How to succeed at cash-based telepsychiatry: 10 Worst Fears That Never Came True — Christopher O’Brien


Join our guest Chris O’Brien, PharmD as we discuss why he decided to go completely virtual and cash-based. Learn how he has built a thriving private practice and how he overcame his worst fears about doing telepsychiatry. Get practical tips on finding the right tools and technology, navigating telehealth regulations, recruiting, and marketing to potential clients.

Transcript (click to expand)

(A = Milton) (B = Chris)
A: Thank you everyone for tuning in for another week of Telehealth’s secrets to success, video podcasts. I am Milton Chen, the CEO VSee, The Telehealth company behind about 1200 plus customers plus this mark or four thousand plus physician network.
So this week I have a special guest, Dr. Chris O’Brien, an advanced practice pharmacies and the founder of Cash based Telepsychiatry practice, who is now practicing a 100% by telehealth. So I was really excited to hear his insight on how he can do a 100%. And he’s also a long-time Martial art practitioner and will be testing with his skills for their black belts at the end of this year. So I’m pretty excited to share about that. So Chris’s dream is to able to work for anywhere in the world as he is living in California. So it’s great to have you here today.

B: Thank you Dr. Chen for having me, it’s a pleasure.
Yeah, so it’s been a dream of mine. I remember, back in the Regional Center we used to do team assessments, and our teams like hikers actually went to our median. Yeah, I was able to participate in a team. This is long before telehealth really kind of picked up. And it was cool, and he had this fantasy of… Well, I could live in our median and still see our patient in California.

A: Yeah, I think. There is no reason why you shouldn’t be able to do that. I think what’s nice about the psychiatry is there’s no devices and there is really visual communications.

B: I mean, there is physical assessment. We have to launch it for side effects and so fourth. Clearly, you know, another clinician can do that, but yeah, I learned to it nicely. It’s almost, you feel kind of guilty with these fantasies of living elsewhere.

A: So we could do, hopefully, explore and share with the audience how we can make your fantasy of living anywhere and working anywhere come true. I guess before we dive into this. Just tell us about, can you share us about your interest in martial arts. Can you like kick through five boards or like beat up people.

B: No. No, I wish. Martial arts is a big part of my upbringing, you know. I started like Japanese arts and Chinese arts like Wing Chun. And then it kinda broke off a while and went in the military on to school, but then I have children. So, I though it was kind of cool. Because to me, a black belt is somewhat like a college degree, you know. It’s something, that you will always have. No, can take it from me. And its kind of transformative, not just about fighting. So now I have both of my children and my son has been since he was like four years old. Like a little Buddhist monk. I thought it will be really cool if, you know, I would get my second black belt but this time in the style that he’s training. And then also, Jiu Jit Su has really been the forefront and having the courage to kinda start over. Because when you change more short you’re also humbling yourself. So it’s a lot like lessons in life.

A: Got it. By the way, I have another burning question for you, yes sir. So what is advanced practice pharmacies, and how does that relate to the practice in telepsychiatry?

B: Yeah, you know, I remember when I first got my credentials and everything, people at the airport – cause you know I commute back and forth between Los Angeles and Northern California, I mean, they said “what do you do?” You know. And for the longest time I would just say I am a psycho-pharmacologist. Because I don’t know what else to say. If I said I was a psychiatric pharmacist, they would think I am instantly in an industry or involved in pharma, so it was hard. I think the best way to explain it is it’s a _______ (4:05), not a pharmacy. Who’s had additional training and can now be more part of the treatment and evaluation team.

A: Got it, got it, got it. So does that mean… so for example, as part of your goals, you can help other psychiatrist. Help them. Give them advice, things like medication, and so on. How does that differ for maybe just like a normal maybe pharmacist in there? Is that just special or…?

B: So, traditionally my crew started off as a consultant to treatment teams and psychiatrists. And over time, especially when I was at CHLA, eventually, it’s kinda like you end up having your own patient load. You know over time because there’s overload. So I functioned that as a consultant on difficult cases and then also I ended up having my own patient panel over time. So its about having the physicians to become comfortable with you, they know who you are, and or the have a additional training.

A: Got it, got it. Okay, I think its like explaining that its pretty neat to hear how the pharmacist you’re extending and how they are becoming these positioning standards for medication management. I think that’s a big area.
Before we can start now. I guess maybe a downside checking on some of the latest news. Example this week, there’s a Forbes article. I think that’s going round, I think a lot of people siding by the digital health strategy, that he’s know about, his telemedicine dead arm, before it arrives. Which I thought it really a lot. So his basic premise was to say, like all the chat box, this camera, like Google is working on a bunch of things. Like AI Google, Amazon, you have these sorts of chatbox. Now they can sort of communicate about specific things, like mental health, like symptom checker and all these things. I am just curious. What’s your like respect or opinion?

