Most "future proof specialty"; or one with the least likely chance to have to deal with BS in the future

[Chibucks15]

I see your point. But bruh it’s psych. It’s not like they’re using tons of fancy equipment they have to pay off. The overhead is barely anything compared to other fields.

You should look into that case. Lots of misconceptions surround it. It wasn’t the first time they’d been warned about the temperature of their coffee. The burns on that lady’s leg were so severe she legitimately almost died. She also only requested that McDonalds pay the amount that wasn’t covered by Medicare and McDonald’s decided to put up the big fight. They were given multiple opportunities to settle for much less than what was awarded ($640,000).Liebeck v. McDonald's Restaurants - Wikipedia

See now I feel like an ass. My point stands without that case still though. People sue for some absurd reasons

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[Candidate2017]

I really like psych. But one thing that always bothered me about the specialty however was how few psychiatrists accept insurance compared to every other specialty, and in general. I understand it’s easier, they earn more this way, and quite simply they can-in large part because there’s a shortage of psychiatrists. But I think it’s immoral-physicians have a duty to serve others. I have some issues with concierge medicine too, but at least it’s clear they’re serving the wealthy.

I did not take an oath to become an employee of insurance companies and hospitals or the government. Psychiatritss have opted out of insurance due to discrimatory underreimbursement for mental health, even with the Parity Act.

The majority of patients suffering from mental illness ar “regular” middle class people with insurance that reimburses them 50% for a visit to an out of network/cash practice. Their out of pocket cost for a monthly 60 minute psychiatric visit (meds and therapy, which is the standard of care) is a fraction of their monthly payments for cable/phone/internet/alcohol/cocaine. These aren't stroked out 80 yo PM&R patients. Even poor people in the U.S. can afford the latest iphone, gaming systems and Air Jordans.

Also, psychiatry is a specialty. Surgeons refuse treatment based on patient profile and suitability (age, comorbidities, alcohol consumptom, obesity etc). So do I. If a patient cannot (more likely do not want to) engage in my treatment plan, they can go back to their PCP or low level provider.

The people who need psychiatrists the most are those with schizophrenia and bipolar disorder. Bread and butter depression/anxiety can easily be handled by midlevels, or PCPs. What is a psychiatrist offering those patients that midlevels/PCPs can’t? If it’s refractory or complicated depression/anxiety then perhaps quite a bit, but for bread and butter not much.

First, when you or your loved ones experience depression and get treatment from a low level provider or PCP, let me know if you feel it’s merely “bread and butter” depression and if you are satisfied with your treatment results. It's the "bread and butter" depression/anxiety that is higher risk for suicide than the chronically depressed with chronic suicidal ideation.

Second, schizophrenics are well-covered by medicaid and wrap around services in the community mental health model. Long acting injectable antipsychotics cost thousands per shot but are free through medicaid. (The minority of severe, middle class patients covered by their spouse’s or parent’s private insurance are the worst off and I often tell them they need to somehow get on medicaid). The issue for the majority of schizophrenics is not access, but compliance. This is a societal and social work issue as society has deemed autonomy trumps forcing medications upon outpatient schizophrenics.

 

[RangerBob]

I personally think disdain towards doctors not accepting insurance should be redirected to the insurance companies themselves - they have bred this uprising to not accept insurance by throwing up as many roadblocks to reimbursement as possible. Several years ago I was working with a doctor who had to close her clinic early one day for a meeting with BCBS because they were 4 months and tens of thousands of dollars behind on paying her. No doctor should have to put up with that. I am going through medical school because I want to work with patients, not so that I can sit on the phone fighting with insurance companies for a portion of my day. I'm sure I'm preaching to the choir given that you probably deal with this yourself as a physician, but I personally do not think a doctor should be looked down upon because they choose not to play into this obviously corrupt and one-sided payment model that insurance companies have devised.

The problem is multifaceted, but I’m very much not a fan of insurance companies-they often don’t do what’s in their customers interest and I also experience the problems you stated as well. BCBS was holding my claims for 6 months. Fortunately my billers kept hounding them and Medicare pays me within two weeks of submitting charges (with Medicaid being the worst offender), so we got through the initial rough period. I am fortunate I have minimal overhead as well.

My personal opinion is we should work with the system we’ve got. Obviously it needs to be fixed, but patient care/access suffers when we start limiting what insurances we take. In the end, that’s what it’s about-patient care and access, not my ease of operations.

I do understand how much simpler life would be, and how much more I’d make, if I stopped taking insurance. But it doesn’t feel right, and traditionally, it has been the realm of physicians who cater to the wealthy to open cash practices. It’s just not the kind of doctor I set out to be.

I do hope we someday have a better system. But for right now I’ll work with what we have.

 

[RangerBob]

I did not take an oath to become an employee of insurance companies and hospitals or the government. Psychiatritss have opted out of insurance due to discrimatory underreimbursement for mental health, even with the Parity Act.

