Rarely in psych is something not possible. To make DPC psych a reasonable model (I’ve seen it work), start by choosing your favorite diagnosis. Treat it like a side gig and over years try to accumulate patients with only that diagnosis. Be known as “the person” for that condition in the area. Have some limits on what the monthly fees provides. Have a flexible schedule to accommodate these patients until you are big enough to only have this practice.
Multiple conditions, variety, cluster B, etc don’t work well with DPC psych.
And this is why DPC is unfeasible for most of psych. After 2 years of COVID, the patients who love their telepsych therapists are the Cluster B and dependent patients who can call them every other day when they have a panic attack because they can't get in to see their psychiatrist every week. As someone with a large percentage of Cluster B in my patient panel for 3rd year, DPC with that panel sounds like the worst possible setup I could imagine.
I still don't understand what advantage this holds over just doing fee for service cash pay. Starting as a side gig and heavily screening/filtering patients are things people do all the time.
Like TH said, the biggest perk is that you know your monthly income regardless of how many patients you're seeing. If you see zero patients, you're still getting paid the full amount. Which is nice, but the risk of the opposite in psych (too many calls to handle) far outweighs that benefit imo.
I see mental health as very time focused so you could break us down into "units" and each unit could be 15 or 30 minutes. Assuming six hours a day for patient care and leaving two hours a day for emails and text messages etc -- then if each unit is 15 minutes, then you have four units per hour times six hours per day times five days per week or hundred = 120 hours per week or 360 hours per month.
If your goal was 120 K per year for salary and overhead, then it's an easy 10,000 per month or about $28 per unit which equals $56 per half hour or 112 per hour. And then you can offer a number of variations on this so that for may be $50 per month they get to 15 minute sessions or one 30 minute session etc. Basically getting them to prepay but it also means that coming back to you on a regular basis. For they could have the hundred and $20 per month package for one full hour etc. the benefit of having the membership/prepaid model is that you would include emails as part of the membership value. This way they may not necessarily need to see you for every visit. And then if they need to schedule additional minutes they can either move up to a higher membership model or payout higher price for individual appointments.
There's a lot of poor understanding of psychiatry here. Unless a patient is just asking for a med refill or a slight adjustment, 15 minutes is NOT an adequate amount of time to address most patient's problems. Heck, I will frequently have patients where 30 minutes is inadequate to fully address their problems. DPC for primary care is great because annual check-ups can be scheduled and a lot of "urgent" issues can be addressed relatively quickly. An "urgent" psych issue, which may just turn out to be high anxiety or poor coping skills, may drag on well past 30 minutes, even if you are adamant about boundaries. You can't just tell a suicidal patient that they should go to the emergency room and hang up if they say no. You can't evaluate and advise a distraught patient or patients having a panic attack until they're calm enough to speak to you. You can't hang up on someone who is manic or psychotic and making statements of HI towards specific people. A DPC model in psych does NOT encourage people to learn to manage their own problems and cope, the entire basis of "direct access" is that they can reach you anytime they perceive it's needed which just reinforces dependency and poor coping.
However, let's look at the example given:
Let's say you're a responsible psychiatrist who does 30 minute f/up appointments for 6 hours a day + 2 hours for e-mails/texts per day. So 12 slots per day (pretty standard for regular outpatient positions) at 22 days per month (if you work 5 days a week) is 264 encounters per month assuming you never take vacations. Let's say the
average patient on your panel is seen every other month (which seems very frequent, but personality and anxiety patients are likely to utilize more than that if they're able to in my experience), so that's a 528 patient panel. Now lets say your salary target is $275k/yr and miraculously total annual overhead is $24k/yr meaning your gross target is $300k/yr. T comes out to 25k per month, and at 528 patients they are paying ~$48/mo to be seen once a month. Which actually sounds like a great deal, BUT...
This assumes that you will be able to see 12 patients every day within 6 hours, which is very unrealistic unless you have a stable patient population or are cutting corners. It also assumes that every appointment is a follow-up and that you aren't doing ANY new evals, which in a DPC model where patients expect comprehensive and high quality care means 90-120 minute initial intakes. So if you do 1 intake per day, that's over 2 years where 1/3 of your encounter slots are taken up by 1 patient, meaning you can really only see 7-8 patients per day.
