what about this psych business idea?

[vistaril]

So what if one were to set up shop in a medium size area....not too big, not too small.

Let's say a place like fayetville, nc. Or even a little bigger in Greensboro, nc. You know....200-350k in the city limits, but if you go 50 mins in any direction you get
an area of 650k...maybe a little more. Not those places in particular since I have no idea what the MH scene is like there, but you get the point.

Then you just come in and bust up the whole MH scene by taking on contracts promising services at ridiculous rates/stipends(in terms of how low they are). Like there is a fairly big psych hospital and the stipend has always floated around 700k, but you come in and say "I'll do it for 150k". And the hospital is like....sure. Same thing for cmhcs in the
area. just come in and offer to take over things for absurdly low rates.

Ok, so then you are holding the bag with all these crappy contracts. But you have *a lot* of the available work for psychs in the area. At least with the inpatient and community systems. And so then with this power you go to the local providers and say "this is what the deal is....take it or leave it? I don't give a damn"......

well the natural thought will be that all these psychs will leave it and try going to another area. The reality is that a lot of people don't have geographic flexibility. A lot of the psychs(and definately the psych nps) have established ties in that area which makes it impossible to leave. Maybe they have a spouse with a high powered job. Maybe they are divorced and share custody in such a way that neither parent can leave. And on and on.....

So your providers may not like the situation.....but hey, people take what they can get. If you have gobbled up a critical mass of available work, you can go a long way in setting the market. The providers don't like it? F them....they can take their ball and go home and not work. Or do telepsych or some crap.

I think this could work for a motivated psych looking to muck things up....remember it's not even important what the contract numbers are. What matters is that you just have exclusive access to the beds and community setup, and once you have muscled your way in there it's all downhill.....

I couldn't do it because it's just not me, but......

---

Members don't see this ad.

 

[nexus73]

I’d think if the psychiatrists waited you out, even a month, you’d lose all your exclusive contracts. Doesn’t really work if the inpatient service has no coverage or the cmhc has no appointment availability or anyone to do refills. Would you then be on the hook to cover all this alone? Or have to hire locums? With what money, you have garbage contracts.

The real move is to do your plan as step one, then have everything fall apart. You can’t satisfy the contracts so every hospital/clinic etc has to urgently try to rehire docs or hire locums. Then in swoops a new group with every doc in town (and you out of sight not as the point person) heavy handedly demanding top dollar just undercutting the locums rates.

 

[Bartelby]

What happens when you can't find enough people willing to take those terrible jobs and you can't fulfill your contracts? Plus would hospital admins all jump on the idea of trusting some random person who promises adequate staffing at one fifth the usual cost? Doesn't seem workable.

 

[erg923]

So what if one were to set up shop in a medium size area....not too big, not too small.

Let's say a place like fayetville, nc. Or even a little bigger in Greensboro, nc. You know....200-350k in the city limits, but if you go 50 mins in any direction you get
an area of 650k...maybe a little more. Not those places in particular since I have no idea what the MH scene is like there, but you get the point.

Then you just come in and bust up the whole MH scene by taking on contracts promising services at ridiculous rates/stipends(in terms of how low they are). Like there is a fairly big psych hospital and the stipend has always floated around 700k, but you come in and say "I'll do it for 150k". And the hospital is like....sure. Same thing for cmhcs in the
area. just come in and offer to take over things for absurdly low rates.

Ok, so then you are holding the bag with all these crappy contracts. But you have *a lot* of the available work for psychs in the area. At least with the inpatient and community systems. And so then with this power you go to the local providers and say "this is what the deal is....take it or leave it? I don't give a damn"......

well the natural thought will be that all these psychs will leave it and try going to another area. The reality is that a lot of people don't have geographic flexibility. A lot of the psychs(and definately the psych nps) have established ties in that area which makes it impossible to leave. Maybe they have a spouse with a high powered job. Maybe they are divorced and share custody in such a way that neither parent can leave. And on and on.....

So your providers may not like the situation.....but hey, people take what they can get. If you have gobbled up a critical mass of available work, you can go a long way in setting the market. The providers don't like it? F them....they can take their ball and go home and not work. Or do telepsych or some crap.

I think this could work for a motivated psych looking to muck things up....remember it's not even important what the contract numbers are. What matters is that you just have exclusive access to the beds and community setup, and once you have muscled your way in there it's all downhill.....

I couldn't do it because it's just not me, but......

Where is the patient and/or product quality in all this, Gordon G? Are these not a consideration?

Also, when a cabinet guy quoted us way less than half what the other estimates were, we were suspicion (obviously) and started asking questions. We didn’t like the answers. You really think all these hospitals won’t be asking you a bunch of questions and looking into your practice/history?

 

[PikminOC]

Where is the patient and/or product quality in all this, Gordon G? Are these not a consideration?

Also, when a cabinet guy quoted us way less than half what the other estimates were, we were suspicion (obviously) and started asking questions. We didn’t like the answers. You really think all these hospitals won’t be asking you a bunch of questions and looking into your practice/history?

Hospitals want the cheapest cog.

 

[TexasPhysician]

Maybe this would have worked pre-internet but not now. Let’s say you were successful and quickly got every contract in the area. If you lower rates by too much, I could probably start a cash practice for a low rate and beat it. Let’s say I’m lazy though. I get telepsychiatry offers for $150/hr every week. Maybe I’d take $140/hr from you if I loved the facility, but any lower and I’d just take the telepsych offer. Some people would probably take the telepsych offer even if it was lower just because it simpler and you upset them enough by cutting their rate.

 

[erg923]

Hospitals want the cheapest cog.

I get there are people here who think al these admins are amoral sons a bitchs (pretty broad brush) but they certainly aren't stupid. There are so many things that could go wrong with this just from a common sense standpoint.

 

[clausewitz2]

I get there are people here who think al these admins are amoral sons a bitchs (pretty broad brush) but they certainly aren't stupid. There are so many things that could go wrong with this just from a common sense standpoint.

"Bob's House of Discount Psychiatry: Now With 50% More Lawsuits!"

 

[PikminOC]

"Bob's House of Discount Psychiatry: Now With 50% More Lawsuits!"

They don't care. They have coverage

 

[PsyDr]

So what if one were to set up shop in a medium size area....not too big, not too small.

Let's say a place like fayetville, nc. Or even a little bigger in Greensboro, nc. You know....200-350k in the city limits, but if you go 50 mins in any direction you get
an area of 650k...maybe a little more. Not those places in particular since I have no idea what the MH scene is like there, but you get the point.

