What specifically has driven up psychiatry salaries

[Candidate2017]

I don't understand how this is enforceable. If insurance (or anyone) makes a good faith effort to secure an intake appointment but nothing is available that month despite contacting numerous clinics, then they're still punished?

States have wide latitude to regulate. See abortion, 2nd Amendment, etc. It's pretty easy for states to enforce their will or promote policies via taxation or criminalization (or lack thereof).

At a minimum, compliance can be enforced by heavy taxation/fees levied on noncomplying insurance companies. And at the very worse, the state can revoke an insurance company's privilege/license to do business.

How do they justify punishing people for not providing resources that don't exist or aren't available in the volume necessary?

By getting elected based on promises that sound good to the average voter, but are unworkable. The ends justify the means.

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[nexus73]

If supply is low, you pay more to get what you need. Insurance has gotten off scott free IMO, not providing for necessary services in areas where their insured live. They even reimburse less in small towns, where they should be paying way more to get doctors to move there. But of course, most places insurance has no skin in the game, so patients in a 40K person town have zero psychiatrist most likley. But sounds like California is forcing them to have skin in the game. Good.

 

[Stagg737]

If supply is low, you pay more to get what you need. Insurance has gotten off scott free IMO, not providing for necessary services in areas where their insured live. They even reimburse less in small towns, where they should be paying way more to get doctors to move there. But of course, most places insurance has no skin in the game, so patients in a 40K person town have zero psychiatrist most likley. But sounds like California is forcing them to have skin in the game. Good.

Eh, I guess it depends on what you feel the responsibility of insurance companies is. Imo, they hold no responsibility in terms of "providing services", only ensuring they are covered. Insurance does a lot of scummy stuff, but the point of (any) insurance is as a form of pre-paid coverage that may or may not be utilized, not as a provider of whatever service is being covered which is what it seems the state of California is trying to make them do.

 

[tr]

Eh, I guess it depends on what you feel the responsibility of insurance companies is. Imo, they hold no responsibility in terms of "providing services", only ensuring they are covered. Insurance does a lot of scummy stuff, but the point of (any) insurance is as a form of pre-paid coverage that may or may not be utilized, not as a provider of whatever service is being covered which is what it seems the state of California is trying to make them do.

The law doesn't say the insurance companies have to provide the medical care themselves.

They're saying that if care with a participating provider is not available in a reasonable timeframe, the insurance company has to cover the care by a non-participating provider who does have availability, without charging the patient extra. That's eminently reasonable.

Kaiser is a full service entity that provides both the insurance and the care under one roof. That's their own business model, not something that was legislated. But if they don't have enough in house providers, it's not fair to stick the patients with the Hobson's choice of either waiting a year for care or paying exorbitant out-of-network rates.

California requires insurance companies provide access to psychiatry (or any specialist) within 15 business days. So this would affect Kaiser. If they can't do so they are supposed to cover out of network care

 

[nexus73]

Eh, I guess it depends on what you feel the responsibility of insurance companies is. Imo, they hold no responsibility in terms of "providing services", only ensuring they are covered. Insurance does a lot of scummy stuff, but the point of (any) insurance is as a form of pre-paid coverage that may or may not be utilized, not as a provider of whatever service is being covered which is what it seems the state of California is trying to make them do.

Insurance sells a product offering to pay for and access to health services. They even do this in network out of network garbage that is hugely limiting, which they control that restricts access. Insurance maintains ghost panels with doctors who have moved or even died to improve the appearance of the access to doctors their insurance product will provide. Insurance decides what to pay doctors, which basic economics tells us will increase or decrease supply of available doctors contracting with that insurance. Insurance is in control of all of this, so yes I believe they are on the hook for assuring reasonable access to basic services like psychiatric care.

 

[Stagg737]

The law doesn't say the insurance companies have to provide the medical care themselves.

They're saying that if care with a participating provider is not available in a reasonable timeframe, the insurance company has to cover the care by a non-participating provider who does have availability, without charging the patient extra. That's eminently reasonable.

Kaiser is a full service entity that provides both the insurance and the care under one roof. That's their own business model, not something that was legislated. But if they don't have enough in house providers, it's not fair to stick the patients with the Hobson's choice of either waiting a year for care or paying exorbitant out-of-network rates.

I was speaking more generally, but I can see that argument specifically for Kaiser now. I don't think I realized that Kaiser itself was an insurance provider to the general public in Cali, so that does make sense. Thank you for clarifying that.

Insurance sells a product offering to pay for and access to health services. They even do this in network out of network garbage that is hugely limiting, which they control that restricts access. Insurance maintains ghost panels with doctors who have moved or even died to improve the appearance of the access to doctors their insurance product will provide. Insurance decides what to pay doctors, which basic economics tells us will increase or decrease supply of available doctors contracting with that insurance. Insurance is in control of all of this, so yes I believe they are on the hook for assuring reasonable access to basic services like psychiatric care.

I don't agree with the bolded. Patients can access services with or without insurance coverage, it's the entire reason cash-only PP or DPC is feasible. The fact that OOP cost of healthcare services is prohibitive for many patients is not the responsibility of insurance companies. Insurances (in any industry) can stipulate what is covered and coverage is part of the contracts we sign as patients. Like I said, there's plenty of examples of health insurers doing scummier things than you mentioned, but insurance cannot prevent patients from accessing care, only whether they are going to cover that care or not. The situation with Kaiser may be a bit different if both the insurance and healthcare services are managed under the same branch (ie, those on the insurance side can call their clinics and cancel patient appointments), but this is not how insurance traditionally works.

 

[FlowRate]

I was speaking more generally, but I can see that argument specifically for Kaiser now. I don't think I realized that Kaiser itself was an insurance provider to the general public in Cali, so that does make sense. Thank you for clarifying that.


I don't agree with the bolded. Patients can access services with or without insurance coverage, it's the entire reason cash-only PP or DPC is feasible. The fact that OOP cost of healthcare services is prohibitive for many patients is not the responsibility of insurance companies. Insurances (in any industry) can stipulate what is covered and coverage is part of the contracts we sign as patients. Like I said, there's plenty of examples of health insurers doing scummier things than you mentioned, but insurance cannot prevent patients from accessing care, only whether they are going to cover that care or not. The situation with Kaiser may be a bit different if both the insurance and healthcare services are managed under the same branch (ie, those on the insurance side can call their clinics and cancel patient appointments), but this is not how insurance traditionally works.

