Secret Formula PB+5

I have frequent consults with beginning or seasoned practitioners looking to get on Medicaid as private practitioners.  Their logic on the surface makes a lot of sense coming from their agency backgrounds.  A majority of their patients in agency are on Medicaid, and they may want to keep them as they transition to private practice.  And many of us went into this work because we want to help a range of people, including the most impoverished or differently abled.  These are laudable goals, and I want to assert that they are not incompatible with private practice.  But I do think that Medicaid is, at least in terms of building one.

What happens when your patient misses their appointment?  With Medicaid you cannot charge them for a missed appointment.  And after they miss two or three, you may have the conversation about “are you really interested in treatment?”  They say yes, miss again, and you fire them, or don’t call them back and feel guilty and frustrated; or they drop out of treatment feeling like they’ve failed yet again.  And in Massachusetts, the newest vendor of Medicaid, Beacon Health Strategies, is trying to change the provider contract to say that you are not allowed to fire them for no-shows!  Outrageous, but hey, you signed the contract, so until NASW or APA fights this statewide that is your agreement.

This is such a lose-lose!  Private practitioners are not able to make a living, low-income patients are not able to get consistent treatment, and everyone feels like a failure, except the insurance company which pays nothing.  But there is a way to build social justice and healthy treatment into your practice right at the beginning, I call it my Pro Bono + 5 session.

Imagine this, you decide that you want to start out in private practice, and while you are building it you want to be able to take referrals from your old agency, which usually has mostly Medicaid patients.  So you call them and let them know that you have 2 immediate openings for your pro bono plus 5$ sessions.

Your what?

You explain that while you don’t take Medicaid, you are offering two sessions in your practice where you contract with the patient that as long as they are on Medicaid you will never charge them more or less than $5.  You don’t participate in Medicaid, but you won’t bill Medicaid either.  You’ll only ask them for a nominal $5 fee payable each week as part of your committment to building a socially just practice.  When you meet the patient, you explain this to them, and explain your no-show policy.  They keep their appointment, they pay the $5.  They miss the appointment, they pay the $5.  If they’re sick or unable to make the session, you’ll gladly offer them a phone session, because they’ll still be paying the $5.  This is made clear the first appointment, with whatever your normal policy is.  You see, you can’t do phone therapy on Medicaid, but on your PB+5 plan you can.  For the patient, they are getting a great discount and affordable treatment.   For the beginning private practitioner you are getting great clinical experience, including talking about the fee and your therapeutic contract, and feeling like you are doing some diverse work, which hopefully helps you feel more confident in being circumspect when filling the rest of your week.  The referring agency gets to win in that they can refer someone immediately.   Win-win.

This is not a new concept.  Freud created the Vienna Ambulatorium to provide free psychoanalysis almost 90 years ago.  We all know that Freud saw many upperclass patients, but he also allotted some time for low-cost or free treatment.  You can do the same.  And I suggest that you set a fixed number of sessions right at the start of your practice, which will help you later keep the number of full-pay or insurance appointments fixed as well.  So what do you think?

Self-Promotion, No One is Gonna Do It For You..

When I am doing workshops with colleagues or consultations on building a practice, I am often struck by how mortified they become at the thought of self-promotion.  And yet, I know too well what they are up against.  I have been marketing myself for a while now, in a dozen different venues in multimedia, and it is only recently that I have begun to do so without the negative self-talk or twinges of guilt.

What was I worrying about?  Well, in the past I worried that people would say to themselves, “I am so sick of Mike tooting his own horn” or think of me as a narcissist or superficially greedy, etc.  Boy did I have to get over that, and if you want to be a successful business owner, you will too!

Back when I worked in a large institution it was fine to hide out, do good work with my patients and bring home a paycheck week after week.  But when you decide to start a private practice, you are basically committing to becoming a business.  And businesses need marketing.

One of the great things about being a solo practitioner is that your research and development department and your marketing department is the same person, you!  Self-promotion is much easier when you have a product or services that you believe in.  So I look for opportunities to do the things I enjoy, and then show my colleagues and clients how this adds to my value.  When a recent insurance company began stepping up its efforts to bully clinicians, I had no trouble rising to the occasion.  I like reading up on parity, researching and educating myself about the business climate, and thinking about how language can be used by HMOs to disempower therapists.  And after a few conversations with colleagues, who were clearly looking for a fresh approach to that problem in their practice, I realized that I had something of value to offer.  So now I’m doing workshops on the subject and loving it.

