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> What is the biggest challenge for a private practice psychotherapist to develop/sustain their business?After my introduction, I list some general factors/decisions typically encountered in private practice.introduction:I’ve been in private practice for about 26 years. I am a licensed professional counselor (LPC), certified addictions counselor (CAC), and an approved evaluator for the Department of Transportation (DOT-SAP). This last credential allows me to evaluate employees who violate DOT drug and alcohol regulations (such as UPS drivers, pilots, or those whose work involves transporting potentially dangerous chemicals).I specialize in working with impaired professionals, folks with co-occurring disorders ( mental health and substance abuse issues), and adolescents and young adults. I provide individual, family, and group therapy.Factors to consider in private practicetype of office:When I first opened my practice, I had to decide if I wanted a home-based or traditional office. I initially opted for traditional office space, then had a home-based practice, and am back to renting office space.characteristics of the office:Each time I transitioned, I needed to consider location, parking, easy access from major routes, wheelchair accessibility, privacy, and how best to decorate my office to provide a welcoming and calming environment.My home offices included a separate entrance, a waiting room, powder room, and office.Every office and waiting room needed sound-proofing. We converted the garage into an office suite at our last home. We had the contractors provide additional sound-proofing and I used 2 or 3 of those common ‘white noise machines’.In my current office space, I have extra insulation between my office and waiting room, and have a white noise machine near the suite door and another just outside the therapy room.referrals:Obviously, I needed to attract clients to my new practice. Fortunately, my previous work at agencies and facilities led to some valuable referral sources.I informed my contacts about my new private practice and they kindly sent me referrals. As I became more well-known locally, referrals increased. The majority of my current clients were referred by other clients.length of sessions:My initial consultations are 1.5–2 hours long. I provide 60-minute individual sessions and 90- minute family and group sessions.collaboration with other professionals:I have a trusted network of other therapists, psychiatrists, educational consultants, couples’ therapists, and specialists to whom I regularly refer.Colleagues, mentors, and my therapist provide invaluable input when I feel stuck or unusually triggered by a client.fees:I asked local colleagues about typical fees for my specific credentials, experience, and services.There are very few clinicians in my area who provide outpatient treatment for substance abuse and co-occurring disorders.My full-fees for psychotherapy evaluations and ongoing individual or family therapy are thus somewhat higher than non-specialized providers.I charge less than the local average for group therapy.My fees for DOT-SAP services are slightly lower than those charged by other DOT-SAPs in my area.Roughly 1/3 of my current ( non-insured) clients pay full fee, which allows me to see the rest at (sometimes substantially) reduced fees.Additionally, I typically see 1 or 2 pro-bono clients each year. (pro-bono means ‘for the public good’ and usually refers to clients who pay no fee)forms:Private practioners need some relatively standard forms, including information about HIPAA, releases of information, informed consent, as well as policies regarding payment, late cancellations, and other house-keeping issues.notes:I take rough notes during session and later that day write neater and comprehensive DAP notes ( Data, Assessment, Plan).I keep client charts in a locked and secure location. I also have a professional will that details my wishes about client charts and current clients should I suddenly die or become unable to continue my practice.malpractice insurance:Usually, you can purchase relatively inexpensive malpractice coverage through your national licensing board.If you have a home office, you will likely need a rider that covers both your home office and your clients. In my rented office space, I needed to acquire a separate insurance policy to satisfy my landlordmarketing:I use http://www.vistaprint.com to print economical business cards and tri-fold customized brochures.I have a website as well as paid listings on two of the largest therapist listing sites.I periodically mail out brochures and business cards when referrals lag for more than a month or so, or when I move or modify my practice.For example, I notify (new and existing) referral sources when I’m about to launch a new therapy group.I always hand- address envelopes and personalize my letters. Generally, I believe people are less likely to discard mailings specifically addressed to them.insurance:In the last 18–24 months, referrals dropped considerably in my region. For the first time in my private practice career, I now participate with some insurance panels.Although the contracted reimbursement rates are substantially lower than even my lower fees, I now have a steadier flow of referrals, and can make therapy more affordable to insured clients.My income is currently comprised of ~25% insurance payments and ~75% private-pay.I’m also an ‘out of network provider’ (such an odd phrase) for some major insurance carriers. So, if I don’t participate in a particular client’s insurance plan, they can still recoup some percentage of my fees through their insurance company.I recently discovered a free (!) online billing service for my insurance claims: Office Ally - Home.for more information:Although I could write volumes on this subject (perhaps I already did), I think this covers the general issues in private practice.For more information, I suggest viewing articles and videos on private practice at good therapy.org and subscribing to a national or international list-serv for psychotherapists ( I subscribe to Clinicians’ Exchange; just mesage me if you’d like to subscribe).I also recommend Dr. Ken Pope’s well-researched articles: www.kspope.com and the practice institute’s site:Business and Marketing Consultants for Mental Health Private Practice. Although I’ve not read them, Lynn Grozski has written several books about private practiceAmazon.com: books on private practice psychotherapy: BooksFinally, please feel free to ask me questions in a comment on this answer or via direct message.Good luck!

