 5 levels above them at a large system. To a certain extent this is also a reason why top non-research clinicians in our field are generally not direct hires in large systems.

can you elaborate on what you mean by this?? sorry, im really not familiar with this ughhh

 

[Sushirolls]

can you elaborate on what you mean by this?? sorry, im really not familiar with this ughhh

Open your own practice, expand it a bit with a few psychiatrist employees, maybe a few office locations you own the building for. Control your payer mix, or do cash only = financially doing better than many hospital executives.

Thus, why I and a few others continue to parrot, "open your own practice."

 

[asdf123g]

Open your own practice, expand it a bit with a few psychiatrist employees, maybe a few office locations you own the building for. Control your payer mix, or do cash only = financially doing better than many hospital executives.

Thus, why I and a few others continue to parrot, "open your own practice."

Where does one gain this knowledge on how to open your own PP? I'd love to, I just have no clue how to.

 

[dl2dp2]

Where does one gain this knowledge on how to open your own PP? I'd love to, I just have no clue how to.

APA has a manual for members. That's where I'd start. This forum is good too, read Sushiroll's practice log. Ask around if you trained at a residency with a track record of people starting or going into PP.

For example, in my residency, there's actually a course devoted to how to run a PP for PGY4s.

The level of success in PP is also wildly variable. Someone I know who's 1 year out from fellowship grosses ~ 1M in revenue in a solo practice. Meanwhile, there are senior clinicians who are not making ends meet due to lack of savvy in marketing, patient recruitment, and knowledge of payors, etc. It's also not a job for everyone. A sizable minority of qualified people don't do well with small/solo PP, and end up going back to a facilities job. However, my impression is in general if you are 10 years out and still sustaining a PP, you are crushing it. You might not be making surgeon money in total, but you are making surgeon money on a per hour basis and have a much more flexible lifestyle. People in that kind of situation almost never work full 40 hour work weeks.

 

[Psychresy]

APA has a manual for members. That's where I'd start. This forum is good too, read Sushiroll's practice log. Ask around if you trained at a residency with a track record of people starting or going into PP.

For example, in my residency, there's actually a course devoted to how to run a PP for PGY4s.

The level of success in PP is also wildly variable. Someone I know who's 1 year out from fellowship grosses ~ 1M in revenue in a solo practice. Meanwhile, there are senior clinicians who are not making ends meet due to lack of savvy in marketing, patient recruitment, and knowledge of payors, etc. It's also not a job for everyone. A sizable minority of qualified people don't do well with small/solo PP, and end up going back to a facilities job. However, my impression is in general if you are 10 years out and still sustaining a PP, you are crushing it. You might not be making surgeon money in total, but you are making surgeon money on a per hour basis and have a much more flexible lifestyle. People in that kind of situation almost never work full 40 hour work weeks.

Do you think people in that position you described don't work a full 40 hours because they just don't want to or they don't have the volume to do so?

 

[dl2dp2]

Do you think people in that position you described don't work a full 40 hours because they just don't want to or they don't have the volume to do so?

Some of this, some of that. I think if you really want to fill you can generally fill in most markets charging a lower fee, especially if you do only psychopharm. People who don't fill have certain expectations of what their practices look like, and are okay with making less money.

 

[finalpsychyear]

Some of this, some of that. I think if you really want to fill you can generally fill in most markets charging a lower fee, especially if you do only psychopharm. People who don't fill have certain expectations of what their practices look like, and are okay with making less money.

I fully support in what i see that providers DO NOT want to work 40 hours of clinical work seeing 100+ patients. If you run a busy cash or good payor mix 4 day work weeks in the low 30 ish clinic hours is a great balance. You will naturally value time exponentially more once you have paid off loans, debts, cars, etc.

 

[milesed]

Someone I know who's 1 year out from fellowship grosses ~ 1M in revenue in a solo practice.

Can you elaborate any on this- types of visits, time spent for each, days/weeks worked/year, cash vs insurance, etc.?

 

[drillers]

APA has a manual for members. That's where I'd start. This forum is good too, read Sushiroll's practice log. Ask around if you trained at a residency with a track record of people starting or going into PP.