Then you just come in and bust up the whole MH scene by taking on contracts promising services at ridiculous rates/stipends(in terms of how low they are). Like there is a fairly big psych hospital and the stipend has always floated around 700k, but you come in and say "I'll do it for 150k". And the hospital is like....sure. Same thing for cmhcs in the
area. just come in and offer to take over things for absurdly low rates.

Ok, so then you are holding the bag with all these crappy contracts. But you have *a lot* of the available work for psychs in the area. At least with the inpatient and community systems. And so then with this power you go to the local providers and say "this is what the deal is....take it or leave it? I don't give a damn"......

well the natural thought will be that all these psychs will leave it and try going to another area. The reality is that a lot of people don't have geographic flexibility. A lot of the psychs(and definately the psych nps) have established ties in that area which makes it impossible to leave. Maybe they have a spouse with a high powered job. Maybe they are divorced and share custody in such a way that neither parent can leave. And on and on.....

So your providers may not like the situation.....but hey, people take what they can get. If you have gobbled up a critical mass of available work, you can go a long way in setting the market. The providers don't like it? F them....they can take their ball and go home and not work. Or do telepsych or some crap.

I think this could work for a motivated psych looking to muck things up....remember it's not even important what the contract numbers are. What matters is that you just have exclusive access to the beds and community setup, and once you have muscled your way in there it's all downhill.....

I couldn't do it because it's just not me, but......

You couldn't do it because you'd be sued to oblivion under a number of anti-trust statutes.

 

[dl2dp2]

Then you just come in and bust up the whole MH scene by taking on contracts promising services at ridiculous rates/stipends(in terms of how low they are). Like there is a fairly big psych hospital and the stipend has always floated around 700k, but you come in and say "I'll do it for 150k". And the hospital is like....sure. Same thing for cmhcs in the
area. just come in and offer to take over things for absurdly low rates.

Ok, so then you are holding the bag with all these crappy contracts. But you have *a lot* of the available work for psychs in the area. At least with the inpatient and community systems. And so then with this power you go to the local providers and say "this is what the deal is....take it or leave it? I don't give a damn"......

There was another thread here that was the same idea, except in a different direction. What's stopping a psychiatrist from buying all the contracts and demand a 100% pay raise or else let the hospitals high and dry?

These kinds of things are uncommon in psychiatry, probably for a variety of reasons, not all of which are clear to me--so I can't readily articulate a list of reasons. There was a well known group contract management negotiation failure in NC (since you are talking about the state) with Atrium and the local anesthesiology group. Why this kind of thing doesn't happen in psychiatry is unclear. Frankly, I know that you happen to be in a contract management organization, but similar organizations are very rare (comparatively) in psychiatry vs. other specialties. Large psychiatry group practices outpatient is even very uncommon. I have a vague theory that most of the capable psychiatrist (FMGs you cite who are making millions) are raking it in with a small-medium practice where they do part time clinical work. My gut sense is that you don't need to manage a very large organization to make 1M+ a year in this field, which is why this is uncommon.

Similarly, why is it so uncommon to have private equity ownership of psychiatrist's practices? I suspect there is no value add at scale in this industry.

You couldn't do it because you'd be sued to oblivion under a number of anti-trust statutes.

No. This is not the reason.

 

[vistaril]

They don't care. They have coverage

this....tikitorches knows what he is talking about as well.

For hospital admins the ideal is getting coverage and getting it at the lowest possible stipend. Everything else is secondary....

 

[vistaril]

They don't care. They have coverage

this....tikitorches knows what he is talking about as well.

For hospital admins the ideal is getting coverage and getting it at the lowest possible stipend. Everything else is secondary....

 

[vistaril]

I’d think if the psychiatrists waited you out, even a month, you’d lose all your exclusive contracts.

I don't think they could. You have to remember that some of the psychs would be hired at the same places where they would be dismissed. It would be a lot more patients, but people have to work....

 

[Mad Jack]

So what if one were to set up shop in a medium size area....not too big, not too small.

Let's say a place like fayetville, nc. Or even a little bigger in Greensboro, nc. You know....200-350k in the city limits, but if you go 50 mins in any direction you get
an area of 650k...maybe a little more. Not those places in particular since I have no idea what the MH scene is like there, but you get the point.

Then you just come in and bust up the whole MH scene by taking on contracts promising services at ridiculous rates/stipends(in terms of how low they are). Like there is a fairly big psych hospital and the stipend has always floated around 700k, but you come in and say "I'll do it for 150k". And the hospital is like....sure. Same thing for cmhcs in the
area. just come in and offer to take over things for absurdly low rates.

Ok, so then you are holding the bag with all these crappy contracts. But you have *a lot* of the available work for psychs in the area. At least with the inpatient and community systems. And so then with this power you go to the local providers and say "this is what the deal is....take it or leave it? I don't give a damn"......

well the natural thought will be that all these psychs will leave it and try going to another area. The reality is that a lot of people don't have geographic flexibility. A lot of the psychs(and definately the psych nps) have established ties in that area which makes it impossible to leave. Maybe they have a spouse with a high powered job. Maybe they are divorced and share custody in such a way that neither parent can leave. And on and on.....

So your providers may not like the situation.....but hey, people take what they can get. If you have gobbled up a critical mass of available work, you can go a long way in setting the market. The providers don't like it? F them....they can take their ball and go home and not work. Or do telepsych or some crap.

I think this could work for a motivated psych looking to muck things up....remember it's not even important what the contract numbers are. What matters is that you just have exclusive access to the beds and community setup, and once you have muscled your way in there it's all downhill.....

I couldn't do it because it's just not me, but......

You would lose the contracts and likely get sued into oblivion when you failed to deliver on promised services

 

[vistaril]

What happens when you can't find enough people willing to take those terrible jobs and you can't fulfill your contracts? Plus would hospital admins all jump on the idea of trusting some random person who promises adequate staffing at one fifth the usual cost? Doesn't seem workable.

it wouldn't be 'some random person'. It would be a board certified psychiatrist with what would presumably be a decent local rep.

As to your final question, would hospitals love it if that psychiatrist took the hassle of their hands for a fraction of their usual cost? Absolutely......is that a real question.

 

[Mad Jack]

I don't think they could. You have to remember that some of the psychs would be hired at the same places where they would be dismissed. It would be a lot more patients, but people have to work....

