If you are…

• Working at a part-time job while building your private practice on the side
• Working full time at an insurance or agency job and are thinking about starting a private practice
• Currently have an insurance private practice and want to transition to cash-pay
• A psychiatry resident or PMHNP finishing your education and want to start a private practice in the future

…then you are probably feeling overwhelmed with all the unknowns and “what if’s” of having a cash-pay private practice.

But the truth is that deciding to build a psychiatry private practice is more than just a leap of faith; it’s a financial balancing act that requires meticulous planning and analysis. If you’re like me, and you find reassurance in the clarity of hard numbers, I’ve got you covered. 

In this blog, I’d like to guide you through a comprehensive breakdown of how to evaluate your financial situation, and determine if (or when) the moment is right for you to quit your job and immerse yourself in the growth and development of your private practice.

Why Switch From Insurance to a Cash-Pay Psychiatry Private Practice?

The American Psychiatric Association (APA) now reports that 2 out of 5 psychiatrists experience professional burnout — that’s almost half of all practicing psychiatrists.

Do any of these sound familiar?

• Only being allotted 20-minute chunks per patient
• Having 3+ intakes booked with less than 1 day of notice
• Spending hours following stringent notes procedures, instead of using that valuable time to help patients or grow your clinical skillset
• Fighting with insurance companies about what qualifies as a serious illness for a patient to receive a specific medication
• Given no time to have noncontroversial conversations with patients about nutrition, exercise and sleep
• Feeling like a “cog in the machine” with zero control over your career 
• Having to chase down insurance claims to get paid… only to be compensated 40% of what your actual billing rate is

The truth is, there is a rising level of frustration and dissatisfaction among providers working in bureaucratic systems, and according to a recently published New York Times article, The Moral Crisis of American Doctors, it might be a bit more complicated than just “burnout.”

In a previous blog post, I wrote about which factors contribute to moral injury among psychiatric providers, and how you can avoid it and enjoy fulfillment in your career.

Basically, moral injury is caused by the lack of autonomy in treating patients the way that they need to be treated and in doing what we, physicians, are skilled at best. We are taken aback not by the long work weeks, but instead by a broken health care system that makes it practically impossible to properly care for our patients and that prioritizes profits over patients.

I’ve noticed that more and more psychiatric providers are leaving their jobs and turning away from bureaucratic systems to start their own cash-pay private practices, even those that have established and well-paying careers. I know this because they are applying to my career mentorship program and seeking guidance on how to build a private practice that puts the patient first, not corporate profits.

Psychiatric providers are realizing that transitioning from insurance to cash-pay has numerous benefits, such as:

• More autonomy in how you treat your patients and the type of modalities that you practice
• Less time spent on administrative work
• Smaller patient panel means you can connect with and treat each patient better
• The ability to set your own rates and work less while earning more
• Providing higher-quality, more personalized care (and practicing integrative psychiatry!)
• Reduced burnout and increased job satisfaction
• No more hassle with insurance reimbursement

So where exactly do you start if you want to make a career transition to a cash-pay psychiatry private practice?

Let’s get into it.

Start With a Side Job

Before you fully transition to a cash-pay psychiatry private practice, consider maintaining a part-time job for financial stability. When teaching psychiatrists and psych NPs in my mentorship program, I always emphasize the importance of having a safety net to ensure you can cover your expenses while focusing on building your practice. Ideally, commit 1-3 days a week to part-time work. This balance provides enough income to cover expenses without significantly hindering the focus on your practice.

Think of your side job like a trapeze artist’s safety net – it’s there to support, not to detract from the main act, which is your private practice. Your side job can help you make sound, fear-free decisions for your practice. 

A very important note about side jobs: overcommitting to various professional endeavors can dilute your focus. A short-term sacrifice in income and time may be necessary, but it’s for a significant long-term benefit: the successful establishment of your dream practice.

Evaluate Your Readiness to Cut Back Hours

If you’re working full time at an agency or insurance job, you will most likely need to cut back hours to have enough time to build your private practice. Expect to invest at least 15-20 hours a week into building your private practice.

From my experience coaching 350+ psychiatric providers in Dream Practice Academy, if you are able to put in ~15 hours/week, you can expect to launch your practice within 2-3 months. The more time you spend building and growing your practice in the beginning, the sooner you’ll be able to rely solely on your practice income and quit your old job altogether.

If you’ve started building your practice but are struggling to find time for marketing efforts and growing your private practice, ask yourself: What would stop you from cutting back the hours at your side job tomorrow?

1. If it’s finances, how much income do you need each month to cover your expenses? 
2. Instead of working your side job 4-5 days a week, can you cut back to 1-3 days a week?

If you have a few months of savings and can comfortably afford it, consider reducing your hours at your current job rather than quitting outright. Use the extra time to focus on building your private practice, especially on marketing efforts, even if you’re not yet seeing patients. Marketing is essential for attracting new clients!

P.S. Feeling overwhelmed with planning the finances for your private practice? you can use my Income Projection Spreadsheet to calculate your projected income and plan ahead for your private practice. Access the Income Projection Spreadsheet, along with a wealth of other private practice resources, in my free Dream Practice School community.

Now let’s get into the nitty-gritty details of and perform a financial analysis to know exactly when you can quit your side job.

The 6-Step Financial Process of Transitioning to a Cash-Pay Private Practice

At this point it’s possible that the thought of not having a steady income combined with the uncertainty of starting a business is starting to make your palms sweat and your eyes twitch from stress.

I highly recommend breaking it down by the numbers so you can see – pen to paper – what is realistic for you now, and how to start planning for this transition in the future. 

Step 1: Calculate your monthly income 

• When calculating your income, consider all sources, including your partner’s income if applicable. 
• Let’s say your monthly income is $5,000. 

Step 2: Calculate your practice’s monthly overhead

• Always be clear about your business expenses and make sure to count everything – softwares, credit card transaction fees, marketing costs, insurance, etc. 
• Let’s say your overhead is $500 (YES, you can start a minimum viable telepsych private practice at ~$500/month)  

Step 3: Estimate your living expenses 

• Include all your expenses here – mortgage, groceries, utilities, student loan payments, etc. 
• Let’s say your monthly living costs come out to be $6,000. 

Step 4: Income vs. expenditure

• Now deduct your overhead and living expenses from your income. In this example we came out with a deficit of $1,500.
• $5,000 – ($500+$6,000) = -$1,500

Step 5: Savings estimation

• Crucially, assess how many months of savings you have as a buffer.

Step 6: Evaluate the opportunity cost

• The ultimate goal is to ideally have your practice’s income exceed your expenses, allowing for savings growth. It’s okay to run a slight deficit initially, but ensure it’s manageable and not overly stressful. 
• The benefit of quitting your side job is the ability to focus on the practice. It also raises the stakes a bit which can be extremely motivating. Chances are, the more time you have to dedicate to your practice, the faster it’ll grow.

As you have more time to focus on building up your private practice, the deficit is going to quickly turn into surplus. 

For those with limited savings and a projected deficit upon quitting the side job, my advice would be to delay leaving the job until you’ve accumulated 3+ months of savings, or are generating more income in your private practice.

The truth is, if you don’t ever jump in with both feet, your practice is going to grow MUCH slower. Remember, your DREAM is having your own private practice, your side job really isn’t your passion or life goal. 

When I started my private practice I had ZERO side income. I just focused on seeing the patients I had and marketing to grow my practice. I think that’s part of the reason why my practice grew so fast — I didn’t have anything else distracting me.

You don’t have to be that extreme — just start by cutting back a few days. Just remember, the more time you devote to your private practice, the faster it will grow.

Regardless of the amount of hours you’re working at your side job, you want to be mentally fully committed.

Bonus strategy: How to Transition Patients From Insurance to a Cash Private Practice

There is one specific situation where I’ll sometimes recommend quitting your job and going all in on your private practice – and that’s if you have an insurance job (or insurance-based practice) and you think a certain percentage of your patients might want to follow you into a cash practice.

Let me give you some reassurance: the benefit of having an established patient panel at an insurance job is that many are likely to come with you to your practice, which means you don’t need to stress about finding new patients right away.

Having an established patient panel will make it much easier to start your private practice, since there is a greater chance these patients will follow you to your private practice. 

Transitioning Out of An Insurance-Based 1099 Contact or W2 Job 

Is it legal to tell patients where you’re going? Yes, as long as you don’t have a non-compete clause in your contract. A non-compete clause prohibits providers from actively recruiting patients from their institution to follow the provider elsewhere.

However, recently, the F.T.C. announced a new regulation called The Final Rule. This rule will ban non-compete agreements from restricting employees’ ability to work for rival companies, effective September of this year.

This is very exciting as it will benefit those that want to start building a cash-pay psychiatry private practice while still working at their agency or insurance job. You can read more about this upcoming change in this article.

Here’s how you can navigate this in the meantime: 

If your contract contains a non-compete clause, it’s crucial not to breach it by freely soliciting that information to the patient or encouraging them to join your private practice. At the same time, patients are autonomous individuals and can make their own decisions! During your patient’s last appointment, you can casually mention, “By the way, this will be my last appointment with you. I’ll no longer be working here.” They’ll likely ask why or where you’re going, giving you the opportunity to explain that you’re starting your own practice.

While you don’t need to explicitly say, “come to my private practice,” some patients may express interest. In this case, it’s important to make sure that your website appears in search results when they look for your name. Most patients will be curious and eager to learn more.

