Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, October 18, 2014


Hello. Sorry for the prolonged absence. I've been pretty busy with a number of things. I've started studying for Boards in earnest. It's unpleasant, and I don't feel like I'm getting anything useful out of the experience, but it does take up time.

I've also been dealing with family stuff of the happy variety. I do feel like I'm getting something useful out of that, but it does take up time.

My husband and I are both self-employed, so we get our medical insurance from Freelancer's Union. I'm not sure if that exists everywhere, but we have it here, in NYC, and it's a great idea because you don't have to buy individual coverage at skyscraper prices if you don't work for some company. We've had it for several years and the coverage has been decent, if not stupendous.

But in keeping with all the plans under Obamacare, starting in January, Freelancer's is no longer going to offer any plans with out of network coverage. And this is a big deal. Not so much because I won't have out of network coverage, myself, although that's important. But because some of my patients are also insured through Freelancer's, and will be losing their out of network coverage. And I don't accept any kind of insurance. I'm guessing that in the not-too-distant future, employer-sponsored plans with out of network benefits will also go the way of the dodo. Why should companies pay for that, right?

Not all my patients pay my full fee. But those who do can often afford it only because they have reasonable reimbursement. And even those who don't pay my full fee use their insurance to help cover whatever I'm charging them.

So what's gonna happen in January? I'll either have to charge less per session, or my patient's will have to see me less frequently, or not at all. I'm anticipating a significant drop in my income. So significant, in fact, that if I don't find a way to make up the difference, in a couple years, I won't be able to afford to run my practice.

This is not an exaggeration. NYC real estate prices are ridiculous. As a reference point, the cheapest studio apartments in Manhattan rent for about $1250 a month-and those aren't even professional offices, and they're in a neighborhood where it's not worth having an office if you want patients. Add to that all the other costs of running a practice, plus food, clothing, shelter, and family expenses, and I'm toast.

My practice is not atypical for NYC. Most psychiatrists in private practice, the ones I know and whose work I respect, anyway, don't take insurance. And these days, it's not just psychiatrists who are completely out of network-other MD's have stopped, too. And I happen to know that my full fee is way on the low side for NYC.

It seems like it's time to reinvent myself. Do I refuse to see patients who can't pay me in full? Do I increase my full fee so those patients who still have out of network coverage can help compensate for those who don't? Do I figure out a way to market myself to that portion of the population who can afford my fee? Do I start accepting Groupons? Do I go concierge style? Do I accept whatever patients can pay me, and take a second job as a barista? Do I play the lottery on a regular basis? Do I develop a clever psych app? Do I monetize my blog? Do I find some other way to offset my losses? Gambling? Home pornography? Airbnb?

You may have noticed that I didn't include accepting insurance as one of my options. I don't consider it a viable option. If I were to sell out that way, I'd be bogged down in all kinds of extra scutwork, the insurance companies would do everything in their power to avoid paying me (United still owes me a couple thousand from back when I accepted medicare), and even when they did pay me, it wouldn't be enough to allow me to maintain my practice.

Or maybe I close my practice completely and find a new profession, after pouring a good percentage of my life, and enough money to feed a small third world country for a year, into medical school, residency, and analytic training.

When I was getting ready to leave my inpatient job and open my practice, I spoke to a friend/colleague who had started her practice two years earlier. She told me that she had written herself a script, which she memorized, of how to tell patients what her fee was. She did this because after accepting $5 per session fees in the clinic, as a resident, she thought it would be hard to keep a straight face when she quoted her fee as $250 a session (this was maybe a dozen years ago).

I'm finally getting to the point where I feel like I deserve my fee. Like I have the knowledge, skill, expertise, and experience to warrant what I charge. I've noticed feeling that way lately. It's been a nice change. And now it's not going to matter.

I can't honestly say I'm surprised by any of this. It's just an extension of what I wrote about in Coverage vs. Care:

1. Everyone has health coverage.
2. Doctors will stop accepting that coverage because they can't afford to practice with those reimbursement rates.
3. Patients will stop going to the doctors who don't accept their coverage.
4. Doctors who don't accept coverage will lose all their patients.
5. Doctors who don't accept coverage will be forced to start accepting insurance or close their practices.
6. Goto 2.


  1. I think it depends upon where you practice as to what works. I work in a large city on the West Coast and I take insurance. Many psychiatrists here do not but I take it because the reimbursement rate is reasonable. I am worth my private fee but few folks can pay that even in this large city with lots of tech money. I only take three carriers: I have a biller who does all the work for a reasonable fee and I don't worry about how often folks can come in because mostly they can pay the co-pay. I am not an analyst but I am that rare breed of shrink who also does therapy. I do not envy your position. I can't afford to visit New York much less live there!

    But I do want to say that not ALL insurance sucks. Some do and I won't take the ones that really, really do suck (And they know who they are). They MIGHT all suck in a few years but I have never been harassed or not paid by an insurance company. Only one out-of-network plan asked me for a treatment plan. I did do it and it worked. I don't know the answer and in a few years I may retire anyway if things change...

  2. I guess I can believe that not all insurance sucks, but I haven't encountered any that don't, personally or professionally. It sounds like you've found a reasonable compromise for your work, though, which is at least hopeful.

  3. This is the way I look at a $250 fee.

    It is what my plumber, electrician, heating and air conditioning guy, and chimney sweep charge - just to show up at my house. If they have to start taking tools out of their truck it gets a lot more expensive in a hurry. Do I think a psychiatrist/psychoanalyst should be paid at least a blue collar wage? You bet I do.