B: Yeah, I mean looking at Google, its actually, I have a friend who’s actually is an AI, you know not with Google, but within our company. So everything is like so hush or a secret. Until a couple of glass of wine when he starts to open up to me and telling me about it. And like I am no where near his level. He’s in PhD like yourself, and so he’s in a whole other category. And then I listen to some on YouTube – I listened to a presentation about Google’s AI. The first presentation was about the chat box like you were describing, an the second long presentation by two physicians that are team leaders at Google, and they’re working on this. And you know it really came down to precision and specificity, and whether you can do that with artificial intelligence. They are telling and talking something like 10,000 repetitions, you know, for where the algorithms that therefore evolve and learn, which is the definition of intelligence. I guess my concern is health care changes so rapidly and you just kind of wonder how to update this information ’cause it’s gonna be pulling from some sort of database. I don’t think it’s like a secret database, but its some kind of database. And it’s pulling out information and to be intelligent. So I don’t… I think it has a role, you know, there are several medical disciplines or specialties that there’s not enough providers, so then it can be a tool for those providers. So I can see that in any place and actually, that is occurring.

A: So yeah, that makes sense. I think my vision is always… I felt like the AI child and entire medicine, in fact it goes almost two sides of the same coin, so that the role of this AI child body is to minimize the productivity it has served for the providers in there that could do some be more productive, or maybe through an assessment or anything. And really, it’s the human beings having the best clinical outcome.

B: You know, there’s even a doctor in Star Trek, and they had all the equipment in computer.

A: That’s a great point.

B:That why its also going to work out.

A: So everyone will be happy. By the way Chris, thank you so much for sharing a thoughts on that. You know you’ve got a great presentation for us today. Like how do you start your own cash based telehealth practice. And I would love to, maybe, I would like to turn the floor all to you and have you share your experience with us.

B: Okay thank you. Yeah, and I’m proud to share this. It takes a lot to start a practice and trying to obtain information. It was a challenge, it’s very time consuming. So let me do what I practice. And then I can…yeah, I have access.

PRESENTATION
Okay I’ll just jump right into it. Okay, so what we’re gonna cover… how pharmacist collaborate with physicians? What is an advanced practice pharmacists? I’ll try to go quickly over that, ’cause that may not be interesting to a lot of people, but I think the pros and cons of cash-based telepsychiatry will be important considerations if you’re switching over from a third-party payer system over into a cash-based practice. And practical tips in getting started. And then I’ll answer any questions that you folks may have.

Okay, so I think the first thing is also, you know, have a goal. And so the goal of telehealth in general has been increased access to quality patient care. That’s also the reason for advanced practice pharmacist evolving into physician extenders, is to increase access to quality patient care. And I’m sure all of you already know the definition telehealth, but it’s kind of hard to jump into a presentation if you don’t define what it is. So telehealth is basically an intervention telecommunication to communicate with a patient. And telepsychiatry of course, would be a subset of that. Again, from the quickly through this part, you guys already know it.

Okay, so what is an advanced practice pharmacist, it’s basically a new category, but the thing is, there’s always been clinical pharmacists. And there is always been pharmacists on parts of treatment teams. California kind of spearheaded in the United States. The ability to kinda formalize it and have an additional license. Other countries have used advanced practice, pharmacists as well a United Kingdom, Canada, Australia and in 38 other state. They permit collaborative drug therapy management between pharmacists and physicians.

Okay, and then, what else is special about it? While we have between two to four years with additional training. Clinical supervision and testing were primarily physician extenders, and we’re focused and specialized areas of pharmacotheraphy.

Okay, and it’s not just like the the psychiatric pharmacy, but there are several. And there are some other organizations as well, but the Board of Pharmacy Specialties is the most recognized in our industry. And so we am care, critical care, nuclear nutrition oncology, pediatric, generalize pharmacotherapy and lastly, my specialty which is a psychiatric pharmacy.

For qualifications. So there’s a licensing side and there’s a board certification side. For the licensing side, they’re rigorous about compliance, so we have to either have board specialty in relevant area, complete a post-graduate residency, or a third option is 1500 hours of clinical experience under collaborate practice agreement within ten years, but that separate from what’s needed for board certification. So for example, myself, I had four years of additional supervision before I sit down for examination.

Enough of that, one more thing. So what can an advance practice pharmacist actually do? They can perform patient assessments, or interpret all drug therapy related tests. We can refer patients to other healthcare providers, which is something I commonly do and, of course, drug therapy management. You know, initiating adjusting based on treatment outcomes and is performed or protocol and in collaboration with a treating prescriber.