If your side job doesn’t have a noncompete clause, you’re free to inform patients about your private practice and ask if they’d like to continue working with you in that setting. If your side job accepts insurance and your private practice operates on a cash-pay basis, consider offering a temporary sliding scale to accommodate those patients. Just be sure to estimate the conversion rate of patients who will follow you and allocate enough time in your schedule to accommodate them.

You may be thinking: 

But how do I convince my patients to follow me to my private practice? What if they don’t understand the value of paying cash for my services if they can just use their insurance? 

Those are all very valid fears. 

If you have patients that like you and want to keep seeing you, it’s very likely that at least 25% of them would be willing to pay cash for your services. In fact, several members in Dream Practice Academy who have made this transition will see anywhere from 20-40% of existing patients transition to their cash-pay practices. 

My advice is to give your patients a letter (or email) and include the following information:

• State that you are leaving to start a private practice to provide better care for your patients.
• Include any additional offerings that you will include in your private practice that you don’t have the time for in this role, like therapy, nutraceuticals, comprehensive lab testing, etc.
• Offer a time-limited sliding scale (~6 months) to make the transition from insurance to cash smoother for them. Make sure the hourly rate you offer is around  double of what you are making at your current job. That way you can break even faster. Hourly rate = Monthly gross revenue / TOTAL work hours (this should include both clinical and admin time). 
• Appeal to your patients’ sense of fairness, and explain that you need to get out of the insurance system in order to provide your highest level of care. It’s very likely that they will understand and would rather pay you directly than throw money at some unknown large organization. 

Let’s look at an example scenario: 

Let’s say you make $150,000/year, work 40 hours/week, and have 500 patients on your panel. 

That’s $12,500/month / 174 hours (50*4.33 AVG weeks in a month) = $71.80/hour.

Let’s say you’d like to charge $315/hour in your private practice, but to make the transition easier for your existing patients, decide to offer a 6-month sliding scale rate of $215/hour. 

• If 5% of your patient panel followed you, that would be 25 patients. 

• If 10% of your patient panel followed you, that would be 50 patients. 

• If 20% of your patient panel followed you, that would be 100 patients. 

That means that you can immediately replace half of your income working significantly less hours – all before you’ve even started marketing!

To see this play out in a real-life example, the below post is from a PMHNP in Dream Practice Academy who followed this exact strategy, and ended up converting 30% of patients from his insurance job to his cash-pay practice! 

Transitioning Your Insurance Practice to a Cash-Pay Model 

This approach is also beneficial if you currently have an insurance private practice and want to transition your patients to cash-pay.

And please note, you do not need to have pre-existing relationships with patients to build a successful private practice. Sure, having an immediate referral source and patients who already know you and want to make the transition is great, and make the financial transition much easier, but it’s not a factor that determines your long term success. 

In fact, I work with several providers in Dream Practice Academy who are starting telepsych private practices and are planning to work with an entirely different patient population than they do in their current insurance-based practice.  It is absolutely possible! 

Are you ready to take the leap into Cash-Pay Psychiatry Private Practice? 

Remember, courage isn’t the absence of uncertainty; it’s about triumphing over it.

Having mentored 350+ psychiatric providers on starting and growing their cash-pay private practices, I can confidently say that with careful planning and a clear understanding of your financial landscape, you will be well-equipped to navigate the transition to cash-pay.

…From those that started the transition to cash-pay while still working in their insurance jobs, but are now 100% all-in on their cash-pay private practice:

This is another success story of a PMHNP in my mentorship program who was able to phase out of his insurance-based private practice and go from seeing 25 patients/day to making $30k/month while working 25 hours/week.

Now that you’re ready to start mapping out the financial opportunities for your cash-pay psychiatry private practice, I can predict what will likely come next: internal doubt.

Before you let those doubts take over, let me redirect you on how to tune out the haters, ignore your internal doubts, and follow your private practice dreams 🙂 

Join My Free Dream Practice School

Ready to ditch the broken healthcare system and unlock your full career potential? Join my free community to start learning what it means to be an integrative psychiatrist entrepreneur with your own cash-pay psychiatry private practice – and how to make it happen. You’ll even get access to some of my protocols!

I hope to connect with you soon! 

The post How to Transition From Insurance to a Cash-Pay Psychiatry Private Practice: A 6-Step Process appeared first on Zen Psychiatry.

How do you currently measure “success” in your private practice? Is it the number of patients you have, how many hours you work, or how much you charge?

While there are numerous ways you could measure success (and your version of success might be different than mine), there is one common denominator among everyone that reached their own version of success in private practice – they work smarter, not harder. 

What does this mean, exactly?

Let’s say your practice is full. You’re working on your own schedule, charging what is considered “high” rates and seeing patients within your niche. By traditional measures, you’ve reached success.

But what people don’t know is that you…

• Work 50-60+ hour weeks
• Never go on vacation
• Feel like you are still somehow behind on a million business and admin tasks (even though you spend hours on them every day)

You’re spending your precious time on things like documentation, managing scheduling, handling prescription requests, responding to emails and phone calls, reviewing intake forms, filing taxes, etc.

Basically, you’re STILL doing everything that you wanted to do less of when you left your insurance-based job in the first place and started your own private practice.

But here’s the thing: you didn’t go into private practice to waste your time on meticulous, low-value, admin tasks – you did it to have more time doing what you love, which is helping patients and changing their lives!

In the world of owning a private practice, where you must sustain the delicate balance of caring for your patients and running a business at the same time, you might find yourself knee-deep in the day-to-day grind. It can be easy to get lost in the shuffle of patient appointments, notes, and the other nitty-gritty details. But here’s the thing – spending all your time ‘inside’ your business might mean you’re missing the forest for the trees. 

So how do you optimize your private practice to spend LESS time on low-value work, and MORE time on activities that are rewarding and lucrative?

How do you scale your practice to bring in your dream patients?

Before we dive into private practice optimization strategies, you need to have a specific understanding of where you’re spending your time, your true hourly rate, and where your revenue is coming from.

Get ready to roll up your sleeves and pinpoint the gaps and opportunities in your private practice.

Let’s get into it.

Complete a Private Practice Audit 

If you’re charging high fees but still feel like you’re not making a lot of money for the amount of work that you do, it’s time to figure out where the holes are in your business. 

If you’re working harder than you think you should be, or if everything just feels cumbersome and difficult (and you don’t understand why it’s so difficult), then you need to take a pause and do a practice audit. 

While it’s crucial to be hands-on, drowning in the minutiae can make you miss the strategic moves that have the potential to take your practice to the next level. It’s like being so busy fixing individual puzzle pieces that you forget to step back and see the whole picture. 

That’s why completing a private practice audit is the first step you need to take to optimize your private practice. 

Waiting until your practice hits the 12-month mark gives you a solid data foundation – the kind you need to see patterns, strengths, and spots that could be optimized. They say what’s measured gets managed, so I’m going to show you how to do just that.

Before diving into strategic decisions and pivots, it’s essential to complete audits in two key areas of your business: admin time and your patient panel. 

Step 1: Audit Your Time Spent on Admin Tasks 

An admin audit can help you figure out exactly which admin tasks are taking up most of your time, so that you can come up with solutions for optimizing those areas in your practice.

For one solid week, keep track of all the requests you receive from your patients in-between appointments and record the details of each request in a spreadsheet. Be sure to note how they contacted you, what their request was, and what you did to resolve the request.

After one week of tracking the requests, go back to the spreadsheet and figure out which requests tend to come up the most and take up most of your time. Then write down potential solutions and ideas for how you can streamline those requests in the future.

For example, if you noticed that you get a lot of scheduling requests, consider automating this task by creating an auto-scheduling widget in your EHR for patients to book their appointments without your involvement.

Your admin audit will reveal a lot about where your time is being spent in the business, and make it clear where you need to eliminate, automate, or potentially delegate those admin tasks (the last resort).

Step 2: Audit Your Patient Panel

The next step is to audit your patient panel. Why is this important? Because it will help you objectively pinpoint the type of patients that you want to keep (and continue attracting) to your practice, and those who no longer fit your practice mold. 

This part of the audit is likely to take you the most time to complete, but is a crucial step of the optimization process. 

Export your patient list from your EHR system into a spreadsheet (you only need their names). Then in columns include the following information: 

1. Patient’s hourly rate 
2. Patient’s year-to-date revenue (meaning how much did you make from that patient in a 12-month period)
3. Patient’s revenue potential (based on how often you expect to see this patient)
4. Patient’s boundary respect rating (based on any past interactions)
5. Patient’s history/stability rating (based on patient’s conditions) 
6. Patient’s ancillary work rating (meaning how much additional work is required in between appointments)

The Private Practice Audit Spreadsheet

If you’re starting to feel overwhelmed, or think “I’m not a spreadsheet person…” luckily for you, I created a templated spreadsheet to make auditing your patient panel and admin time much easier and straightforward.

It’s called “The Private Practice Audit” and will help you accurately track different data points of your practice, recognize gaps and opportunities, and make a game plan to streamline and optimize your private practice. Simply put, auditing your private practice will help you recognize how to make more while working less. 

You can access the audit inside of my free community, Dream Practice School.

Once you join Dream Practice School you’ll have immediate access to The Private Practice Audit, which also includes a guided video on how to:

1. Audit your patient panel, create a rating system, and implement a plan of action based on the results
2. Calculate your revenue per hour
3. Track, audit, and create solutions to eliminate admin tasks

Optimize Your Practice Based on Audit Findings 

Now that we’ve shed light on why auditing is key to a thriving private practice, let’s dive into the fun part – optimization. Picture this as the moment you switch from autopilot to manual control, fine-tuning your practice for maximum efficiency and impact.