Unlikely, you can't buy up every job in an area. Most psychiatrists would rather just walk and open their own practice if places aren't offering the conditions or wages they want. We started a new clinic in my area with three providers that was full in less than a month in an area like you're describing and receives over 300 referrals each month for new patients

 

[vistaril]

Maybe this would have worked pre-internet but not now. Let’s say you were successful and quickly got every contract in the area. If you lower rates by too much, I could probably start a cash practice for a low rate and beat it. Let’s say I’m lazy though. I get telepsychiatry offers for $150/hr every week. Maybe I’d take $140/hr from you if I loved the facility, but any lower and I’d just take the telepsych offer. Some people would probably take the telepsych offer even if it was lower just because it simpler and you upset them enough by cutting their rate.

most people don't get paid 'rates' for inpatient work. They get paid for what they do. If they are willing to hustle and supervise nps and do volume work, I would anticipate they would make a little more than 150 an hour under this arraignment. You have to remember the psych who has the contracts is keeping all the collections(the stipends were just slashed hugely)…..now within those collections are going to be lots of no pays, self pays, committed capped outs, etc....but there will be enough in the way of codes to pay the psychs(and nps) who do the work if the volume is there on their part. Volume in this case would be the name of the game....

 

[Mad Jack]

it wouldn't be 'some random person'. It would be a board certified psychiatrist with what would presumably be a decent local rep.

As to your final question, would hospitals love it if that psychiatrist took the hassle of their hands for a fraction of their usual cost? Absolutely......is that a real question.

Hospitals may let you sign the contract knowing that you'll either deliver the goods or be sued and forced to cover for a new contract with another provider if you can't deliver. So they may pay you 150k on a 700k contract, but if you fail to provide services as stipulated, their suit would be foe the 150k back plus enough money to hold up the obligations you had committed to. At that point you'd vmbe very in the hole.

 

[vistaril]

There was another thread here that was the same idea, except in a different direction. What's stopping a psychiatrist from buying all the contracts and demand a 100% pay raise or else let the hospitals high and dry?

These kinds of things are uncommon in psychiatry, probably for a variety of reasons, not all of which are clear to me--so I can't readily articulate a list of reasons. There was a well known group contract management negotiation failure in NC (since you are talking about the state) with Atrium and the local anesthesiology group. Why this kind of thing doesn't happen in psychiatry is unclear. Frankly, I know that you happen to be in a contract management organization, but similar organizations are very rare (comparatively) in psychiatry vs. other specialties. Large psychiatry group practices outpatient is even very uncommon. I have a vague theory that most of the capable psychiatrist (FMGs you cite who are making millions) are raking it in with a small-medium practice where they do part time clinical work. My gut sense is that you don't need to manage a very large organization to make 1M+ a year in this field, which is why this is uncommon.

it's becoming more common. And a lot aren't as large as mine(where 10 or so hospitals across a couple hundred miles are considered), but I'm seeing it pop up a lot more. Apparently you are practicing some version of psychiatry spares you from us unwashed masses that make up the bulk of the field so maybe you will be spared from it.....I really don't know. For the vast majority of providers and practice settings however, this is very much a real thing and threat.

I browse the job postings across the country and if you read between the lines you will see that a lot are situations where someone owns the countract with the hospital and they are slicing and dicing it. Sometimes it wasn't even clear from the job posting and it looked like a hospital employed position, but a little digging turned it up. Now how they pay the psychiatrist signing on as the employee could take a range of forms...but make no mistake the hospital and guy who holds the contract has the leverage.

Hospitals realize it is a huge win for them. And the guy with the contract(whether he is doing all the work, a little of the work himself, or none of the work) is usually making out too.

Some orgs aren't going to go for it, but I'm seeing more and more contract shopping.

I just filled out a peer reference form for a colleague for a 30ish bed psych unit in....Oklahoma. I'm nowhere near Oklahoma. I contact him and say "dude, what is this about?". He shrugs and said why not? He has an np there and he'll log on and knock it out after she sees them, and he's into the black easily just from the stipend alone after her salary and other costs. The codes are gravy...…

A lot of psychs are still sitting around thinking they have the upper hand. They say "well I know this area and there are only so many of us here so they have to play ball and meet our demands"......this is especially true when the providers believe they have more leverage because it isn't 'an attractive place to live', whatever the hell that means. the hospital in this case played the ultimate trump card and just did an end around on them and left them holding the bag.....game, set, match.

A lot of psychs sadly aren't aware of this push, and very few of us are spared from it. or going to be spared. I know I'm not. The best thing to do for most of us is probably try to scratch and claw and get a few contracts ourselves. But the hospital systems love the way this is going to be shaping up in the future....I know that

 

[vistaril]

Hospitals may let you sign the contract knowing that you'll either deliver the goods or be sued and forced to cover for a new contract with another provider if you can't deliver. So they may pay you 150k on a 700k contract, but if you fail to provide services as stipulated, their suit would be foe the 150k back plus enough money to hold up the obligations you had committed to. At that point you'd vmbe very in the hole.

the psych *would* be able to deliver though. Worst case they just grind like crazy for a bit as they hop from one np to another. They'd make a ton of bank doing this, and after awhile when the left out psychs see things are still up and running without them they would have no choice but to come and board and help sign off on the nps themselves....

 

[Mad Jack]

the psych *would* be able to deliver though. Worst case they just grind like crazy for a bit as they hop from one np to another. They'd make a ton of bank doing this, and after awhile when the left out psychs see things are still up and running without them they would have no choice but to come and board and help sign off on the nps themselves....

Not really. They tried to run consilt services like this in the hospitals nearby and the NPs all quit, so the services had to be replaced with extremely expensive locums until a residency was started. The psych docs that had formerly worked there started a lucrative private practice offering treatment for privately insured patients, TMS, and esketamine, hired a few therapists, and never looked back.

 

[AD04]

I am in agreement with @TexasPhysician and the person above. It will never be too low as there are other alternatives than to take your contract:

- start your own private practice
- do telepsychiatry
- do locums

Some people gravitate towards the cheapest option. But a lot of people will gravitate towards quality, especially when it comes to their own health or of their loved ones.