It is very tempting to trade the structure of an institution for the imposed structure of managed care.  Don’t do it!  If you do you have only yourself to blame.  As I tell my consultancy clients, you need to remember that the most important difference between you and the insurance company reviewer is that you have better things to do with your time.  The reviewer is a salaried employee who is paid to call you and conduct these clinical reviews.  Whether you are on the phone 5 minutes or 50 minutes, they get paid.  You don’t.  In your time you could be:

  • Seeing another patient.
  • Devising a workshop strategy
  • Networking with a colleague
  • Being the first to call a potential referral back
  • Writing your newsletter or blog
  • Designing your website
  • Writing your google ad
  • Writing an article for your professional magazine
  • Depositing checks in your bank
  • And more!

The way the intimidation tactics work is that HMOs are banking on your need to buy into a system, even a system of oppression, rather than your own.  Yes, they may say they are not going to pay for any more sessions, that’s their mission.  So make the call brief, and use the time to self-promote some other part of your business.

Self-promotion scares many of us even more than HMO reviews, but self-promotion ultimately pays better and gives you more freedom, motivates you to stay current and innovative, and puts you back in the driver’s seat rather than the victim seat.  I want to know:  What can you do to toot your own horn today?

Remember the Alamo, er TOPS!

I was just reminded by Liz Z. on a poll comment (there’s still time to weigh-in on the one-question poll btw, and read the interesting comments) about BCBS alliance with BHL consulting group and the TOPS.  I think this was a timely reminder for myself and any who are feeling discouraged at our work.

When BCBS first rolled the TOPS out, we were all flooded with propaganda about it, how it was going to revolutionize things.  And there were the subtle incentives (a higher rate for those who filled out the form) and the not so subtle disincentives (those who did not fill out these forms would be required to do more onerous authorizations ultimately.)  I remember the time I got back the results with one of my higher functioning patients, recently unemployed, who had endorsed “had unwanted thoughts or images,” and was considered at high risk for psychosis.  I remember trying to embrace the TOP process and then I remember feeling alternately angry and insulted.

It seemed like the TOP was here to stay, and then it wasn’t.

The TOP failed to stick because we refused to do them.  We objected on legal grounds, questioned its validity, and most importantly took action by refusing to do them.  Websites like this one sprung up:

And now a year later, the TOP is rapidly becoming a distant memory.  I think the moral to the story is that we can effect change.  I hope that we can galvanize ourselves in the coming months and not take the “you can’t fight city hall approach.”

Be proactive, read your mail!

So if you are a Tufts Provider, October 1st is a special day. What? You don’t know what I am talking about? Well I know for a fact that as of October 1st if you submit a B&W copy of your paper claim form, it will be rejected. Yep, no red CMS-1500, no checky. I am sure hundreds of my colleagues are going to find this out on October 20th, when they receive rejected claims letters, and they’ll be ranting about the system. Yes, the system sucks, but it is the system you choose to get paid by, so read your mail.

The above does not really effect me, I have a billing service and we submit all of our claims electronically (CMS-billing.com btw, they rock). But I wanted to share that with you for a couple of reasons. First, to hopefully save you some headaches, but second, and more important to give an example of how keeping your business in the black requires dealing with what we therapists often consider “mundane.”

We’re all about bearing witness to people’s suffering; helping them transform their lives; healing relationships; changing behaviors that hurt them and others. That’s the lofty profession we want to see ourselves in, and yes, it is a lofty profession. But we’re also in business, and if you don’t get with the program you’ll be out of business. When you get provider updates from the companies you work with, READ THEM. Yes, they are boring, but they will save you time and money. It takes 5 minutes to read the “60-Day Notifications” articles in the Tufts newsletter for example. A lot less time then it takes filling out a claim, mailing it, waiting 3 weeks, finding out it was rejected, calling to be sure what that weird code means, talking to someone, scrambling to find some forms, realizing you don’t have them, running to Staples to order more, waiting for them to come in, and resubmitting so that you can get paid 3-6 weeks later because you still use paper claims.

Bear witness to your own suffering; transform your life by working smarter; heal your relationship with your inner businessperson whom you need to VALUE; and change your behavior around the administrative aspects of your business, it is hurting you and those around you (unless you never ever gripe to your spouse about the paperwork, get nasty on a call to a service rep about something you should have known about, or get distracted when you are sitting with a patient because you haven’t been paid yet.)