While you may disagree, a major part of the function of state DOI's is ensuring network adequacy. If you offer "insurance," don't cover out of network care, and literally no one is "in network" then are you actually offering insurance, at all?

 

[nexus73]

I was speaking more generally, but I can see that argument specifically for Kaiser now. I don't think I realized that Kaiser itself was an insurance provider to the general public in Cali, so that does make sense. Thank you for clarifying that.


I don't agree with the bolded. Patients can access services with or without insurance coverage, it's the entire reason cash-only PP or DPC is feasible. The fact that OOP cost of healthcare services is prohibitive for many patients is not the responsibility of insurance companies. Insurances (in any industry) can stipulate what is covered and coverage is part of the contracts we sign as patients. Like I said, there's plenty of examples of health insurers doing scummier things than you mentioned, but insurance cannot prevent patients from accessing care, only whether they are going to cover that care or not. The situation with Kaiser may be a bit different if both the insurance and healthcare services are managed under the same branch (ie, those on the insurance side can call their clinics and cancel patient appointments), but this is not how insurance traditionally works.

You're an insurance apologist, you've got no place here!

Perhaps under the current laws in most states insurance does not have this obligation. I loudly applaud California for making this an obligation for insurance companies in their state.

Small towns with zero psychiatrists will have insurance paying docs who move there LESS THAN DOCTORS IN BIGGER CITIES! It's a miscarriage of supply and demand economics and ultimately hurts the patients who have the insurance and cannot access services becuase insurance will not pay market rates to assure access to care, so docs won't move to smaller towns. Insurance has all the control in this situation so I firmly believe they have such a duty.

 

[Stagg737]

While you may disagree, a major part of the function of state DOI's is ensuring network adequacy. If you offer "insurance," don't cover out of network care, and literally no one is "in network" then are you actually offering insurance, at all?

No? If the coverage is truly that poor why purchase that insurance at all? But are you talking about specific MH coverage or general medical? Because our field is at a crossroads in a grey zone . Insurance is behind society in recognition and implementation of MH care needs. We also define ourselves very differently from any other medical area in many ways as evidenced by how we legally hold psych patients without capacity. I can see why people feel legislation for MH coverage is necessary, and I don't disagree. However, insurance as a concept is about pre-paying for later coverage of a service, not providing access to a service.

You're an insurance apologist, you've got no place here!

Perhaps under the current laws in most states insurance does not have this obligation. I loudly applaud California for making this an obligation for insurance companies in their state.

Small towns with zero psychiatrists will have insurance paying docs who move there LESS THAN DOCTORS IN BIGGER CITIES! It's a miscarriage of supply and demand economics and ultimately hurts the patients who have the insurance and cannot access services becuase insurance will not pay market rates to assure access to care, so docs won't move to smaller towns. Insurance has all the control in this situation so I firmly believe they have such a duty.

Lol, wut? Just because I understand the definition and concept of insurance doesn't make me an apologist. Forcing insurance to provide access is forcing them to go beyond what their purpose is. Again, I realize that MH is different and I'm not opposed to legislation regarding this given the crap insurance companies pull to not have to meet the basic expectation of coverage.

To your last paragraph, you've got it backwards. If we're talking pure supply and demand the demand in rural areas is much smaller than cities, even with lack of supply. My outpatient clinic literally covers half a state through telehealth and the demand for half the state is a fraction of what the demand of the city of 500k I work in is even with me being one of 3 clinics for half the state. My timeline to see a new patient is still a month or two quicker than for our resident clinic at our large academic center or our local CMHCs. Frankly, there isn't really a justification in a pure supply/demand model to pay a physician covering a small population to earn more than their urban counterparts other than an "everyone deserves access but no one wants to work here" ethical argument.

 

[sloh]

Let’s get back on topic with Kaiser jobs! So Kaiser both insures and provides care for their patients. And with the exception of Kaiser gigs like [mention]FlowRate [/mention]they lowball their outpatient facing specialists relative to the work assigned.

“But access!!”

“All hands on deck!!”

“Be a team player!”

“Fair market value!!”

Stfu. FYPM.

 

[tr]

No? If the coverage is truly that poor why purchase that insurance at all?

Excuse me, did you have an option to choose your insurance provider from among a plethora of excellent options whose differences in pricing and coverage were clearly laid out for you?

Oh no? What's that you say? Your insurance provider was selected for you by your employer, without your input, and differences among the three plans they offered were so complex and opaque that you threw up your hands and picked Option C at random?

Oh ho ho, I'm sorry, it seems you may have mistaken the US health insurance market for an ideal free market, economically defined, where buyers may freely choose from a range of products whose relative merits and prices are well understood by all involved.

That's actually not what we have here. In case you weren't aware. What we have is an opaque dumpster fire where both prices and access are artificially controlled by various behind the scenes players cutting various restrictive deals with each other, and prices have essentially no correlation with product quality and are fixed by executive fiat, dartboard, or other random process.

Pretending to apply free market principles of supply and demand to the US health care system is an entirely useless exercise. They just don't apply.

 

[FlowRate]

No? If the coverage is truly that poor why purchase that insurance at all? But are you talking about specific MH coverage or general medical? Because our field is at a crossroads in a grey zone . Insurance is behind society in recognition and implementation of MH care needs. We also define ourselves very differently from any other medical area in many ways as evidenced by how we legally hold psych patients without capacity. I can see why people feel legislation for MH coverage is necessary, and I don't disagree. However, insurance as a concept is about pre-paying for later coverage of a service, not providing access to a service.

I mean any state with a strong DOI upholding MH parity laws there's not a huge difference between MH/nonMH care.

How would you know the coverage is that poor prior to purchasing the product? Insurance companies aren't exactly transparent about their networks.

Let’s get back on topic with Kaiser jobs! So Kaiser both insures and provides care for their patients. And with the exception of Kaiser gigs like [mention]FlowRate [/mention]they lowball their outpatient facing specialists relative to the work assigned.

“But access!!”

“All hands on deck!!”

“Be a team player!”

“Fair market value!!”

Stfu. FYPM.