Yes. It is true. Physicians in the US, UK, Canada, and Australia all have very high rates of burnout and paperwork contribute significantly to the burdens they deal with and worsen clinician burnout.All the excerpts below arefrom my book, Burnout Prevention and Recovery:BUREAUCRATIC TASKSThe amount of time “Physicians spend 20% of their time on non-clinical paperwork”67 varies. Some physicians report that they spend twice the amount of time documenting than they spend with patients. In a physician’s own words, “I spend as much time on documenting a patient visit as I spend with the patient.”68How would you feel if just one aspect of your work required knowledge of 130,000 pages of regulations?The government is not one entity; it is many different areas of government, from the 130,000 pages of Medicaid regulations to employment law and licensing mandates. The government also includes layers. Federal, State, and local laws all affect the practice of medicine. If a physician lives near a state border they have to jump through licensing hoops in more than one state (and pay for the privilege).This diagram doesn’t reflect the need to keep up with new research and continuing education requirements.Paperwork has a detrimental effect on the workload of physicians, nurses, and other clinicians.WORKLOADTasks that require a physician’s direct involvement could use a re-evaluation and new best practices should be developed across the board. Administrative and bureaucratic tasks have been incrementally added to physician workloads from a variety of sources and the weight is approaching the final straw.In one physician’s words, “I still like seeing patients in the exam room but as soon as I walk out the door to the piles of paperwork I could just keep walking.”279“81% of physicians describe themselves as either overextended or at full capacity, up from 75%in 2012 and 76% in 2008.28044% of physicians plan to take one or more steps that would reduce patient access to their services, such as cutting back on patients seen, retiring, working part-time, closing their practice to new patients, or seeking a non-clinical job, leading to the potential loss of tens of thousands of full-time-equivalents (FTEs).281One huge problem is the number of people who have their fingers in the physician pie.It doesn’t make sense to have physicians doing things that others could do. When you have a dozen separate constituents issuing requirements and not paying attention to what others have required it is a recipe for disaster.The Physicians Foundation survey of over 13,000 physicians revealed they spend 22% of their time on non-clinical paperwork.300 We caution against only addressing administrative burdens. The physician burnout crisis was looming before the regulatory and other administration burden increases of the past decade. They may be the straw that broke its back, but reversing those won’t heal the wounds or prevent new ones.The Annals of Internal Medicine provides insight via Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians, which includes an overview of the administrative burden and suggestions for reducing that burden.301The burden of paperwork is heavy with pre-certs, pre-auths, and scheduling other procedures and visits for the patient, let alone the demands and requirements of documenting the work each provider does with/for their patients and populating their respective EMR systems with clinical data. Staff hired to handle paperwork require more training which means they are more expensive.Physicians are often required to document the same condition or services in multiple ways. In an era of electronic records, this should be automated.The administrative burdens in healthcare are too numerous to enumerate here.Our recommendation is that a team that includes all interested parties that understands the basis of motivation and stress as well as many myriad regulations from the government, medical boards, insurers, CMS, and other parties that impose administrative burdens on physicians and healthcare organizations as well as a number of physicians, practice administrators, nurses, allied health personnel, and IT experts form a task force with the driving force being to create a streamlined way to handle healthcare documentation efficiently, to identify redundancies, to question requirements that don’t serve useful purposes or that could be managed in less burdensome ways. The task force could make specific recommendations to legislators and regulators to modify burdensome requirements that don’t improve patient care.The task force could solicit comment from the industry. It would be a monumental task but in an industry that loses the equivalent of 1.6% of new entrants to suicide each year and countless more to burnout, it is a task worth doing. The process should be done in an apolitical manner with the goal being to establish best practices and where appropriate, recommending law and regulation changes to support best practices.Where it exists, peer reviewed research should also be considered.This should not be about dictating clinical decisions, but about the administrative burden placed on the healthcare system and demoralizes providers while adding unnecessary time and financial burdens.ELECTRONIC MEDICAL RECORDS (EMR) (PAPERWORK)Forty-six percent of physicians indicate Electronic Medical Record (EMR) requirements have detracted from their efficiency.302Paperwork is part of the physician’s role. As a child, long before insurance company mandates and the ACA, I remember my physician writing in my chart each time I saw him. There are certain aspects of paperwork that it makes sense for physicians to do because it would take as long to tell someone else what to write as it would to write it and clarity could be lost in the translation. Additionally, the provider is responsible and liable for the content of the record, thus, each provider must have a process of review and ”sign-off” on each record. It