For example, in my residency, there's actually a course devoted to how to run a PP for PGY4s.

The level of success in PP is also wildly variable. Someone I know who's 1 year out from fellowship grosses ~ 1M in revenue in a solo practice. Meanwhile, there are senior clinicians who are not making ends meet due to lack of savvy in marketing, patient recruitment, and knowledge of payors, etc. It's also not a job for everyone. A sizable minority of qualified people don't do well with small/solo PP, and end up going back to a facilities job. However, my impression is in general if you are 10 years out and still sustaining a PP, you are crushing it. You might not be making surgeon money in total, but you are making surgeon money on a per hour basis and have a much more flexible lifestyle. People in that kind of situation almost never work full 40 hour work weeks.

that's awesome and says a lot about your institution. would you mind DM'ing me where you went

 

[dl2dp2]

Can you elaborate any on this- types of visits, time spent for each, days/weeks worked/year, cash vs insurance, etc.?

It's full cash. Primarily psychopharm. He "lucked out" in that he purchased an existing practice through owners financing. He's an MBA so very savvy about how to valuate business. Other details I am not privy of. He generates a revenue of 1M, but I don't think he nets 1M. Roughly I think the breakdown would be $600 per hour, 35 clinical hours a week, 48 weeks a year. Typically in this biz you have at most 1-2x revenue valuation or 4x profit. So assume an owners financing package with interest of 5% (total interest of 100k), he'd have EBITA ~ 600k. If he lives frugally for 5 years he'll then have another 200k dividend once the mortgage is done.

The rough math here is the owner derives 1M total revenue from a full time clinician, with 200-300k overhead including capital investment, then take a 50% cut, pay the employee 300k, and take in an end of year dividend of 300k. Part of the overhead will also accrue through capital investment. So a comparable employed position would max out around 300k W-2.

This lifestyle compares very favorably to a mid level banker or a legal partner at a mid sized firm, which typically have similar compensation structure (~300-450k base, everything else is dividend/performance/bonus). OTOH Very little travel. Very little nights/weekends/deadlines. You need another 5ish hours a week for admin/billing, etc. a week. Minimal overhead--don't need a secretary. Assuming 80 visits a week, one visit a month you have about 300-350 patients. This level of admin work you can usually do yourself, or at most hire a remote low cost secretary for appointments, etc.

that's awesome and says a lot about your institution. would you mind DM'ing me where you went

I went to one of the top 10 programs by doximity in a major metro.

 

[AD04]

It's full cash. Primarily psychopharm. He "lucked out" in that he purchased an existing practice through owners financing. He's an MBA so very savvy about how to valuate business. Other details I am not privy of. He generates a revenue of 1M, but I don't think he nets 1M. Roughly I think the breakdown would be $600 per hour, 35 clinical hours a week, 48 weeks a year. Typically in this biz you have at most 1-2x revenue valuation or 4x profit. So assume an owners financing package with interest of 5% (total interest of 100k), he'd have EBITA ~ 600k. If he lives frugally for 5 years he'll then have another 200k dividend once the mortgage is done.

The rough math here is the owner derives 1M total revenue from a full time clinician, with 200-300k overhead including capital investment, then take a 50% cut, pay the employee 300k, and take in an end of year dividend of 300k. Part of the overhead will also accrue through capital investment. So a comparable employed position would max out around 300k W-2.

This lifestyle compares very favorably to a mid level banker or a legal partner at a mid sized firm, which typically have similar compensation structure (~300-450k base, everything else is dividend/performance/bonus). OTOH Very little travel. Very little nights/weekends/deadlines. You need another 5ish hours a week for admin/billing, etc. a week. Minimal overhead--don't need a secretary. Assuming 80 visits a week, one visit a month you have about 300-350 patients. This level of admin work you can usually do yourself, or at most hire a remote low cost secretary for appointments, etc.