 

[dl2dp2]

A lot of psychs sadly aren't aware of this push, and very few of us are spared from it. or going to be spared. I know I'm not. The best thing to do for most of us is probably try to scratch and claw and get a few contracts ourselves. But the hospital systems love the way this is going to be shaping up in the future....I know that

Maybe. The money here then isn't in the clinical work but on the management consulting side. It would be an interesting question to work on (i.e. what *is* the current evolution of local practices in Oklahoma?) I bet you can do some quality surveys on practitioners and get a sense of what's going on. THEN you can say oh yes, let's clamp everyone 20% and see if they'll move. In fact, you can just try it out now by advising the entity to let you manage their contract as a test and clamp out the lowest-performing subgroup. These are common techniques in management consulting.

On the defensive side, to move more nimbly it's probably a good idea to start thinking about exits if the local practice environment is unfavorable. I am surprised by the fact that there are no ownership arrangement options at all for you--maybe it's high time for you to start one. Imagine a group that offers the same contract to the hospital but is psychiatrist-owned. You get a dividend from running the business optimally. Wouldn't you want to join that practice? I bet your colleagues would too.

 

[Mad Jack]

it's becoming more common. And a lot aren't as large as mine(where 10 or so hospitals across a couple hundred miles are considered), but I'm seeing it pop up a lot more. Apparently you are practicing some version of psychiatry spares you from us unwashed masses that make up the bulk of the field so maybe you will be spared from it.....I really don't know. For the vast majority of providers and practice settings however, this is very much a real thing and threat.

I browse the job postings across the country and if you read between the lines you will see that a lot are situations where someone owns the countract with the hospital and they are slicing and dicing it. Sometimes it wasn't even clear from the job posting and it looked like a hospital employed position, but a little digging turned it up. Now how they pay the psychiatrist signing on as the employee could take a range of forms...but make no mistake the hospital and guy who holds the contract has the leverage.

Hospitals realize it is a huge win for them. And the guy with the contract(whether he is doing all the work, a little of the work himself, or none of the work) is usually making out too.

Some orgs aren't going to go for it, but I'm seeing more and more contract shopping.

I just filled out a peer reference form for a colleague for a 30ish bed psych unit in....Oklahoma. I'm nowhere near Oklahoma. I contact him and say "dude, what is this about?". He shrugs and said why not? He has an np there and he'll log on and knock it out after she sees them, and he's into the black easily just from the stipend alone after her salary and other costs. The codes are gravy...…

A lot of psychs are still sitting around thinking they have the upper hand. They say "well I know this area and there are only so many of us here so they have to play ball and meet our demands"......this is especially true when the providers believe they have more leverage because it isn't 'an attractive place to live', whatever the hell that means. the hospital in this case played the ultimate trump card and just did an end around on them and left them holding the bag.....game, set, match.

A lot of psychs sadly aren't aware of this push, and very few of us are spared from it. or going to be spared. I know I'm not. The best thing to do for most of us is probably try to scratch and claw and get a few contracts ourselves. But the hospital systems love the way this is going to be shaping up in the future....I know that

As someone fairly familiar with one undesirable market, I find this completely laughable. A health system with a literal multibillion dollar endowment was unable to recruit even a single psychiatrist here over the course of two years while paying average wages because the working conditions and contracts were trash. Well, that's kind of incorrect- they recruited one psychiatrist, but she quit after two weeks when she realized what a **** show the job was.

Big cities maybe you could provide a little squeeze, but who is going to take a job that pays less than the average outpatient gig you could start up yourself? We're psychiatrists, a third of us don't even accept insurance. We can be that picky. To believe we could be strongarmed into working trash jobs for paltry wages neglects the reality of our unique independent practice options, which strongly reduce the ability of others to dictate our terms

 

[Stagg737]

Maybe this would have worked pre-internet but not now. Let’s say you were successful and quickly got every contract in the area. If you lower rates by too much, I could probably start a cash practice for a low rate and beat it. Let’s say I’m lazy though. I get telepsychiatry offers for $150/hr every week. Maybe I’d take $140/hr from you if I loved the facility, but any lower and I’d just take the telepsych offer. Some people would probably take the telepsych offer even if it was lower just because it simpler and you upset them enough by cutting their rate.

Bingo. It's relatively easy to start a cash-only practice in many places for psych, even some of the more "undesirable" ones like OP mentions. With the advent of telepsych this just makes it even easier to attract clients from a wider reach in a state (I see some patients who live 4+ hours away now). $75 for a f/up appointment every 3-6 months is not that much and plenty of patients would prefer to pay $75 for 30 minutes than see someone who barely remembers their name for 5-15 minutes in the meat grinder.

Some people gravitate towards the cheapest option. But a lot of people will gravitate towards quality, especially when it comes to their own health or of their loved ones

Another bingo. After a certain level of quality drop, it's cheaper to pay a little more out of pocket than the hassle of trying to get any care or straight answers for $20 or even $50 bucks less. Not to mention when care gets so bad that patients are being harmed and it ends up costing multiples more than the cash only guys. Idk where you're at, but near me there's also a shift towards DPC for primary care and some of them are forming relationships with psychiatrists. So for some it may be far cheaper to get the worst possible insurance plan and pay cash for DPC + MH care.

Sure, there's plenty of docs out there lazy enough to just bite the bullet and take the deals being talked about. There's also plenty of them resourceful enough to have plans B, C, and D who can do their own thing and give those undercutting them the finger on their way out.

 

[dl2dp2]

Bingo. It's relatively easy to start a cash-only practice in many places for psych, even some of the more "undesirable" ones like OP mentions.

Well yes, but you are making the assumption that we are trying to solve a different problem. While it is true that the reality is psychiatrists who prefer inpatient psychiatry have the option to exit and go outpatient and charge cash, let's suppose that this option is not available. Vistaril is asking the question what is the most optimal way to contract management a group of inpatient psychiatrists either on the provider side or on the payer/client side.

But I largely agree, the scenarios are unlikely for now as psychiatrists have this fairly unique thing where your relationship is direct and intimate and longitudinal with the patient, and plenty of people recognize the quality difference between MD and NP. Outpatient mental health market is distorted in a different way in that it's more similar to a consumer product (i.e. clothing) than to healthcare service.

I actually think more interesting innovations in inpatient mental health will emerge. Just pulling things out of my ass here: with the rise of HSA, etc. I don't see a lot of value add with bloated and overpaid hospital inpatient units. The reason they are so expensive is that they must be JACHO, etc. there's a lot of regulatory cost. Theoretically much of voluntary inpatient psych is just a hotel. The level of medical work inpatient nursing staff in an unlocked unit is minimal and can be replaced by a much cheaper hospitality trained staff. This is already the model for much of inpatient substance use care...