So, one difference between nurse practitioners, PAs, and pharmacists. Is that, if you’re not supervising physician, it’s a collaborating physician, so we kind of maintain or an insurance and are responsible for our actions may be a little bit more. Not that they’re not, but track it down here.

Collaboration
So here’s what a collaborative agreement looks like. This is one I had with Doctor Smith; his my collaborating psychiatrist. And so basically, we define our scope of practice, what we’re gonna do, and either you can have a collaborative grief or you can have an order to provide drug therapy management for a patient on a page by page basis. Or you can have a protocol. So like Dr. Smith and I, we see lots of patients so we just have a protocol between us. Basically, I perform things, but if something’s not going well with the patient then I’ll refer back back to Doctor Smith.

Pros and Cons of Cash-based Telepsychiatry
Okay, this is something to be interesting that everyone, I hope, the pros and cons of cash-based telepsychiatry. And who’s better as a metaphor than Clint Eastwood.
Okay, the good side of things. And it’s kind of interesting question, too, because cash-based telepsychiatry, we’re looking at from both a patient perspective, a clinician perspective, but then also these are two different things as well. Where you have a cash-based and you have telepsychiatry. These are four different things to try and think about. Because we’re not just asking the question, “What’s the benefits of telehealth? We’re actually asking the benefits of telehealth that someone’s paying for out of pocket.

So the good.
Patient. There is more availability, so patients feel very cared for you. One of the things I first started doing this, it was all just kind of fear that you wouldn’t be able to have very therapeutic relationship. And it’s actually the opposite. People are much more comfortable in their own homes, they like the idea of not commuting to some place. It’s really been a big plus. So, in reality is actually enhance therapeutic relationship. Much more patient panel, in translating the better care, there’s no waiting rooms for the patient. It’s easy to collaborate on difficult cases. The population I serve a lot of times there is a behavior analyst, involved, there is other doctors involved staff and you can collaborate with everyone using this technology which is good for the patient.
It’s great for families, when there’s more than one child. Convenience and access to care, offset out-of-pocket cost. So, when I charge… I mean, essentially, it’s the price of an expensive gym membership, right? And a lot of people first here, like you on accept insurance, but then they see what is being offered, how they’re gonna be cared for and they don’t mind at that point.
And for the Clinician side. Overall, my well-being is enhanced, it’s amazing to have the flexibility to not have to drive some place to not have to maintain office staff and all the costs you go with that. Many times I’ve dealt with patients who have been discharged from 72-hour hold or have been incarcerated and come off not on under medications and unstable. I’ve been attack several times, so for me it’s kinda nice to be able to focus on my interview, focused on treatment planning, without worrying about trying to fight against maybe someone who is a little bit hostile at the moment. So I kind of like that.
I’m responsible for owning for the patient. When there’s a third-party pair. Sometimes can be issues with them not agreeing with your diagnosis and reimbursement, so forth. When responsing to the patient, the proof is in the pudding. if the patient’s quality life is better, and if they’re getting on with their life because you’re helping them. Then they’ll continue to see. So that’s nice. I get to wear shorts. Not today, I have respect for Milton, but I can wear shorts and a tie if I want. Which is kinda cool

Okay, the bad.
And not really that bad. So for a patient, they do wanna be able to use your insurance. I think a general attitude towards health care is people don’t think they should pay for it. That’s not of the general mentality about healthcare. So some patients may not like the fact that can’t use their insurance and they have to pay for it. You have manage first experiences well. So a lot of times you expect the patient to be able to use VC for example, and they don’t have the camera set up correctly or they can’t hear you, and you can’t hear them. That can lead to frustrations, and as we all know, first experience is really important. So just like when you greet the patient the first time it’s the first step towards developing the therapeutic relationship. Now you have another layer, you kinda have to manage to make sure you could still have that. You want that first experience to be good with the patient that shows your trying develop your core with them.
There is a land receive “Scioto medication” So, for example, managing of ADHD, oftentimes do you schedule to stimulant. And so you have to mail that out.
Clinicians, what well with that. So if you wanna represent telehealth based, you kind of have to plan for professional social encounters. So if you’re working in a practice and you have staff and so forth, there’s natural social encounters and is important right for your well-being. So if you’re a solo practitioner are you working from home or even office in place? You have to kind of maybe plan a little bit more, for your own mental health.
Less patients can use your services, so generally just find that trading neurotic kind of range type patients are not that ill or the ones that kind of pay and it’s kind of like that. So the less patients can use your services ’cause generally they’re gonna be healthier and employed. Although there are institutions that will also find your services valuable enough that they’ll pay out of their budget. And I kind of mentioned this before, there’s a reliance on others for physical assessment, blood pressure monitoring and bleeding. Sometimes we you ask a family to monitor their child’s blood pressure, and get some really interesting readings. So it’s something that really you have to plan for.