1. Streamline Your Admin Work 

There are 3 ways to optimize business systems in a private practice – eliminate, automate, and delegate. To audit your admin tasks, figure out what tasks take up the most time in your day and solve for them by following these steps:

1. Eliminate – Does the task even need to be done?
2. Automate – Can you use a software solution to automate the process?
3. Delegate – Can you hire someone to do this for you?

For example, can you eliminate your after hours phone line, automate your billing via an EHR software like IntakeQ, or/and delegate making new patient charts to an assistant?

The key to doing this right is to implement these in order. Don’t delegate what you can automate, and don’t automate what you can eliminate!

In fact, a common mistake that I often see psychiatrists make when trying to optimize their private practice is jumping straight to hiring an assistant or receptionist to do their admin tasks for them.

The truth is, you don’t need to pay someone else to do a task that might not even need to be done, or can be done for cheap with a software solution. Besides, there is a huge learning curve with hiring and training an employee, which is why it should always be the last step in your optimization process.

2. Phase out patients who aren’t aligned with your practice

Once you complete your patient panel audit you’ll be able to see your practice at a 30,000 foot view, and identify the patients who are no longer a good fit for your practice. 

For example, you may have patients from when you first started building your practice that are not truly aligned with your practice. Now is the time to re-evaluate your patient panel for your long-term goals, and phase out the patients that don’t fit within that mold.

Now would also be the time to phase out any insurance patients that are left in your practice if your end goal is to have a cash-pay private practice.

What’s the best way to do this?

My advice is to give your patients a letter 2-3 months in advance and include the following:

• State that in order to provide better care for your patients, you will stop accepting insurance and will be a cash only provider.
• Include any additional offerings that you will add to your private practice, such as psychotherapy, nutraceuticals, comprehensive lab testing, etc.
• Speak to your patients’ concerns and offer a time-limited sliding scale to incentivize them to stay in your practice.
• Appeal to your patients’ sense of fairness and explain that you need to get out of the insurance system in order to provide your highest level of care. It’s very likely that they will understand and would rather pay you directly than throw money at some unknown large organization. 

By the way, I also have a templated letter for this (and many other scenarios) that I share with my mentees in Dream Practice Academy.

3. Raise your fees

Now this next step might give you a little bit of anxiety… but bear with me.

Do you know what the difference is between a $300/hr psychiatrist and a $1,000/hr psychiatrist? I’ll tell you what it’s not: clinical skills.

I know what you’re thinking:

“I need more experience before I increase my fees.”

“I’ll be under too much pressure if I increase my fees.”

“I’m not ready yet.”

A common misconception psychiatric providers have is that they think they need more clinical skills, experience, or training before they can increase their fees. 

The truth is, at a certain point it is not your clinical skills that become the limiting factor for raising your fees. So to answer the question, it’s the way you position your clinical skills into specific services that makes the difference between a $300/hr psychiatrist and a $1,000/hr psychiatrist.

While raising your fees is usually thought of solely as a way to make more money, it also acts as an important barrier to entry into your practice. Having higher fees can ensure that the patients that do come into your practice are much more aligned with your treatment philosophy and will be more invested in the treatment process.

How To Raise Your Fees With Existing Patients

There are two main ways you can move up the value chain and raise your fees:

1) Add new services and features to your practice

2) Take the services you already provide and reposition them to be more appealing

Don’t be afraid to challenge yourself and get creative with ways that you can increase the value you provide to your patients, because that’s exactly how you get to the point of charging high fees that other people think are insane. 

And guess what? If you figure out how to position yourself in a way that your patients find extremely valuable, they will be happy to pay those fees because they know that the value you provide them with is worth more than what you charge.

4. Optimize your marketing strategies to bring in MORE dream patients 

Now that you know who the patients are who ranked high in your practice audit, you can optimize your marketing to attract more patients just like them.

For example, where did they hear about you? What are the common demographic and psychographic factors they have in common? How can you pivot your messaging to speak more directly and clearer to them? What other providers do they see, and are you connected to them for potential referrals? What terms did they search on Google to find you? 

While it might seem tempting to have a more generalized niche and to treat a wide variety of patients, the benefit of niching down is that you can position yourself an expert to a particular group of patients.

Instead of marketing yourself as a psychiatrists who can treat all, you market yourself as THE go-to psychiatrist for your niche. For example,

• THE go-to psychiatrist for high-functioning CEOs, lawyers, and entrepreneurs with ADHD
• THE go-to psychiatrist for healthcare workers struggling with burnout
• THE go-to psychiatrist for women struggling with hormonally-related mood conditions

This could also mean introducing more advanced marketing strategies, like running a Google Ads Campaign, launching a blog strategy, building a YouTube channel, or dipping your toes into the world of social media marketing. 

Take Your Practice To The Next Level

I know running a psychiatry private practice can feel overwhelming when you don’t have any guidance on what’s “next”.

What happens when you reach the point where you have no more time to give, but aren’t satisfied with the amount of money you make? Or feel like your time isn’t being optimized? How do you get to the next level to have a better work-life balance and spend more time doing things you love outside of work?

I work with several psychiatrists who come to me with an already established practice, but need help making decisions to streamline, pivot, and transition their practices into a more balanced, better functioning business.

If you’re in that position now and are looking for additional guidance on your private practice journey, I invite you to join Dream Practice School. This program is exclusive for psychiatric providers who are interested in private practice and integrative psychiatry. We currently have 2k+ providers enrolled (and growing daily)!

Even if it seems like your practice is in a good place, I still encourage you to go and complete the Private Practice Audit – you might be surprised by what you find.

You can also follow me on Instagram @thepsychiatrymentor, and on YouTube The Psychiatry Mentor for more valuable private practice and integrative psychiatry tips and resources. 

I hope to connect with you soon.

The post How To Optimize & Scale Your Psychiatry Private Practice appeared first on Zen Psychiatry.

Is your calendar booked in back-to-back 15-minute increments all day, every day? Do you have days where you have 2-3 new patient intake appointments? Are you able to spend the time with each patient that you, THE expert in patient care, believe is necessary? 

You may read these examples and think, “Yeah, I’m just burned out. Everyone is burned out.”

The truth is, there is a rising level of frustration and dissatisfaction among providers working in bureaucratic systems, and surprisingly, it is not caused by burnout…

…But instead by moral injury.

Are Psychiatrists Burned Out, or Suffering From Moral Injury?

The American Psychiatric Association (APA) now reports that 2 out of 5 psychiatrists experience professional burnout — that’s almost half of all practicing psychiatrists.

Let that sink in.

Almost half of psychiatrists are experiencing burnout.

So what does that mean exactly?

According to a recently published New York Times article, The Moral Crisis of American Doctors, it might be a bit more complicated than just “burnout.”

The article argues that the frustration and exhaustion that psychiatrists are feeling is actually not caused by psychiatry burnout, but instead by moral injury.

According to the article, psychiatry burnout or moral injury is a consequence of “the demands of administrators, hospital executives and insurers forcing them [doctors] to stray from the ethical principles that were supposed to govern their profession.”

Basically, moral injury is caused by the lack of autonomy in treating patients the way that they need to be treated and in doing what we, psychiatrists, are skilled at best. 

What Psychiatry Burnout Looks Like:

• Being allotted 15 minute appointment times for patients who need 1 hour
• Having 3+ intakes booked with less than 1 day of notice
• Spending hours following stringent notes procedures, instead of using that valuable time to help patients or grow your clinical skillset
• Push back from insurance companies who won’t authorize your treatment plans
• Push back from hospital admin staff on the level of care you’re able to provide, “we can’t fit that into a CPT code”
• Feeling like a “cog in the machine” with zero control over your career
• Given no time to have noncontroversial conversations with patients about nutrition, exercise and sleep

Moral injury is what drives the high burnout rate for psychiatrists. 

Oh, and what about your hourly rate?

Take a quick minute to do a simple calculation – your annual salary divided into 52 weeks. Take that number and divide it by the number of hours you clock each week.

Sure, a $275,000 salary looks good on a piece of paper, but when you’re working 70 hours weeks, does $75/hour really justify your credentials and expertise?

According to the National Library of Medicine, “high work demands without adequate resources, poorly defined roles of consultants, responsibility without authority, inability to effect systemic change, conflict between responsibility toward employers vs. toward the patient, isolation of consultants in community mental health teams and lack of feedback were identified as sources of stress [in psychiatrists].”

The thing is, we as providers don’t mind working long hours if it means we get to help our patients. Hard work doesn’t scare us – we went through medical school (or other extensive psychiatric training) knowing exactly what we signed up for.

However, what we can’t stand is being forced to act in the best interest of the bureaucratic system, prioritizing profits over acting in the best interest of our patient.

Here’s the truth:

We are taken aback not by the long work weeks, but instead by a broken healthcare system that makes it practically impossible to properly care for our patients and that prioritizes profits over patients.

What Psychiatrists Are Saying About Burnout and Moral Injury

In my psychiatry career mentorship program I have a private community forum for psychiatric providers to network, connect, relate, and share resources.

When the NYT article on The Moral Crisis of American Doctors was circulated on my forum several members jumped in to share their experience with burnout and moral injury while working in traditional healthcare systems.

Here’s what they had to say:

While it may seem impossible for you to change a whole system, we must remember that to make a big impact, you need to start with small steps.

Perhaps if enough clinicians opt out of the broken healthcare system, the system may have to change and adequately compensate psychiatric providers for the important work we do. 

