After butting heads with managed care companies and living with their interference for the last decade, a growing number of frustrated psychiatrists are finding ways to construct a rewarding professional life by reducing their dependence on income from managed care patients.

Psychiatrists employing these career strategies usually follow one of two paths—restricting their practices to fee-for-service patients or diversifying their professional lives to supplement patient care with activities such as forensic psychiatry, teaching, or consultation-liaison work.

Los Angeles psychiatrist and APA Treasurer Maria Lymberis, M.D., thought she had identified a tactic for detouring around the managed care hassles and roadblocks in the early 1990s. Though she had a sizable number of private-pay patients at the time, she saw the difficulty of trying to survive without managed care patients. As a result, Lymberis joined with 20 other psychiatrists who formed a partnership with a private hospital. They hoped that this strategy would restore the control over their professional lives that managed care had wrested from them. The venture, however, did not work out, she noted, leaving her again dependent on managed care contracts to generate income.

In 1996 she decided she could no longer endure the practice restrictions that managed care firms imposed on psychiatrists and withdrew from them all, realizing she would have to live with a big drop in the number of patient referrals to her practice.

"It is very easy for psychiatrists to avoid managed care" if they are willing to change the way they traditionally have practiced and to live with more uncertainty, she told Psychiatric News. It requires "flexibility and a singular focus" on the needs of patients and their families, she noted. "This means no ‘theoretical orthodoxy.’ The challenge is to identify what is really needed in each case, not what I would prefer to do."

Lymberis realized that if she was going to avoid managed care, she had to be "willing to see patients when they can come, even if it means home visits for the bedridden elderly, late hours, extended sessions, phone sessions, and Saturday or Sunday sessions."

It is critical, she added, that psychiatrists have a "capacity to tolerate anxiety over the ups and downs of the referral curve. Feast-or-famine patterns will be common."

K. Lynne Moritz, M.D., maintains a very busy private practice in St. Louis without any income from treating managed care patients. She describes being free of managed care as "the most interesting and rewarding thing I could possibly do."

Moritz said that years ago she vowed to involve herself in professional activities that "reinforce and make visible" beliefs about psychiatric practice that she holds dear. These are activities, she said in an interview with Psychiatric News, that "disabuse people of myths about mental illness and psychiatry and put forward what’s right" for people with psychiatric problems.

"I have for a long time been outspoken about problems with managed care, particularly the way it has shifted treatment to a system where people with mental illnesses are either underserved or unserved," Moritz stated. Many patients choose to remain with managed care providers, she added, "simply because they don’t know what they’re missing" in terms of quality care.

Moritz has built a fee-for-service patient base through referrals that come from her visibility in the community. "I spend a lot of time giving talks to professional and lay audiences, which is something I love to do," she said. She is also active in the local medical community, having just completed a term as president of the St. Louis Metropolitan Medical Society.

Moritz pointed out that she had little difficulty building a successful private practice—about 70 percent of her practice is psychoanalysis—without managed care patients. Several years ago, she did have patients in managed care, but when they changed insurers or terminated treatment, she replaced them with patients who did not encumber her the way managed care did.

"Some patients have had to make sacrifices to pay for treatment with me," she said. "Some have even financed their treatment through a second job." She added that she does negotiate discounted fees for patients who cannot afford her standard fee.

Psychiatrists may have to face the prospect of lowered income for a year or two if they choose to follow a managed care–free path, Moritz noted, "but the rewards are so great," they outweigh the difficulties. The key to generating referrals for early career psychiatrists is "being visible and getting involved in activities that reward them emotionally. People respond to that, and that’s where the best referrals come from," she stressed.

The chair of APA’s Committee on Private Practice also has devised a strategy that allows him to practice without depending on complying with managed care rules if he wants to be paid. Michael Hughes, M.D., is part of a two-psychiatrist, one-psychologist group practice in Coral Gables, Fla., in which he is the only one who will not take on patients insured through managed care.

Originally part of a much larger inpatient and outpatient practice, Hughes got fed up with managed care when dealing with insurance issues and contract negotiations became "an ordeal" that robbed him of clinical practice time. "We have chosen to be clinicians rather than businessmen," he said of himself and his partners.

Hughes, a child psychiatrist, said his current practice is primarily psychotherapy oriented, and he treats both children and adults. About five months ago he dropped all of his managed care contracts.

Hughes has also kept his income up by expanding his practice in forensic psychiatry, though he noted that he is not certified in that subspecialty. Since his days as chief of child and adolescent psychiatry at the University of Miami about 20 years ago, he has been doing some forensic work, but about four years ago began to market himself more in that arena. He sent brochures describing his approach to forensic evaluation and treatment to family and to personal injury lawyers, he said, but most of his referrals have come from word of mouth.

What is indisputable, Lymberis stressed, is that "in both up and down economic times, patients need treatment," and psychiatrists are uniquely skilled at "dealing with the whole person. If you do it right, private psychiatric practice is a win-win venture."

This article was written in conjunction with APA’s Private Practice Committee.