Ugly..
it’s a very strong term. (Patient) So the only negative big negative I think, for telehealth in general, for outpatient psychiatry is when the patients try to use you for emergency situations instead of using emergency services like 911 or certain hotlines for for suicidal thinking. Using you for that, which can be a mistake and that can lay care and emergency.
For the clinician, I think sometimes I feel some risk with HIPAA violations, cause someone’s in their house and other people are walking around and here you are talking with the patients. So you kinda wonder. So you kind of have to manage that as well. A little bit funny but not too funny is I do have two children, and they come home from school at 3:30 and then my heart starts to beat, because I know when they come through they’re gonna be loud, they’re gonna arguing and they might come into my office, which is not great. So that has to be managed. And if you promise 24 hour availability. So don’t think they talked about before doing this presentation was not to use a term, concierge that’s kind of falling out a little bit, but in general, if a patient’s paying you, they’re gonna expect better service, so you have to keep that promise.

Important Considerations of Switching Over
You gotta know your why, why do you wanna do it? For me, it was more an issue of less patients to manage and manage them better, so that was important to me. And also, again, the flexibility of being elsewhere than your patient is and still be able to care for them. Some of your patients will need… so if you already have an existing practice and you’re moving over to cash-based only some of your patients will need to be referred out to another clinician and if you can carry them a long time, that can be difficult, depending on their psychiatric history, so you have to plan for that. You have to become comfortable selling your services. It’s something where you feel kinda icky about it ’cause you don’t feel like you’re selling widgets, you’re selling health care and you have to get over that hump a little bit that really you’re providing a message of people saying, “Hey I’m here, but you’re not providing a hard sell and sometimes that can be hard for people. It was hard for me to kinda do that, right? And you have to have referral sources. You have to have sufficient savings as you work on obtaining new patients, ’cause you have to be able to pay your bills and loans, and what not. Most people should really discuss this with their insurance carriers as well, to make sure that they cover telehealth. And was kinda cool when you’re on a team, or you’re in a clinic someplace, usually there’s cross-auditing of patient records. So I think that’s still important and you kind of have to build it in to somehow you can get feedback on your case load. Otherwise you can all be all kinda need to be kinda readjusted sometimes on how we assess and treat.

Practical Tips on Getting Started
You have to have a business and a working plan. It sounds so cliche but you’d be surprised how many people to set off and don’t have these. It’s really important. And actually as you write these documents, it’s almost like an exercise and asking the Y again and really whatever mental image you’re gonna have look at practice is gonna look like is gonna become much more clear as you’re writing these documents. This was something I think is really helpful is used marketers with health industry experience. Because you got to use social media marketing for sure, you got to have an online presence and general marketing. There’s a lot that goes into this and having someone with health industry experience, can be great. It does, it can become expensive. So again, you have to really look at what your goal is, then you try to predict. I spend 5 hours on marketing, but I make 20 dollars in service fees, so you have to kind of figure out what that is, what your ratio is gonna be.
You have to know how to obtain your patients and have amazing customer service. So it becomes kind of different. So I think for a lot of clinicians, is like there’s more patient need than providers. So supply-demand. So sometimes, that’s why I think some people, how do I say this? We expect to get picky. Sometimes you might not provide the best customer service but you have to change that attitude, ’cause now you’re searching for the patient and their expectations are higher. So they call, you answer or you have a service that’s gonna do that for you. If someone goes on your website, there should be an immediate way for them to read you. So, web design becomes much more important. You have to use proven technology platforms and I research is a lot. VC was probably think the second or third company I looked at, but they have so many users and it’s so solid, once you tried out their app, it’s really amazing. So that, I’m a huge user of Google apps which is also a HIPAA compliant. So really kind of figure out what technology you’re gonna use and how not to make it overly expensive, that is gonna be really important.
The other thing is kind of practical is not to take in too me new intakes at a time. If you’re very aggressive in your marketing, and imagine trying to handle a hundred new intakes in a month, and so manage your other patients that is to be very difficult. So you also have to kinda bounce out, how many patients you can take. Then sometimes you have to turn down your marketing efforts a little bit as not to get too many; ’cause if you start to delay the intakes, like I try to make sure that if its a referral, I see them within a week. To me, that’s good customer service, and if it goes up, I can or met the expectation then I’m not providing what I am promising. It’s important to do your practice or organically grow. My patients are actually self referred, they’re people who have learned about my service from other people. Now they come to me, so I just have some money on marketing early, but at the end of the day, it’s really people that know that you’re there and they come to you.