 

[nexus73]

Well yes, but you are making the assumption that we are trying to solve a different problem. While it is true that the reality is psychiatrists who prefer inpatient psychiatry have the option to exit and go outpatient and charge cash, let's suppose that this option is not available. Vistaril is asking the question what is the most optimal way to contract management a group of inpatient psychiatrists either on the provider side or on the payer/client side.

But I largely agree, the scenarios are unlikely for now as psychiatrists have this fairly unique thing where your relationship is direct and intimate and longitudinal with the patient, and plenty of people recognize the quality difference between MD and NP. Outpatient mental health market is distorted in a different way in that it's more similar to a consumer product (i.e. clothing) than to healthcare service.

I actually think more interesting innovations in inpatient mental health will emerge. Just pulling things out of my ass here: with the rise of HSA, etc. I don't see a lot of value add with bloated and overpaid hospital inpatient units. The reason they are so expensive is that they must be JACHO, etc. there's a lot of regulatory cost. Theoretically much of voluntary inpatient psych is just a hotel. The level of medical work inpatient nursing staff in an unlocked unit is minimal and can be replaced by a much cheaper hospitality trained staff. This is already the model for much of inpatient substance use care...

We don't have unlocked psych units around here

 

[dl2dp2]

We don't have unlocked psych units around here

Suppose you are not a psychiatrist, but you are in charge of hiring psychiatrists as a specialist for a purpose. You start a locked inpatient unit. How might you attract a group of patients who might pay you $x (call it $10k) from their HSA, instead of taking insurance?

This is not so far fetched as you think. I know that there are private cash knee replacements and anesthesiology groups in a few of the states in the midwest and south. These are not your proverbial "rich" areas. The physician groups just stopped taking insurance. The patients could theoretically fly to a place that takes their insurance, and it might be far cheaper, but they don't.

 

[Old&InTheWay]

Suppose you are not a psychiatrist, but you are in charge of hiring psychiatrists as a specialist for a purpose. You start a locked inpatient unit. How might you attract a group of patients who might pay you $x (call it $10k) from their HSA, instead of taking insurance?

This is not so far fetched as you think. I know that there are private cash knee replacements and anesthesiology groups in a few of the states in the midwest and south. These are not your proverbial "rich" areas. The physician groups just stopped taking insurance. The patients could theoretically fly to a place that takes their insurance, and it might be far cheaper, but they don't.

You think there are people who would voluntarily pay $10k to be locked up?

 

[Merovinge]

You think there are people who would voluntarily pay $10k to be locked up?

To be fair people pay much more than this for SA treatment. I'm not saying I necessarily agree, but I also can understand the desire for inpatient treatment where the people next to you are not sufferings from chronic psychosis if you are high SES and have something like severe depression. I get asked frequently by family's or even patients about which inpatient units have the lowest acuity so there is certainly some market there.

 

[nexus73]

I don't have a good sense of non-substance abuse residential treatment options for adults. It's an interesting idea that parents will send their kids to a wilderness program or a residential program somewhere for 6 months, but adults aren't spending $10K on a nice inpatient stay to take a break from life stress. These types of places must exist.

 

[vistaril]

I am in agreement with @TexasPhysician and the person above. It will never be too low as there are other alternatives than to take your contract:

- start your own private practice
- do telepsychiatry
- do locums

Some people gravitate towards the cheapest option. But a lot of people will gravitate towards quality, especially when it comes to their own health or of their loved ones.

sure the second and third options are possible outs, but for a lot of people these aren't going to be realistic. especially locums. Locums often involves traveling, which a lot of people can do. And saying "just do telepsychiatry" circles back around to the issue of telepsychiatry *being bad* for psychiatrists in general. Telepsych dramatically increases the labor pool for hospitals and systems, thus altering the market in a bad way for psychs. Do you not understand this? Thats how my colleague was able to snatch up that inpatient contract in Oklahoma.....good for him, but better for the hospital/system and very bad for psychs in Oklahoma.

As for the first, under my initial question many of the patients/sites a provider wouldn't have access to. Because they are closed contracts. You can't do inpatient because they are closed units, and thats also going to affect the referrals(do you think the inpatient docs are going to refer the good patients to you or them/their colleagues lol)....can't do cmhcs for same reason. So you'd be left to fight for a shrinking pile of available patients, and be playing catch up with built in disadvantages as well(referrals).....

 

[vistaril]

Bingo. It's relatively easy to start a cash-only practice in many places for psych, even some of the more "undesirable" ones like OP mentions. With the advent of telepsych this just makes it even easier to attract clients from a wider reach in a state (I see some patients who live 4+ hours away now). $75 for a f/up appointment every 3-6 months is not that much and plenty of patients would prefer to pay $75 for 30 minutes than see someone who barely remembers their name for 5-15 minutes in the meat grinder.

A *possible* gross of 150 dollars *max* under ideal circumstances and before all expenses, taxes, overhead, cancellations, no shows, etc is......not good lol.
You'd end up making less than the nps we hire.

 

[vistaril]

As someone fairly familiar with one undesirable market, I find this completely laughable. A health system with a literal multibillion dollar endowment was unable to recruit even a single psychiatrist here over the course of two years while paying average wages because the working conditions and contracts were trash.

my guess is that's the same situation that was going on in Oklahoma.....and that frustration led to them working out a deal with my colleague that suddenly saves them a bunch of money and their coverage issues are now gone. And the local psychs in Oklahoma are left holding the big with a **** eating grin on their faces. Hell they probably still haven't figured out what they just got hit with.

The fact that situations like you describe exist make them even more ripe for such a poaching event. If you can't see where things are headed with respect to that, I don't know what to tell you.....

Give it a few years max and I wouldn't be surprised if this hospital system you described has done the exact same thing. Hell the guy I know may even get the contract lol....

Finally your delusion that psychiatrists hold the cards and are in a position of power going forward here is far from the truth. It's borderline delusional. And in a rather unfortunate way for psychs, pockets where facilities 'can't find anyone' and are struggling to recruit decent people at good wages actually makes it worse for the psychs because it makes it more likely for situations that just happened in Oklahoma to happen.

The arraingment I'm discussing where a psych a thousand miles away covers a unit with a local psych np(they are in person, he is not) isn't common now, but a lot of things aren't common.....until the are. The advantages for the facility are obvious. And the sad thing is for us psychs is that even if it doesn't become common, it can still exert major downward pressure on the market as a whole. Once these arraingments become more known as a possibility to the C suite people(and they will), it's going to be yet another devastating hit to our field....