The majority of patients suffering from mental illness ar “regular” middle class people with insurance that reimburses them 50% for a visit to an out of network/cash practice. Their out of pocket cost for a monthly 60 minute psychiatric visit (meds and therapy, which is the standard of care) is a fraction of their monthly payments for cable/phone/internet/alcohol/cocaine. These aren't stroked out 80 yo PM&R patients. Even poor people in the U.S. can afford the latest iphone, gaming systems and Air Jordans.

Also, psychiatry is a specialty. Surgeons refuse treatment based on patient profile and suitability (age, comorbidities, alcohol consumptom, obesity etc). So do I. If a patient cannot (more likely do not want to) engage in my treatment plan, they can go back to their PCP or low level provider.



First, when you or your loved ones experience depression and get treatment from a low level provider or PCP, let me know if you feel it’s merely “bread and butter” depression and if you are satisfied with your treatment results. It's the "bread and butter" depression/anxiety that is higher risk for suicide than the chronically depressed with chronic suicidal ideation.

Second, schizophrenics are well-covered by medicaid and wrap around services in the community mental health model. Long acting injectable antipsychotics cost thousands per shot but are free through medicaid. (The minority of severe, middle class patients covered by their spouse’s or parent’s private insurance are the worst off and I often tell them they need to somehow get on medicaid). The issue for the majority of schizophrenics is not access, but compliance. This is a societal and social work issue as society has deemed autonomy trumps forcing medications upon outpatient schizophrenics.

I simply was stating all bread and butter cases can be handled by midlevels, and that outsourcing the “hardcore psych” stuff like severe bipolar and schizophrenia to NPs that do take insurance, wasn’t good for patients or the profession.

For bread and butter anything, not just depression, midlevels can handle it quite well. It’s the 10-20% of more complicated cases (which they won’t always recognize) where a PCP/specialist can do more.

I cannot even tell you how many people in my city cannot find a psychiatrist because there’s already a shortage of them to begin with, and so many don’t take insurance here.

It is frustrating that I have a buddy who is a neurosurgeon and takes charity and Medicaid, but we have psychiatrists who won’t take any insurance. I’m happy for you if your system works for you, but it doesn’t work for most of the patients I care for. Clearly our country needs to prioritize mental health, but more psychiatrists taking insurance would certainly help with access.

I have tremendous respect for paychiatrists-they treat patients other doctors want to run away from/ignore. Good psychiatrists do more to improve quality of life than most other specialists, in my personal opinion.

 

[madiso30]

This thread does not help my motication to study for my metabolism exam on Wednesday.

 

[RangerBob]

I can agree with that but let’s take the fight to insurance companies and other leeches instead of calling out our colleagues unless they are doing something truly unethical. It used to be easier maybe since the generation before mine did not have .25-.5 a million in debt. Everyone is out to make a buck off the doctors backs making it harder for us to do charity work when we are worse of financially than the person working the cash register at
Walmart

Want charity work? Bring my debt to zero. Otherwise I’m here to ethically fend for myself until it’s paid off. Sorry not sorry

If only we could all have zero debt. I feel like I’m starting the 400m dash 300m before the starting line.

 

[BorntobeDO?]

I see your point. But bruh it’s psych. It’s not like they’re using tons of fancy equipment they have to pay off. The overhead is barely anything compared to other fields.

You should look into that case. Lots of misconceptions surround it. It wasn’t the first time they’d been warned about the temperature of their coffee. The burns on that lady’s leg were so severe she legitimately almost died. She also only requested that McDonalds pay the amount that wasn’t covered by Medicare and McDonald’s decided to put up the big fight. They were given multiple opportunities to settle for much less than what was awarded ($640,000).Liebeck v. McDonald's Restaurants - Wikipedia

I liked because you are right about the McDonalds case, but you are completely wrong about psych overhead. In order to even take medicare and medicaid you have to have computer charting which is an automatic 40k a year. Then you need billing and coding staff which also add cost. And in most settings you need staff to do followup and help with the social aspects that affect all medicaid patients. That stuff isn't free, and is very similar in cost to an FM setup.

Medicaid reembursement and even regular medicare cannot cover the cost of opening a individual practice. So any doc who is taking on those patients is engaging in charity or getting subsidized in some other way.

 

[Rekt]

But don't you want to needlessly panic and speculate?

I am really glad to see this thread swinging a bit back into sane territory.

I get that there's lots to be worried about with the future of medicine, but some of stuff people have been posting here basically amounts to "It's all over now!" or "I wish I never went to medical school because being a DO is literally worse than cancer."

Am I exaggerating? Sure. But sweet baby jesus there's been a lot of cringe inducing, neckbeard talk on this forum recently.

Imagine using the words cringe and neckbeard unironically in 2019.

Yeah very good idea to keep your head in the sand until the problems are too great to do anything about. Nothing wrong with awareness unless it hurts your feelings of course.