Philosophy
It’s important to have a philosophy, so our mind and actually well for therapy works is low commission to client ratio. Being very client-centered saying they serve is like, I always make sure that if I get a message from VC, I’m answering it within of that hour and I never do not answer emails that I receive during the day, so I let make sure that taken care of. So being highly available, service-driven, and really provide high quality care at of course means keeping up on learning and changes in healthcare.

B: So I’m open to any questions you folks may have.

A: Chris, thank you so much for that great presentation. So I guess for the audience members, we’re gonna open up to questions and feel free to just have your question there.

Question and Answer (AQ = Audience Question) (B = Answer)
AQ1: What are the Google apps that are HIPAA complying that you have used?
B: Okay, so when you have to use a contact Google, I forgot what it’s called, but it’s the provider agreement thing. And so essentially, Gmail is actually as far as I know, all the switch are, but you should also contact Google yourself and make sure. But yeah I use their across the board.

Okay, great. One sec, let me just put this up. I guess I have a question here.

AQ2: How do you start a marketing program from scratch?
B: Yeah, that part is difficult. You know what, I originally… Okay, so when think of what to focus on were institutions that were looking for psychiatric providers. And so for that actually, my very first effort was, actually, with telemarketing. But I make sure that it wasn’t gimmicky. I’d make sure that the purpose was to let people become aware that we exist and then over several months the clients are to come. I am looking into social media marketing, but so far, I mean, not enough referrals I haven’t had to do that yet.

A: I got it. I guess, Chris, my question. For sample, I mean you have a lot of referrals but your very successful to establish a physician. So if you were to give the say psychiatrist with maybe a slightly new or either like a rule of thumb you can give you know for example if you have so much years of practice and maybe that you don’t really need to do any marketing or maybe if your new you have some guidelines you can share with the audience.
B: Yeah, so its kind of the fact. As much as I try to educate myself about marketing, I could never educate myself enough. So my option was gonna be, if I was to start with being completely unknown, I would go to a marketing company that specializes, cause they’re formally trained and we all know how important that is, and also they’re experienced in healthcare marketing. I can’t think of the name of the firm right now, i don’t know if its appropriate for me to say it, but there’s some you can research.

A: Got it. Inside marketing firms, are they doing things like SCO for you? Are they doing like advertising on Facebook? Like can you share, what do they usually do for you on the market?
B: Okay, so again, I research all this and, and they can do all those things for you. The thing is, though, sometimes it can be several thousand of dollars a month. I remember they see us and they think deep pockets. I remember the racial proposal was 6,000 a month. And I’m like, “No, my practice is not that big yet.” They can be a little a few hundred dollars a month for someone that can do Facebook and do your website. And SCO is important but it’s not as important as it used to be.

AQ3: Do also do a group therapy sessions, you know practice as well with you only?
B: No, no. So for mental, So, there is usually supportive psychotherapy, you know a person that gets you moving on getting your career going, your self-esteem esteem and everything. I spoke with Dr. Smith about this and we decide we really just focus on pharmacotheraphy and we prefer out. Cause in my experience, other psychiatrist and psychologist should be providing therapy if that’s what the patients needs and we have to focus on medication therapy management.

AQ4: So, she’s an alternative medicine practitioner specializing a formal Indian medicine so she often needs to refer to a psychiatrist, with a therapists. So she’s asking, so for example, how would.. if she has a patient or a particular client that lives in a particular state. What’s the best network for her to find a psychiatrist maybe like yourself that she could refer to?
B: I hate talking about my competition, but, there are some large practices out there or actually not call them practice. They are large organizations and they offer telepsychiatry. These are business-to-consumer type and then maybe you to can google them. So yeah, that’s how you.

A: I guess my hunch, you know there’s a lot of this that are big, where you can find these psychiatrist. My hunch is she’s probably looking for more like independent like you. Like if she has a relationship in the future, like any time she gets in California she could refer to. She’d know the next person to see in New York she could refer to. It’s more like that type. A therapist she could build a relationship with.
B: Patient reviews are so huge now. So I think you just google whatever that city is and type in telepsychiatry I think you’re gonna get the big players, but I think also you’re gonna come across solo practitioners, as well. Where they’re good at what they do go.

AQ5: Is telehealth a more practice insurance cover in all states? And specifically, are there any companies you would recommend that’s buying and practice insurance.
B: I think you have to really research that on your own. You know the policies can change. I use HPSL just because I always used them. It covers me for, but again, this is like on those questions, I get scared to answer. I am sure it’s really important to kind of call around and see. Or maybe if you have colleagues or practicing telehealth.