 

[Sushirolls]

Suppose you are not a psychiatrist, but you are in charge of hiring psychiatrists as a specialist for a purpose. You start a locked inpatient unit. How might you attract a group of patients who might pay you $x (call it $10k) from their HSA, instead of taking insurance?

This is not so far fetched as you think. I know that there are private cash knee replacements and anesthesiology groups in a few of the states in the midwest and south. These are not your proverbial "rich" areas. The physician groups just stopped taking insurance. The patients could theoretically fly to a place that takes their insurance, and it might be far cheaper, but they don't.

This would be fantastic. This is needed. But the giant roadblock is the certificate of need. Most states are CON which prevents opening up any type of psych unit.

 

[vistaril]

Maybe. The money here then isn't in the clinical work but on the management consulting side. It would be an interesting question to work on (i.e. what *is* the current evolution of local practices in Oklahoma?) I bet you can do some quality surveys on practitioners and get a sense of what's going on. THEN you can say oh yes, let's clamp everyone 20% and see if they'll move. In fact, you can just try it out now by advising the entity to let you manage their contract as a test and clamp out the lowest-performing subgroup. These are common techniques in management consulting.

On the defensive side, to move more nimbly it's probably a good idea to start thinking about exits if the local practice environment is unfavorable. I am surprised by the fact that there are no ownership arrangement options at all for you--maybe it's high time for you to start one. Imagine a group that offers the same contract to the hospital but is psychiatrist-owned. You get a dividend from running the business optimally. Wouldn't you want to join that practice? I bet your colleagues would too.

as for the money not being on the clinical side but on the management side, yes and no. For one you really need to be a psych to pull it off. And two don't discount how much revenue can be brought in by 140-150 inpatients per day(with nps of course) + stipends for those.

As to your last paragraph, sure thats tempting to make a go at something like that. But you have to understand that the contracts in place now with our group(and an even larger group...Grayson, anyone can look them up) ares ones that the hospitals and cmhcs are mostly satisfied with. They are certainly satisfied with their costs and responsibilities, which is really the most important thing. So any new start up who wants to do it that way with a little twist on the practice is going to be facing a *major* uphill battle there.

I actually got approached by IBH(another local group) not too long ago and basically the pitch was "hey, maybe you aren't happy there come work for us". I said well what have you got now in terms of contracts? And they have none here....just a scattering of snfs, but no hospitals. They said if you join we can get some, but that's easier said than done. It would be much much harder for someone to swim upstream like me who just tried to start this practice as you describe.

But take grayson, for example. They have an ownership/partner track. There are 6 partners, and I would guess about 12-13 nonpartner psychs now spread across multiple practice sites. They might advertise there is a route to get to partner, but nobody really believes that.

So yeah in an ideal world having a group where there were 6-7 psychs and it was equally owned and we were all sharing in the profits and stipends would be nice....but it would just be really really hard to pull off from scratch.

Finally, one last problem is that when multiple groups are bidding against each other for the hospital contracts(as is the case here), what that does to the price for the hospital is not good. For us the psychs. An example- We get paid a certain amount extra to cover weekends, and at one point several of us came together and complained about the rates. Saying this is crazy and the per patient total should be more. But they explained that what *they* end up getting per patient on these inpatients sucks, and the reason for that is that in order to get the contract you have to keep going lower and lower and lower. A big hospital will come to us and say "is that the best you can do?". Then they will go to Grayson and say "here is what they did....can you beat this?" Now IBH is in the fold competing and driving down those stipends even more.....and these are units where the stipend is important due to the number of self/no pays and the number of stalled out committed patients. So then the practice shows us what they actually get due to this downward pressure.....

Now are they worried about it not getting covered if it's too low? Sure, with the way the psych nps it always gets covered. Does quality of care plummet? Maybe, maybe not.....let's be real most of the nps in those sort of settings do as well as the psychs. So really what they are paying me and others for is just to sign off on the notes in some of these settings.....

 

[nexus73]

my guess is that's the same situation that was going on in Oklahoma.....and that frustration led to them working out a deal with my colleague that suddenly saves them a bunch of money and their coverage issues are now gone. And the local psychs in Oklahoma are left holding the big with a **** eating grin on their faces. Hell they probably still haven't figured out what they just got hit with.

The fact that situations like you describe exist make them even more ripe for such a poaching event. If you can't see where things are headed with respect to that, I don't know what to tell you.....

Give it a few years max and I wouldn't be surprised if this hospital system you described has done the exact same thing. Hell the guy I know may even get the contract lol....

Finally your delusion that psychiatrists hold the cards and are in a position of power going forward here is far from the truth. It's borderline delusional. And in a rather unfortunate way for psychs, pockets where facilities 'can't find anyone' and are struggling to recruit decent people at good wages actually makes it worse for the psychs because it makes it more likely for situations that just happened in Oklahoma to happen.

The arraingment I'm discussing where a psych a thousand miles away covers a unit with a local psych np(they are in person, he is not) isn't common now, but a lot of things aren't common.....until the are. The advantages for the facility are obvious. And the sad thing is for us psychs is that even if it doesn't become common, it can still exert major downward pressure on the market as a whole. Once these arraingments become more known as a possibility to the C suite people(and they will), it's going to be yet another devastating hit to our field....

How does your friend in Oklahoma staff all his pysch units. 1NP and 1MD for 30 patients? How does this look across multiple hospitals. It seems manageable once it's up and running, but the hard part is getting it started as you shift from hospital employed docs to an outside group taking over and contracting to cover all inpatient needs.

 

[Stagg737]

A *possible* gross of 150 dollars *max* under ideal circumstances and before all expenses, taxes, overhead, cancellations, no shows, etc is......not good lol.
You'd end up making less than the nps we hire.

I'm not saying that's what the final gross would be, just using numbers someone else had thrown out for telepsych rates ($140-150/hr). Overhead and expenses also don't have to be that high once you've got a patient base. I had an attending in med school with a cash-only practice whose total overhead was <$15k/yr + $30k for an admin assistant.

Let's change the hourly rate to $300k/hr. There's still an abundance of patients in many areas willing to pay $150 OOP every 3-6 months for quality care. You're right that there are plenty of things out of our control, but there's also enough flexibility in psych that one could walk away and find (or make) a solid position.

Also, let's be real. If there's a setting where most NPs can provide the same quality of care as most psychiatrists, there's something very wrong happening.