I don't quite understand how the numbers add up. It is a solo cash practice with overhead of 20 - 30%? Are the numbers inflated to transfer self money through real estate? Is the owner employing another doctor as an employee? If so, what is to stop the doctor from leaving and opening a competing practice? Or is the owner paying himself as the employee?

I am surprised that this person purchased a cash practice. What exactly is he purchasing? The patient list and real estate?

 

[cookymonster]

Someone at my hospital messed up bigtime and cc'd me their agreement with the agency.

They make 67% on top of what I make per hour.
132% more for weekday 24 hour pager call.
388% more (wish I was making this up) for weekend 24 hour pager call.
Also their contract specifies that the agency gets paid extra for overtime hours (>8 hours a day), which is not anywhere in my contract.
Had no idea I was getting hosed this bad.

 

[Sushirolls]

Oh, yeah. Hospitals will hemorrhage money on locums. But get this, if you ask for increase pay in parameter XYZ, they will give you a cold shoulder or potentially show you the door. The disconnect in Big Box shop admin can be mind boggling, to run off their good permanent people only bleed out on locums. I've seen too much of this.

 

[dl2dp2]

I don't quite understand how the numbers add up. It is a solo cash practice with overhead of 20 - 30%? Are the numbers inflated to transfer self money through real estate? Is the owner employing another doctor as an employee? If so, what is to stop the doctor from leaving and opening a competing practice? Or is the owner paying himself as the employee?

I am surprised that this person purchased a cash practice. What exactly is he purchasing? The patient list and real estate?

Overhead is often inflated, and obviously I haven't seen his P&L so I can't tell you. I'm using generous numbers to give generous estimates. I don't know how much he paid for the practice, but based on these generous estimates I'd put fair market somewhere between 1-2M. However, he may very well have paid less, which means he's making even more money.

Patient list. It's a long list, and from the story he told he filled 50% of his practice from day 1. I don't even think the real estate is there. I think 350 cash psychopharm patients is possibly worth 1M. Maybe? I'm maybe too generous.

 

[dl2dp2]

Someone at my hospital messed up bigtime and cc'd me their agreement with the agency.

They make 67% on top of what I make per hour.
132% more for weekday 24 hour pager call.
388% more (wish I was making this up) for weekend 24 hour pager call.
Also their contract specifies that the agency gets paid extra for overtime hours (>8 hours a day), which is not anywhere in my contract.
Had no idea I was getting hosed this bad.

This is actually a bad sign. If the hospital is this poorly managed I can only imagine how their nurses etc are managed. I would run...

 

[dl2dp2]

you do realize patients can just leave right? Paying 1 million dollars for patient charts is absurd

They can, but the majority don’t as they just come once a month or less, and if they leave they have to go through the entire intake process again, which can cost a lot. Furthermore, if they leave they may not find the same service for the same price. It’s all supply and demand. I’m doing a very very rough comparables analysis bud. When you do actual financial due diligence for a leveraged buy out like this, you'd survey the attrition rate and factor that in. P/E is 3x which seems reasonable to me for a low small town grocer growth industry like this. A back of the envelop DCF actually would put this practice at somewhat higher value than 1M. All this is standard stuff and plenty of consultants can do business appraisal for you--the only difference here is this doctor most of the sourcing and analysis himself, with some help, presumably, of a lawyer.

It's JUST like buying a rental building. Every year some people would leave, but then you just find replacements.

Furthermore, these contracts are often structured that if you lose a lot patients in the process your valuation changes in the pay period, vaguely resembling a convertible note. OTOH, owners mortgages are backed by income streams of the practice, so the current owners often are willing to give a low interest rate.

Of course, someone not as savvy, such as you, would be all like holyshizzzballz 1M for charts never ever ever when I already have 500g of student loans. And thusly you'll be twiddling your thumb waiting in your office for 5 years. When people think about risk adjust return, they often don't factor in opportunity cost.