AQ6: So as she’s asking, so how many prominent types do you just have? Do you just have initial and follow-up? Would you have more like depend on the types or follow-up?
B: And that’s a great question. Cause I’ve done a couple of things that are i think a little scary. I’ll tell you why, because depending on what’s going on with the client, with the patient. So basically, what I offer, I offer an initial intake. I usually takes about an hour, I also worth record review and so forth. Then what I have is it’s a subscription service, and so I charge a monthly fee that’s automatically paid, I don’t have to chase patients down for payment. But what I promise is, for example, during that adjustment and you just need to see them briefly, I don’t share juncture for that, or they’re not doing that well, I don’t charge extra. So I call them brief re-follow ups, so we do message for follow-up, but there’s something’s going on or an adjustment and some one’s having a side effect or whatever. I call his little urgent ten-minute sessions, and I just kind of build it into my days all. I always make sure I have ten minutes in between patients so that I get involved with the patients.

AQ7: He’s asking. Do you have this patient have the search of financial commitment like, for example like a sign up with you six months or one month or whatever?
B: No, ’cause I don’t think it’s good to, for this industry, to kind of do it that way. The therapeutic relationship is not there and when the not comfortable with you, then they should be able to go to a different clinicians to receive care.

A: So Chirs, I have a question. I your presentation you mentioned, you charge roughly where comparable to may be expensive gym membership fee. To me, as like my reaction. I feel like that’s really way under charging your service. if it okay to ask how did you came up with that pricing.
B: Some of it is kinda like… and it’s not that low, it’s not like….its high. Actually Milton and I, we actually have lunch one time. And I remember the reaction. I get me as well as I was like I was a car to charge the way.
Yeah, I don’t think I’m under-charging in the sense that if we’re providing a twenty-minute follow-up and you’re seeing like three patients or two, two or three patients. So I guess for me, I guess I never thought healthcare needs to be so expensive and I don’t have staff, I got enough for renting in office, but the overhead is really super low. And here’s the thing, especially to start my practice off at the beginning is I grand further people in. So, their rates whenever I increase ’cause there were times is naturally going to happen, they are gonna go up, but the initial patients that come with me, special organizations are using my services. It was an incentive, but I was gonna go over.

A: I see. Okay, got it. I think maybe is still my advice to most physicians. So, they can probably charge more like you.

AQ8: How do you handle providing service across state lines?
B: I think legally, I need to talk to my insurance care about this is, and actually say for it. If great comes down to down the board in that state, where you can do, what you can’t do. But I think in some cases, you can consult, but you definitely can’t treat unless you have a license to practice in that state. But again, this is kind of a question for the whatever a medical board or the pharmacy is and also insurance carrier. Maybe a short consultation with attorney would be really good to.

A: Okay, got it, got it. But I have a personal question first. So you mentioned, so you don’t have any staff, do you feel like you gotta have a virtue of like a front desk person system that takes away some of the busy work, then you can even provide better spend more time with a patient when you feel like just not necessarily. The reason I asked you, is you can actually have some of these who are, once you do tele-medicine, you could have the virtue front desk people. Those are totally expensive.
B: Yeah, yeah, so I see kind of a milestone. So, as I got busier and busier as the practice is growing, we’re not completely fully yet, so as we start to get more full then definitely, we have to staff. And then also the competitive me, then you want to add more clinicians on and…yeah

AQ9: Okay, got it, okay, that makes sense. And so we have a question from the…She’s a pediatric nurse practitioner who provides a primary care, but she’s seen the process of integrating mental for children adolescent with different practice. So she’s asking if you have any words of wisdom on how she can proceed.
B: As far as, yeah, I mean if she wants to provide services for kids and adolescence I think she definitely should work with pediatricians and refer. Cause, actually when I was at the Department of Developmental Behavioral Pediatrics, when I was at CHLA and a lot of doctors become uncomfortable and prescribing psychotropic medications to children in adolecence because it’s off-label, and there’s a lot of liability with that. So I think if you simply network with pediatricians, you can get any referrals for that, especially when it goes outside of impulses words, right?

AQ10: How long are your performance time slots?
B:So its an hour for initial intakes and then 20 minutes for med follow-ups. And I’m have been experimenting with patients kind of, they actually pick their time slots themselves. So it’s so far has been working out. The only thing is, sometimes it gets a little bit weird that you need to follow-up with a patient. And they didn’t schedule themselves, so sometimes you have to track it, and like “hey we really need to see you again, we started doing that and this.”

AQ11: Yeah, so I have a question from Alex, he’s asking. Did you ever accept commercial insurance before, and if so, why did you stop?
B: No, I didn’t. I spent 20 years in the regional center system. And then I decided to go off on my own. And at that time, that was our paired and so yeah.