 

[Ho0v-man]

I liked because you are right about the McDonalds case, but you are completely wrong about psych overhead. In order to even take medicare and medicaid you have to have computer charting which is an automatic 40k a year. Then you need billing and coding staff which also add cost. And in most settings you need staff to do followup and help with the social aspects that affect all medicaid patients. That stuff isn't free, and is very similar in cost to an FM setup.

Medicaid reembursement and even regular medicare cannot cover the cost of opening a individual practice. So any doc who is taking on those patients is engaging in charity or getting subsidized in some other way.

Ah. Didn’t even think about not having computer charting in 2019. That sounds amazing. You’re right I’m wrong.

 

[Sardonix]

Imagine using the words cringe and neckbeard unironically in 2019.

Yeah very good idea to keep your head in the sand until the problems are too great to do anything about. Nothing wrong with awareness unless it hurts your feelings of course.

Lol, c'mon friend, you can do better than that. I wasn't even particularly referring to your posts with such choice words, but I digress.

I am all for ranting on an online message board, especially as a DO student, but I'm tired of reading these vague, over-generalizing comments that essentially condemn entire swaths of medicine based on overly negative outlooks that aren't particularly founded in fact. It's boring and I don't see the point in it. And you know what? If I talked like that come interview day I'm pretty sure no one would hire me because no one wants to work with people like that.

Call me naive, but I find my outlook much more productive than metaphorically vaping in the corner and talking about how medicine--a field I chose to go into--is all doom and gloom like some emo kid in middle school.

 

[Drrrrrr. Celty]

We have low level providers at our psych ward. They do the stuff no one wants to do, like take insane amounts of call. They take moonlighting hours away from residents but I don’t think they affect attending pay since attendings dont want that job. 90% of psychiatrists are outpatient anyway.

On the outpatient side, psych NPs are walking advertisements for psychiatrists. NPs are still nurses and their training is geared towards doing (prescribe something, anything in the name of patient care) rather than constant learning and thinking about differentials, medication choices, risks, side effects, alternatives (practice medicine, manage the disease process). Psych patients also undervalue, overvalue, and misreport various symptoms. NPs are not able to tease out nuances that dictate treatment. Their process is: Sad? SSRI. Can’t sleep? Hypnotic. Irritable? Mood stabilizer. Strange thoughts? Antipsychotic. Can’t focus? Stimulant. Anxious? Benzo. This leads to ineffective polypharmacy, terrible side effects, patient dissatisfaction and tremendous appreciation when they finally get to see a psychiatrist after 12 months of terrible treatment and a 3 month wait.

This is sort of how you practice Psychiatry though. Psychiatry's backbone is polypharmacy and terrible side effects and you need to respect that reality when you prescribe those kind of medications. That's the inherent nature of what psych as a consultation should is, you're treating disorders that have failed treatment with the straight forward medication algorithms. Which means they're either PD, resistant, or psychotic features which are hard to make stable.

It's literally because of this that NPs shouldn't have anything to do with prescribing these meds. They don't understand the long term reality of these meds. As I've mentioned before, more PCP need to be making up for the inadequate psychiatry access to deal with this. But again, we're asking a lot of PC as is.

 

[Drrrrrr. Celty]

This thread does not help my motication to study for my metabolism exam on Wednesday.

Your half of your non-med or dent friends won't earn as much money as you do as a resident, the rest won't earn half as much as your doctor's salary.

 

[BorderlineQueen]

I really like psych. But one thing that always bothered me about the specialty however was how few psychiatrists accept insurance compared to every other specialty, and in general. I understand it’s easier, they earn more this way, and quite simply they can-in large part because there’s a shortage of psychiatrists. But I think it’s immoral-physicians have a duty to serve others. I have some issues with concierge medicine too, but at least it’s clear they’re serving the wealthy.

The people who need psychiatrists the most are those with schizophrenia and bipolar disorder. Bread and butter depression/anxiety can easily be handled by midlevels, or PCPs. What is a psychiatrist offering those patients that midlevels/PCPs can’t? If it’s refractory or complicated depression/anxiety then perhaps quite a bit, but for bread and butter not much. Psychiatrists are kind of making themselves obsolete if they aren’t handling the complicated cases they’re best suited to treat if you ask me...

Take PM&R for example. One could argue an NP or hospitalist could do most of what we do, and perhaps run the inpatient unit. And in some areas hospitalists do serve as primary. As patients get more medically complicated we see more and more hospitalist support, with them covering the “medical” issues and PM&R covering the “rehab” issues. For general debility and even a lot of trauma cases, you could argue these other providers can do most of what I do.

But they can’t take optimal care of a patient with a TBI, SCI, or stroke. These are the “hardcore” rehab patients. If I stop treating these patients, then what good am I? What am I really offering patients that someone with less experience, whether a hospitalist or NP, couldn’t offer? I’d be making myself obsolete as well.