 

[calvnandhobbs68]

They can, but the majority don’t as they just come once a month or less, and if they leave they have to go through the entire intake process again, which can cost a lot. Furthermore, if they leave they may not find the same service for the same price. It’s all supply and demand. I’m doing a very very rough comparables analysis bud. When you do actual financial due diligence for a leveraged buy out like this, you'd survey the attrition rate and factor that in. P/E is 3x which seems reasonable to me for a low small town grocer growth industry like this. A back of the envelop DCF actually would put this practice at somewhat higher value than 1M. All this is standard stuff and plenty of consultants can do business appraisal for you--the only difference here is this doctor most of the sourcing and analysis himself, with some help, presumably, of a lawyer.

It's JUST like buying a rental building. Every year some people would leave, but then you just find replacements.

Furthermore, these contracts are often structured that if you lose a lot patients in the process your valuation changes in the pay period, vaguely resembling a convertible note. OTOH, owners mortgages are backed by income streams of the practice, so the current owners often are willing to give a low interest rate.

Of course, someone not as savvy, such as you, would be all like holyshizzzballz 1M for charts never ever ever when I already have 500g of student loans. And thusly you'll be twiddling your thumb waiting in your office for 5 years. When people think about risk adjust return, they often don't factor in opportunity cost.

I agree in principle that you'll probably retain a lot of patients (as long as the person you're buying from is straight up retiring and not moving one town over or setting up telepsych and stealing their patients back). It is a huge pain in the butt to change practices once you've been seeing someone for years and patients certainly don't want to go pay $350 for a whole new intake with a possible change in treatment plan if they don't have to.

However, I'd also say that this would be with the caveat that your practice style is very similar to the person you're replacing. I'm sure this was done in this case but I'd want to see a large random sampling of charts. If you're buying out Dr. Feelgood's practice who was giving out Adderall, Klonopin and Ambien like Halloween candy to half his patients and you're gonna come in and be a hardass about controlled substances....well you're either going to practice against your principles or lose a lot of patients=money really quickly.

 

[Psychresy]

It's JUST like buying a rental building. Every year some people would leave, but then you just find replacements.

It's totally different. When you buy a rental property, you still have the asset if renters leave. When the patient's are the asset and the patient leaves, you no longer have the asset.

 

[AD04]

Someone at my hospital messed up bigtime and cc'd me their agreement with the agency.

They make 67% on top of what I make per hour.
132% more for weekday 24 hour pager call.
388% more (wish I was making this up) for weekend 24 hour pager call.
Also their contract specifies that the agency gets paid extra for overtime hours (>8 hours a day), which is not anywhere in my contract.
Had no idea I was getting hosed this bad.

Take it as a learning experience. Now you know how to negotiate your next locums contract.

 

[AD04]

They can, but the majority don’t as they just come once a month or less, and if they leave they have to go through the entire intake process again, which can cost a lot. Furthermore, if they leave they may not find the same service for the same price. It’s all supply and demand. I’m doing a very very rough comparables analysis bud. When you do actual financial due diligence for a leveraged buy out like this, you'd survey the attrition rate and factor that in. P/E is 3x which seems reasonable to me for a low small town grocer growth industry like this. A back of the envelop DCF actually would put this practice at somewhat higher value than 1M. All this is standard stuff and plenty of consultants can do business appraisal for you--the only difference here is this doctor most of the sourcing and analysis himself, with some help, presumably, of a lawyer.

It's JUST like buying a rental building. Every year some people would leave, but then you just find replacements.

Furthermore, these contracts are often structured that if you lose a lot patients in the process your valuation changes in the pay period, vaguely resembling a convertible note. OTOH, owners mortgages are backed by income streams of the practice, so the current owners often are willing to give a low interest rate.

Of course, someone not as savvy, such as you, would be all like holyshizzzballz 1M for charts never ever ever when I already have 500g of student loans. And thusly you'll be twiddling your thumb waiting in your office for 5 years. When people think about risk adjust return, they often don't factor in opportunity cost.

If this guy is only buying patient lists, I guess he really hedged his risk:

- decreased valuation based on patient attrition
- collateral of loan tied to business and not to personal assets
- generous pay-back terms

Anyways, this guy took on a huge risk and got a huge reward. Kudos.

