Reinvention

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.

Chairs

What kind of chair do you use in your office?

Like most shrinks in private practice, I sit a lot. And I happen to have back problems (old muscle injury). So it's been hard to find the right chair.

The way my (small) office is set up, I use the same chair for sitting in when I'm seeing patients face to face, and when I'm working at my desk. At the moment, I'm using a Setu Chair.

I got the kind without the arms, because I thought it would give me more freedom of movement, but I think it makes it harder for me to take notes, or even just sit back comfortably. It's also not height adjustable (this model), so I use a footrest with it. The nice thing about it is that the instructions consist of two words: Sit Down! No adjustable doodads. Nothing complicated. And it does mold to your back nicely. But I still seem to ache a lot, even with stretching and strength training.

How do you figure out which chair works for you? If you go to a store to try it out, it's not like you're going to sit there for 3 hours to see how it feels.

In the past, I've used a Mirra chair:

But the controls were too cumbersome, and it wasn't all that comfortable.

My husband uses an Aeron at his desk:

I've never found it that comfy.

I recently read about the second iteration of the Think Chair:

This looks promising, but again, how do you know until you've sat in it for several hours straight?

One day, in the far off future, when I have a big enough office to fit both a desk chair and a sitting chair, what I want is the Saarinen Womb Chair with Ottoman:

I also love the idea of an Eames Chair with Ottoman:

In all honesty, I'm crazy about this chair, but I've wondered what it would do to my back to sit in it all day.

That's the thing. There are all these different ergonomic desk chairs, but they're made for working at...wait for it...desks!

And the lounge chairs are more for reading.

It reminds me of doctor shoes. I learned this as a medical student and resident. There are great shoes for running. And there are great shoes for walking. But what you need when you work in a hospital are great shoes for standing. Because that's mostly what you do. I used to think those Dansko clogs looked silly on surgeons, and the Merrell clogs are ugly. But they work for standing.

Is there such a thing as a shrink's chair? One that's designed for attentive listening in a not completely reclined position, that lets you move around a little, and doesn't let you sink down til it's bad for your posture? This could be a challenge for Herman Miller.

Just for fun, here are some of my other favorite chairs:

The Swan

The Egg

The Marshmallow

The Flight Recliner

The Papa Bear

Do other people have similar sitting issues? And if so, how have you solved them?