I'm curious to hear more details about the job you had in CA. Usually I hear about pretty darn strong salaries in addition to the typical high end benefits/ancillary/pension stuff. How many patient facing clinical hours per day were you doing?

 

[calvnandhobbs68]

No? If the coverage is truly that poor why purchase that insurance at all? But are you talking about specific MH coverage or general medical? Because our field is at a crossroads in a grey zone . Insurance is behind society in recognition and implementation of MH care needs. We also define ourselves very differently from any other medical area in many ways as evidenced by how we legally hold psych patients without capacity. I can see why people feel legislation for MH coverage is necessary, and I don't disagree. However, insurance as a concept is about pre-paying for later coverage of a service, not providing access to a service.

It's like your company assigning you The General car insurance for coverage, you get into a crash, you can't drive your car until it's fixed, The General says you have to use one of their "in network" mechanics for repair but sorry they have a 6 month backlog cause we pay crap so these mechanics are the only one who will fix our cars, we won't pay for an "out of network" mechanic at all.
Oh you need to go to work you say? Sorry, I guess if it's really bad we'll let you take an ambulance there and back if it's an "emergency" but might only pick up 50% of that ride too.

 

[G Sheb]

Excuse me, did you have an option to choose your insurance provider from among a plethora of excellent options whose differences in pricing and coverage were clearly laid out for you?

Oh no? What's that you say? Your insurance provider was selected for you by your employer, without your input, and differences among the three plans they offered were so complex and opaque that you threw up your hands and picked Option C at random?

Oh ho ho, I'm sorry, it seems you may have mistaken the US health insurance market for an ideal free market, economically defined, where buyers may freely choose from a range of products whose relative merits and prices are well understood by all involved.

That's actually not what we have here. In case you weren't aware. What we have is an opaque dumpster fire where both prices and access are artificially controlled by various behind the scenes players cutting various restrictive deals with each other, and prices have essentially no correlation with product quality and are fixed by executive fiat, dartboard, or other random process.

Pretending to apply free market principles of supply and demand to the US health care system is an entirely useless exercise. They just don't apply.

There are actually some pretty decent options for the self-employed, outside of Obamacare insurance. They all do out of network coverage.
You don't actually have to be "self-employed" to get them.
I was surprised that some companies will offer international health insurance, and it runs a price similar to the local ones and with even better coverage than the Obamacare crap.
Yep, the health insurance market is crazy.

 

[calvnandhobbs68]

There are actually some pretty decent options for the self-employed, outside of Obamacare insurance. They all do out of network coverage.
You don't actually have to be "self-employed" to get them.
I was surprised that some companies will offer international health insurance, and it runs a price similar to the local ones and with even better coverage than the Obamacare crap.
Yep, the health insurance market is crazy.

The reason is that they don’t have to meet ACA requirements for minimum coverage. You’re not actually getting some great deal people don’t know about. The plans can do things like disqualify pre existing conditions or put a lifetime cap on benefits. The coverage looks relatively good for the price you pay in premiums but there’s no free lunch there…the company is limiting its expenses some other way, usually by doing things that disqualify it as providing minimum coverage on the exchange.

There are also instances where the plans technically aren’t ACA compliant so they aren’t offered on the exchange but it’s for something minor. I have a plan like that which would basically be a “Gold” high deductible PPO plan so qualifies for an HSA but isn’t offered on the exchange due to some technicalities about what plans can count as HSA plans on exchange. I buy it so I can contribute to an HSA.

 

[B52slinger]

I absolutely suspect rates are underreported. I'm pgy4 and will earn 700k for 45 hours a week next year.

I believe the MGMA average of about 320k sounds about right for 1 job.
But it doesn't account for the number of people doing multiple jobs. Which is not the majority of psychiatrists but common enough that the true specialty average is definitely higher than reported.

 

[finalpsychyear]

I believe the MGMA average of about 320k sounds about right for 1 job.
But it doesn't account for the number of people doing multiple jobs. Which is not the majority of psychiatrists but common enough that the true specialty average is definitely higher than reported.

only if you exclude PT workers and more filtering would you get that. Then again you could do that for any field and it would raise the income average. Your talking about a tiny percentage who are juggling multiple jobs. The posts in my area midwest are all sub 300 for a w2 employed psych through hospitals.

 

[Splenda88]

I believe the MGMA average of about 320k sounds about right for 1 job.
But it doesn't account for the number of people doing multiple jobs. Which is not the majority of psychiatrists but common enough that the true specialty average is definitely higher than reported.

I suspect the MGMA average for most specialties underestimate true median and average salary due more people working part time than people who are working multiple jobs.

 

[psychemdoc]

I suspect the MGMA average for most specialties underestimate true median and average salary due more people working part time than people who are working multiple jobs.

That’s an interesting observation and I would guess it to be accurate as well, but I wish there was some data on it.

 

[G Sheb]

The reason is that they don’t have to meet ACA requirements for minimum coverage. You’re not actually getting some great deal people don’t know about. The plans can do things like disqualify pre existing conditions or put a lifetime cap on benefits. The coverage looks relatively good for the price you pay in premiums but there’s no free lunch there…the company is limiting its expenses some other way, usually by doing things that disqualify it as providing minimum coverage on the exchange.

There are also instances where the plans technically aren’t ACA compliant so they aren’t offered on the exchange but it’s for something minor. I have a plan like that which would basically be a “Gold” high deductible PPO plan so qualifies for an HSA but isn’t offered on the exchange due to some technicalities about what plans can count as HSA plans on exchange. I buy it so I can contribute to an HSA.

It’s a “great deal” relative to what is offered on Obamacare or employee insurance.
Out of network coverage, international coverage!, inpatient/outpatient/preventative, similar deductibles and copay, no limit, some pretty Cush stuff (private room..etc) for the price of a silver plan.
They probably screen for pre-existing conditions I can’t remember, but what do I care? Edit: I don’t think they do actually since they don’t ask for any medical documents.
Of course the company is looking to make some profit but the point is that the market is skewed in weird ways and there is good insurance if you know where to look .

 

[Psychresy]

That’s an interesting observation and I would guess it to be accurate as well, but I wish there was some data on it.

I suppose you also need to consider those who are working academic as well, which brings down salary.