 

[dl2dp2]

It's totally different. When you buy a rental property, you still have the asset if renters leave. When the patient's are the asset and the patient leaves, you no longer have the asset.

To each his own, I have no interest in debating you. If you think that piece of business has no value, don't buy it. Someone bought it and is doing great. I'm just telling you a story. You don't have to believe me. In many ways the practice is more valuable because there's no depreciation: the capital investment to maintain a practice tends to be fixed, rather than increasing. It's like saying Google has no value (beyond its office towers) because they don't own tangible assets. If you know anything about rental building valuation you'd know that the value is based on the actual rent roll collected, rather than the intrinsic value of the building. If a new owner can all of a sudden increase the rent roll, the building ipso facto becomes more valuable, so much of the value of the building resides in the software of running the building.

If this guy is only buying patient lists, I guess he really hedged his risk:

- decreased valuation based on patient attrition
- collateral of loan tied to business and not to personal assets
- generous pay-back terms

Anyways, this guy took on a huge risk and got a huge reward. Kudos.

You more or less got it. However, based on what I know now I think the risk he took is not as high as what it might appear on paper. What's actually trickier is to FIND a practice like this to BUY and go through the process of properly valuate and reach an agreement with the seller. That opportunity is rare. Most older psychiatrists slowly dissolve their practices. I also don't know to what extent did he personally guarantee the loan--I suspect some level of that is involved and he probably paid a downpayment in cash.

Much like buying commercial real estate: there are things that cash flow from day 1 with sellers financing, but it's not easy to find. It's actually not risky to do a 0% down purchase of that type, even if portions of the downpayment is a second mortgage on a personal loan.. He saw a lucky opportunity and grabbed it because he knew what he was doing.

 

[cookymonster]

I don't really have leverage to negotiate, unfortunately. They can just move on to the next doc who will take their crappy rates. I hate to sound like vistaril but it seems like a seller’s market for locums right now. And if anyone has followed my posts in other threads, I am extremely picky about work opportunities which limits my options.

If this is in any way helpful, it’s to use with direct negotiations with hospitals. The problem is that when I’ve attempted to cut out the middleman in the past, I’ve either been screwed, offered a nurse practitioner rate, or been told to pound sand.

 

[dl2dp2]

Latest numbers: 40 hours a weekday job locum full time at a NYC state hospital (MPC), capped out at 10 patients a day. No nights no weekends no call, $200+ an hour. BAM. If anyone wants the recruiter's contact PM.

 

[Psychresy]

Latest numbers: 40 hours a weekday job locum full time at a NYC state hospital (MPC), capped out at 10 patients a day. No nights no weekends no call, $200+ an hour. BAM. If anyone wants the recruiter's contact PM.

Wow, that's amazing for the work load and location.

 

[whackamole21]

Latest numbers: 40 hours a weekday job locum full time at a NYC state hospital (MPC), capped out at 10 patients a day. No nights no weekends no call, $200+ an hour. BAM. If anyone wants the recruiter's contact PM.

I finish residency in NYC in three years, these types of jobs will be at the top of my list!

 

[Ironspy]

Latest numbers: 40 hours a weekday job locum full time at a NYC state hospital (MPC), capped out at 10 patients a day. No nights no weekends no call, $200+ an hour. BAM. If anyone wants the recruiter's contact PM.

Full-time employed psychiatrists there make 195k for comparison (public info for state employees)

 

[Psychresy]

Full-time employed psychiatrists there make 195k for comparison (public info for state employees)

Can you just work as locums indefinitely?

 

[JKinSC]

Can you just work as locums indefinitely?

Theoretically, at least, the hospital will be trying to fill the spot with an employee. Though, frequently this can take a long time, especially when the position isn’t paid well.

 

[jbomba]

Theoretically, at least, the hospital will be trying to fill the spot with an employee. Though, frequently this can take a long time, especially when the position isn’t paid well.

Let's say I strictly want to work locums. Would it be possible to do 40 hrs a week 48 weeks a year x 20 years? In other words can I make a career of locums or will I frequently be unemployed when positions get filled?