And we’re already starting to see this happen.

Psychiatrists that have established and well-paying jobs are leaving these bureaucratic systems and building their own private practices.

How do I know this?

Because they are applying to my mentorship program, The Dream Practice Academy, and seeking guidance on how to build a private practice (and learning high-yield integrative psychiatry in tandem) that puts the patient first, not corporate profits. 

How Can You Escape Psychiatry Burnout and Moral Injury?

Whether you’re a psychiatrist that feels burned out by the system, or want to prevent psychiatry burnout before you start your career, there are measures that you can take to improve your mental wellbeing and increase your sense of professional fulfillment.

1. Set boundaries between your professional and personal life

Due to the nature of our profession, it can be difficult to set boundaries. This can apply to our relationships with our patients, as well as in our personal lives.

It’s common for us to have the mindset that we HAVE TO say “yes” and help people, even if doing so is detrimental to our own mental health. You just have to remember that failing to set boundaries is exactly what contributes to psychiatry burnout and moral distress.

2. Take the time to clear your mind and focus on your hobbies

We all know the importance of self-care – we tell it to our patients all the time! It’s time we start practicing what we preach and take the time to do what we love outside of work, too.

This can mean being active and spending time outdoors or tapping into your creativity using painting or drawing. Whatever your hobbies are, take the time to do something that will clear your mind and help you de-stress. Being able to disconnect from work is crucial to maintaining our sanity and having the mental capacity to help our patients in the way that we strive for.   

3. Start an integrative psychiatry private practice and achieve complete career autonomy

If you want to ultimately avoid psychiatry burnout, and leave the rigid system that limits your ability to grow as a clinician, the best thing you can do is start your own private practice.

The way I view it is that there is an innate desire for providers to do everything in our power to get a patient better. And there is a vast population of patients who desperately want more than just 15 minutes of your time. 

The Future of Psychiatry

This is why I believe that the future of psychiatry is,

1. Solo practitioners — who remove the middleman from patient care, so that they can provide the kind of care that inspired us to go into psychiatry in the first place
2. Integrative psychiatry — where we use all healing modalities – traditional and complementary – in concert to give our patients the best outcomes

What so many psychiatrists don’t realize is that they can have unlimited career potential, and are able to overcome psychiatry burnout, when they work for themselves instead of for someone else.

Unlimited potential to make a profound impact on their patients’ lives.  

To have complete autonomy over their work. 

To choose the types of patients they work with, and how much they charge. 

To expand their toolbox of treatment modalities beyond just writing a script.

But all of this requires us to step outside of the very system we were all trained to be part of. And that’s not easy – but it IS worth it.

The Role of an Integrative Psychiatrist Entrepreneur

This is a role I’ve been in since graduating residency, and one that has allowed me to offer a level of care to my patients that I’m proud to provide and that truly gets them feeling better faster, while also being completely autonomous in my practice.

But the main reason I love this role is because in an increasingly complex world, the overly simplistic symptom-medication model of traditional psychiatry is one of the most pressing challenges of our field.

Just think about it.

There’s so much more you can offer patients above just medication alone.

You can take into account all of the biological, psychological, and spiritual factors that affect someone’s mental health, and you can explore all facets of healing to not just treat symptoms, but to alleviate suffering.

Imagine owning your own private practice where you could:

• Offer longer appointment times that are designed for the patients to tell their whole story
• Develop treatment plans that honor patients’ belief systems
• Educate patients that biology isn’t the only contributing factor to mental illness
• Work with your DREAM patients to optimize their lives with nutraceuticals, psychotherapy, mind-body approaches, lifestyle coaching, and many others. 

All while having complete autonomy over your work, achieving financial abundance, avoiding psychiatry burnout, and helping your patients truly thrive.

(Yes, it really is possible!)

A New Career Path: The Integrative Psychiatrist Entrepreneur

Most providers stay in broken systems because they feel they have no better options, or don’t have the skill sets or mental frameworks to start a business.

We believe that we have to grind, struggle, and “put in our time” until we have enough experience to go out and do it on our own. 

We have this limiting belief that we can’t learn on our own and that we must follow a rigid training standard first. 

• We need the extra credentials
• We need to do the fellowship
• We need to learn everything that there is to learn before we even consider presenting it to a patient. 

But I’m here to change this narrative.

How To Transition Your Career Into Private Practice With Business Experience or Integrative Psychiatry Training

I know this because it’s exactly how I carved my own path to becoming an integrative psychiatrist entrepreneur. 

I didn’t do an integrative psychiatry fellowship – I learned integrative psychiatry in real-time with the patients who were sitting in front of me. 

I didn’t go to business school, but I did read hundreds of books, invested in training, and hired mentors to learn the ropes.

This is how I learned integrative psychiatry and built my cash-pay private practice, and how I now coach psychiatric providers just like you to do the same thing.

Just like Lisa Wang, M.D.

And Jess Romeo, PMHNP

And hundreds of other psychiatric providers who are part of my mentorship program.

It’s now my role to share this information with you — to show you what’s possible and unlock your potential as a clinician.

Is Private Practice Right For You?

I am always honest about both the pros and the cons of running a private practice, so here are a few:

Cons: Requires a ton of responsibility and organization

• Figuring out scheduling
• Being in charge of billing
• Responding to emails 
• Marketing to find your own patients (the system won’t do it for you)
• Coordinating vacation coverage 
• No corporate W2 insurance/benefits 

The good news is that these are not insurmountable obstacles to figure out, and in my opinion, the pros far outweigh the cons.

Pros: Autonomy to care for patients on your terms and the ability to actually help them:

• Longer appointment times
• Flexibility and autonomy over your schedule
• Freedom to not accept insurance 
• Freedom to practice with an evidence-informed approach 
• Ability to build meaningful rapport and relationships with your patients
• Higher income working fewer hours (remember the hourly rate exercise from earlier…)

The independence and significance that running my own practice brings into my life makes the tradeoff well worth it.

Unlock Your Career Potential and Leave Psychiatry Burnout Behind

If you feel aligned with this philosophy and vision, then I want to propose a new roadmap to you. One that you’ve probably never seen before. 

First, learn integrative psychiatry WHILE building a private practice.

Second, start seeing cash-pay patients on the side while you cut back hours at your insurance-based job.

Third, evolve your career to full time integrative psychiatrist entrepreneur!

You see, this isn’t an all-or-nothing decision. You don’t have to fully quit your job and start from scratch.  You also don’t have to dedicate a year to training before you can get started. 

Learning, growing, and evolving happens in stages. 

If you’re ready to,

• Say goodbye to psychiatry burnout
• Offer a level of care that transforms your patients’ lives 
• Have complete autonomy, financial abundance, and joy in your work
• Capitalize on your unique strengths while attracting your DREAM patients who you love working with 
• Make MORE MONEY while WORKING LESS hours 

Then I invite you to take the first step.

Join My Free Dream Practice School

Ready to ditch the broken healthcare system and unlock your full career potential? Join my free community and start learning what it means to be an integrative psychiatrist entrepreneur with your own practice – and how to make it happen. You’ll even get access to some of my protocols!

You can also follow me on Instagram @thepsychiatrymentor, and on YouTube The Integrative Psychiatry Private Practice Hub for more valuable private practice and integrative psychiatry tips and resources.

I hope to connect with you soon! 

The post Psychiatry Burnout: Leave the Cycle and Start a New Career Path appeared first on Zen Psychiatry.

Photo by Sigmund on Unsplash

If you’re confused, don’t worry, you’re in good company. 

This topic comes up a lot on my bi-weekly Q&A career mentorship calls so I wanted to write this post clarify and consolidate the information we do have from the American Psychiatric Association (APA) and DEA on the telepsychiatry policies, procedures, guidelines, and special exemptions as of June 2023. 

Do I have all the answers? No. Honestly, not even the governing bodies who are making these policies do either because the new telepsychiatry guidelines and telemedicine special exemptions have not yet been finalized. 

If you’re new to my blog, my name is Elana Miller, MD, I’m an integrative psychiatrist and 2X cancer survivor with a telehealth private practice based out of Los Angeles, CA. I’ve been a telepsychiatry OG since October 2019 when my cancer relapsed and I received a life saving stem cell transplant (about six months PRIOR to COVID). I also have a career mentorship program where I teach psychiatrists and psych NPs how to build successful integrative psychiatry private practices. 

As someone who has been providing telepsychiatry services for the last four years, I can tell you that the changes brought on by the PHE have been a game-changer for our industry. Patients can now receive care from the comfort of their own homes, and providers can see patients from anywhere, as long as the patient is located in a state where they’re licensed. 

Telehealth has proven to be a valuable tool for delivering mental health care, and I’m excited to see how it will continue to evolve in the coming years.

Things are changing quickly, so let’s jump in. 

When Did The Public Health Emergency End?

After several years of being extended for three-month increments, the federal public health emergency (PHE) officially expired on May 11th, 2023.

Although the public health emergency is a federal mandate, many states developed their own rules and exemptions over the last two years. Therefore, make sure you’re following your state’s telepsychiatry guidelines. If you have questions about what these guidelines are, you can contact your malpractice insurance for the specific rules.

DEA Telepsychiatry Guidelines

While the PHE has ended, the DEA is at least aware that after so many years of the practice of medicine in general (and psychiatry in particular) has shifted to tele, and that it would not be reasonable to patients and practitioners to change things overnight. 