 

[calvinhobbes]

Let’s get back on topic with Kaiser jobs! So Kaiser both insures and provides care for their patients. And with the exception of Kaiser gigs like [mention]FlowRate [/mention]they lowball their outpatient facing specialists relative to the work assigned.

“But access!!”

“All hands on deck!!”

“Be a team player!”

“Fair market value!!”

Stfu. FYPM.

This couldn’t be more true
They brainwash you into thinking you’re working for the best company of all time and the salary is the highest and best of all time, and then they snowball you with absurd amount of responsibilities that aren’t “doctor” related. If you have poor upper management and support staff, you’re screwed and are left doing all of the secretary role. They slam you with a large amount of patients with little to no wiggle room for schedule changes. Want to take lunch an hour earlier? Sorry, lunch is only at Noon. Want to take a few hours for a doc appt or schedule a sick day or vacation day for yourself? Sorry, schedules were made a year in advance and we can’t accommodate you. Want to have any type of freedom or control over your job? Sorry, you’re just a cog in the machine and not even patients are the winners…the insurance company is.

I would never recommend anyone work for Kaiser. The only benefits really (besides their “awesome” pension and benefits package) is that California does not allow a “non-compete clause” so basically you can quit Kaiser anytime and start a new job the next month across the street if you wanted to lol. And, they have powerful lawyers so you never ever ever have to worry about getting sued.

 

[Stagg737]

Put the pitchforks away, I feel like I'm on trial during McCarthyism, lol.

Pretending to apply free market principles of supply and demand to the US health care system is an entirely useless exercise. They just don't apply.

Well duh, I only brought that up because another poster tried to do that. Supply and demand doesn't really work with basic life needs. You could make an argument that s/d could apply to the purposes of more traditional psychodynamic therapy, but I don't know any psychiatrists who actually do this.

Excuse me, did you have an option to choose your insurance provider from among a plethora of excellent options whose differences in pricing and coverage were clearly laid out for you?

My options actually weren't bad, but I know that's not the norm. Of course not, but you can replace the bolded with pretty much any product and the same would still be true.

Oh ho ho, I'm sorry, it seems you may have mistaken the US health insurance market for an ideal free market, economically defined, where buyers may freely choose from a range of products whose relative merits and prices are well understood by all involved.

That's actually not what we have here. In case you weren't aware. What we have is an opaque dumpster fire where both prices and access are artificially controlled by various behind the scenes players cutting various restrictive deals with each other, and prices have essentially no correlation with product quality and are fixed by executive fiat, dartboard, or other random process.

Not at all, like I said, I'm fully aware of all scummy and shady things insurance companies do, you and others are just listing them out. Just because I don't think insurance is directly responsible for providing access doesn't mean they aren't responsible for providing reasonable coverage. I think people are conflating coverage and access or just considering them the same thing. They are not. At all. It's also the biggest reason I thought the federal insurance mandate was idiotic, insuring everyone does not mean they'll actually be getting healthcare, even if coverage is fantastic.

Again, everyone's just listing the crappy stuff insurance does. I know. The US healthcare system is a cluster, and chronically has an identify crisis about what kind of system it is (basically a mutt with components of multiple systems). However, to bring things back to the Kaiser topic, most insurances/coverage providers are not like Kaiser where they are the insurer and the clinic. Obviously, Kaiser is also responsible for access and DOIs in states where systems like Kaiser exist are going to play a larger role in access to care and not just the coverage side. To my original question/point, I understand how California/Kaiser can indirectly mandate intakes there, but I still don't understand how this is a feasible expectation when the insurer and clinic aren't both in house.

 

[Stagg737]

Let’s get back on topic with Kaiser jobs! So Kaiser both insures and provides care for their patients. And with the exception of Kaiser gigs like [mention]FlowRate [/mention]they lowball their outpatient facing specialists relative to the work assigned.

“But access!!”

“All hands on deck!!”

“Be a team player!”

“Fair market value!!”

Stfu. FYPM.

This couldn’t be more true
They brainwash you into thinking you’re working for the best company of all time and the salary is the highest and best of all time, and then they snowball you with absurd amount of responsibilities that aren’t “doctor” related. If you have poor upper management and support staff, you’re screwed and are left doing all of the secretary role. They slam you with a large amount of patients with little to no wiggle room for schedule changes. Want to take lunch an hour earlier? Sorry, lunch is only at Noon. Want to take a few hours for a doc appt or schedule a sick day or vacation day for yourself? Sorry, schedules were made a year in advance and we can’t accommodate you. Want to have any type of freedom or control over your job? Sorry, you’re just a cog in the machine and not even patients are the winners…the insurance company is.

I would never recommend anyone work for Kaiser. The only benefits really (besides their “awesome” pension and benefits package) is that California does not allow a “non-compete clause” so basically you can quit Kaiser anytime and start a new job the next month across the street if you wanted to lol. And, they have powerful lawyers so you never ever ever have to worry about getting sued.

Has this always been the case with Kaiser though? I feel like 10 years ago docs I talked to had nothing but praise for Kaiser and how they were such a great system to work for and how they hoped Kaiser would move into the midwest. My biggest issue was when they gave patients direct access to their physicians through the inbox, but from my understanding that's a relatively new policy. Has Kaiser always been low-key bad or was there a time when it really was great?

 

[calvinhobbes]

Has this always been the case with Kaiser though? I feel like 10 years ago docs I talked to had nothing but praise for Kaiser and how they were such a great system to work for and how they hoped Kaiser would move into the midwest. My biggest issue was when they gave patients direct access to their physicians through the inbox, but from my understanding that's a relatively new policy. Has Kaiser always been low-key bad or was there a time when it really was great?

I think it’s always been this way, but most docs stay long enough and become immune to the problems and just shrug off the negative aspects, drink the kool aid, and count down the days until they get vested and are ready for retirement. But big brother is always watching and if you’re okay with a puppeteer pulling your strings 24-7, I guess it can work for the right person. Things became harder when the inbox was introduced with EPIC and of course when the Affordable Care Act mandated that Medicaid patients must be seen, which overburdened your already full panel of patients. Being asked quarterly to call your Medicaid patients to “check in” and make an appointment was annoying lol, I felt like that that was the role of a secretary or medical assistant, not something I should be doing.

