Does it make sense to hire NPs?

[Coriolanus]

I am a psychiatrist in solo private practice in the Northeast who accepts insurance. I'm wondering if anyone with experience can tell me what are the benefits of expanding one's practice by hiring one or more psych NPs, probably to work a mix of in-person and telehealth? I'm mainly interested in if anyone has done this themselves, or has close knowledge of colleagues who have taken this route.

Right now my practice is doing quite well, I work 4 days/week and have way more demand than I can handle, i.e. I have had to temporarily cap my practice to meet the needs of existing patients in terms of scheduling follow-ups.

Although I like what I do, I'm not sure I want to continue the grind of outpatient psychiatry for 25+ more years, day in, day out. I'd like to create a small-to-medium group practice where eventually by employing enough mid-levels I would be in a position to adopt a more administrative/consultative role in the group. Not sure if this is even realistic, or if the "juice is worth the squeeze" of having to pay one or more NP salaries while taking on more malpractice risk, administrative tasks, etc. I imagine in a perfect world after 3-5 years (maybe less), I might be able to move beyond the growing pains phase, and start to see increasing returns on my initial investment in terms of time and salaries/overhead.

But part of me worries in a few years I might find myself in a position of missing the solo private practice days, overworked, stressed and missing the simplicity of working on my own with no employees and just my biller as an independent contractor. Thanks in advance for anyone's advice.

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[Sushirolls]

Many of the patients I see have been seen by ARNPs, and I'm dong clean up with meds and diagnosis when they walk in the office.
If you do proceed with hiring a midlevel, go with a PA-C.
The pros/cons you outlined, you need to answer. Do you want more money and the hassles of being a manager? Or you want the freedom of solo?

 

[comp1]

I seriously have not seen many mental health PAs. I know of one who splits his time between straight up ED medicine and addiction stuff. It seems like you know the benefits already, potentially more income and potentially developing a more managerial than directly clinical role. This kind of thread is absolute tasty BAIT to the NP bashers, so I'm quite sure you'll get a lot of that. Ultimately, as a manager, it would be your job to find qualified NPs, just as if you were hiring a psychiatrist. Qualified MDs and NPs do exist, as do unqualified. You unfortunately did not mention your specific state. Most of the Northeast is independent practice, so it really would be like hiring a psychiatrist. If you were in PA or NJ, however, you would have to have a collaborative agreement with the NP and it might be a bit more of a clinical role than you were hoping for if you were to adhere to the spirit of the state law.

 

[calvnandhobbs68]

I mean are you just looking for validation for your business decision? You know the benefits and drawbacks already. I mean just be real with yourself, it's a cash grab, if it were anything other than that you'd be trying to partner with other physicians. We all know basically nobody actually "supervises" NPs even if the NPs do technically work for them. This isn't a unique business model, I'm sure there are several places around where you work currently who are doing this and you could discuss with them...unless they don't want the competition.

Benefits:
- You likely end up doing less direct work overall as you transition your income to this or make a lot more money by doing some clinical work and getting a cut from a stable of NPs.
- You get to pretend that you're "expanding access to mental healthcare".
- You make a ton of money by having a bunch of NPs moving the meat for you all day every day

(Possible) Drawbacks:
- You have to deal with more HR/legal/actual practice management stuff because you actually have to manage people now (ex. what happens when one of them quits, gets sick, has problems with another NP/PA or you, etc)....eventually you become more of a manager than clinician over time
- You're legitimizing this group of NPs with you as the "psychiatrist" running the practice while likely allowing a bunch of more likely than not underqualified individuals do whatever they want to the patients who come see you...but you assure patients on your website and your paperwork that your NPs work "directly in collaboration" with you so they're in good hands
- Other psychiatrists talk behind your back about the trainwrecks they get from the patients who transfer out of your practice who have only ever seen an NP

 

[ObsequiousAplomb]

Comment changed

 

[calvnandhobbs68]

And if you had spent any time in private practice you would know that actually expanding access only hurts psychiatrists and patients while helping NPs and corporate shills. See? I can accuse you of untrue things too and be rude like you, too!

.....What?

 

[ObsequiousAplomb]

.....What?

there was a mean comment between ours that appears to have been deleted, which makes it look like I was responding to you. Don't worry, I agree with you.

 

[theduderino]

I'm also in the position of transitioning from a solo insurance practice to a small/medium group practice. Currently I'm partnering with other psychiatrists and a therapist, all as ICs, no mid-levels. I considered hiring mid-levels since the supply is higher, but ultimately felt like it would require a lot of hand holding/supervision to ensure a minimum quality. A few random thoughts:

-quality between individual mid-levels varies widely. I talked to a practice manager at a local clinic that works with psych NPs. Some psych NPs get out of "school" not knowing how to prescribe medications. Others have tons of experience and would be much easier to supervise. There are one or two NPs in the community I'd happily work with because I've seen the quality of their work. You'll need to develop relationships and/or referral sources to recruit good mid-levels. This would be my personal determinant of whether it makes sense to go down this route. I like having colleagues to discuss cases with but I am not trying to be a finishing school for mid-levels. How much time are you going to spend in supervision? Are you going to audit each chart? How are you going to handle a case that a mid-level is not addressing adequately? These questions are less pressing when you are working with other docs, although they still exist to some degree. Managing people takes time, so consider the opportunity cost and personal cost of this.

-I know mid-levels do bill for psychotherapy add-on codes, but how do you ensure they actually are providing psychotherapy/have some adequate fund of knowledge? What kind of training do they have? Are you going to provide some introduction to supportive therapy or MI? I don't know the answer to this and it was part of the reason I was nervous about partnering with mid-levels. Part of the appeal of my practice is we provide some integrated therapy with med mgmt - it probably would dilute the clinic brand if we had someone that has no idea what they're doing in regards to therapy.

-how are you planning to market/generate business for the clinic? This should inform what type of clinician you recruit. It may or may not be enough to simply have open slots for new patients, depends on your local demand. You need to cultivate relationships with referral sources as the clinic grows and have a coherent pitch that all your clinicians can provide quality care. It's different than developing these relationships for a solo practice (it's always easier to "sell" yourself). This becomes more important as more people depend on you to bring in the referral volume.

-you need to retool your admin policies when more clinicians join the practice. I had a bunch of idiosyncratic admin things that made sense to me but did not scale well with multiple other clinicians. With mid-levels in particular you'll need to think carefully about how you handle controlled medication starts - some NP heavy clinics around my area decline all ADHD referrals without neuropsych testing. It seems like a pointless waste of resources to refer all potential ADHD patients to neuropsych testing but makes sense if your clinicians that can't handle doing a thorough eval,

-you will need an admin (at least PT) when more people join the practice.

-you might need to take additional insurance products to ensure higher referral volume, which will increase the admin workload.

-higher patient volume opens doors to things like developing a TMS or ketamine service. This isn't a comment on the clinical value of these things, just that having more clinicians makes stuff like TMS more likely to succeed financially.


If you do go this route, I would start with one NP/PA and possibly take them on as a IC and figure out how to streamline the backend stuff before you take on a small business loan or something to hire people on salary.