Therefore, while the details of the Telemedicine Special Exemption are being worked out (see below), the telemedicine flexibilities and exceptions we have been granted under the PHE have been officially extended six months, until November 2023.

Therefore, at this time, nothing has really changed for us telepsychiatrists now that the PHE has ended. Even more, after November 2023, we will still have another year, until November 2024, before we need to see patients in person for whom we established care during the PHE.

Will There Be Exemptions To The Ryan Haight Act (RHA) after the Telepsychiatry Flexibilities Expire? 

Yes. On March 1st, 2023 the DEA released their proposed regulations for the Ryan Haight Act (RHA), specifically on how practitioners should proceed if they currently have patients on controlled substances who they’ve never met with in person. The good news is that both the DEA and APA recognize the nuance involved and are working together to make new telepsychiatry guidelines, policy, and procedure exemptions that make sense for both the providers and their patients. 

Photo by Mary Eineman on Unsplash

Take my telehealth practice for example –  I’m licensed in California and see patients from all over the state. Requiring my patients to travel hundreds of miles to come see me for frequent in-person appointments is simply not practical. This would obviously have major negative implications on my practice and limit my patients’ access to care.  

DEA Proposed Exemptions

In recognition of these challenges, the DEA has proposed several telepsychiatry exemptions that providers can take advantage of to continue seeing their patients via telehealth. These regulations are currently receiving comments and have yet to be finalized, but here are the proposed exemptions that I think are most relevant to us telepsychiatrists in private practice:

1. For schedule IV controlled substances, you can prescribe a 30 day supply as long as you see the patient for an in-person appointment within 30 days.
2. For either schedule II or schedule IV controlled substances, you can prescribe without seeing the patient in person as long as a primary care physician has seen the patient in person and provided you with a referral. This can be particularly helpful for patients who live in remote areas or for those who find it difficult to travel long distances for in-person appointments.

To me, #2 above seems like a totally doable workaround for those of us who have tele-dominant practices and may have patients for whom it would be cumbersome to travel to see us in person.

My plan is to create a templated letter to give to patients that can be easily signed off by their PCP and sent back to me (I will be sharing this letter with the mentees in my mentorship program so they can use it too). . 

Honestly, I think the final version of the telemedicine exemptions currently being drafted/revised will be even more flexible than this. Honestly, the cat is out of the bag. Everyone – clinicians and patients alike – prefer the flexibilities of telemedicine. Baring irresponsible prescribing by large corporations (I don’t want to get sued, so let’s just say a little company that stars with “C” and ends with “erebral” there is no reason why an in person exam is necessary for most patients.

If you’d like to read all of the DEA’s proposed exemptions, you can do so here. 

4 Ways To Prepare For Telepsychiatry Guideline Updates Post-PHE:

1. Be Sure Your Malpractice Insurance Covers Telehealth 

This was new information I learned at the APA webinar in January, but not all malpractice insurance policies cover telehealth visits. 

Take the time to double check this!! While the PHE is still in effect, we are all technically operating under your state’s Ryan Haight Act telepsychiatry guidelines. At this point, I would be less worried about citations, and more about liability. If you were to have an adverse event and don’t follow the rules explicitly, there is potential that your malpractice insurance won’t cover you. 

With major telepsychiatry regulation changes like the Ryan Haight Act, the goal is to prevent catastrophic issues from happening – like getting sued – which is why it’s always safe to follow the rules and make sure you’re covered. 

This takes 5 minutes to do, so give your malpractice a call after reading this article. 

2. Prepare to Apply For a DEA License In ALL The States You Prescribe Controlled Substances In

Under the current telepsychiatry guidelines, if you see patients who are located in a different state other than where you’re located, you do not need a separate DEA registration for each of those states. However, this will change once the telemedicine exemptions expire in November 2023/2024.

At that point, the new telepsychiatry policy is that you WILL need a DEA registration in all states where you prescribe controlled substances. 

Now, I only have one DEA License because I only see patients in California, but there are several members in my mentorship program who are licensed in multiple states and say that the turnaround time for DEA license is pretty quick, about 1-2 weeks. When you apply for a new DEA license in a separate state you will need to have a physical address in that state in order to submit your application. More information on this below. 

Quick tip: if you are moving to a new state you can move your existing DEA license for free. 

3. Make A Plan To Sublet An Office for In-Person Appointments

As an FYI, according to the American Psychiatric Association, it is likely that virtual addresses will be audited in the future.

I have several members in my mentorship program who sublet office space from coworking businesses like wework or Regus where you have the option to pay for different membership plans based on your needs (e.g. office space, a mailbox, etc). As a side note, most coworking businesses have a front desk staff who can be there to accept and forward your mail. 

I currently have my public-facing practice address as a virtual address. This is what I use on my medical license, which is publicly searchable. However, my DEA license is registered to my home address because this is where I see patients (which is what the DEA requires). However, I don’t believe a clinician’s DEA address is publicly searchable (I tried to find mine online via the DEA website, and couldn’t). If anyone wants to try to find my home address online via the DEA website, go for it and let me know if I’m incorrect in the comments!

In terms of prepping for the end of the telemedicine exemptions, my plan is to sublet an office part time (I mean, could be as little as one day a month) to see patients in person once in a while to make sure I’m compliant with the rules.

Photo by Drew Coffman on Unsplash

4. Document Your Patients’ Physical Location

A simple proactive measure that you can start doing now is to document where your patients are physically located in your treatment notes. 

This will make it easier to keep track of which patients on controlled substances will need to come in for in-person appointments or need a PCP referral once the public health emergency ends. 

Additionally, at some point it will be required to note in your electronic prescriptions where the patient is located when prescribing a controlled substance.

My Telepsychiatry Plan For 2023-2024

I hope you found this information helpful! As updates continue to emerge from the DEA and federal policies, I will try to keep this post updated and keep my email list updated as well (if you’d like to join, you can enter your email address on this page). 

Remember, you will have a grace period of six months to adapt to the new telepsychiatry policy and procedure changes now that the PHE is lifted. Don’t stress too much, and just take it one step at a time.

To summarize, here are the action items I recommend for you you take right now: 

1. Be sure your malpractice insurance covers telehealth visits 
2. Document which patient’s are currently on controlled substances and note their physical location in your treatment notes

And here are the action items I will be taking before the telemedicine exemptions have expired in November 2024:

1. I will check on subletting an office to see patients in person.
2. I will write a templated email to any patient’s who are on prescribed controlled substances with an option to come in for an in-person visit or getting a PCP referral 
3. I will write a templated letter that I can give those patients to give to their PCPs to simplify the process of getting a referral.

I know telepsychiatry legal policy and procedure changes can feel scary, especially when it comes to healthcare and prescribing controlled substances. I think especially as solo private practice owners we can over-worry about doing something wrong and inadvertently putting our business and patients at risk. 

It’s a major relief to be part of a community where everyone is in the same boat, and experiencing the same changes together. Especially during a time like this, I am really proud of the 350+ psychiatry providers in my mentorship program who can collaborate on making post-PHE plans, stay up-to-date on the latest information, and support each other through the transition.

You can also follow me on Instagram @thepsychiatrymentor and on YouTube The Integrative Psychiatry Private Practice Hub for more valuable private practice and integrative psychiatry tips and resources. I hope to connect with you soon! 

The post Telepsychiatry Guidelines & Ryan Haight Act appeared first on Zen Psychiatry.

First a quick introduction. I’m Elana Miller, MD, and I’m an integrative psychiatrist and 2x cancer survivor passionate about combining Western medicine, Eastern wisdom, and holistic approaches to help people live fuller and happier lives. I also mentor psychiatrists on integrative psychiatry protocols and business strategies to be successful in cash-pay psychiatry practices. 

Trust me, if you implement the strategies I share in this article you will avoid at least 75% of the mistakes I see when I’m coaching psychiatrists on how to start their practices (and by this point I’ve coached nearly 100, so I’ve really seen the most common mistakes). 

The best strategies for creating a psychiatry practice actually come from the business world, not the medical world. It’s not that surprising because… I’m going to let you in on a little secret…  doctors are generally not very good at business.

You can’t really blame us. We don’t learn any business or even finance really in medical school or residency – we learn how to treat patients. The problem is that many of the personality traits and skill sets that make us good clinicians – like perfectionism and conscientiousness – are actually our worst enemies in business. Nothing will hamstring you more in private practice than trying to be perfect right out of the gate. 

As you’re reading this post I challenge you to shift into an entrepreneurial mindset. Put the prescription pad down and *figuratively* pick up your hammer. Let’s jump in and start building!

Strategy #1: Start with a Minimum Viable Practice, or “MVP”

First and foremost, the goal is to grow your practice sustainably – with maximal profit and minimal overhead. 

Here’s what I mean: 

I’m sure you’re envisioning all the possibilities of your cash-pay psychiatry practice – maybe a beautiful office with nice decorations and furniture, or a group practice, or even building a large wellness center with multiple providers. I love these visions, and you should hold on to them as inspiration. However, it’s important to remember that you don’t need to, and really shouldn’t, aspire to start there on day one. 

There is an acronym, “MVP,” that comes from the startup world from a book by Eric Reiss called The Lean Startup. It stands for “minimum viable product,” so I adapted it from the startup world into “minimum viable practice.”

His thesis is that software companies make a massive mistake when they build complicated software solutions in advance of actually having any customers. Why? Because they build the wrong product. One that customers don’t actually care about or want, and when they release it to the world, no one buys. Instead, he advises, build the minimum viable version of your software solution. Get early adopters as customers (aka patients), and then iterate and improve based on their feedback.