    In the midwest, we are in the process of many people going into private practice and eliminating insurance. There are also a number of mental health clinics that you can contract with and they will take care of the billing hassles so that you can accept some insurance. There are even some employed positions where psychiatrists are protected rather than exploited. Another bonus is that housing costs vary anywhere from 25-35% of what they are on either coast (for equivalent housing). Winters can be extreme but the quality of life is excellent. So consider the Midwest and even upper Midwest.

    1. I've honestly never thought about relocation, but maybe. I'm genuinely touched by your suggestions (and those of anon, above). Thanks.

      A little over a year ago, the central air conditioning in my office started to leak. I found a guy online and he came over quickly, and did an excellent job. He charged $400 just to walk in the door.

  4. Have you ever thought of getting a part-time job to supplement your practice? Psychotherapy research or hospital work part-time? It is not ideal for what you want to do, but it might be a compromise.

  5. I've been trying to decide whether and how to comment on this topic, one I continually ponder. Here are some thoughts:

    1. It's a matter of priorities, financial and ideological. If you need the income badly enough, you'll take insurance, see people you'd rather not, work harder, etc. Nothing wrong with that, life is tough. Conversely, if you can afford open hours, you can be a lot more selective. For whatever reasons — frugal lifestyle, high principles, sheer luck? — I've leaned toward the latter over the years.

    2. It's not black or white. As Anon wrote, it's no crime to take insurance. I'm still a Medicare provider even though it doesn't pay as well. I consider opting out and offering my existing Medicare patients a sliding-scale fee that, in a few cases, might slide to zero. I dunno, maybe I'll do that someday. For the time being, it isn't that big a deal to send an envelope of claim forms to Medicare every month or so.

    3. Health care is in flux. The KevinMD blog illustrates the tension between those who advocate direct-pay medical practices (what you and I mostly do), and advocates of universal coverage (single-payer, "Medicare for all" etc). One MD commenter called docs like me hypocritical for favoring universal coverage and then not accepting it ourselves (he's strictly cash-on-the-barrelhead). Interesting problem... but not mere hypocrisy. I have no idea how health care will be paid for in 10-15 years.

    4. Value is very subjective. Some of my attorney patients charge 3 times what I do hourly. My $200/hr fee (it's on my website) is low for San Francisco, I assume very low for NYC. Yet it's completely out of the question for many people, even in our affluent cities. The plumber and air conditioning guy only come once, we offer a weekly (or more) service. To some degree it's arbitrary what people find affordable, a cultural convention. Would I prefer a world where psychiatrists earn $600/hr and attorneys $200? I guess, but I'm not holding my breath.

    5. Consider expansion, not reinvention. You don't need to give up and find a new profession. But it wouldn't hurt to consider add-ons, niche services, side jobs, and the like. No, not Airbnb. I knew a psychoanalyst who also worked part-time at a community mental health clinic, and other psychiatrists who write books. I've done a little psychotherapy supervision for pay, and chair a hospital committee. Keep an open mind, and don't let the bastards grind you down.

  6. Insurers are definitely moving to cut plans with out-of-network benefits, especially in the individual market. I'm guessing that this predates the ACA. The plans are more expensive.

    The freelancers' union website blames Obamacare by saying that "it completely changed the healthcare landscape." They don't provide any citations or refer to any regulations, so this sounds like bullshit to me. Blaming Obamacare is very popular, and I don't see any evidence that this can be attributed to Obamacare.

    Do you have a cite? I e-mailed someone who does consulting in this area, and he said that there was no such regulation. I'm genuinely curious to know if you've come across one.

    1. I don't have a citation. but my understanding is that plans on the exchange have no out of network benefits. To me, this seems like it can be used as precedent and justification for private insurers.

    2. I don't know what is happening in NY, but I looked at the MA connector plans for the unsubsidized plans, there is one Bronze Plan with out of-network benefits. $4k deductible for out-of-network. I think that they don't have out-of-network benefits, because they can offer more comprehensive benefits at a lower cost. That doesn't mean that it's mandated by Obamacare.

      A lot of doctors, for example, blame things on HIPAA inaccurately. They claim for example that they can't talk to family members when family members are providing information without the consent of the patient. They can't tell the family member anything, but they can certainly listen. I know of one specialist who told a friend of mine that he couldn't send test results to a referring PCP (totally kosher) but then offered to e-mail them to the patient (a HIPAA violation).

      In Massachusetts, we have a law which aims to limit the growth of total healthcare spending to 3.6%. Insurers are saying that they can't increase rates because of this law which is not true. They certainly can, since the law says nothing about rates but TME (higher rates with fewer lab tests or less use of home-care agencies would be fine).

      People say a lot of things to justify what they want to do. That's not evidence that Obamacare is to blame. The ACA has many failings, but there are many more things that people blame on it.

  7. ACA is what businesses and government pull on people all the time. Looks good on paper (or coming out of their mouths) but the reality is something far different.

    When I brought up the fact (also on Kevin MD btw) that it did nothing to help people in the middle of poor and rich, I was meet with snide dismissal. Now stories such as below are appearing. Note: I ignored the spin at the end; I don't know anyone who wasn't already trying to do this as we have had high deductibles with employer sponsored plans for years in this area.


    Recently I started hearing of next year's employer benefit plans from those at other companies. I don't find out about mine until next week. And what I hear are that coverage amounts for doctor visits are being drastically reduced. This has the same effect on people as raising their rates, but I guess since it meets the letter of the law, who cares?

    Years ago, I would have liked that people bought catastrophic care plans and paid the majority of their medical bills themselves. But, now, I am beyond mad that we are being asked to participate in this type of scenario defacto through outrageous deductibles and limited insurance reimbursement BUT with prices that have sky-rocketed due to third party interference.

    The absolute worst of both worlds.