Then, your third f/up of the day is seen for 25 minutes, and finishes up with "And oh, by the way, I forgot to tell you I've been getting hot flashes, getting really shaky, headaches and nausea, and sometimes feel kind of confused lately. Is that from the medicine?" So now you have to spend extra time with them assessing for a bunch of other possible problems and ensure they're not at risk of a medical emergency, which puts you another 30 minutes behind. But you still want to make sure you see your patients, so you figure you may just have less time to answer e-mails.
Then you have to call your borderline patient for a safety check because they were discharged from an ER yesterday after he refused to be admitted to inpatient for SI. You call and their SI is much worse, they can't stop thinking about cutting their neck to kill themselves, and they've been having increased self-harm via cutting over the last several weeks. You're obviously very worried about them, so you stay on the phone with them until an ambulance can pick them up because they really need to go to the ER but don't feel safe to drive. OR, you're seeing your bipolar patient who has been stable for a couple years but is now presenting as pretty manic and saying they're going to kill their mother and tell you exactly how they'll do it, but they're refusing to go to the ER. So now you have to wait until the police get there to take them for an eval for an involuntary admission, which takes another 45 minutes.
Thankfully, one of your patients couldn't make their appointment, but you had 2 others who had to cancel because you were too behind and they thought that "direct" access meant they'd be able to see you when they needed it. So in the end you have some angry patients, but you only lost 30-40 of your minutes dedicated to answering e-mails. You go through the first few which are simple, but then you get to one that's 5 paragraphs long written by a schizophrenic patient's mother about how they've been acting bizarre and she's really worried. So you call them because it's a potential emergency requiring immediate admission, and after listening to her neuroses for 20 minutes you're finally able to tell her to take him to the ER like the last 2 times this happened, but he doesn't want to go. You then explain to her that because he's not a direct risk to himself or others, you can't file an involuntary petition but if she is worried for his or anyone else's safety she should call the police. 20 minutes later, you finally get back to your other e-mails which are filled with anxious patients who have various worries about their medications or whatever.
Sounds pretty extreme, but the situation with the detoxer who was hiding benzo use, the aggressive manic patient, and the schizophrenic patient was my Tuesday afternoon last week. No, all of the above is not likely to happen at once, but "emergencies" are fairly common. And yes, this happens in regular outpatient offices as well, but those patients don't expect to have constant access to their psychiatrist like DPC patients do. They expect easier access and high quality care, which is often not realistic with larger psychiatric patient panels in DPC unless you take years to build it up and screen patients.
Say you take half the patients and charge $95/mo to keep the panel smaller and income numbers the same. Still sounds great as patients could probably see you a bit more frequently, but what if there is an emergency like getting called after hours by a suicidal patient? Are you willing to always be on call like some DPC physicians are and patients expect? How do you enforce those boundaries in a model that has a primary selling point of easier access to patients who already don't respect boundaries? What about the labs for drug monitoring and medication levels? Should we cover those via contracts like PCPs using DPC models or tell the patients they have to pay out of pocket or with insurance? How is that different from any other psychiatrist? If you take kids it's even more of an issue, as those encounters will often take longer and collateral from parents will be needed.
And all this is supposed to make a net profit of $275k after overhead realistic? As a psychiatrist, why would I bother with all the above when I could just charge cash at $300/hr and make more without having to worry about the raised expectations? Even better question, why should we bother with DPC model when we can work somewhere making base of $300k + RVU bonus + receive full benefits, retirement, vacation and sick days, malpractice insurance, and not have to deal with administrative aspects while seeing 10-12 patients per day who don't have the raised expectations of a DPC model?
It's feasible for psych to do, but there are so many more aspects that psych deals with that medicine doesn't in terms of our patients, much less value in it for the patients, and much higher stress load on the psychiatrists that it just doesn't seem worth it in our field. Especially when just doing a cash-only practice is a very reasonable option. It's so much less flexible in terms of other jobs/activities that we can do because of patient expectations. I've been to AtlasMD talks, and the model really does sound fantastic and one I'd love if I were a PCP. But for psych, I just don't see how it would be worth it.
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