 

[dl2dp2]

This would be fantastic. This is needed. But the giant roadblock is the certificate of need. Most states are CON which prevents opening up any type of psych unit.

Yeah. I realized that a lot of this has to do with regulation. It's not just CON--there's also JACHO, etc. The regulatory cost is also ongoing and not a one-shot deal. There are also various issues w.r.t. Stark/anti-kickbacks, etc. Compliance cost with something like this is very high.

Now are they worried about it not getting covered if it's too low? Sure, with the way the psych nps it always gets covered. Does quality of care plummet? Maybe, maybe not.....let's be real most of the nps in those sort of settings do as well as the psychs. So really what they are paying me and others for is just to sign off on the notes in some of these settings.....

I think you are correct in that you have identified the right problems, but you are not coming up with any solution. I don't have an answer but you but I think the answer resides in maximizing the value proposition rather than fighting for a crumb of service that's of diminishing value. Exactly how to do this requires some creativity and research.

E.g. I would encourage you to start the conversation with meeting with partners at Grayson. Do they have an executive IOP? Is there a maternal/infant program? What about substance abuse? what about TRD (i.e. ketamine, etc)? What about a specialized PTSD service? What about commercial clinical trials? Where IS the value proposition? What kind of psychiatry do you really want to practice? It's understandable that you have thought of all the pertinent negatives, but if you want to come up with a solution you need more of a growth mindset. You can't just be like, oh here are a list of jobs that are around and they are getting worse. Complain on SDN. The end.

 

[Mad Jack]

I'm not saying that's what the final gross would be, just using numbers someone else had thrown out for telepsych rates ($140-150/hr). Overhead and expenses also don't have to be that high once you've got a patient base. I had an attending in med school with a cash-only practice whose total overhead was <$15k/yr + $30k for an admin assistant.

Let's change the hourly rate to $300k/hr. There's still an abundance of patients in many areas willing to pay $150 OOP every 3-6 months for quality care. You're right that there are plenty of things out of our control, but there's also enough flexibility in psych that one could walk away and find (or make) a solid position.

Also, let's be real. If there's a setting where most NPs can provide the same quality of care as most psychiatrists, there's something very wrong happening.

Even in the sticks, there's a guy out here that charges $300/hr, only does hour sessions, that has a loyal following. No-name medical school and training, he just built a reputation. He's still so busy he hasn't taken new clients in years

 

[Mad Jack]

as for the money not being on the clinical side but on the management side, yes and no. For one you really need to be a psych to pull it off. And two don't discount how much revenue can be brought in by 140-150 inpatients per day(with nps of course) + stipends for those.

As to your last paragraph, sure thats tempting to make a go at something like that. But you have to understand that the contracts in place now with our group(and an even larger group...Grayson, anyone can look them up) ares ones that the hospitals and cmhcs are mostly satisfied with. They are certainly satisfied with their costs and responsibilities, which is really the most important thing. So any new start up who wants to do it that way with a little twist on the practice is going to be facing a *major* uphill battle there.

I actually got approached by IBH(another local group) not too long ago and basically the pitch was "hey, maybe you aren't happy there come work for us". I said well what have you got now in terms of contracts? And they have none here....just a scattering of snfs, but no hospitals. They said if you join we can get some, but that's easier said than done. It would be much much harder for someone to swim upstream like me who just tried to start this practice as you describe.

But take grayson, for example. They have an ownership/partner track. There are 6 partners, and I would guess about 12-13 nonpartner psychs now spread across multiple practice sites. They might advertise there is a route to get to partner, but nobody really believes that.

So yeah in an ideal world having a group where there were 6-7 psychs and it was equally owned and we were all sharing in the profits and stipends would be nice....but it would just be really really hard to pull off from scratch.

Finally, one last problem is that when multiple groups are bidding against each other for the hospital contracts(as is the case here), what that does to the price for the hospital is not good. For us the psychs. An example- We get paid a certain amount extra to cover weekends, and at one point several of us came together and complained about the rates. Saying this is crazy and the per patient total should be more. But they explained that what *they* end up getting per patient on these inpatients sucks, and the reason for that is that in order to get the contract you have to keep going lower and lower and lower. A big hospital will come to us and say "is that the best you can do?". Then they will go to Grayson and say "here is what they did....can you beat this?" Now IBH is in the fold competing and driving down those stipends even more.....and these are units where the stipend is important due to the number of self/no pays and the number of stalled out committed patients. So then the practice shows us what they actually get due to this downward pressure.....

Now are they worried about it not getting covered if it's too low? Sure, with the way the psych nps it always gets covered. Does quality of care plummet? Maybe, maybe not.....let's be real most of the nps in those sort of settings do as well as the psychs. So really what they are paying me and others for is just to sign off on the notes in some of these settings.....

If NPs are doing as well as psychiatrists for decompensated inpatients in your areas, either your NPs are exceptional or your psychiatrists are abhorrent

 

[calvnandhobbs68]

To be fair people pay much more than this for SA treatment. I'm not saying I necessarily agree, but I also can understand the desire for inpatient treatment where the people next to you are not sufferings from chronic psychosis if you are high SES and have something like severe depression. I get asked frequently by family's or even patients about which inpatient units have the lowest acuity so there is certainly some market there.

Yeah this is a little bit of a thing at least in some areas. I know a unit around here that supposed to be a pretty nice “mood disorders” unit where you basically just have a bunch of depressed and really anxious patients. I think it’s still locked though.

I mean you get the appeal. How many of you would honestly want to send your depressed mom/brother with SI to an acute unit where their neighbors are chronically psychotic/heavy substance use/violent patients if you had the money.

 

[AD04]

And saying "just do telepsychiatry" circles back around to the issue of telepsychiatry *being bad* for psychiatrists in general. Telepsych dramatically increases the labor pool for hospitals and systems, thus altering the market in a bad way for psychs. Do you not understand this? Thats how my colleague was able to snatch up that inpatient contract in Oklahoma.....good for him, but better for the hospital/system and very bad for psychs in Oklahoma.

As for the first, under my initial question many of the patients/sites a provider wouldn't have access to. Because they are closed contracts. You can't do inpatient because they are closed units, and thats also going to affect the referrals(do you think the inpatient docs are going to refer the good patients to you or them/their colleagues lol)....can't do cmhcs for same reason. So you'd be left to fight for a shrinking pile of available patients, and be playing catch up with built in disadvantages as well(referrals).....