You want to do a version of this in your practice. Start with a low overhead practice with the minimum tools needed to function, and then improve and optimize after. Once you have an established flow of patients and revenue, THEN you can make investments to grow and bring your dream vision to life.

This is how you establish a trajectory of sustainable growth. If you’re not profitable from week one, you’re doing it wrong. 

I once knew of a colleague who was starting a practice, and she had this expansive goal in mind of what she wanted to do. She envisioned a comprehensive center that offered holistic care, with psychiatrists, therapists, coaches, dieticians, etc., a “one stop shop for patients.” 

The problem was, she built it all out from day one. So she had a massive, expensive office, and multiple full time staff that she was paying salary and benefits to. And she didn’t have a single patient. And you know what? She didn’t get any, because it turns out her target market didn’t really care about having a one-stop shop for everything. 

She was so consumed with creating the practice, that she didn’t spend any time or money on marketing to get patients in the door, or even speaking to her potential patients to figure out what they actually wanted. After losing tens of thousands of dollars over the first few months, she folded the practice. This happens WAY TOO often. 

Please, please, please don’t make this mistake!! 

What do I need to start a psychiatry private practice? 

We have a massive advantage in starting a low overhead practice in psychiatry. We’re not starting dental practices or surgical practices where you need to spend $100,000 on equipment just to get started. We just need a chair, a computer, and we’re basically good to go. We have the advantage of being able to open our practices for minimal cost, so we should take advantage of that fact. 

Check out my tele-psych set-up below. This is how I’ve been practicing for the last 4 years! 

Start lean, mean, and scrappy. Be smart and practical with your expenses. When I say minimum, I mean it!

Minimum Viable Softwares & Set-Up

1. Malpractice insurance
2. An EHR with eprescribe capabilities (I like Luminello for now, but am waiting the edge of my seat for IntakeQ to launch their eprescribe capabilities this year)  
3. A phone number and professional email address (that is HIPPA complaint)
4. A virtual fax number (because pharmacies don’t yet know it’s not 1995 anymore and WILL fax you things) 
5. A business bank account and merchant account so you can accept payment (aka credit cards)

If you want an office space to see patients, consider subletting part-time from a colleague, or companies like REGIS and WeWork offer flexible shared workspace plans at affordable rates. 

Just as important, here are the things you DON’T need:

• A lawyer
• An accountant
• A fancy logo
• An expensive website that costs thousands of dollars (you can build your own version of a website on Squarespace) 
• An office and admin assistant 
• Anything that distracts you from actually getting patients in the door!

Trust me, if you can turn down the volume of your perfectionism you’ll be able to make progress faster and easier, and the practice you build will be based on feedback from your patients of what they need, which will be better for both you and them in the long run. 

How much does it cost to start a psychiatry practice? 

This is really dependent on your malpractice insurance, which softwares you invest in (quick tip: ALWAYS get multiple quotes for malpractice insurance, you can negotiate the rates), and how many office supplies you need up front. 

Generally speaking, if you start with a cash-pay telepsychiatry practice (which is how I see patients 98% of the time) you should be able to operate at ~$500-1000/month, including the costs of malpractice insurance, software, and some budget for office supplies. 

A quick financing tip as it relates to sustainable growth: you should know your overhead costs like the back of your hand so you know exactly how many patients you need to cover those costs, and your livability costs. We’re not just trying to make our money back, we also need enough to cover our cost of living, pay back loans, and save.   

The advantage of being a cash-pay private practice provider is that you have complete control and autonomy over how much you charge and how many patients you wish to see, so there are a lot of scenarios you can play around with here. And it can be kind of fun! 

Let’s say your overhead costs for your practice is $700, and your living expenses are $4,000 a month. So your livability number is $4,700 each month.   

Now you can reverse engineer it – how much should you charge to sustain your livability? How many new patients would that require each month, and how many recurring patients? 

This leads me to my next point, who are these patients and why would they want to see a cash-pay provider instead of someone in-network? 

Strategy #2: Clarify Your Unique Selling Proposition (aka Your Secret Sauce) 

A unique selling proposition, or USP, is another concept I’m borrowing from the business world. It’s a unique selling point or message that defines what makes a product or service different from, and better than, its competitors. It is a marketing concept that was first proposed in the 1950s by an advertising executive named Rosser Reeves.

So how does this apply to cash-pay psychiatrists? 

Let’s say I’m a potential patient interested in your practice. A USP answers the question, Why should I choose you as opposed to any other psychiatrist, specifically another psychiatrist who would accept my insurance?

If you don’t define this for your patients, trust me, they will define it for you and on terms you don’t want. If you don’t differentiate yourself, you will essentially be a commodity – no matter how highly trained you are. 

You’ll be like a cup of coffee from any Joe Smo coffee place down the street, and you don’t want to be any ol’ cup of coffee, you want to be Philz coffee. You want to be hand crafted, artisan coffee with art in the foam, and you want people to drive out of their way and pay double because your coffee is so good. As a cash-pay provider, this is a critical first step in your marketing strategy. 

If you don’t differentiate yourself, you will attract the worst kinds of patients – those that are shopping based on cost, rather than value (essentially looking for the cheapest psychiatrist), or those looking for a psychiatrist who has no boundaries and will answer their calls at all hours and prescribe them as much Adderall and Xanax as they want. 

Instead, you want to clarify your niche, deeply understand their problems, and position yourself as an expert with the knowledge and skills to solve their problems. This will make the marketing steps when you launch 1000x easier, because instead of trying to market to everyone that you do everything, you find your niche and speak to their struggles specifically and the unique solutions you offer.

How to Find Your Niche 

It took me an embarrassingly long time to really understand what niche meant. I thought niche meant a problem, like anxiety or depression or PTSD, but those are just disorders. A niche is a group of people, like women in their 30s-40s who have anxiety. The reason that distinction is important is because a niche has many problems other than just their diagnosis, and when you understand what other service providers your niche goes to (you can think much bigger than just “therapists” – what about functional medicine docs? Or acupuncturists? Personal trainers?) it will give you infinite ideas of people you can network with to grow your practice.

Let’s find your niche by answering the questions below: 

1. Who is your dream patient? What’s their age? Gender? What is their profession? What are their common interests? 
2. What are the problems they’re struggling with?
3. How do you solve their problems? What outcome do you provide them? (Because people pay for outcomes, not processes)
4. What unique methods and frameworks do you use to provide them this outcome? What’s unique about the way that you practice psychiatry?

Then you’ll put it all together into a sentence or short paragraph that you feature on your website, at the very top, along with a photo, so with just a quick glimpse patients have a strong sense of who you are, what you do, and what you believe in. 

Let’s use my USP as an example, 

The first part, “ancient wisdom meets modern medicine” communicates that I’m not a typical psychiatrist that only prescribes medication, and that’s very appealing to my niche. The more you make your USP statement about the patient and what their desires and needs are, the better. 

Your Lived Experience is Your Special Sauce

It’s okay to share personal aspects of your life on your website. In fact, I encourage it. 

I don’t know about you, but when I was in residency training it was considered to be a bad thing to have personal experience in the area in which you were treating patients, as if it would lead to unchecked countertransference. 

I remember when I was going through chemotherapy and was telling people I wanted to specialize in working with cancer patients, I was told I shouldn’t do that because it would hit too close to home. 

Too close to home? Did they think I would just go through the rest of my life forgetting that I had cancer, and working with a cancer patient would suddenly remind me, and I would immediately lose the ability to think coherently or be helpful to my patients? I understand people were well-intentioned in their advice, but it was misguided advice, and I could not disagree more with the premise. 

I mean, who would be better at providing psychiatric care for cancer patients than a psychiatrist who had done it herself and come through on the other side? Even my non-cancer survivor patients have told me they were attracted to me as a practitioner because while they may not be cancer survivors, they’ve experienced some sort of trauma or difficulty and felt that I would understand them and their experience, and I do. 

Your lived experience is your special sauce, and don’t let anyone tell you otherwise. Patients love knowing that their providers are real human beings just like them. I have several mentees who share that they have patients gravitate to their practice because of a shared lived experience like religion, culture, trauma-informed, etc. 

It also makes practicing more fun, more impactful, more joyful when you’re working with your favorite kinds of patients and using your unique skill set to really help them. 

So lean into your uniqueness. It’s not a weakness, it’s a superpower.

Strategy #3: Meld Good Business With Good Medicine 

As a cash-pay psychiatrist you are uniquely positioned to offer a level of care that just isn’t accessible in an insurance-based model, and it’s important to define what that will look like for you and your patients. 

In my opinion there is a disease in the practice of psychiatry today, and it’s the siloing of mental health care between Western allopathic medicine and alternative medicine. A false dichotomy has been created between the Western and wellness communities that is perpetuated by both sides — and the victims are our patients.

From my vantage point, there seem to be very few providers in our field who truly appreciate the nuanced and complex nature of health and wellness, especially the role that relationship, framing and mindset play in psychiatric outcomes. Instead we have two groups who, at their extremes, seem indoctrinated and nearly incapable of thinking in shades of gray.

Patients don’t want to have to choose between two extreme viewpoints – either medication only from a psychiatrist or whatever they get from an alternative provider, rather than receiving care that is personalized and tailored to their unique needs and circumstances and that includes all modalities that can be helpful to them.

By providing integrative psychiatric care, you have the opportunity to become SO exceptionally valuable that patients are GLAD to pay you everything that you want to charge, and more. 

What does it mean to practice integrative psychiatry? 

