Cash-only private practice -help with joining

[vistaril]

I'm going to chime in here. I'm not psych (I'm peds) but in my area (Austin TX) child psychiatrists are so rare and hard to come by that I think a child psychiatrist could EASILY set up a lucrative cash only practice and fill his appointment slots by day #1. I cant speak to adult psych but I know when I try to refer a child to psych it takes at least 8 months to get them in somewhere.

Out of all the different peds subspecialists, child psych is the hardest to get someone in a timely manner. You guys should be able to take advantage of that.

not neccessarily:

1) child psych does have a somewhat different supply-demand curve than adult psych
2) difficulty in being able to secure an appt DOES NOT neccessarily imply that a premium will be paid for services. For example, in areas which have the most severe supposed shortages of child psych, they also tend to have lower numbers of people who are going to be willing to cash pay. The more populated areas of northern virginia do have a number of potential self pay child patients, but they also don't have the extreme shortage present in other areas for example.
3) the 'cash pay' child psych patients that can also generative volume(ie read money) are adhd patients. There are other providers that can and do see these patients. Development peds(arguably better than child psych for many things) and more importantly pediatricians. General pediatrics can and do more than handle run of the mill adderall kids.
4) the dx that tend to be more severe and disturbing where you are saying 'wow this kid needs a psychiatrist'(lower functioning autism spectrum disorders, childhood psychotic disorders, severe childhood mood d/os, children who are irrepairably damaged due to childhood abuse and resultant psych issues) and really need to get them in to see child psych(rather than just general peds for an adderall refill) aren't going to be from cash pay families. There is going to be lots of medicaid kids in there.

All that said, most all my comments on these issues refer to adult psychiatry and not child psychiatry(of which I am less familar). But basically, the take home point is that a shortage of something doesnt always equal easy opportunity for cash pay.

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[PikminOC]

that's why psychiatrist B better walk on water and show me things that will make obvious and meaningful improvements relative to psychiatrist A. And let's be honest, the vast majority of psychiatrists out there aren't that much better than the guys who do take insurance(which are most psychiatrists).......

there is *competition* out there for insured pts in most areas for med mgt. There are tons of decent psychiatrists in the community who feel pressured to dole out stims for very questionable adhd cases and pass out some benzos to keep *insured* pts coming back....

In many areas, the difference between a lot of the cash pay guys and the take insurance guys are the following:

-the insurance guys will give out small doses of stims for some questionable adhd cases if they don't have a super sketchy feel about it. and they may say no to some. Also, they will not increase the dose crazily and will check monitoring databases and dot the i's. For benzos they do low doses and prns, and set reasonable limits.
-the cash guys typically have jacked up regimens like Xanax 2mg TID and Adderall instant release 80-90mg a day total.....and pretty much don't give a flip about monitoring to any extent. In fact, they would rather not find out about reasons to no longer prescribe because that would create a bunch of hassles for them.

now, this obviously doesn't include the cash guys who cater to very sophisticated and affluent patients who feel that the person is a great psychiatrist. But this is usually dynamic therapy(or at least based on such) and doesn't really have a med mgt focus at all. A different category all together.

Any cash pay psychiatrist who is not an expert columbia trained analyst who also has additional analytical training who can draw pts that way or is not an extreme candyman(ie 6-8 mg xanax today + 90mg of adderall per day) simply doesnt have a compelling case to attract self pay patients over other psychiatrists.

I think it's great that you know everything already!! Nothing more for you learn.

 

[vistaril]

I think it's great that you know everything already!! Nothing more for you learn.

I am very observant on things that impact me.

 

[PikminOC]

Yep.

 

[kumar28]

my stance still stands...vistaril = douchebag

 

[notdeadyet]

my stance still stands...vistaril = douchebag

No name-calling, please. You can be irritated with someone's tone and hate their ideas, but name calling is a violation of Terms of Service and just poor old fashioned manners.

 

[kumar28]

but what if he really is...

 

[OldPsychDoc]

but what if he really is...

Just as it would be unprofessional to tell a patient "You're not bipolar--you're just basically an *****---", it's sometimes more professional to keep your thoughts to yourself.

 

[F0nzie]

Although Vistaril seems pessimistic regarding cash based practice and everybody else seems to only talk about it like it's a cake walk, I haven't seen anyone here prove him wrong with hard data that demonstrates a sure fire way for the average psychiatrist to get a significant return of investment using this model.

