TCPR: Can you walk us through an example?
Dr. Byrne: Sure. Let’s say you need to make 250 dollars an hour and then take off your administrative overhead so that you walk home with 150 dollars an hour. And then you figure, well, if I see someone for a therapy appointment, it’s about an hour. If it’s a med management visit, I do half an hour. That’s enough time for me to see the patient, write the prescription, schedule the next appointment, and write my notes. That’s how you decide how much visits are going to cost. Maybe you live somewhere with a low cost of living and you don’t need to charge that much to make what you want and work 40 hours a week or 20 hours a week. Or maybe you live in New York and it’s super expensive and if you want to do those same work hours, you’re going to have to charge a lot more, but it will be sustainable. It’s a very different way of thinking about it, but I think it provides a higher quality of life and less chance of burnout if you do it this way.
TCPR: I think that’s great advice, particularly since burnout is a big problem in our field. Within your practice, is there a specific structure to your patient appointments?
Dr. Byrne: Yes. First of all, patients have to be on time. We promise no wait time, so a lot of our business is structured to make sure that people are seen on time. If they arrive 15 minutes late, they don’t get an extra 15 minutes. Administrative staff checks them in, calls us, then we come out and greet them. The actual appointments I structure into thirds. The first third is open-ended questions to let them talk: what’s going on; how they are doing. The next third is more targeted questions: the things I need to know. The last third is to talk about what we’re doing: the next treatment step, the overall plan, prescriptions. And when they leave the office, I’m pretty diligent about doing their notes immediately. I really strongly believe if you can walk home at the end of the day with no notes to do, you feel like a million bucks. I build time buffers into my schedule to do my notes.
TCPR: How long are your visits?
Dr. Byrne: Typically, adult psychotherapy is going to be a 45–50 minute appointment, and a medication management visit is going to be 20–25 minutes. For children, we’re doing 60–75 minutes face-to-face and a 90-minute block for intake since you have parents coming. In our practice, what we say is 20–25 minutes face-to-face, but we block 30 minutes so we can do notes, go to the bathroom, take a break, etc. Our long appointments will be 45–50 minutes face-to-face, and again we build in that 10–15 minutes in between. I think it’s really important to know what you need as a buffer between appointments and that you don’t shortchange yourself because you’ll regret it. And you have to be really practiced and skilled at starting and stopping on time.
TCPR: Definitely, and with some of us that does takes practice. In terms of billing time, how do you handle paperwork charges, phone time, and those sorts of things? I know that there are often misunderstandings when patients are billed for things they don’t expect.
Dr. Byrne: Everything that our administrative staff can do that does not involve the doctor’s time, they will do, and we will not charge extra. These are things like prior authorizations, nonclinical phone calls, and basic paperwork like an excusal note to an employer saying the patient was at a doctor’s visit on a given day. If there’s something that specifically requires the doctor’s time, then we would bill in 15-minute increments, and it’s at the doctor’s discretion whether to bill for it or not.
TCPR: That makes sense. Do you talk to your patients about this in advance?
Dr. Byrne: That’s a really good question. Let me start by saying this is where training your administrative staff is huge. In our office we practice with scripts to learn how to talk to patients about this. We say something to our patients like, “You can expect a really high quality of service from us, and we will respect your time. We don’t double or triple book. If we call you on the phone, we’re going to have your chart open and be ready to talk to you; we’re not going to be taking other phone calls; we’re not going to be doing other things. We want to make sure that your time with the doctor is used effectively and efficiently, and we ask in return that you respect our time as well.” We have a “free pass” system that we don’t really advertise, but if somebody cancels or misses an appointment, we will say, “Okay, it happened once. Let’s reiterate the policy; next time it happens, we’ll bill you for it.” We do get some frustrated patients, especially if they’re new to the practice, so we spend time up front going through these types of details.
TCPR: How would you explain to your patients the difference between a clinical and a nonclinical call, for example?
Dr. Byrne: If I start a patient on a new medicine and they call me a day later and say, “I’m having a side effect; what do I do?” I would not typically bill for that time. But if a patient wants to talk to me for 15 minutes to get through a panic attack, I would bill for that phone time. I make the distinction this way: If my patient wants me to do therapy outside the sessions, which a lot of people do, then that time has to get billed. Another tricky area is refills.
TCPR: In what way?
Dr. Byrne: We have a separate fee for refills outside of appointments as well as controlled substance refills outside of appointments. We want to disincentivize people to miss their appointments because if we think they need to be here, there’s a reason. And we charge more for a controlled substance refill because that requires extra work on the doctor’s part to provide a proper level of high-quality care. You have to go into the controlled substance database, check the chart, make sure you’re not trying to fill something too early. Patients will complain, “Well, I’ve never paid for a refill anywhere else.” And we’ll say, “You will always have enough medication if you come to your appointments as scheduled.”
The idea is to design a sustainable practice that is not going to cause you to burn out and overload yourself, because that’s what doctors tend to do. Only you can answer the question, ‘What do I need to make to feel good about what I’m doing?
~ Jennie Byrne, MD, PhD
TCPR: On your website, you tell patients that they will need to provide a copy of their credit card at the initial visit. How did that come about? I would guess that many people would say, “Are you kidding me?”
Dr. Byrne: We tell them upfront: We keep your credit card on file for any charges outside of your appointment, like therapy phone calls or missed appointments. Sometimes people get upset, but at this point we have a system here that’s been working long enough that the administrative staff handles these conversations really well.
TCPR: It sounds like you’ve put a lot of time and thought into running a successful, business-minded practice.
Dr. Byrne: I think it’s a really great time actually to be in private practice. If you think about it as a business and you start out on that foot, you’ll do very well. You’re never going to be wanting for patients; we have something that people really need. And you can design your practice to be all sorts of different things depending on how much time you are willing to put into it.
TCPR: Thank you for your time, Dr. Byrne.