Integrative psychiatry is not “green pharmacy,” or prescribing a supplement as opposed to a medication. I prescribe medication, AND I recommend complementary supplements.

It’s not functional psychiatry either. You can think of integrative psychiatry as a big circle that encompasses the overall holistic approach, and functional psychiatry as a subset of that – a small circle within integrative psychiatry.

Integrative psychiatry is a way of evaluating and treating patients from a holistic framework, one that respects patients’ belief systems and appreciates that good outcomes in our field come from good relationships between clinician and patient. It’s a philosophy rather than any one specific treatment modality.

Integrative psychiatry is, 

• A way of assessing and treating a patient that encompasses ALL aspects of that person, mind, body, and spirit.

• Patient-centered, personalized care that is respectful of the patient’s belief system. We customize treatment plans based on what our patient believes will work, within reason. 

• Treats patients as individuals, not as statistics — If the patient is telling you a different story than what you’ve read in a textbook or research study… listen to the patient, not the textbook!

A massive amount of the benefit we see from psychiatric interventions comes from the placebo effect. Have you ever seen a research study where the active treatment separated from placebo by 10%, but the placebo group had a 40% improvement? Why are we obsessing about the 10% and ignoring the 40%? Why are we not optimizing for that? 

Integrative psychiatry is an evidence-informed approach to treatment 

Now your question might be, this sounds interesting, but is it evidence-based? I would encourage you to ask a more nuanced question – is it evidence-informed? 

When someone says, “that’s not evidence-based,” I want to ask them, can you be a little more specific? Are you saying there’s active evidence that it’s harmful? That there isn’t any evidence at all because it hasn’t been studied? That there’s evidence, but it’s mixed? Those are all very different things. And the next question becomes, if there’s no evidence, or the evidence is mixed, what is the risk? 

An evidence-informed approach asks what are the potential benefits measured against the potential costs, whether toxicities, side effects, money, or time. Of course, interventions with higher potential costs, toxicity, or side effects should still require a higher burden of proof before being recommended. 

On the other hand, interventions with low potential cost, toxicity or side effects shouldn’t require the same burden of proof. I don’t need a Cochrane review before recommending exercise for a patient, or meditation, or many low risk nutraceuticals, especially if a patient believes it will work (because then at least I’m leveraging rapport, relationship, and the placebo effect).

At worst, nothing will happen, at best, there will be some moderate benefit that I can layer on top of the benefits from medication.

Integrative psychiatry is not about extremes, but about wisdom, common sense, and restoring balance. An integrative provider has a unique skill set and opportunity to cross the chasm in a way that allopathic and naturopathic only providers can’t.

What’s possible for you 

Now the upside to all of this for you, is that if you become one of those clinicians who’s skilled at operating in the middle – who can prescribe Prozac but also knows how to do therapy, to recommend evidence-informed supplements, to council your patients on nutritional and mind-body interventions, to do it all wisely and moderately – you will have an endless supply of patients, because there is a massive demand for this kind of psychiatry. 

I started the Build Your Dream Integrative Psychiatry Practice mentorship program to help practitioners like you build impactful and successful cash-pay integrative psychiatry practices. I now support almost 100 people across the US (and a few globally, too) to achieve their private practice dreams. Being part of a community of like-minded individuals who are all working towards the same goal provides invaluable support and makes the process much less intimidating. 

A few weeks ago someone in the program posted on our community forum asking everyone where they would like to be in a year from now, and here were some of their responses: 

• “Full-time private practice, fully booked, enjoying my work and spending more time in my art studio”

• “Full time practice and hire NP or psychiatrist, baby makes it to 12mo unharmed, ditch moonlighting, revenue $350k”

• “Online private practice set-up to earn $200,000 in 10 hrs/wk so I can exit 1 of my current jobs; school debt finally paid off (after 20 years!); preparing for maternity leave”

• “Close my practice to new patients and shift focus on creating a group educational community for nurse practitioners. I hope my practice + group program will bring in my income goal of $300k+.”

The best part of this is that every single one of these responses came from someone who started their cash-pay practice within the last 12 months. A year ago from today, they were where you are now.​

Ready to get started? Join my FREE Dream Practice School.

So here’s to a successful year for you – one in which your dream cash-pay psychiatry private practice comes to life. 

The post How To Build A Cash-Pay Psychiatry Practice In 2023 (Better Than Reddit) appeared first on Zen Psychiatry.

If you’re reading this article I assume you landed here because you’re burned out and ready to get the *hell* out of whatever traditional psychiatry setting you work in. Congrats on taking the first step and making a plan to transition into private practice! 

I started my integrative psychiatry private practice, Zen Psychiatry, in 2017 and fell in love with the process of building a business and all things entrepreneurship. Having the freedom to practice the way I want to, seeing the type of patients I want to see, and having the autonomy to structure my work life are great perks too ;-). Owning a private practice makes it easy to love what I do every single day. 

I transitioned my practice entirely to telehealth in October 2019 when my Acute Lymphoblastic T Cell Lymphoma relapsed, so you could say I was a pro at quarantining and seeing patients over video before everyone else did! COVID completely changed the trajectory of how we offer psychiatric care to patients and I don’t see the telepsychiatry model going anywhere anytime soon. Actually, I would say 95% of my patients actually prefer using telehealth because of the convenience of being able to see me in their own home and without a commute. As a physician, telepsychiatry has not interfered with any new or existing patient relationships, nor inhibited me from doing my job (I’ve found even more advanced treatment approaches like prolonged exposure therapy have been doable via video).  

Back to the business of it, unfortunately we don’t learn much (if anything) about how to start a private practice in residency or medical school. I’ve spent the last 4+ years building, testing, and iterating things in my practice until I found what worked. Now that my practice is full, I’ve shifted gears a bit to mentor early career psychiatrists and share more of the valuable lessons and insights I’ve gained along the way.

The goal of this article is to offer you the most efficient plan to set up your telepsychiatry practice and get your first patient – and that means making money with the lowest amount of overhead expenses possible. And yes, your time counts as overhead, so read on for a zero-fluff telepsychiatry business plan to get you on your way. 

1. Adapt the “Just-In-Time” Mindset

If you take one thing away from this article I want it to be this: start your practice lean, mean, and scrappy. Otherwise known as a Just-In-Time mindset.  

The just-in-time mindset was developed by author Eric Reiss in his book The Lean Startup. The book was originally written for tech entrepreneurs but many of the principles carry over to private practice too. 

The idea is don’t try to be perfect out of the gate when you are starting a business (and a private practice IS a business), because you will be wasting your time optimizing for the wrong things. Instead, start lean, mean and scrappy and then build what you need after once you have a few patients and have a sense for what systems you need to run everything efficiently. A lot of physicians are too perfectionistic (which is good for medicine, but bad for business). If you learn how to take your “physician hat” off while setting up your business systems you will be more successful.

If your mind automatically jumps to creating a logo, building a website, hiring an accountant, setting up a corporation, learning every approach to CBT for OCD…stop right there. You don’t need any of these things right now, and it’s only enabling an avoidance strategy to actually start. Just take it from Oprah… 

Perfectionism is the enemy. Be extremely conscientious in your clinical care, but allow for a certain amount of chaos within your business. When I got my first patient back in 2017, I didn’t yet have a way to bill that patient, an EHR to write their note in, or even a chair for them to sit in (I got all that figured out the weekend before our initial appointment!). If there’s a little bit of chaos, you’re doing it right. Why? Because if you focus too soon on the wrong things, you won’t have time to focus on the RIGHT things, which is your marketing strategy for getting patients in the door.

2. Build Your Telepsychiatry MVP Legal and Software Structure for

The term MVP stands for minimum viable product, and in our case, it’s the minimum required structure needed to see your first patient. Legal and software services aren’t the most exciting thing about private practice but the basics are essential and required. The items below are what to take action on right now so that you can start seeing patients. 

Legal Checklist For a Telepsychiatry Practice

1. NPI

If you’re reading this I guarantee you already have an NPI from residency or other clinical training. So you’re off to a good start, check!

2. DEA License

First, you’ll need to register your DEA to the physical location where you’re working. Assuming you are offering telepsychiatry from your home, you would register your home address to your DEA. However, for privacy reasons, you can register your home address as your primary location and a different address for any public-facing documentation. For example, my home address is registered on my DEA but the public-facing address is actually a PO Box. Pro tip: you can work with USPS to convert a PO Box address to a street address with a suite number (Eg, Main Street #1234 instead of PO Box 45). 

You can find more information about registering for a telepsychiatry DEA license here.

Second, if you are planning to see and prescribe to patients in other states via telepsychiatry you will need a DEA license in those states. I am only licensed in California, however there are several practitioners in my program who are licensed in multiple states and have offered a lot of guidance on how to set this up without being physically located in multiple states. One way to do this is to obtain a virtual address with companies like Regis Corporation where you don’t have a physical space, just an address. A few providers in the group will travel to see patients in other states and temporarily rent an office at a shared workspace like a WeWork, and use that address for their DEA. You can also always contact your local state for their opinion as a lot of legislation varies state-by-state. 

Note, you don’t need to be licensed in multiple states to get patients, and I actually don’t recommend going out of your way to get multiple licenses. Trust me, there are more than enough patients in one city, let alone one state, to fill a practice! 

3. Malpractice Insurance

Malpractice insurance is something I highly recommend not being price sensitive to, but instead choose based on the value and experience they can offer to support you in your practice. 