I agree with this 100% also most anxiety and depression is managed by pcps. Around 70-80% of all scripts for psychotropics are written by pcps. It’s a shame that the people who need psychiatrists more are the super mentally ill who can’t afford it . I read on jama psychiatry only 39.7% percent of psychiatrist accept medicaid. So where are these people supposed to go? I don't know what percent of PMHNP's accept insurance but if a PMHNP accepts medicaid that's where the person with bipolar and schizophrenia will go. As much as we hate on midlevels some of them do have a need. You can't not accept insurance and see only patients with depression and anxiety and complain about a PMHMP stealing your job.

 

[BorderlineQueen]

This is sort of how you practice Psychiatry though. Psychiatry's backbone is polypharmacy and terrible side effects and you need to respect that reality when you prescribe those kind of medications. That's the inherent nature of what psych as a consultation should is, you're treating disorders that have failed treatment with the straight forward medication algorithms. Which means they're either PD, resistant, or psychotic features which are hard to make stable.

It's literally because of this that NPs shouldn't have anything to do with prescribing these meds. They don't understand the long term reality of these meds. As I've mentioned before, more PCP need to be making up for the inadequate psychiatry access to deal with this. But again, we're asking a lot of PC as is.

Lol that's not how you practice psychiatry if you think Concentration problems= give stimulant you are wrong. Concentration problems can stem from depression or anxiety. Anxious=benzo that's wrong you shouldn't be giving something addicting for that in a long term sense. Strange thoughts can stem from anything that does not equal give anti psychotic. The thing is most PMHNPs cant diagnosis to save there live. The diagnosis is the first step you can't go from step 1 to step 2. That's why you see weird med choices with them. They cant' properly diagnose. You can't just throw meds at every symptom or you'll have a patient on 5-7 meds.

 

[BorderlineQueen]

The issue for me is that these essentially no pay patients can still sue your ass. Why take the risk/liability (depending on what you do)? If it wasn't so litigious I would likely feel differently.

Most medicaid/medicare patients can't afford a lawyer. It's the ones who are making 200k+ a year who will threaten to sue.

 

[Mad Jack]

I really like psych. But one thing that always bothered me about the specialty however was how few psychiatrists accept insurance compared to every other specialty, and in general. I understand it’s easier, they earn more this way, and quite simply they can-in large part because there’s a shortage of psychiatrists. But I think it’s immoral-physicians have a duty to serve others. I have some issues with concierge medicine too, but at least it’s clear they’re serving the wealthy.

The people who need psychiatrists the most are those with schizophrenia and bipolar disorder. Bread and butter depression/anxiety can easily be handled by midlevels, or PCPs. What is a psychiatrist offering those patients that midlevels/PCPs can’t? If it’s refractory or complicated depression/anxiety then perhaps quite a bit, but for bread and butter not much. Psychiatrists are kind of making themselves obsolete if they aren’t handling the complicated cases they’re best suited to treat if you ask me...

Take PM&R for example. One could argue an NP or hospitalist could do most of what we do, and perhaps run the inpatient unit. And in some areas hospitalists do serve as primary. As patients get more medically complicated we see more and more hospitalist support, with them covering the “medical” issues and PM&R covering the “rehab” issues. For general debility and even a lot of trauma cases, you could argue these other providers can do most of what I do.

But they can’t take optimal care of a patient with a TBI, SCI, or stroke. These are the “hardcore” rehab patients. If I stop treating these patients, then what good am I? What am I really offering patients that someone with less experience, whether a hospitalist or NP, couldn’t offer? I’d be making myself obsolete as well.

You deal with this by having a sliding scale so that the more affluent clients cover the ones that can't pay as well. A duty to serve the public does not equal a duty to accept insurance. Around here we run into issues because Medicaid requires copays and you aren't allowed to waive them if you accept Medicaid, so you have patients that you would be forced to turn away that you could see pro bono in private practice, for instance.

 

[Mad Jack]

The issue for me is that these essentially no pay patients can still sue your ass. Why take the risk/liability (depending on what you do)? If it wasn't so litigious I would likely feel differently.

This depends on the state. In my state you get statutory immunity for volunteer services, so you basically just structure your free care into a nonprofit separate from your main business and you are functionally immune to lawsuits except in the case of gross negligence.

 

[BorderlineQueen]

Ah. Didn’t even think about not having computer charting in 2019. That sounds amazing. You’re right I’m wrong.

Lol this comment is hilarious.

 

[Mad Jack]

My n=1 experience is that they don’t care as long as the benzos keep flowin’.

And they're far more likely to get them from a non-psychiatrist

 

[Drrrrrr. Celty]

Lol that's not how you practice psychiatry if you think Concentration problems= give stimulant you are wrong. Concentration problems can stem from depression or anxiety. Anxious=benzo that's wrong you shouldn't be giving something addicting for that in a long term sense. Strange thoughts can stem from anything that does not equal give anti psychotic. The thing is most PMHNPs cant diagnosis to save there live. The diagnosis is the first step you can't go from step 1 to step 2. That's why you see weird med choices with them. They cant' properly diagnose. You can't just throw meds at every symptom or you'll have a patient on 5-7 meds.