 

[dl2dp2]

Let's say I strictly want to work locums. Would it be possible to do 40 hrs a week 48 weeks a year x 20 years? In other words can I make a career of locums or will I frequently be unemployed when positions get filled?

They will give you plenty of warning before replacing you with a permanent placement. During this time you can find another locum. You won’t be unemployed but you’ll move around a lot if this is the career you want.

 

[ksharp33]

Latest numbers: 40 hours a weekday job locum full time at a NYC state hospital (MPC), capped out at 10 patients a day. No nights no weekends no call, $200+ an hour. BAM. If anyone wants the recruiter's contact PM.

Could you PM me the contact info? It’s not letting me PM you for some reason. Thanks!

 

[rjs2131]

Locums telepsychiatry...is this a thing? Anyone have experience with it?

Also, I know this has been discussed at times but for those with locums experience, what companies have you found to be the best to work with?

 

[Psychresy]

What about locums ER coverage?

 

[Ironspy]

Could you PM me the contact info? It’s not letting me PM you for some reason. Thanks!

Just PMed you a copy of the email. Range was 210-230/h

 

[Ahamis]

Locums in California state hospital pays more than that.

 

[chocomorsel]

It's full cash. Primarily psychopharm. He "lucked out" in that he purchased an existing practice through owners financing. He's an MBA so very savvy about how to valuate business. Other details I am not privy of. He generates a revenue of 1M, but I don't think he nets 1M. Roughly I think the breakdown would be $600 per hour, 35 clinical hours a week, 48 weeks a year. Typically in this biz you have at most 1-2x revenue valuation or 4x profit. So assume an owners financing package with interest of 5% (total interest of 100k), he'd have EBITA ~ 600k. If he lives frugally for 5 years he'll then have another 200k dividend once the mortgage is done.

The rough math here is the owner derives 1M total revenue from a full time clinician, with 200-300k overhead including capital investment, then take a 50% cut, pay the employee 300k, and take in an end of year dividend of 300k. Part of the overhead will also accrue through capital investment. So a comparable employed position would max out around 300k W-2.

This lifestyle compares very favorably to a mid level banker or a legal partner at a mid sized firm, which typically have similar compensation structure (~300-450k base, everything else is dividend/performance/bonus). OTOH Very little travel. Very little nights/weekends/deadlines. You need another 5ish hours a week for admin/billing, etc. a week. Minimal overhead--don't need a secretary. Assuming 80 visits a week, one visit a month you have about 300-350 patients. This level of admin work you can usually do yourself, or at most hire a remote low cost secretary for appointments, etc.



I went to one of the top 10 programs by doximity in a major metro.

Seriously. A psychiatrist not only doing cash only but charging $600 an hour?
What kind of seriously sick people can afford this?

 

[romanticscience]

Seriously. A psychiatrist not only doing cash only but charging $600 an hour?
What kind of seriously sick people can afford this?

$200 for 20-min x 3?

Or

Challenges of $600-a-Session Patients (Published 2008)

Wealthy patients, used to getting what they want, can present countless challenges for their therapists.

www.nytimes.com

 

[dl2dp2]

Seriously. A psychiatrist not only doing cash only but charging $600 an hour?
What kind of seriously sick people can afford this?

This is not very unusual of a rate in major markets ($300x2 for psychopharm, or $500+ for combined). Actually kind of on the lower side.

FYI, Medicare rate for 99214+90833 = ~130+~80 = $210, so Medicare rates are only ~ 20-30% lower than cash rates, which is a fairly small disparity in all of medicine. Something like hip replacement Medicare rates are often 100% below cash/commercial rates.

FAIRHealth OON data shows (average) 99213 = $290 90833=$140 for Manhattan (as an example). This is typically the "reasonable and customary" rates for reimbursement used by insurance company for OON service.