If I am starting a business involving significant financial risk, I want to know the good and the bad. Not just the good. As I start my own practice I need to know these factors in order to change and innovate or it's destined to fail as many other practices have.

We should also recognize that successful cash practices do exist, and those people are not likely to share on a public forum how to run one like a well-oiled machine. I do think it takes a different kind of individual to run one successfully.

 

[billypilgrim37]

We should also recognize that successful cash practices do exist, and those people are not likely to share on a public forum how to run one like a well-oiled machine. I do think it takes a different kind of individual to run one successfully.

There's a bit of a bias here as well--if you're the sort of person who is very good at running a tight, successful practice, that probably makes you a little less likely to fart around on a message board with a bunch of residents and med students!

I agree that Vistaril's views on the limitations on private practice seem really reasonable. He's not the voice of reason often, but it's not hard to agree with his "there's no free lunch" perspective. It's really hard to deliver good care and make a lot more money than other people who are delivering good care and also working hard. But I don't know of a lot of psychiatrists starving, so that's good.

It's also the argument he makes that is least affected by his tendency to imagine that every location is exactly the same as his (wherever that is).

 

[vistaril]

Although Vistaril seems pessimistic regarding cash based practice and everybody else seems to only talk about it like it's a cake walk,

well, let me be clear that i think cash practices are possible in some cases. I even know(not well) some people who do them and do very well.

But they are very well thought of analysts who trained at institutes after their residency(at a name program where analysis is more prominent), always had an interest in such therapy, and beginning in prep school have the pedigree that can attract those sorts of clients. They do not represent the students, residents, or attendings on this forum. They don't represent the typical graduate of Columbia/MGH/Cornell/Yale/etc either.

But this forum seems to believe that there are boundless opportunities for cash pay practices to exist(at those same price points) for the same sorts of patients that most are seeing now with insurance. For example the run of the mill dysthymic patient referred by primary care with Blue cross who you see and have on Zoloft and Wellbutrin. The competition for those patients is amongst psychiatrists to bring them into your practice and be able to get 70 bucks from their insurance company.....not to get 250 bucks from them cash pay. If something doesn't make sense, then it doesn't make sense.....

Now it is possible to try to incorporate small numbers of cash pay patients in limited fashion in addition to some other job. For example, if one has a contract with a cmhc for an outpt gig monday-thursday and has one free day a week to do their own thing, it would be more feasible to slowly build a cash practice that one extra day...just because the number of patients you are going to need is so tiny by comparison.

 

[JourneyAgent]

The overuse of the Professionalism Rap Game just allows for pretentious pricks to keep existing comfortably and unchallenged in their niche in medical hierarchy.

To me, professionalism is honesty. Not adherence to elaborate appearances. What get's passed off as professionalism is often obsequious appeasement and accomodation of cowards and tyrants. A necessary evil at times...but nothing to be elevated to an insidious approximation of honor.

I think vistaril has some axe to grind with this profession, that to me, does not feel reformist in intention, but subversive. If it does not suit the good mannered of this community to root it out, allow us, the more nefariously at ease to do it. We leave the parliamentarians to your duties.

But let's not tisk tisk the willingness to do the honest dirty work of the world.

 

[kindasorta]

The overuse of the Professionalism Rap Game just allows for pretentious pricks to keep existing comfortably and unchallenged in their niche in medical hierarchy.

To me, professionalism is honesty. Not adherence to elaborate appearances. What get's passed off as professionalism is often obsequious appeasement and accomodation of cowards and tyrants. A necessary evil at times...but nothing to be elevated to an insidious approximation of honor.

I think vistaril has some axe to grind with this profession, that to me, does not feel reformist in intention, but subversive. If it does not suit the good mannered of this community to root it out, allow us, the more nefariously at ease to do it. We leave the parliamentarians to your duties.

But let's not tisk tisk the willingness to do the honest dirty work of the world.

"Professionalism" is the hammer and sickle of medical training.

 

[someguy321]

journey... who gives a F***

 

[JGimpel]

In my most humble opinion with a recent business-side of this:
Rent your own office space and spend the money to have it decorated in the classiest way you can afford. Just having a "green room" for patients to sit in won't be enough to keep cash pay patients.

Hire a former med office manager with at least 2 years of billing oversight to help you get your EMR and billing set up. A quick time and materials contract with a local IT company that does this sort of thing a lot may be enough. You have more of a way to adjust your payor mix this way.