Really depends on region I guess and also office you work for, but other people I talked to at other locations all sort of say the same thing: Kaiser is too big for it’s own good and someone somewhere just dumps all the work on someone else, that attitude trickles down, and you as a doc get frustrated, the patients get frustrated, etc etc etc. The worst are the snotty docs who are in leadership roles, collect a higher salary than you, see one patient once a month to maintain their “clinical” status, and develop “educational” programming for you to attend and if you miss one b/c of any reason, you’re reported to your director for being non-complaint. I think the best and brightest docs do not work for Kaiser bc they see through all the BS. Honestly it’s the mediocre and lazy affff docs who stay and work at Kaiser bc they’re comfortable at doing the least amount of work with little to no repercussions ( but as long as you do those mandatory modules , you’re golden!) lol. *no hate for my fellow peers who work at Kaiser lol, but they know what I mean, ask anyone who works at Kaiser what they’re directors and supervisors are like, and they’ll all tell you the same thing: no one cares about you, and if you complain, lol good luck on that next performance review…

 

[Stagg737]

I think it’s always been this way, but most docs stay long enough and become immune to the problems and just shrug off the negative aspects, drink the kool aid, and count down the days until they get vested and are ready for retirement. But big brother is always watching and if you’re okay with a puppeteer pulling your strings 24-7, I guess it can work for the right person. Things became harder when the inbox was introduced with EPIC and of course when the Affordable Care Act mandated that Medicaid patients must be seen, which overburdened your already full panel of patients. Being asked quarterly to call your Medicaid patients to “check in” and make an appointment was annoying lol, I felt like that that was the role of a secretary or medical assistant, not something I should be doing.

Really depends on region I guess and also office you work for, but other people I talked to at other locations all sort of say the same thing: Kaiser is too big for it’s own good and someone somewhere just dumps all the work on someone else, that attitude trickles down, and you as a doc get frustrated, the patients get frustrated, etc etc etc. The worst are the snotty docs who are in leadership roles, collect a higher salary than you, see one patient once a month to maintain their “clinical” status, and develop “educational” programming for you to attend and if you miss one b/c of any reason, you’re reported to your director for being non-complaint. I think the best and brightest docs do not work for Kaiser bc they see through all the BS. Honestly it’s the mediocre and lazy affff docs who stay and work at Kaiser bc they’re comfortable at doing the least amount of work with little to no repercussions ( but as long as you do those mandatory modules , you’re golden!) lol. *no hate for my fellow peers who work at Kaiser lol, but they know what I mean, ask anyone who works at Kaiser what they’re directors and supervisors are like, and they’ll all tell you the same thing: no one cares about you, and if you complain, lol good luck on that next performance review…

Honestly this sounds more like the VA system than a privately owned group. Weird.

 

[sloh]

good luck on that next performance review…

This constant low grade dread working for Kaiser is really underrated—especially when you’re banking on that pension. You are truly a cog.

Golden handcuffs golden handcuffs.

 

[sloh]

Has this always been the case with Kaiser though? I feel like 10 years ago docs I talked to had nothing but praise for Kaiser and how they were such a great system to work for and how they hoped Kaiser would move into the midwest. My biggest issue was when they gave patients direct access to their physicians through the inbox, but from my understanding that's a relatively new policy. Has Kaiser always been low-key bad or was there a time when it really was great?

You’re correct the patient inbox messages is a source of a lot of the burnout. That’s why I usually tell who ask about what it’s like working for Kaiser that it depends on the specialty and it’s generally not a great experience for outpatient facing specialties. Family Medicine seems to be the worst.

I also hear Kaiser is where your skills go to die as an anesthesiologist (my partner is an anesthesiologist). Because you’re forced to supervise a lot and your own skills deteriorate.

Kaiser employment is truly for the average doc who is not smart or savvy enough to think a little outside the box. It’s a job that dovetails perfectly after training because you’re told exactly what to do. For better or worse. Usually for worse if you can actually take those blinders off. Oh but you can’t use your clinical skills outside of your Kaiser job! Blind forever.

 

[calvinhobbes]

You’re correct the patient inbox messages is a source of a lot of the burnout. That’s why I usually tell who ask about what it’s like working for Kaiser that it depends on the specialty and it’s generally not a great experience for outpatient facing specialties. Family Medicine seems to be the worst.

I also hear Kaiser is where your skills go to die as an anesthesiologist (my partner is an anesthesiologist). Because you’re forced to supervise a lot and your own skills deteriorate.

Kaiser employment is truly for the average doc who is not smart or savvy enough to think a little outside the box. It’s a job that dovetails perfectly after training because you’re told exactly what to do. For better or worse. Usually for worse if you can actually take those blinders off. Oh but you can’t use your clinical skills outside of your Kaiser job! Blind forever.

You said it perfectly. The inbox is hell and never ending. And if you don’t check your inbox, tsk tsk you’re a “bad” doctor bc your patients need you right away!!! (Well then what the hell is the medical assistant doing all day? Oh yeah she’s busy answering your colleague’s inbox who is covering for another doctor’s inbox because that other doctor unexpectedly quit, etc, etc, so and so forth. It’s a hot mess express lol.

They make you follow their clinical “guidelines” and if you do something that’s not in their pathway of steps to follow, you get branded as non-compliant and not following “best practices”. Lol …when in reality their “best” way to practice is just another way of saying “save money for our home-base aka Kaiser insurance.”

 

[nexus73]

what’s the possibility to answer every inbox message with “please schedule an appt we need to discuss at next visit”?

 

[sloh]

what’s the possibility to answer every inbox message with “please schedule an appt we need to discuss at next visit”?

Lol I tried this and was told by my chief that doing so was taking up too many slots that could be used for new patient visits and "real" follow-ups.

Hey Kaiser. STFU. FYPM.

 

[sloh]

You said it perfectly. The inbox is hell and never ending. And if you don’t check your inbox, tsk tsk you’re a “bad” doctor bc your patients need you right away!!! (Well then what the hell is the medical assistant doing all day? Oh yeah she’s busy answering your colleague’s inbox who is covering for another doctor’s inbox because that other doctor unexpectedly quit, etc, etc, so and so forth. It’s a hot mess express lol.

They make you follow their clinical “guidelines” and if you do something that’s not in their pathway of steps to follow, you get branded as non-compliant and not following “best practices”. Lol …when in reality their “best” way to practice is just another way of saying “save money for our home-base aka Kaiser insurance.”