I use MIEC for malpractice insurance and really like them. I’ve never had to file a claim before but whenever I have a question or need advice on something like how to discharge a patient or how to get rid of an after-hours number, they have been extremely helpful and responsive. They are a little pricer than some of their competitors like The Doctors Company and PMRS, but they offer discounted pricing for early-career psychiatrists. 

4. A Way To Collect Payment

The only way you should be collecting payment is via credit card. I repeat, only accept credit cards! There are so many benefits to using a credit card processor to accept payment, like automated billing, ensuring a collection rate of 100%, ease of managing your revenue numbers, adn saving you hours of admin time.  

Stripe, Square, and PracticeQ are three great options with processing fees under 3% and integrate with most EHR systems (more on this below). Do not get caught up in thinking a 3% transaction fee is too much to pay when you can be saving HOURS of time having this set up as an automated process (as well as greatly reduce the likelihood that a patient won’t end up paying you).

Ryan Haight Status As of 2022

The Ryan Haight Act is frequently brought up during my Q&A mentorship calls, so I’m guessing you probably have a few questions about this too.

The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (RHA) requires that any practitioner issuing a prescription for a controlled substance conduct an in-person medical evaluation. However, during Public Health Emergencies (PHE) – which as of June 2022 we are still classified under – the Act is temporarily exempt. 

The COVID-19 Public Health Emergency went into effect in January 2020 and placed a temporary hold on the Ryan Haight Act to provide accessibility to healthcare during the pandemic. Over the last 2 years there have been several extensions with the latest update extending through mid-July. However, according to the Department of Health & Human Services department federal officials have pledged to provide a 60-day notice to healthcare providers before the Act is reinstated. At this moment there have not been any new announcements made so I anticipate another PHE extension will be made through at least mid-October.

Personally, I have not been spending my time creating an action plan or worrying about what this will look like in the future. At the end of the day pharmacies are not going to stop filling your prescriptions overnight, and the DEA isn’t going to raid your home office the day after the Act is reinstated. 

Reinstating the Act under its current literature would limit accessibility for many patients and be a major step backwards for healthcare. I anticipate a lot of pushback from both patients and providers, and potential new policy for how telehealth and prescribing controlled substances is regulated in a post-pandemic world. I ultimately wouldn’t let this stop you from starting your telepsychiatry practice right now. Once more finite plans are announced there will literally be millions of healthcare providers who are in your same shoes. And when that time comes, we’ll all be figuring it out together. 

You can find more information on the Ryan Haight Act and exemptions here. You can also contact your malpractice insurance for more details specific to your state. 

Best Softwares For a Telepsychiatry Practice

Don’t make the mistake of being penny wise and pound foolish when it comes to investing in software. I’ve spent a LOT of time researching and testing different softwares in my practice to help streamline and automate processes that were taking too much of my time. The idea is that if you need to spend an extra $50-100 on a software that is going to save you at least an hour of time, it’s probably worth it. As a private practice psychiatrist you’re likely charging hundreds of dollars an hour, so when you do the math $50 is equivalent to at least 10 minutes of your time, if not much more 

Below are the software solutions I recommend currently (as of June 2022) for telepsychiatry psychiatry private practices. 

Practice Management and EHR: IntakeQ/PracticeQ

By far the best software I’m going to recommend is IntakeQ. It is extremely user friendly, efficient to use, and basically includes every aspect of practice management (outside of eprescribe) that you need. 

You can use IntakeQ for charting, scheduling, intake forms, billing (easy to set up auto billing via credit card that is integrated with scheduling – merchant account via Square or Stripe integration), superbills, and telehealth (integrates with Doxy). 

When I started, I looked into a BUNCH of different options for charting/EHR and settled on Luminello for charting and eprescribe. At the time, I think it was the best option and I still use it now. However, Luminello seemed overly clunky to me for intake forms, scheduling and billing. IntakeQ blew any other software out of the water (also really useful for gathering credit card authorizations for billing, having patients submit rating scales, etc). 

HOWEVER, many of the early career psychiatrists in my mentorship program have said that the practice management software now available from IntakeQ (branded now as PracticeQ) is even better than Luminello, including for charting patients notes, which is a new feature they added since I started. I have moved my scheduling and billing over to IntakeQ and continue to use Luminello for charting and eprescribe, but for people who are starting their practices now I recommend using IntakeQ/PracticeQ right out of the gate. They also recently announced that they’ll be launching eprescribe sometime between July-September 2022.  

Eprescribe: iPrescribe (or similar)

Lab ordering: set up an account directly with Quest or LabCorp to order labs electronically. In the meantime, giving the patient a lab order written on a prescription pad (scan and email if needed) works in a pinch when you are first starting your practice. FYI – getting in touch with Quest and LabCorp can be kind of a hassle so don’t be surprised if it takes some time to hear back.

Phone: Google voice is fine, phone.com or RingCentral good if you want extra features like phone tree or have multiple phone numbers (ie you have an assistant or something like that).

Email: Google Workspace, easy to use and it’s HIPAA compliant.  

eFax: SR Fax (integrates with IntakeQ) – unfortunately even though we live in the 21st century pharmacies will still fax you as if it were 1980 so you will need a fax number.

Telehealth Platform: Doxy – I’ve been in practice for 4 years and still use the free version, but if I need to do anything advanced like screenshare lab results with patients, I’ll just pay $10 for a day pass. That has been more cost effective for me rather than paying for a subscription. 

3. Identify How You’re Different & Market Yourself

Before you even THINK about marketing you need to first understand what differentiates you from other psychiatrists that would make a patient choose you as opposed to someone else.

So many psychiatrists avoid this step. But if you don’t spend the time to clearly identify who you help, what value you offer, and the way in which you help them, it will deter you from attracting your dream patients. 

Why? Because you’ll essentially become a commodity (although a highly trained one), which means that patients will see you as interchangeable with any other psychiatrist and will therefore shop based on who is cheapest/has the worst boundaries/will just prescribe them Xanax or whatever. 

One of the first things I help mentees with in my career mentorship program is identifying and articulating their differentiating factors for their bios, Psychology Today profiles, and website copy before they start marketing. The more you communicate what makes you unique on your website or when communicating with patients, the more the “right” kind of patients for you will self-select into your practice. Just take a look at the My Practice page – you KNOW right away what I do, who I help, and what I’m about. 

This isn’t just limited to your clinical experience and background. Think about how your personal experiences have influenced the type of patients you enjoy working with and how you treat them. How would your patients describe you? How would your friends and family describe you? What’s your favorite thing about working with your dream patients? 

PsychologyToday

PsychologyToday is one of the best tools you have at your disposal to start building your patient panel right away. PT is a massive database that gets 40 million visits a month, and is essentially a search engine just for therapists and psychiatrists. This is where your dream patients are looking for you.

However, almost all Psychology Today profiles I see are mediocre at best, which means all you have to do is have an above average profile and you will get all of the Psychology Today traffic in your area. Think about it from a patient’s perspective and what they would look for in a psychiatrist as opposed to trying to impress other psychiatrists in your profile. 

When a patient searches for a psychiatrist in their area, Psychology Today will return a list of providers that they will scroll through. They’ll see your picture, name, where you’re located, phone number, and the first 40 words of your bio – you need to optimize this space and draw their attention.

Don’t use jargon, speak the language the patient speaks, have a clear and professional photo, and don’t be vague. Say what’s unique about you that would make a patient want to see you as opposed to someone else. 

Don’t do this:

Instead, do this:

I highly recommend adding a video alongside your headshot. Even if your video doesn’t really say anything other than “Hi, I’m Dr. so and so, welcome to my practice.” Patients want to see your picture, hear your voice, read a little about who you are, and then contact you. Plus, it seems that bios that include a video seem to rank above others that do not. 

Building Referral Relationships

You already know the obvious stuff like reach out to therapists and other psychiatrists. You can think a lot bigger than this — who is your ideal patient, and where do they hang out? Do they go to certain online forums, see other non-MD providers, purchase other wellness services? You can network with anyone whose niche overlaps with yours who isn’t a direct competitor. Think of providers like, 

• Functional medicine doctors
• Nutritionists
• Acupuncturists
• Women’s Health Physicians

If you already have patients on your panel, consider coordinating care with their other providers and building relationships with them too. Networking is a numbers game – don’t just reach out to 5 people and give up because nothing has happened. 

Don’t Give Up Too Soon

The obstacle is getting comfortable with being uncomfortable. Private practice success doesn’t happen overnight. In fact, I highly encourage my mentees to keep some sort of part time locum or moonlighting job to help pay the bills as you build up your private practice patient panel. 

If you can be consistent and methodical without getting discouraged or giving up too soon you will be successful. Remember: lean, mean, and scrappy! We learn by doing, so don’t be afraid to try new things in the beginning then cut out what doesn’t work. 

And last thing… If you couldn’t tell, I’m kind of obsessed with talking about business and love sharing it with others who are starting their own telepsychiatry private practices too. I’ve been working since last summer with a group of psychiatrists and psych NPs teaching integrative psychiatry protocols and business best practices for private practice success. 

We now have over 140 members in the group and I’m getting messages from them daily about how they’re filling their practices and loving their work! The most recent message was from a psychiatrist who just filled her cash-based telepsychiatry practice in Iowa and Wisconsin… so don’t listen to people telling you this kind of practice is limited to major cities like New York or Los Angeles only.

Ready to get started? Join my FREE Dream Practice School.

The post How To Start a Telepsychiatry Private Practice (For The Not-So-Business-Savvy Psychiatrist) appeared first on Zen Psychiatry.