Regarding telepsychiatry snatching up all the contracts, that just isn't true. If it is true, why isn't there is one large telepsychiatry corporation that snatches up all the contracts in the US? I can tell you that there is no way my place would take that deal. People do care about quality.

I don't think psychiatrists in OK are hurting that much from your friend taking over that contract.

When I was in private practice (independent from a hospital), I was getting referrals from inpatient units frequently. This is the same experience as my friends and peers in the same specialty, in different parts of the country. I am currently working on inpatient unit, we don't keep all the referrals in house.

Anyways, not many people want to build practices based on patients that were DC from psychiatric units.

 

[Mad Jack]

Regarding telepsychiatry snatching up all the contracts, that just isn't true. If it is true, why isn't there is one large telepsychiatry corporation that snatches up all the contracts in the US? I can tell you that there is no way my place would take that deal. People do care about quality.

I don't think psychiatrists in OK are hurting that much from your friend taking over that contract.

When I was in private practice (independent from a hospital), I was getting referrals from inpatient units frequently. This is the same experience as my friends and peers in the same specialty, in different parts of the country. I am currently working on inpatient unit, we don't keep all the referrals in house.

Anyways, not many people want to build practices based on patients that were DC from psychiatric units.

Our inpatient unit literally has run out of places to refer people to. Getting an urgent appointment within 14 days of discharge is a challenge if they aren't established. If a psychiatrist dropped their name, they would have a full service within months between unit discharges and word of mouth that there's a new guy in town. Vistaril seems uniquely disconnected from reality and has been pessimistic beyond reason for as long as I've been around. You could say the sky was a lovely shade of blue and he'd insist it looked like suffering

 

[vistaril]

Also, let's be real. If there's a setting where most NPs can provide the same quality of care as most psychiatrists, there's something very wrong happening.

Don't agree with this at all. I think there probably are settings where psychs are superior, but I doubt most.....I would have to see some evidence that in a typical outpt med mgt practice psychs are better than psych nps,and I've never seen such....

 

[vistaril]

Our inpatient unit literally has run out of places to refer people to. Getting an urgent appointment within 14 days of discharge is a challenge if they aren't established. If a psychiatrist dropped their name, they would have a full service within months between unit discharges and word of mouth that there's a new guy in town. Vistaril seems uniquely disconnected from reality

my pm box full of people saying "thanks for posting like it really is" and then asking me a bunch more questions says otherwise.

Come to think of it I'm behind responding to some of them so to the people who are out there and have messaged questions in the
last few days I'll get to them by the weekend.

As to your point about building a practice....sure in some areas getting patients for an outpt practice that is insurance based and medicare based is very doable(a little harder in others). Making good money from it can be a different story.

 

[vistaril]

I think you are correct in that you have identified the right problems, but you are not coming up with any solution. I don't have an answer but you but I think the answer resides in maximizing the value proposition rather than fighting for a crumb of service that's of diminishing value. Exactly how to do this requires some creativity and research.

If I was capable of pulling off such things Id be in a lot better position honestly. Not just in my job but life in general.

Part of it is just resistant to change on my part as well. What I do has become comfortable, it is fairly easily, I'll probably make about 425k or so this year and that doesnt include 401k add on, don't pay anything for great health insurance, probably work more like 35 hrs a week M-F than 40, free dental, etc....now I have to work some weekends and see a lot of patients for that, but as crappy as some aspects of the job are there is still a resistance to change at some level too.

The other part I didn't mention is that even though I dont work much with the psych nps directly, I still give the practice like three formal collaborative agreements with that salary. So my boss isn't interesting in paying me 425k(lets say 335 for the M-F part) to see my 35 inpatients a day. Thats not going to make him money sans stipend after my salary and expenses and taxes and benefits. He makes the money on the delta on what the nps for those three collabs produce. Like one of them has a 2 days per week contract with a distant cmhc to do high volume med mgt. The cmhc of course just needs a psych np who has a collaborator, and we provide that. The cmhc is paying us more than the 110k or so she makes just for those 2 days per week.....

So thats where the money is made- the psychs themselves arent bringing in much due to their salaries. It's the psych nps and that delta between what they bring in(in clinic and through cmhc type contracts) and their small salaries where the money is made. And people like me give the practice those collaborative slots(since the owner of the practice can only use so many)....

 

[clausewitz2]

If I was capable of pulling off such things Id be in a lot better position honestly. Not just in my job but life in general.

Part of it is just resistant to change on my part as well. What I do has become comfortable, it is fairly easily, I'll probably make about 425k or so this year and that doesnt include 401k add on, don't pay anything for great health insurance, probably work more like 35 hrs a week M-F than 40, free dental, etc....now I have to work some weekends and see a lot of patients for that, but as crappy as some aspects of the job are there is still a resistance to change at some level too.

The other part I didn't mention is that even though I dont work much with the psych nps directly, I still give the practice like three formal collaborative agreements with that salary. So my boss isn't interesting in paying me 425k(lets say 335 for the M-F part) to see my 35 inpatients a day. Thats not going to make him money sans stipend after my salary and expenses and taxes and benefits. He makes the money on the delta on what the nps for those three collabs produce. Like one of them has a 2 days per week contract with a distant cmhc to do high volume med mgt. The cmhc of course just needs a psych np who has a collaborator, and we provide that. The cmhc is paying us more than the 110k or so she makes just for those 2 days per week.....

So thats where the money is made- the psychs themselves arent bringing in much due to their salaries. It's the psych nps and that delta between what they bring in(in clinic and through cmhc type contracts) and their small salaries where the money is made. And people like me give the practice those collaborative slots(since the owner of the practice can only use so many)....

Ahh, now it all makes sense. You are uncomfortable that a huge chunk of your salary comes from you providing meaningless "collaborations" to NPs (i.e. frank and naked rent-seeking exploiting regulatory loopholes) so it is important that you tell us all that this is the future and everyone else will be doing the same thing in a few years.

I'm sorry you hate your job. I don't blame you for it.

 

[Sushirolls]

my pm box full of people saying "thanks for posting like it really is" and then asking me a bunch more questions says otherwise.

Come to think of it I'm behind responding to some of them so to the people who are out there and have messaged questions in the
last few days I'll get to them by the weekend.

As to your point about building a practice....sure in some areas getting patients for an outpt practice that is insurance based and medicare based is very doable(a little harder in others). Making good money from it can be a different story.

Your local micro environment perhaps is reflective of how things might be with "colabs" and "psychs" and "psych NPs" but is not reflective of the US as a whole, especially with most states as independent practice states for ARNPs.