I'm not saying that a mental status exam will not elucidate significant etiologies that drive patient presentation. But I also think that the diversity of etiology is rarely reflective of differences in medication management if the symptoms resulting are the same. But that's a whole different conversation and one on paradigm and acknowledging the reality of mental illness as a whole person v.s environment discussion.

What I'm talking about is that yes, a lot of psych is treating symptoms discretely. You're having difficulty sleeping while on maxed out zoloft? Here's Trazodone or Doxipin or Elavil. You have anxiety not controlled by SSRI, here's buspar or seroquel. So on. It's not any different than the medical treatment of hypertension, you have high blood pressure you get a medication. Just because your anxiety is due to lifestyle factor which patient is entirely unable to change or wont doesn't change the treatment regiment aside from a social work consult.

Likewise for a lot of hard disorders it's alright to have patients on multiple drugs. If a patients bipolar is controlled with 4 meds it's a lot better than not controlled on one. NPs for sure will probably chose the most absurd medications however, ex. saw someone on klonipin plus ssri plus sub therapudic seroquel for bipolar mania once.

 

[Ho0v-man]

Lol this comment is hilarious.

I mean this is an anonymous internet message board so I guess I did break protocol by admitting I’m wrong instead of endlessly arguing about it in an attempt to be right in some tangential way lol

 

[BorderlineQueen]

I'm not saying that a mental status exam will not elucidate significant etiologies that drive patient presentation. But I also think that the diversity of etiology is rarely reflective of differences in medication management if the symptoms resulting are the same. But that's a whole different conversation and one on paradigm and acknowledging the reality of mental illness as a whole person v.s environment discussion.

What I'm talking about is that yes, a lot of psych is treating symptoms discretely. You're having difficulty sleeping while on maxed out zoloft? Here's Trazodone or Doxipin or Elavil. You have anxiety not controlled by SSRI, here's buspar or seroquel. So on. It's not any different than the medical treatment of hypertension, you have high blood pressure you get a medication. Just because your anxiety is due to lifestyle factor which patient is entirely unable to change or wont doesn't change the treatment regiment aside from a social work consult.

Likewise for a lot of hard disorders it's alright to have patients on multiple drugs. If a patients bipolar is controlled with 4 meds it's a lot better than not controlled on one. NPs for sure will probably chose the most absurd medications however, ex. saw someone on klonipin plus ssri plus sub therapudic seroquel for bipolar mania once.

I mean you're right in a simplistic way.I'm not talking about severe bipolar or treatment resistant depression. A good psychiatrist will tease out why someone on zoloft cant's sleep. Or why someone is still anxious on an SSRI. But most simply don't have the time that's why you end up with polypharamcy. It's also why patients prefer to see a psychiatrist who doesn't accept insurance. You get 45-60 minute appotiemnts and much better care IMHO. Those psychiatrist have the time to be able to tease everything out.

 

[Sardonix]

I mean this is an anonymous internet message board so I guess I did break protocol by admitting I’m wrong instead of endlessly arguing about it in an attempt to be right in some tangential way lol

I think that's why they said it was hilarious, or at least that's what I gather.

For the reasons you admitted, everyone's guard is so up that when someone legit says they're sorry the other person is still preparing for an attack lol

 

[Drrrrrr. Celty]

I mean you're right in a simplistic way.I'm not talking about severe bipolar or treatment resistant depression. A good psychiatrist will tease out why someone on zoloft cant's sleep. Or why someone is still anxious on an SSRI. But most simply don't have the time that's why you end up with polypharamcy. It's also why patients prefer to see a psychiatrist who doesn't accept insurance. You get 45-60 minute appotiemnts and much better care IMHO. Those psychiatrist have the time to be able to tease everything out.

I don't think you realize how often you're going to get the answer of I just can't or worse when you get an answer that you recognize if you were in that situation would also make you not only struggle to sleep, but find the will to survive.

People who pay for concierge medicine are generally the well to do and wealthy well. Mental illness unfortunately is at its worse in the folks who have neither the means or have really no hope or opportunities to change their life and thus have no money to afford anything aside from the resident clinic.

 

[BorderlineQueen]

I don't think you realize how often you're going to get the answer of I just can't or worse when you get an answer that you recognize if you were in that situation would also make you not only struggle to sleep, but find the will to survive.

Hold on lol sorry I don't understand this post??? What do you mean?

 

[Drrrrrr. Celty]

Hold on lol sorry I don't understand this post??? What do you mean?

What would you like me to explain?

 

[Ho0v-man]

This might be the first thread in sdn history where multiple people admit to being wrong. Now we can finally heal!

 

[BorderlineQueen]

What would you like me to explain?

So because someone says those things a psychiatrist must prescribe meds?