is the redundancy of paperwork and unnecessary paperwork that can feel as if you’re wasting your time and erode intrinsic motivation.There are options that can be incorporated in the practice that shift responsibility for many paperwork tasks to others.My dermatologist has an assistant that is in the room with us when she sees me. The dermatologist and her assistant have developed a system that does not interfere with communication with the patient. During natural pauses my dermatologist would say a few words, no more than a sentence or two, and the assistant would enter data into an EMR. The paperwork was completed during our visit, although later review by the doctor may have occurred to verify the materials.She also had a multi-tasking way of reviewing patient charts with a treadmill desk. Multi-tasking walking with paperwork could make the time feel more meaningful and productive.Physicians surveyed about implementation of Electronic Medical Records (EMR) reveal conflicting opinions. The number of physicians who think EMR improved the quality of care is about 40% higher than those who think EMR decreased the quality of care. Nearly half think EMR improved patient interactions and a nearly equal number think EMR detracts from patient interactions.303 This seems to indicate that sharing of best practices by organizations that are seeing success with EMR would benefit those who are experiencing decrements in patient interactions.A Medscape article quoted Dr. Dean Sittig, “Electronic health records have brought new types of problems, when you have a drop-down list of medications, it’s easy to select the one right above or right below.” The article went on to mention that a patient died after receiving a paralytic instead of an anti-nausea medication.304The worry that an innocent mistake could be so easily made would be trying on most people. It makes sense that the system could ask follow-up questions to greatly reduce the possibility of another life threatening or deadly error. If the system followed with a question from a drop down box asking why the drug was being prescribed it would alert the doctor if the reasons that could be selected did not match the patients’ condition. It could also follow-up with a verification screen.GOVERNMENT MANDATESBeyond paperwork requirements is the distrust the government displays towards physicians. Failing to trust physicians to uphold the Hippocratic Oath is de-motivating. In the healthcare reform process, the impact on physicians’ emotional well-being seems to have been missed.305Medicaid regulations are ten times larger than the USA tax code. ICD10 is cited as a factor that contributes to physician burnout in comments on the 2016 Medscape survey. The frequent and extensive government mandated changes to health insurance is another factor that is leading to increased physician burnout.Too many Federal and State regulators have oversight of physicians, for example:Office of Civil Rights• Prosecutes HIPAA violations (Federal crime)(e.g.. accidentally send protected health information)Office of the Inspector General of Health and Human Services:• Billing errors can be considered fraud or abuse depending upon the nature of the violation and “intent.”Federal Trade Commission:• Doctors can’t talk about fees with other doctors.• Doctors can’t refuse patients who are self-pay and only take insured patients.Are you single and the only doctor in a small town? Forget about dating anyone because dating a patient is an ethics violation.The Sunshine Act means you have to think about who picks up the tab or you may be in violation of another Federal law.If you’ve been sued for malpractice, the Federal Malpractice data bank lists you as a criminal.Medicare requires audits with auditors who are expected to have findings. They also mandate that you provide them with data and penalize you if you make a mistake.Prescribe the wrong drug or too many of a narcotic to a patient and the Drug Enforcement Agency will Monday morning quarterback your decisions with possible criminal charges.MEDICAL BOARD MANDATESMedical Board re-certification requirements are time consuming and expensive, both in out of pocket costs, travel costs, the cost of closing the practice for a day or several, and study time.Kaiser Health News reported, “Supporters contend the new process will ensure doctors incorporate the latest medical advances into their practices, but many critics dismiss it as meaningless, expensive and a waste of time.”306I doubt the testing means physicians are keeping up because I’m not meeting physicians who are aware of 10-year old research about the new definition and purpose of emotions or about the 5-year old research about the benefits of positivity. That research isn’t in the medical silo so it’s not on the medical board’s radar even though it is important to prevention of both physical and mental illnesses.It would seem a different system might make more sense. Perhaps a data base that researchers could contribute to that provides searchable information to physicians. Physicians could then be trusted to review and document their review of new information. They could share their practice of keeping up to date in brochures with patients or on their website. With so many physicians now hospital based the healthcare institutions themselves could mandate internal updates.The concept of keeping up with all the new information is impossible. When I first started Happiness 1st Institute, I decided I wanted to read all the research published on happiness. The first year wasn’t too difficult but by the second year the happiness industry had exploded and there weren’t enough hours in the day to read all the new research and books being published about happiness, even if that was all I did. I’m pretty sure you’d find the same scenario in many medical specialty areas.People like me, who love to read research and pull all the pieces together into a cohesive whole could sift