Thriving Outside Managed Care in Vermont

Robert S. Emmons, MD
Article Type: 
Report from the States
November/December 1998
Volume Number: 
Issue Number: 

I am a psychiatrist who works in a solo private practice in Burlington, Vermont. I do not belong to any managed care network or insurance plan, nor do I participate in any utilization review process. Each patient pays me at the time of each visit; if his or her insurance plan does provide reimbursement for non-network physicians, then the patient submits the claims. My patients are not fabulously wealthy. My annual advertising budget consists of $132 for a one-line listing in the yellow pages. I do not have a specialized “niche” practice. I am not a senior psychiatrist with years of experience in my community, nor do I have a trust fund. And I’m not just surviving; I’m thriving.

According to the “experts” who paint a picture of the medical world as dominated by monolithic managed care companies, this sort of practice cannot exist. How do I achieve the impossible? I believe that practicing outside managed care is fundamentally a matter of managing anxiety. The purpose of this paper is to share with you the secret to my success.


Defining Success

I work one day a week at a community mental health center. This gives me the opportunity to work with the chronically mentally ill and severely personality-disturbed population. I am paid well by the clinic and the steady source of income it provides helps to reduce my anxiety when the income from my private practice fluctuates.

However, I do not define success by the size of my income. I see myself as successful because I am, by and large, doing the kind of work I want to do. Working outside managed care gives me a number of freedoms. I am free to be selective in the referrals I accept. Unlike many psychiatrists, I aim to work primarily with patients who are in a position to utilize an insight-oriented psychotherapy. I am free to exercise my medical judgment in the best interests of my patients, without being asked to balance those interests against the financial interests of an insurance plan. I am free from pressure to release confidential information to third parties. In short, I practice medicine following the precepts and the tradition of medical ethics of Hippocrates.


Low Living Expenses and Free Time

The freedom to practice medicine as I see fit means more to me than all the material possessions in the world. I don’t get everything I want, but I make enough money to be comfortable. I don’t suffer the misery of having to compromise my principles of medical ethics.

I do have open hours in my schedule. I refer to these hours as “free (time)” rather than “unfilled.” I could have a psychopharmacology practice full of self-pay patients, but I prefer not to. I focus my private practice on psychotherapy.

Recently, I rediscovered competitive running, which I find absorbing and satisfying. When I have a free hour, I’m not wringing my hands waiting for the phone to ring with a new referral — I’m out running.

The harrowing experience of colleagues absolutely puts my free hours into perspective. A senior, well-established psychiatrist in my city reports that since he has been participating in managed care networks, he works one and a half times more hours and earns a third less than before. I am working about a third fewer hours than

I would prefer, and my income has fallen by about a third from its peak — but I am happy and healthy!


Networking With Like-Minded Colleagues

I also belong to the part-time clinical faculty of the University of Vermont Department of Psychiatry. This is volunteer work. My principal activity is psychotherapy supervision. I teach the residents that the psychiatrist’s primary identity is still that of a psychotherapist. Teaching pushes me to keep up on the psychotherapy literature and to continue to improve my skills. If I do have some free hours, what better way to spend them?

I have co-founded a group for mental health professionals in northwestern Vermont who share similar values. As a group, we regularly affirm our individual choices to work outside managed care and share what we have learned about getting along on the road less traveled. This group provides a steady source of inspiration, a good antidote to anxiety.


Professional Confidence

I do good work. Belonging to an insurance plan or managed care network will not ensure a steady stream of referrals. Colleagues will refer to me if I treat them respect-fully, if I practice skillfully and thoughtfully, and if I keep up on advances in psychiatric practice.

Confidence in my abilities also means I’m not locked into the idea

I can only work as a psychiatrist.

If it turns out it is not economically feasible to practice outside managed care, then I have talents and skills that could carry over into another job. In fact, I would rather work in another profession than to practice psychiatry in ways I view as stressful, unsatisfying, and clinically and ethically unsound.

If you perceive you must maintain your medical practice at any cost, then you have closed off a number of options. Closing off options engenders anxiety. I am not at all planning to leave psychiatry. For me, keeping open the possibility of leaving psychiatry works paradoxically to enable me to stay in it.

There it is — the secret to (what I call) success. I do not expect this approach is for everyone. Even if you agree in principle, you might still be persuaded against it by the “experts,” who claim that only a few physicians will be able to survive outside managed care. I submit to you survival as a physician has spiritual and moral dimensions that outweigh any financial considerations. I am doing the kind of work I want to do; I am satisfied with my work, and I earn enough money — I call that thriving, spiritually and professionally.


Dr. Emmons is a board-certified psychiatrist who practices in Burlington, Vermont. His address is 92 Adams Street, Burlington, VT 05401, 802-865-2863.

Originally published in the Medical Sentinel 1998;3(6):225, 227. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).








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