If you're paying into a partner track at the practice you spoke of, you may be enticed to "pay your dues" in the first few years, but see what the termination policies are before you go too much further. If you can stomach watching the partners get the latest cars and fanciest vacations that you helped pay for in your early years, you should be fine. Ask how much of the "books" you can see so you know what the actual overhead is and you may be pleasantly surprised at them "only" making a 10-12% profit off of you and you taking home $260k+ per year.

Continuing onward should you take the offer; all patients should have some sort of med-mal tail coverage (although it's much cheaper for psychiatric providers than a lot of other fields in medicine,) see if your practice will give you a fair option if that happens. A big thing that may bite you if you leave is a non-compete part of the contract. If you have to leave town, spouse in tow, if you decide to leave the practice and you CAN'T take any patients with you without getting sued, this could make the next job a hard one to build.

I hope this was helpful.

 

[PikminOC]

I only have occurrence based malpractice. It is costly but worth it.

 

[Mr. Osh Kosh]

Hey guys first post here. I'm only an MS2 but I was also a psychology major and I have always had a real interest in psychopharmacology. Plus, since we've already had a clinical psych course, I can say with at least a little certainty that I'm gonna end up going into psychiatry. I like working with kids (worked a few summers as a camp counselor and loved it) and forsee myself applying to a few of the 5 year integrated child psych programs. My aunt is also a child psychiatrist and has raved to me about all the freedom she gets by not taking any insurance. I know in her situation she was able to build her practice only after initially working an academic job at a pretty prestigious school. My question I guess is how possible is it to find offers like the OP did, where you can join an existing cash-only group? I realize that things might change once I enter the job market, but I'm curious. I would love to practice child psychiatry free from insurance but is this possible right out of residency? If it is how competitive are such offers, and if not, how difficult is it to start a cash practice right out of residency (assuming it's a moderately well-known program)?

 

[Shikima]

Just as it would be unprofessional to tell a patient "You're not bipolar--you're just basically an *****---", it's sometimes more professional to keep your thoughts to yourself.

Not to derail an interesting thread on Vistaril, but I cannot help but wonder if this kind of a therapeutic alliance is enabling and really not helping the patient towards wellness? Personally, I've always been honest and direct with my patients (some find it refreshing, those with BPD don't). I'd like your and other practioners thoughts please.

 

[strangeglove]

well, let me be clear that i think cash practices are possible in some cases. I even know(not well) some people who do them and do very well.

But they are very well thought of analysts who trained at institutes after their residency(at a name program where analysis is more prominent), always had an interest in such therapy, and beginning in prep school have the pedigree that can attract those sorts of clients. They do not represent the students, residents, or attendings on this forum. They don't represent the typical graduate of Columbia/MGH/Cornell/Yale/etc either.

But this forum seems to believe that there are boundless opportunities for cash pay practices to exist(at those same price points) for the same sorts of patients that most are seeing now with insurance. For example the run of the mill dysthymic patient referred by primary care with Blue cross who you see and have on Zoloft and Wellbutrin. The competition for those patients is amongst psychiatrists to bring them into your practice and be able to get 70 bucks from their insurance company.....not to get 250 bucks from them cash pay. If something doesn't make sense, then it doesn't make sense.....

Now it is possible to try to incorporate small numbers of cash pay patients in limited fashion in addition to some other job. For example, if one has a contract with a cmhc for an outpt gig monday-thursday and has one free day a week to do their own thing, it would be more feasible to slowly build a cash practice that one extra day...just because the number of patients you are going to need is so tiny by comparison.

You don't need to be a psychoanalyst. I'm fact, the majority of graduates of places like Columbia and Cornell are able to start these kind of practices and fill them within a year of graduating, often while doing their fellowship or some academic research/attending job. This may be very specific to NYC, but my point is that analytic training is not required. By the same token, analytic training is usually undertaken because of a strong interest, not because of a desire to make more money, especially given the opportunity costs.


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[Mr. Osh Kosh]

So essentially to start a practice like this on your own you need to go to a name-brand residency? The OP said he was given an offer to join a cash-only group with a partnership track. My question is for those interested in cash-only private practice, is this something that has to be developed on your own after residency or are there a good amount of offers for graduating child fellows where you can join an existing cash-only group? It seems that the trend for psychiatrists these days is to not deal with insurance (esp child) so just wondering what the future job market will hold for those wanting to do cash-only without necessarily starting there own practice.