AQ12: This question is from a Christian. Maybe it’s slightly covered, I guess I’ll ask for her again. She asking if you can speak about sort of reimbursement. How do you feel, how do you collect how do you establish your fees and relate this to potential patients assuming you’re just essentially is just monthly fees?
B: Yeah so I just kind of based it on, when my previous fees were and that’s how I can have established it. Again, I’m gonna increase the rate, but to start the practice of initially I offer, not low, but it’s not like 250 dollars an hour to see the patients, you know. Yeah, but as we progressed, the rates are gonna go up. But to start off, and actually maybe I was not quite aware of what I was doing, but maybe that was a mechanism to kind of get the practice often going as I offer organizations with low rates initially.

A: Yeah, okay, in terms of I get a part of her question is like how do you relate this to a potential patient? You just list this on your web page or is there like; the reason like or like my hunch what she’s asking is often doctors don’t like to talk about money….. How do you do it?
B: I kind of shifted paradigm a little bit and the way I think about this so I kind of goes back to customer service a little bit, so I think more about this. So I’m very transparent with rates and everything is on the website and as the rate goes up, we’re gonna of course update it. Yes, on the website, so people can make a decision and again, I think it kind of boils down to the convenience and the quality of the service, which I try to keep high standard with.

AQ13: Question from Roberts again. So he’s asking how can you handle HIPAA Compliant record release?
B: Yeah, so I built, I think whatever I could with Google I’ve done with Google, so I built and take forms and awesome you see that lot platforms as well. But yeah, I built forms and that’s how do it.

A: Okay, so I guess I have a question. By the way out of all the webinar, we have done, you just get a lot of question, the questions are like flying in. (…)

AQ14: I have a question from Susan. So what are your patient notes, if you don’t have insurance, requirements, what do you actually document?
B: Yeah, so when I was in CHLA, I mean it was rigorous. You know I document everything as if I have to report to someone and plus you know all the collaborating psychiatrists I would be embarrassed if it won’t turn out well written. So I kind of use, I can use a self formula a little bit but.

A: Okay, so it’s basically it’s a self format and nothing fancy beyond that.
B: Now I mentioned certain things that are important. You know making sure they’re compliant. I always document how functional they are, which is the main point.

AQ15: Okay, so I have a question from (…). So if you see a patient have need for a social worker, a case manager or occupational therapy or maybe even a other psychiatry, how do you handle those cases? Do you have a referral, so you refer them to this? Or like, health professionals were like..?
B: Yes, a lot of my patients are already in those type environments where there’s already a network of people and then have another subset which are individuals and families that come to me. And so far, I’ve been trying and I know Milton’s gonna be angry or not but better help is something I’ve been looking at is kind of a collaborating partner.

AQ16: Okay and then I have a question for Krista, asking, So do you have an initial phone contact with the patient to discuss payments in charge or do you just..?
B: Alright, that’s actually interesting ’cause all we’re transparent on the website, but I get the call, or a text message asking. So yeah, I disclosed the point,

AQ17: Okay got it, okay! what will play in terms like the things like the patient agreements consent and stuff, do you just a web from to take care of that?
B: I do everything I can electronically. So I have all the consent or thing stuff using Google Forms.

AQ18: Okay, I guess one of the questions from Alex; so if you have, let’s say a patient who’s having a suicidal practice but refuse to hospital and like do you call 911 for them, or.
B: Yes, I have not have any patients in crisis like that yet, you know manage patients with suicide personality, I have not been to that kind of crisis yet. And again, a majority of the other patients I am sing right now are in a group of environments and so forth. So the caregiver would do that if it was a patient on their own. Yeah, I would definitely call 911 because I know where they live, and I can help out that way.

A: So in your presentation, you mentioned briefly so you know the concierge. You slightly; you didn’t wanna calllightly call you dismay. Just speak a bit more about that. So can speak a little bit more about that?
B: As I get that input ’cause on my website, talk about the concierge practice that’s while it’s a great idea, it sounds nice and everything. And then I just, I don’t know… I thought about was this term is not being used this much. And there are some doctors who felt offended by it. ’cause you think of concierge I don’t know, some of our service. And so, being polite and everything I changed the terminology I have nothing against it, myself.