 

[Drrrrrr. Celty]

So because someone says those things a psychiatrist must prescribe meds?

No. You don't have to do anything. You can let the patients suffer too tho. But that's a facet of medicine as a whole.

 

[BorderlineQueen]

No. You don't have to do anything. You can let the patients suffer too tho. But that's a facet of medicine as a whole.

Interesting concept lol I guess we'll have to agree to disagree. I'm saying is a psychiatrist should listen to the patients complaints and then decide what to do. Most of the best psychiatrist do a little supportive psychotherapy. Only the worst dump a med for every symptom. If a psychiatrist chooses to do that nothing separates them from a PMHNP.

 

[Drrrrrr. Celty]

Interesting concept lol I guess we'll have to agree to disagree. I'm saying is a psychiatrist should listen to the patients complaints and then decide what to do. Most of the best psychiatrist do a little supportive psychotherapy. Only the worst dump a med for every symptom. If a psychiatrist chooses to do that nothing separates them from a PMHNP.

I mean, you choose meds that cover all of those things. But in the end you're treating symptoms and the mental status exam.

 

[BorderlineQueen]

I mean, you choose meds that cover all of those things. But in the end you're treating symptoms and the mental status exam.

I mean we'll just have to agree to disagree on this.

 

[Drrrrrr. Celty]

I mean we'll just have to agree to disagree on this.

We can.

 

[Candidate2017]

I liked because you are right about the McDonalds case, but you are completely wrong about psych overhead. In order to even take medicare and medicaid you have to have computer charting which is an automatic 40k a year. Then you need billing and coding staff which also add cost. And in most settings you need staff to do followup and help with the social aspects that affect all medicaid patients. That stuff isn't free, and is very similar in cost to an FM setup.

Medicaid reembursement and even regular medicare cannot cover the cost of opening a individual practice. So any doc who is taking on those patients is engaging in charity or getting subsidized in some other way.

Exactly.

The typical outpatient clinic requires 4-5 staff per physician to carry out bureaucratic requirements of govt and private insurance. To cover expenses necessitated by EMR, increased payroll/benefits, increased space/rent, we’ll have to see 25-30 patients a day, 8-12 minutes each, like our FM brethren. Since we aren’t even generating income, we’ll need to hire 2-3 NPs to increase patient volume. Then fewer patients get to see a psychiatrist because we have to supervise the NPs. If patients want to discuss anything besides their meds, we’ll shrug and tell them to talk to a counselor. This is called psychiatric med management. In this model it’s not clear to me that patients actually benefit. But this is what govt and private insurance want and what the public gets.

Or, we can just rent a small office, get a desk, some chairs, a notepad, and see 8 paying patients per day for 60 minutes each.

 

[BorderlineQueen]

Exactly.

The typical outpatient clinic requires 4-5 staff per physician to carry out bureaucratic requirements of govt and private insurance. To cover expenses necessitated by EMR, increased payroll/benefits, increased space/rent, we’ll have to see 25-30 patients a day, 8-12 minutes each, like our FM brethren. Since we aren’t even generating income, we’ll need to hire 2-3 NPs to increase patient volume. Then fewer patients get to see a psychiatrist because we have to supervise the NPs. If patients want to discuss anything besides their meds, we’ll shrug and tell them to talk to a counselor. This is called psychiatric med management. In this model it’s not clear to me that patients actually benefit. But this is what govt and private insurance want and what the public gets.

Or, we can just rent a small office, get a desk, some chairs, a notepad, and see 8 paying patients per day for 60 minutes each.

If I did the second option I would do some 10-15 hours a week pro-bono work because I feel bad. But the second option is pretty amazing.

 

[Candidate2017]

I cannot even tell you how many people in my city cannot find a psychiatrist because there’s already a shortage of them to begin with, and so many don’t take insurance here.

It is frustrating that I have a buddy who is a neurosurgeon and takes charity and Medicaid, but we have psychiatrists who won’t take any insurance.

Hey, that's not a fair comparison. Medicaid/care compensates neurosurg $800,000+ per year. Plus facility fees. So of course, neurosurg (and all surgical subspecialties) is happy to take medicaid/care patients.

On the other hand neurosurg, like all surgical subs, declines to take on most patients on which they are asked to consult upon. Surgeons have clinic day to screen for patients who can tolerate surgical intervention. This is the more apt comparison to psychiatry. If someone comes in for evaluation for "depression and anxiety", but refuses to give up drinking and smoking weed all day, says therapy doesn't work, wants me to continue their refills for stimulants and benzos from their NP, and berates me for running 5 min late, then yeah they’re not an appropriate candidate for my interventions.

 

[Sardonix]

Hey, that's not a fair comparison. Medicaid/care compensates neurosurg $800,000+ per year. Plus facility fees. So of course, neurosurg (and all surgical subspecialties) is happy to take medicaid/care patients.