through the massive amount of information that is being created and provide it to physicians in condensed formats.We create as much information in two days now as we did from the dawn of man through 2003. – Eric SchmidtI looked at the number of papers on Medline that are “in process.” The number is currently 1,081,595. It is not humanly possible to read that many journal articles.In 2016, physicians were asked to rate the causes of burnout in a widespread Medscape survey. “Maintenance of certification requirements” tied for fifth place with “feeling like a cog in a wheel” as a cause of burnout.307Given the sheer quantity of new data available we may need to consider a coalition to determine best practices for maintaining and increasing physician knowledge without imposing requirements that physicians attempt the impossible. Consultative teams come to mind as do accessible and searchable data bases.INSURANCE COMPANY MANDATESWithout standardization of processes and “paperwork” (forms, submissions, pre-authorization requests, etc.) the commercial insurance companies place a broad range of demands and restrictions on providers. If the provider wants to be paid for services delivered to a subscriber, then they must accept the nuances of these processes and comply with a multitude of documentation and clinical data requirements. A prime example is the process of credentialing the provider. Most insurers have their specific processes and materials to complete, although NCQA has helped some in standardizing information, the provider may be subject to weeks if not months of delay before you are “recognized” as a provider who can bill for services and be paid.In the 2016 Medscape survey, the most frequently noted free-form comments related to insurance issues and their contribution to burnout.Insurance companies need to recognize that their role in healthcare is optional. The more onerous they are the more they push us towards socialized medicine and concierge medicine. Medical malpractice insurers should recognize the role of burnout on errors and become strong advocates for streamlined processes and other burnout reducing changes.EMPLOYED PHYSICIANSMore than half of physicians are now hospital or medical group employees. That’s an almost 25% increase since 2012 and nearly a 50% increase since 2008. The number of physicians in solo practice has declined to 17% of all physicians.308 This change requires psychological flexibility because the mindset of an employee is different from that of a physician who owns the practice.LEGAL ISSUES & MALPRACTICELegal intrusions into healthcare have many adverse results.• Negative impact on physician income from high malpractice liability premiums• The stress and time involved in defending malpractice suits• Unjustifiable demands• Impact of “defensive medicine” actions generating high volumes of testing which may not be warranted.Malpractice worries are constant for many physicians. 60.3% of physicians see defensive medicine as a factor that is most likely to contribute to the rising healthcare costs. Only 37.4% cited the aging population as a likely factor.309 Tort laws and public opinion both contribute to defensive medicine.When a physician is sued for malpractice, the risk that suicide ideation will occur increases. Organizations may wish to consider mandatory counseling sessions to assess the mental health of physicians being sued and provide them with training that can help them with the stress of the situation. Even if the physician is likely to be found innocent, in an untrained mind negative ruminations can lead to adverse psychological and somatic physical illness outcomes.In January, Medical Economics published an article I wrote about a Florida physician who was being held liable for a patient suicide.310 The physician was a family practice physician treating the patient for depression. A large percentage of depression patients are treated by family practice physicians. In the United States, 3,000 counties have inadequate resources to meet the demand for mental health services. About 30% of all depression treatment is provided by medical doctors. This Florida case has a chilling effect on physician willingness to provide this much needed care.The need for Tort Reform is beyond the scope of this book, however, we do note that the behavioral influence of these legal parameters have a direct effect on providers and customers (patients).Fear of malpractice suits and the cost of malpractice insurance increases burnout. Malpractice insurers have a vested interest in reducing burnout.The burden on doctors has led to more than 50% of them having at least one symptom of burnout.All excerpts are from: Burnout: Prevention and Recovery, Resilience and Retention, Evidence-based, experience-informed, root cause solutionsThe numbers refer to the citations in the book. The entire Bibliography, and the citations, are view-able in the “Look inside” feature on Amazon with no charge.

Which HIPAA form?If you work in a capacity that gives you access to other employees’ Protected Health Information in any way, and the form you’re asking about is one that says something along the lines of, “I understand my legal obligations and will follow the rules for keeping PHI confidential,” your employer can fire you in a millisecond if you refuse to sign the form, and probably should.If you do not work in a capacity that gives you access to other employees’ Protected Health Information in any way, and your employer has asked you to sign a form that says something along the lines of, “I acknowledge that I received a brochure explaining my rights under HIPAA,” then I cannot for the life of me understand why you would refuse to sign it.If you have employer-provided medical insurance or you have applied for FMLA or a disability determination, then your employer cannot proceed with your application until you sign the form. Signing the HIPAA form is for your benefit, not the company’s.