The first year out of residency when I started my job there I was told by my chief that I should emulate one of their physicians (let's call this physician Dr. Sedative) who got the best patient satisfaction scores! She left for another job 6 months later and we absorbed her patients. A couple weeks after she left I get a knock on my office door from my chief. He peaks his head in and says "Hey are you noticing a lot of Dr. Sedative's patients were getting continued on really high dose opioid regimens?" I almost could not keep a straight face.

1 month later I go into my chief's office and say "Hey chief, why does it seem like the standard here is to refer a bunch of patients with axial non-radicular low back pain for epidurals? All the REAL guidelines and evidence recommend against this. I mean, just pull up UpToDate and check for yourself." My chief leans back, lets out a deep sigh, and says "Listen Kaiser padawan, you need to start looking at this job as customer service."

 

[Bartelby]

It's interesting how the inbox gets demonized. I think it is a matter of excessive volume more than a patient's ability to contact you. I prefer an inbox message to voicemail / phone tag, and I find it hard to imagine making myself impossible to contact between appointments. As for direct patient contact, in private practice I know a fair number of people (myself included) who hand out a professional cell phone number to patients. Everyone I have spoken to who does this has told me that patients don't tend to abuse it, which has also been my experience.

As nexus mentioned, a lot of responses can and should be "Thanks for the update. Let's plan to discuss at our next visit" or "let's move up our next visit to further discuss. Can you meet Tuesday at 9a?" You shape the patient's behavior and must avoid carrying on lengthy correspondence via messaging. I spend around 10-15 minutes on clinical messages per day but find that most of these messages are useful/relevant (a pharmacy cannot fill a medication, the person needs to meet sooner about a side effect, etc.).

I think the bigger issue is when your schedule is already over-full you cannot offer adequate follow-up (making it stressful because you then really need to manage things by clinical message conversations), and you don't have any time in your day to manage messages. You are then faced with many stressful demands that the system has ensured you cannot meet, which nobody likes.

 

[calvinhobbes]

Lol I tried this and was told by my chief that doing so was taking up too many slots that could be used for new patient visits and "real" follow-ups.

Hey Kaiser. STFU. FYPM.

It’s funny because I did this too, my chief told me to stop as well. And then I once covered her inbox and she was doing the exact same thing she told me not to do 😂. Patients hated her lol

 

[calvinhobbes]

The first year out of residency when I started my job there I was told by my chief that I should emulate one of their physicians (let's call this physician Dr. Sedative) who got the best patient satisfaction scores! She left for another job 6 months later and we absorbed her patients. A couple weeks after she left I get a knock on my office door from my chief. He peaks his head in and says "Hey are you noticing a lot of Dr. Sedative's patients were getting continued on really high dose opioid regimens?" I almost could not keep a straight face.

1 month later I go into my chief's office and say "Hey chief, why does it seem like the standard here is to refer a bunch of patients with axial non-radicular low back pain for epidurals? All the REAL guidelines and evidence recommend against this. I mean, just pull up UpToDate and check for yourself." My chief leans back, lets out a deep sigh, and says "Listen Kaiser padawan, you need to start looking at this job as customer service."

Did we work in the same location? 😂 this was legit my experience lolol

 

[sloh]

I think the bigger issue is when your schedule is already over-full you cannot offer adequate follow-up (making it stressful because you then really need to manage things by clinical message conversations), and you don't have any time in your day to manage messages. You are then faced with many stressful demands that the system has ensured you cannot meet, which nobody likes.

Ya that is precisely the issue with Kaiser

 

[Stagg737]

what’s the possibility to answer every inbox message with “please schedule an appt we need to discuss at next visit”?

If you prescribe stimulants, 0% chance since half the issue is figuring out what pharmacies actually have enough pills to fill your patient's prescription. A solid 50% of my inbox messages in the past 3 months have been related to figuring out how to get a patient's stimulant prescription. Most of the time it's a patient whose been stable on the same dose for 5+ years. I'll admit that this has played a small role in why I will no longer be prescribing controlled substances in my clinic anymore (last straw kind of thing), and I only do 1 day of outpatient per week.

 

[calvinhobbes]

If you prescribe stimulants, 0% chance since half the issue is figuring out what pharmacies actually have enough pills to fill your patient's prescription. A solid 50% of my inbox messages in the past 3 months have been related to figuring out how to get a patient's stimulant prescription. Most of the time it's a patient whose been stable on the same dose for 5+ years. I'll admit that this has played a small role in why I will no longer be prescribing controlled substances in my clinic anymore (last straw kind of thing), and I only do 1 day of outpatient per week.

I circumvent this issue by printing out a Rx, handing it to the patient, and then the patient can shop around and take it different pharmacies, and see who has what available. Def decreases the “Hi doc! CVS is out of xyz but Walmart has xyz but only 20 pills instead of the 30 you wrote, can you please re-send xyz…” lol

 

[reca]

I circumvent this issue by printing out a Rx, handing it to the patient, and then the patient can shop around and take it different pharmacies, and see who has what available. Def decreases the “Hi doc! CVS is out of xyz but Walmart has xyz but only 20 pills instead of the 30 you wrote, can you please re-send xyz…” lol

Printed rx are not accepted in my state.

 

[hallowmann]

How many people actually stay with Kaiser though?

There are 2 populations of docs at Kaiser in SoCal. Turnover is high. Either you end up as partner of so many years doing it the Kaiser way and assuming that you provide "the best" and "most evidence based" care in the industry, or you're like the other 2/3 that cannot stomach the work for more than a few years.

The thing I see a lot at Kaiser is that either it burns you out and you leave or you become a cog and (at least from my personal experience as a patient) you're checked out, clicking the boxes you're told you need to and waiting to retire with a good pension and insurance for life.

The golden handcuffs of sign-on and retention bonuses (sometimes 5-6 figures), pension, etc. make people stay longer than they would otherwise. It feels like a hybrid between employed big box and the VA.

You must work at a unicorn Kaiser location. **Extra** admin time? Follow-ups **blocking** slots? What usually happens at Kaiser for outpatient facing specialties is the panel continues to grow and grow and grow which obviously results in more and more patient inbox messages/demands.