On the other hand neurosurg, like all surgical subs, declines to take on most patients on which they are asked to consult upon. Surgeons have clinic day to screen for patients who can tolerate surgical intervention. This is the more apt comparison to psychiatry. If someone comes in for evaluation for "depression and anxiety", but refuses to give up drinking and smoking weed all day, says therapy doesn't work, wants me to continue their refills for stimulants and benzos from their NP, and berates me for running 5 min late, then yeah they’re not an appropriate candidate for my interventions.

Haha, that's like 90% of all psych patie--oooooohhh. Ouch.

 

[RangerBob]

Exactly.

The typical outpatient clinic requires 4-5 staff per physician to carry out bureaucratic requirements of govt and private insurance. To cover expenses necessitated by EMR, increased payroll/benefits, increased space/rent, we’ll have to see 25-30 patients a day, 8-12 minutes each, like our FM brethren. Since we aren’t even generating income, we’ll need to hire 2-3 NPs to increase patient volume. Then fewer patients get to see a psychiatrist because we have to supervise the NPs. If patients want to discuss anything besides their meds, we’ll shrug and tell them to talk to a counselor. This is called psychiatric med management. In this model it’s not clear to me that patients actually benefit. But this is what govt and private insurance want and what the public gets.

Or, we can just rent a small office, get a desk, some chairs, a notepad, and see 8 paying patients per day for 60 minutes each.

I won’t lie-8 patients a day without hassle sounds amazing.

I will add that you don’t need to hire any staff to accept insurance-my billers take a small cut of what they collect and they take care of all the insurance crap for me. If I were a psychiatrist, I’d just hire them and do my own scheduling. Quite a few psychiatrists here do that. They’re only overhead is rent/utilities, malpractice, and biller fees.

I’ve heard of PCP’s that rent a clinic room in a larger clinic, and do all their own scheduling, rooming/vitals, etc. it’s not efficient, but they enjoyed the practice more.

 

[nimbus]

The bolded and underlined is completely wrong. The salary has not absolutely gone up. Anesthesia was a million dollar a year field in the 90's fairly easily. I doubt anyone is making that much now unless they are a senior partner.

Huh? That’s news to me. I was an anesthesiologist in the 90’s. It’s better now.

 

[BorntobeDO?]

Huh? That’s news to me. I was an anesthesiologist in the 90’s. It’s better now.

Thank you for contributing I appreciate the response. But I do have a follow up: Are you a senior partner in your group?

 

[nimbus]

Are you a senior partner in your group?

We’re an eat what you kill PP. Everyone is paid the same based on productivity, both partners and nonpartners. Our new hires get paid exactly the same unit value as me and that unit value has nearly doubled since I joined this particular group in 2001.

 

[BorntobeDO?]

We’re an eat what you kill PP. Everyone is paid the same based on productivity, both partners and nonpartners. Our new hires get paid exactly the same unit value as me and that unit value has nearly doubled since I joined this particular group in 2001.

What are the chances your group will sell? Are new partnerships available?

 

[nimbus]

What are the chances your group will sell? Are new partnerships available?

We looked into a sale in 2015 when everyone else was selling. We decided it would ruin our practice and elected not to sell.

Everyone becomes partner if they’re not idiots. However, because of the way our group is set up, there is no financial advantage to becoming a partner. Like I said, everyone is paid the same as a partner from the start. Once you become a partner, you can vote in the board election. Even our committees are open to new hires if they’re interested.

 

[BorntobeDO?]

We looked into a sale in 2015 when everyone else was selling. We decided it would ruin our practice and elected not to sell.

Everyone becomes partner if they’re not idiots. However, because of the way our group is set up, there is no financial advantage to becoming a partner. Like I said, everyone is paid the same as a partner from the start. Once you become a partner, you can vote in the board election. Even our committees are open to new hires if they’re interested.

Good deal. I could definitely see how you could make more with that setup than MAC groups. I hope your group stays that way forever. I am definitely wrong about anesthesia in your scenario.

Does your group allow CRNAs?

 

[nimbus]

Good deal. I could definitely see how you could make more with that setup than MAC groups. I hope your group stays that way forever. I am definitely wrong about anesthesia in your scenario.
Does your group allow CRNAs?

I hope it stays the same until I retire. We are MD/DO only.

 

[BorntobeDO?]

I hope it stays the same until I retire. We are MD/DO only.

I get the strong impression that the majority of groups no longer operate that way tho. Where do you see anesthesia going?

 

[nimbus]

I get the strong impression that the majority of groups no longer operate that way tho. Where do you see anesthesia going?

I think the pace of practice sales has slowed. It’s short sighted thinking to sell in my opinion and the practices that want to sell have mostly already sold.

I have no idea where anesthesia will go. I can only say that it has been a “dead” specialty with threats from all sides for at least 30 years. We even had people in my own group crying doom and gloom when we considered a sale 5 years ago because they wanted to cash out. Their dire predictions did not come to fruition. Nobody knows what the future will bring.