5 minutes. Read your mail.

Many Happy Returns

It may be a coincidence, but when I turned 40 I began to hear the term ROI a lot. For those of you who may not have heard of ROI, it stands for “return on investment.” There is a technical definition of it on Investopedia, but I think I figured out why it kept leaping to my attention last week when I was speaking to someone about dragging my feet on a piece of work I had committed to do.

“I’m just worried that this will be a waste of time.” I was talking about return on investment.

I have always been a worrier about time, and like Marvell always hear Time’s Winged Chariot. But it has usually been from a fear-based perspective, and somehow, ROI has gotten me thinking more about finitude from a more positive perspective. Yes, there is a limited amount of time in my life, so what am I going to do with it? Am I going to spend it angsting about the ever-decreasing amount of it, or am I going to embrace my agency and be mindful of how I am investing myself in life? My colleague, psychologist Susan Giurleo is an excellent power of example for this. We both have psychotherapy and consultation practices, and have watched as health insurers have begun to put the squeeze on providers while continuing to enjoy their own salaries stability. I have become a founding member of AMHP, a group of mental health providers who are becoming activists about this issue. When I asked Susan if she would post an entry on our group discussion she was ambivalent about it, and in her explanation of why she was ambivalent she wrote:

1. I think major efforts will generate a low ROI. We can fight a cut, but

the nation is heading toward insuring more people for less money. Writing is

on the wall for all health care, not just mental health.

2. I’ve found putting my energies into diversifying my income stream has

huge ROI. I’m working toward a business model where I don’t take insurance

because I want to be paid for everything I do at the time of service.

Accepting managed care is just a bad business plan for so many reasons. I’d

rather slide my fee and get the money in hand than have to bill and haggle

with a third party.

There was that phrase again, ROI! Susan’s point makes good business sense, but it also makes good life sense. And the beauty of it is that each of us get to evaluate ROI for ourselves! I can wholeheartedly understand her point of view, and at the same time find that investing my time and effort into AMHP brings returns for me that I find very valuable. I have already begun to meet more of my local colleagues throughout my work on this. I actually enjoy reading about antitrust laws, and discussing this and the business side of my practice. I find political activism very rewarding, and get more energized to research and advocate for AMHP. It has me talking more with colleagues about another interest of mine, working with therapists to make better use of technology like social media. We live in an historic moment in that never before has it been so easy to share so much information with so many mental health providers across the world so quickly! This has been utilized by the health insurance industry to our detriment, but it is accessible to us. And not just in fighting the good fight against managed care. Technology can bring great ROI on our practice. I have used Skype to conduct psychotherapy in Asia, and have supervisees who “beam in” regularly for their appointments. And if you don’t have a website, if you don’t “invest” yourself in the internet, I am convinced that you will see diminishing returns in your practice.

As therapists we invest in our work, and more importantly we ask that our patients invest in it as well. But therapy should never be an act of completely blind faith for a patient, they can and should consider what the ROI will be on the hours and dollars spent. We have an obligation to be able to explain why the work is worth investing in. And we need to get more comfortable with the idea of ROI, because if we don’t define our ROI the insurance companies will. They already have: the briefer the treatment needed to get symptoms reduced to a least common denominator, the better the ROI. As one clinical reviewer at UBH told me last week when I said that a patient’s GAF of 70 was their highest the past year: “Well we need to look at the fact that this is probably their baseline and end treatment.” Oh, really? I guess I should just say to them, “sorry, you can’t become any more insightful, have greater well-being according to UBH. You’ve plateaued at ‘meh,’ so don’t let the door hit you on the way out. My solution to this problem is to say to UBH, sorry, not enough ROI for me, I’m out of your network. Will I need to work harder in other areas to generate revenue? Yes. But will I ultimately have a better quality of life without having to play such profane games, you betcha. Thinking in terms of ROI has made me more confident, more thoughtful about what I take on for work, and what I pass by.

So let me know, what brings you your highest ROI in your work, your life? What brings the lowest? When that car cuts you off, what is the ROI on teaching them a lesson with your horn or finger? When you feel a sense of presence and accomplishment with a therapy’s deep work, remind yourself that you are experiencing a moment of mindfulness. Mindfulness of ROI. Don’t miss it, and when you notice opportunities for ROI act on them, because as Jack’s mother in “Into the Woods” says, “opportunity is not a lengthy visitor.”