Yeah, clearly not CA. Maybe they work in Oregon or Colorado, I've heard much better things from friends there.

Has this always been the case with Kaiser though? I feel like 10 years ago docs I talked to had nothing but praise for Kaiser and how they were such a great system to work for and how they hoped Kaiser would move into the midwest. My biggest issue was when they gave patients direct access to their physicians through the inbox, but from my understanding that's a relatively new policy. Has Kaiser always been low-key bad or was there a time when it really was great?

Its been that way from what I've heard, but the people who love it drink the Kool-Aid and manage the cognitive dissonance by saying how much they love it. If you don't mind clocking in and out, having your practice dictated by "policy", which often seemed more geared towards money saving than "best practices", and being constantly evaluated and analyzed about why you didn't successfully "fill" your time when a patient no-shows, then maybe you'd be fine with Kaiser.

Kaiser employment is truly for the average doc who is not smart or savvy enough to think a little outside the box. It’s a job that dovetails perfectly after training because you’re told exactly what to do. For better or worse. Usually for worse if you can actually take those blinders off. Oh but you can’t use your clinical skills outside of your Kaiser job! Blind forever.

Yeah, this was a big driving force against me working there. Their policies were so cookie cutter, and in CA especially you're not going to truly manage anything outside of depression, anxiety, and personality disorders. SUD, oh that goes to our Addiction department, you don't do it. Psychosis, real bipolar disorder, anything necessitating hospitalization or even ED visits (including severe anxiety, depression, personality), that gets Tiered up and sent to county. Atrophy of skills for sure.

 

[forchinet121]

If you prescribe stimulants, 0% chance since half the issue is figuring out what pharmacies actually have enough pills to fill your patient's prescription. A solid 50% of my inbox messages in the past 3 months have been related to figuring out how to get a patient's stimulant prescription. Most of the time it's a patient whose been stable on the same dose for 5+ years. I'll admit that this has played a small role in why I will no longer be prescribing controlled substances in my clinic anymore (last straw kind of thing), and I only do 1 day of outpatient per week.

Why make that your problem? People call me about that I simply tell them to find out where they have a supply and call in the pharmacy name so I can send it..are you calling around yourself?

 

[randomdoc1]

If you prescribe stimulants, 0% chance since half the issue is figuring out what pharmacies actually have enough pills to fill your patient's prescription. A solid 50% of my inbox messages in the past 3 months have been related to figuring out how to get a patient's stimulant prescription. Most of the time it's a patient whose been stable on the same dose for 5+ years. I'll admit that this has played a small role in why I will no longer be prescribing controlled substances in my clinic anymore (last straw kind of thing), and I only do 1 day of outpatient per week.

those are the worst! Sometimes we get calls from patients demanding we figure out how to get their stim filled but we can't do anything with the supply chain. Besides, many have had discussions about judicious use of any controlled substances but do patients listen? Nope. Supply chain issues? We can't do anything about that, too bad and hence why the office here always had such a strict controlled substance policy. But for reals though, like over 90% of the new patient calls are for stims and we're like, um yea....

 

[FlowRate]

Has this always been the case with Kaiser though? I feel like 10 years ago docs I talked to had nothing but praise for Kaiser and how they were such a great system to work for and how they hoped Kaiser would move into the midwest. My biggest issue was when they gave patients direct access to their physicians through the inbox, but from my understanding that's a relatively new policy. Has Kaiser always been low-key bad or was there a time when it really was great?

The other regions, at least, are still great.

Big brother is always watching and if you’re okay with a puppeteer pulling your strings 24-7, I guess it can work for the right person. Being asked quarterly to call your Medicaid patients to “check in” and make an appointment was annoying lol, I felt like that that was the role of a secretary or medical assistant, not something I should be doing.
[etc]

This is all night and day compared to my peers, supervisors, direct reports, etc. The culture and practice here is way different. My colleague who worked in a SCPMG for several years before moving here never mentioned anything that bad, either.

This constant low grade dread working for Kaiser is really underrated—especially when you’re banking on that pension. You are truly a cog.

Were you there long enough to make shareholder or did you leave first? Seems like once you're in there's no reason to fret over perf review.

Also, as the person doing the performance reviews... it's really chill here / not high stakes.

what’s the possibility to answer every inbox message with “please schedule an appt we need to discuss at next visit”?

Every message? If you're 100% against ever doing inbasket messages then you're not a good fit for working in a managed care setting.

I tell plenty of patients they need an appointment or have my nurse call the patients. But if I can solve the issue in 2-3 sentences? Why make someone waste at least 30 minutes of their day taking time off of work for that?

It's interesting how the inbox gets demonized. I think it is a matter of excessive volume more than a patient's ability to contact you. I prefer an inbox message to voicemail / phone tag, and I find it hard to imagine making myself impossible to contact between appointments. As for direct patient contact, in private practice I know a fair number of people (myself included) who hand out a professional cell phone number to patients. Everyone I have spoken to who does this has told me that patients don't tend to abuse it, which has also been my experience.

As nexus mentioned, a lot of responses can and should be "Thanks for the update. Let's plan to discuss at our next visit" or "let's move up our next visit to further discuss. Can you meet Tuesday at 9a?" You shape the patient's behavior and must avoid carrying on lengthy correspondence via messaging. I spend around 10-15 minutes on clinical messages per day but find that most of these messages are useful/relevant (a pharmacy cannot fill a medication, the person needs to meet sooner about a side effect, etc.).

I think the bigger issue is when your schedule is already over-full you cannot offer adequate follow-up (making it stressful because you then really need to manage things by clinical message conversations), and you don't have any time in your day to manage messages. You are then faced with many stressful demands that the system has ensured you cannot meet, which nobody likes.

Absolutely this. No one is making me respond to patients immediately or carrying on super long conversations. Plenty of my messages are "let's make sure to address that during our upcoming appointment."

If you prescribe stimulants, 0% chance since half the issue is figuring out what pharmacies actually have enough pills to fill your patient's prescription. A solid 50% of my inbox messages in the past 3 months have been related to figuring out how to get a patient's stimulant prescription. Most of the time it's a patient whose been stable on the same dose for 5+ years. I'll admit that this has played a small role in why I will no longer be prescribing controlled substances in my clinic anymore (last straw kind of thing), and I only do 1 day of outpatient per week.