A: I see, got it yeah. I know it sort of like to feel like where you’re creating. Is it high quality, cost-effect the concierge service. Its actually a good confrontation.
A: Okay, traffic in there. I guess for the audience members. If you have any other questions, please. We be and maybe ask as we’re wrapping up like that you for showing us your youth side.. Audience member, you’ve had any further questions, feel free to… you could compact as incisor the questions and that this can be in Christ. Do you have a web page or other things that you can, interesting as paramotor? How can people find you.
B: On the therapy works to TV or we reach there. Okay, I guess my contact information is not on the information I went out friday or.
A: Yeah the web page and yeah we do include the link and there. SO how about that, both direct people that go to your side. and they can ask you have more wisdom? what did I keep it a guide and make an ask you to get more Wise man I’m cute you. You got to have more. Some patient definite refer to.
B: also, the questions were amazing. Some of them challenged me, but that’s pretty cool. So it may be consider more things to.
A: Okay, terrific! Have another question for Robert. So what are your on call mechanism do you provide that on call.
B: I feel like a lot to VC or even though I recommend the VC app to patients they still tend to text me a lotdo a lot of a lit of a lot to the VC app to patients they still kind of text them a lot. It’s great and also is cool about texting? So what cool about texting kinda wanna get to see grain a little bit like never give out for information. You said blemishes or If you problems and if you promise unlimited follow-up, they’re gonna take advantage. Things haven’t happened but anyways, I like texting because you can keep it focused and then you don’t have a patient that get them more circumstantial and you never get supported what they want. So texting is my favor either through the VC app or you know the patients.

AQ19: Do you provide a cold or super bill will voice the patient, so the patient themselves or try to go get the insurance to cover?
B:No, if I would provide it. So there’s two different ways on reimberse. So, it is through an organization, they prefer the sentiment invoice it is the individual. I choose an online payment system but that you know what that means, that they would receive a receipt? Naturally from The.
So they do receive something but it’s not ideation. Super bill. The testing.

AQ20: And there was a couple other questions, apologize. We’re not able to work, coming down after the hour, we have to get to all the questions. Apologized to the audience. But I will pass these information to Chris will post these responses that one would make the recording available when you post on the website, and that is, as we are wrapping up, so we have these… or maybe for three final question, the first question is, in your show a bunch of interesting inside Chris’s audience member can only learn one thing from you today, like, what do you want them to walk away with?
B: Well, You can do it and people know you’re out there, and you’re providing a good service you’re making a long service, you will get the referrals organically and people will be willing to pay for that service.

AQ21: Got it, okay. That’s actually very nice encouraging hopefully audience member can just dive in The next question is, what is this one thing that you believe about telehealth that the rest of the world do not believe yet.
B: Wow, I see it becoming more, I think it has a future actually. It’s disruptive to the way we practice in a way, and that scares a lot of people. In medicine in general even if something that sounds until… until is proven scientifically, I don’t believe it is, I just think that it’s gonna progress and its going to become much more accessible to people and people are using this platform a lot more. Because of the convenience and the huge cost savings.

AQ22: Then the last question is, so you if you have let’s say a couple of minutes to talk privately with President` Trump about telehealth idea, what idea will your plan?
B: I can make a really bad joke and say you have more money to work on the wall but that’s terrible. Not really, not for that. I would just encourage you know what, I think more research in the area would be great. Cause one of the things, you know larger institutions and everything in adopting telehealth, is again is a proven to work and there’s the economics there. So I think, sorry, I think more research in areas convince people to adopt it. Who happened so far.

A: Okay, that makes sense.. I think having a really high quality research back up , too much right now to clinical evidence that makes me either. And then uhm, thank you so much for you time. I guess, and kept up our finishing advertising. Yeah, basically I thank you so much for your time, I guess for the audience member, we’re pretty excited, we’re getting ready for our telehealth. Secret conference is gonna be held in October 2nd view the fort and will have a bunch of really interesting physician will be in doing there. I think mingling there. I think its pretty.. interesting to meet Chris, in person. I think it will be a hang out there. We can have a bunch of live interesting physicians share ideas. So this year, our there is called the New revenue models and happy doctors. Maybe Chris to leading the charge on that. Friends definitely is a interesting place in our sons. On discount, I think a little more longer. The discount registrations would be super happy to see in the Silicon Valley. October. And thank you so much, Chris for a sharing your insights with us.
B: Thank you for inviting me.
A: Okay, thanks Chirs.
B: Thanks, folk.

About the Speaker:

Dr. H.R. Christopher O’Brien, is the founder of TherapyWorks.Tv – a pioneering private telepsychiatry and pharmacy consulting group. He is a board specialist in Psychiatric Pharmacy, and an Advanced Practice Pharmacist. He is also an original co-founder of the Bio-Behavioral Consultation Clinics and has consulted for the Regional Center system for 19 years and at the Sonoma Developmental Center with a focus on developmental disabilities and child adolescent psychiatry for 7 years.

Previously he was the Director of Pharmaceutical Research at NuGene Biopharma, managing clinical trials and the development of new topical products. Dr. O’Brien received his Pharm.D at the University of the Pacific and is also certified in Cognitive Behavioral Therapy. His current focus is the delivery of psychiatric medication management through Telemedicine.

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