1. I never made money off consults. Patients didn’t have psych coverage, wouldn’t pay their bill, or the insurance found a reason to deny the consult. Penny wise and pound foolish but a fact.

2. I never made money off the referrals from most primary care docs who refered patients. Most tended to refer the “tough cases” which meant people too impaired to work and pay their bill or have good insurance. Most tended to send most of their other patients to non-medical therapists thinking that they would refer them up the chain if need be. One criteria for getting refered up the chain by those folks was inability to pay + huge clinical needs.

3. The result of 1 and 2 above is that being available to do consults in the general hospital setting is big business drain on the practice of most psychatrists practice, unless it is supported by the hospital in some way.

4. Therefore, psychiatrists are notoriously unavailable for hospital consults. The same business barriers to availability apply to urgent outpatient consults for primary care. But there is a way, other than institutional subsidies, around that . .

5. A mere handful of primary care docs who actually send all of their psych referrals to one psychiatrist are enough to keep his practice busy. If the pcp’s practice is a healthy mix, the psychriatist’s practice will be as well. He can then refer those who will do well with a non-medical therapist after a good evaluation which they ought to get anyway. 4 or 5 family docs have enough people in their practice to keep a psychiatrist hopping. And if he has any sense, he will be able to afford and more than willing to see their consults and help out. Otherwise, if he is just being sent the most desparate cases, a private practitioner just can’t afford to be too available for consults.