We actually have a tool that tells us supply of stims at a given pharmacy. Is it annoying that this isn't always handled by pharmacy/nursing? 1000% But it's better than playing phone/message tag with the patient and/or pharmacies repeatedly.

Yeah, clearly not CA. Maybe they work in Oregon or Colorado, I've heard much better things from friends there.

Yeah, this was a big driving force against me working there. Their policies were so cookie cutter, and in CA especially you're not going to truly manage anything outside of depression, anxiety, and personality disorders. SUD, oh that goes to our Addiction department, you don't do it. Psychosis, real bipolar disorder, anything necessitating hospitalization or even ED visits (including severe anxiety, depression, personality), that gets Tiered up and sent to county. Atrophy of skills for sure.

Our policies are pretty flexible for the most part. There are some expensive meds that require your having tried other things first but that's no different from trying to get a med prior auth from any other insurer. (edit: and I can still Rx if the patient wants to pay cash for something, the prior trials are just for PA approval.) TMS/Ketamine/ECT are all available. I have patients on LAI's, clozapine, severe/refractory OCD regimen, getting ECT/TMS/esketamine, etc.

So yeah, sounds like CA Kaisers suck more than I had appreciated. I mentioned already I'm not in CA and it's a pretty good gig here. (Hard to imagine a better, realistic, employed gig.)

 

[Stagg737]

I circumvent this issue by printing out a Rx, handing it to the patient, and then the patient can shop around and take it different pharmacies, and see who has what available. Def decreases the “Hi doc! CVS is out of xyz but Walmart has xyz but only 20 pills instead of the 30 you wrote, can you please re-send xyz…” lol

Like Reca said, some states this isn't allowed anymore. I'm also telehealth only, so there's no paper anything in my clinic.

Why make that your problem? People call me about that I simply tell them to find out where they have a supply and call in the pharmacy name so I can send it..are you calling around yourself?

Ugh, I explained it in another thread, I'll post the link if I find it easily. No, I'm not calling around myself the majority of the time, but for some patients in my clinic it's necessary since I cover half of a fairly large state which is very rural. Even with the patient doing legwork, it's not uncommon where patient calls us and tells us where to send it, then I do, then a day later we get another call saying that pharmacy ran out and only had 10 pills and they're having to call around to other pharmacies. Then rinse, repeat with those couple patients every month or two because the pharmacies are constantly out. And yes, I always check the PDMPs to make sure patients aren't lying and I've found no signs of abuse with these patients.

Second to last quote in this thread, you actually already asked me this exact question:

DEA announces proposed rules for permanent telemedicine flexibilities

This seems quite limited, almost no different than Ryan Haight. Seems almost easier to not change anything. No stimulants without in person 30 days max of benzos and bup. Essentially transitioning care to get them somewhere better. Someone reading this differently? three approaches 1)One...

forums.studentdoctor.net

We actually have a tool that tells us supply of stims at a given pharmacy. Is it annoying that this isn't always handled by pharmacy/nursing? 1000% But it's better than playing phone/message tag with the patient and/or pharmacies repeatedly.

This would be game-changing, though I doubt it could be effectively implemented where I'm at since a lot of the pharmacies I send Rxs to are independent pharmacies. Good luck getting them to agree to that without legislation.

 

[calvinhobbes]

Just want to say I’m loving this thread and all of your amazing input

 

[Stagg737]

Meant to post this a while ago, but in our doctors lounge they’ve got data from Dec 2021 on the bulletin board:

 

[FlowRate]

Meant to post this a while ago, but in our doctors lounge they’ve got data from Dec 2021 on the bulletin board:

View attachment 373546

With these things the devil is often in the details regarding comparison group (setting, region, etc.), benchmark hours/rvu's, and what not. Still interesting to see.

 

[psychemdoc]

Meant to post this a while ago, but in our doctors lounge they’ve got data from Dec 2021 on the bulletin board:

View attachment 373546

I agree that the devil is in the details but that’s incredible variation. Even comparing it to the posting right next to it with radiology you simply do not have this wide of a range with a lot of other specialties. Definitely not what people are aware of from pediatric pay to emergency pay is a big difference to most people. Ask any pediatrician or EM Dr for their opinion for proof!

 

[Psychresy]

Good for you if this gig works out well. I suspect, however, there may be some baggage with it given how awesome it sounds, but good luck.

Just coming back to update this thread. The corrections job has been amazing. Have not encountered baggage. I'm making about 4K a shift with tons of downtime during the day. I've continued doing prn inpatient and PES shift coverage - i stopped full time inpatient however to focus more on my outpatient practce. This has looked something like 3-4 days a month. I also have taken a telepsych ER position which is paying me 3500 a day. I hang at home and answer psych consults from the medical floor or medical ER. The patients are seen by ER docs, if there's concern for medical issue that is easily handled. I probably hold/admit more than I would if I were in person, but doing so has let me decrease liability on the 50/50 cases. I continue to do outpatient work through a multi-provider clinic at a 60/40 split in my favor.

All in I generate roughly 70-75K a month with 10 days of corrections, roughly 30 hours outpatient, 40 hours of prn inpatient/PES coverage, and 4 tele shifts. This works out to roughly 20 days of work a month which includes one weekend. So I essentially give myself Fridays off every week.

 

[psychemdoc]

Just coming back to update this thread. The corrections job has been amazing. Have not encountered baggage. I'm making about 4K a shift with tons of downtime during the day. I've continued doing prn inpatient and PES shift coverage - i stopped full time inpatient however to focus more on my outpatient practce. This has looked something like 3-4 days a month. I also have taken a telepsych ER position which is paying me 3500 a day. I hang at home and answer psych consults from the medical floor or medical ER. The patients are seen by ER docs, if there's concern for medical issue that is easily handled. I probably hold/admit more than I would if I were in person, but doing so has let me decrease liability on the 50/50 cases. I continue to do outpatient work through a multi-provider clinic at a 60/40 split in my favor.

All in I generate roughly 70-75K a month with 10 days of corrections, roughly 30 hours outpatient, 40 hours of prn inpatient/PES coverage, and 4 tele shifts. This works out to roughly 20 days of work a month which includes one weekend. So I essentially give myself Fridays off every week.

Thank you very much for these updates!