In terms of service to fee ratio, this is also not very steep. Young professionals who make 100k would very readily pay 2-5k a year for quality psychopharm services. Older people in their 40s/50s can very easily blow 10-20g a year on themselves or their young adult kids, if there's a major issue. For a lot of these cases, people are fairly price insensitive, and if the issues are not addressed, the cost can be astronomically higher than the cost of treatment (i.e. divorce, loss of employment, academic failure, familial estrangement, drug relapse, etc.) I personally think high quality mental health treatment at $600 an hour is a big bargain compared to many other services in medicine (i.e. elective surgeries/procedures), let alone other expensive client focused services (i.e. wealth advisory, lawyering, private business consulting, real estate, etc).

 

[chocomorsel]

I am an anesthesiologist. I make pretty decent per hour money. Between 2-300/hr.
I take all comers of course, Medicare and Medicaid. Currently I do locums but have done PP before.
I know insurance companies are a PIA, when trying to negotiate and sometimes get paid. I get it. But I feel like all people need access to basic healthcare. Even ones on Medicaid and Medicare.
So my questions to the Cash paying psychiatrists is this. Considering that the seriously ill people in psychiatry are most often not gonna have the steadiest jobs, the best insurance, do you feel at all bad for excluding these needy people from your care? Like the teacher who has a psychotic break at 30 and decompensates, takes a LOA, for a few weeks, then back to work but needs frequent close follow up for Bipolar 1. Let’s say she needs an OP psychiatrist or she moves cities. And that’s a good example of a working middle class person who can’t afford $300 a month on top of what she pays at her job for premiums.
Do you think that Cash only in a field like psychiatry where people are often poor is doing the most needy people a disservice? Let’s not even talk about the ones on Medicaid because they can go to the community clinics I have been told.
I hate insurance companies as much as the next person, but it’s what we have in this country. Do these people with proper insurance at work, and proper familial support, do they need to really pay on top of their regular insurance to see you guys?

 

[dl2dp2]

So my questions to the Cash paying psychiatrists is this. Considering that the seriously ill people in psychiatry are most often not gonna have the steadiest jobs, the best insurance, do you feel at all bad for excluding these needy people from your care? Like the teacher who has a psychotic break at 30 and decompensates, takes a LOA, for a few weeks, then back to work but needs frequent close follow up for Bipolar 1. Let’s say she needs an OP psychiatrist or she moves cities. And that’s a good example of a working middle class person who can’t afford $300 a month on top of what she pays at her job for premiums.

How do you feel about interventional pain? Cash psychiatry occupies a similar niche, and is of higher value dollar by dollar.

There are many insurance taking psychiatrists, and the examples you cite the person would be able to find someone, but this person might be somewhat far out of the city, or perhaps affiliated with a hospital, which then has a longer wait. Or she could see an NP or primary care and if they don't solve her problem find a cash psychiatrist. Many different mechanisms to get care. Service price is determined by market supply and demand. Insurance companies refuse to pay a higher price to have a more inclusive network, causing further shortage of supply. OTOH they ARE willing to pay more for your services such that you'd be willing to be part fo the network. I don't think people should have any qualms about something that's not within their control. You know as well as I do that insurance reimbursement is not driven by value. If insurance company reimbursed your service wildly below market, many anesthesiologists would charge cash --- indeed, that's been happening with many cash based surgical centers in certain states, and most certainly anesthesiologists working for many elective procedures (i.e. cosmetic). Many patients prefer that system for a variety of reasons.

There's also something else you are not taking into consideration. Suppose a cash psychiatrist hire a physician on salary, this person would likely max out at $200-300 per hour. While you are getting $300 an hour, the hospital gets a lot more money. A lot of the value of cash psychiatry is the value and ease of business ownership, which doesn't exist in other specialties (except, something like interventional pain). The value of a business is to maximize profit, so if you have qualms about that, it's not the right path for you. There are many ways to practice psychiatry outside of private practice, including working at a nonprofit or government agency or conduct research--though often providers there see 3 patients a day and get on fixed salary, so I'm not sure who's really limiting the supply... You could also elect to give people sliding scale fees, if you find a particular case compelling. But at the end of the day your hours are limited, and you have make choices. I don't find that particularly unethical (at least, not compared to similar highly professions like corporate law or management consulting or dermatology)--plenty of people do, and you are free to choose a different career if you want.