 

[Angus Avagadro]

I think the pace of practice sales has slowed. It’s short sighted thinking to sell in my opinion and the practices that want to sell have mostly already sold.

I have no idea where anesthesia will go. I can only say that it has been a “dead” specialty with threats from all sides for at least 30 years. We even had people in my own group crying doom and gloom when we considered a sale 5 years ago because they wanted to cash out. Their dire predictions did not come to fruition. Nobody knows what the future will bring.

Most groups in our area still use the crna supervision model with more physician only cases now than years ago. Docs are assigned cases where reimbursement is optimal and crnas assigned where supervision is optimal, cataracts,out patient,gi lab, etc. Most practices are not bought out as they have exclusive contracts. Exclusive contracts are popular in the North East, and physician only groups are popular in the West. Regional health network takes over the hospital and weeds out docs they dont want to keep. Why buy an anesthesia practice when you can get it for free? Local university has cut compensation packages several times over the last decade. They only offer a 1yr contract so they can just non renew you if you dont meet productivity metrics. A friend who is a PD for a surgical residency, gets a 1 yr contract. He has been there 30 yrs.
The corporate model in the East is what anesthesia will face for the coming years. It will cease when corporations cant make money off of anesthesia practices. Then they will give the group back to the docs. Saw this happen a couple times when hospitals would employ the CRNAs, lose a money, make the Docs hire them, hospital hires them when reimbursement improves, gives them back when reimbursement drops. Definitely an advantage to physician only practice model.

 

[nimbus]

Most groups in our area still use the crna supervision model with more physician only cases now than years ago. Docs are assigned cases where reimbursement is optimal and crnas assigned where supervision is optimal, cataracts,out patient,gi lab, etc. Most practices are not bought out as they have exclusive contracts. Exclusive contracts are popular in the North East, and physician only groups are popular in the West. Regional health network takes over the hospital and weeds out docs they dont want to keep. Why buy an anesthesia practice when you can get it for free? Local university has cut compensation packages several times over the last decade. They only offer a 1yr contract so they can just non renew you if you dont meet productivity metrics. A friend who is a PD for a surgical residency, gets a 1 yr contract. He has been there 30 yrs.
The corporate model in the East is what anesthesia will face for the coming years. It will cease when corporations cant make money off of anesthesia practices. Then they will give the group back to the docs. Saw this happen a couple times when hospitals would employ the CRNAs, lose a money, make the Docs hire them, hospital hires them when reimbursement improves, gives them back when reimbursement drops. Definitely an advantage to physician only practice model.

Couple points:

1. 1 year employment contracts are common. Even though I’ve been a partner in my group since 2003, I’ve been signing 1 year employment contracts with my group since 2001.

2. Anesthesia will always be profitable. It’s just a matter of who gets to keep the profits.

3. I agree hospitals and hospital systems hold the most power in this triad. For example, look at Charlotte, NC. Mednax paid $200mil to acquire Southeast Anesthesiology Consultants. 7-8 years later Atrium Health decides they no longer want to deal with Mednax and bring in Tom Wherry/Scope anesthesia. Essentially Atrium Health handed to Wherry a franchise that cost Mednax $200mil. It was contentious and Mednax decided to enforce the noncompete of all 90+ anesthesiologists. In the end, Mednax is out and Scope is in at the will of Atrium Health and 90+ doctors found new jobs. This event alone demonstrates the vulnerability of corporate middlemen. In my opinion they are parasites leeching money from the healthcare system.

4. Case distribution and assignment between MD only and ACT is usually based more on workflow and clinical factors than reimbursement. For the record, healthy outpatients and GI are usually among the highest reimbursed cases because the patients tend to have commercial insurance. Cataracts are terrible (because they are mostly medicare) unless you have a fast high volume surgeon. Hearts which are often MD solo also usually have terrible reimbursement because the patient population is usually medicare.

 

[Angus Avagadro]

With regard to non competes, a large group in our area lost their contract. Had restrictive covenant with CRNAs, even paid the a 10k consideration to sign the covenant. All legal and tidy at the time. New group took over, could not manage the contract without the CRBAs. Displaced group sued, said they had a restrictive covenant, judge said I agree, but it will be a hardship for the community. Get me overturned in appeal. This was after a 7 figure legal bill. Docs dropped appeal and moved on.
As far as 1 yr contracts , a 180 day out, along with restrictive covenants are common. I would sign such a contract reluctantly, and ask for language indication the covenant would only be enforceable if I left or was dismissed for cause. If the group or hospital made a business decision to release me, then it should not be enforceable. Local university a few yrs back, non renewed 12 radiologists to hire new fellows cheaper. Why should I have to sell my house and move my kids because they wanted to save money on new hires? Hospital cultures can change quickly. Hospitals get bought, closed down, wheeling WV just had a major hospital close. I dont think 1 yr contracts are in the interest of the employee.