June, 2014. Our numbers are down. I knew it from keeping track of new patient phone calls. In the past I would get two to three new patient calls a day, sometimes as much as five a day. Lately, I would get one or two, and some days none at all. My associate’s numbers are down too. She’s been coming in later, leaving earlier. Some days she hasn’t been coming in at all. I asked her, “What do you think is going on?” She answered that she felt it was the Affordable Care Act. She linked it with the increase in high deductible health plans. I disagreed. “I think it’s increased competition” I offered.
I wasn’t sure our numbers were trending down until I collected the data. Since I keep track of every new patient phone call, as well as every new patient that comes in the door, it didn’t take long. The new patient calls I took for the first six months of 2013 were, on average, 47 per month. In the second half of 2013 I fielded an average of 37.7 per month. In the first half of 2014 I returned an average of 33 new patient calls per month. That’s a reduction of 30% from the same time the previous year.
The number of new patients actually coming in for a first appointment has been holding relatively steady. In 2012 I saw a total of 233 new patients at least once, for an average of 19.5 per month. In 2013 I saw 215 new patients, for an average of 17.9 per month. In the first half of 2014 I saw 113 new patients, or about 19 per month. I also track the new patient “no shows,” and those have increased substantially. I attribute this to scheduling appointments with low functioning patients I might not have been willing to schedule in the past.
So, what about my theory that the lower numbers are due to increased competition? I decided to take a look at who was out there. I first came to Gwinnett County to build a practice in 1980. A social worker and I, as the junior staff at a group practice in Sandy Springs (in urban Atlanta), were sent by the psychiatrist owner of the practice out to Gwinnett County to establish a satellite office. He saw the area as a prime opportunity. It was a rapidly growing bedroom community of Atlanta, and there was no one out there. Actually, there were two psychologists in Snellville who soon moved away, and there was one psychologist in Lawrenceville and one in Lilburn. So, it was wide open.
My associate, Stan, and I opened an office in Lilburn and agreed on a marketing strategy. I would visit the physicians in the area and he would visit the school counselors. We printed up business cards and went to work. We had a busy practice within six months. Within a year we added two more social workers. Initially I supervised them on their clinical work, but by 1990, managed care had taken over the field and they were contracted to work independently. In 1996 I left the group and moved to Duluth to develop a practice of psychologists only. In a few years I added two other psychologists. We’ve been together for over 10 years now.
Gwinnett County, for many years, was a fast growing area. It is a suburban area of churches, ball fields, and shopping malls. Here is a quick view of the population growth in my practice area: 1980 – 167,000; 1990 – 353,000; 2000 – 588,500; 2010 – 805,000; and in 2013 – 859,300. For various reasons, one of which was the location of the Immigration and Naturalization Office on Buford Highway, it has always been the go to place for immigrants settling here. Hispanic, Chinese, and Vietnamese families settled in Norcross. A large Bosnian community formed in Lawrenceville. Indian, Pakistani, Bangladeshi, Caribbean, and Nigerian families are sprinkled throughout. Wikipedia lists 17 Islamic mosques and schools in Gwinnett County. Duluth, where I work, is called Little Korea, and is now the home of 50,000 ethnic Koreans.
So, I wondered, how many psychologists are out there now? Should we relocate our office to a newer, less crowded area like Suwanee or Johns Creek? I started a Google search for “psychologists, Duluth, Georgia.” Since Google brought up non-psychologists as well, I made a list of the master’s level counselors in private practice along with the psychologists. There were quite a few. I began to expand the search to the other towns in this county. Then I asked my office manager to find the websites for BCBS, Aetna, and United Behavioral Health and see if we missed anybody. She did, and the list got longer. It took us many weeks to tabulate the names, addresses, and credentials of the mental health providers in Gwinnett County.
Given the population growth since 1980 I anticipated finding perhaps 30 psychologists and 30 to 40 master’s level therapists. The numbers we found were far beyond my estimates. Here is a breakdown of what we found:
Psychologists / MSW’s, M.Ed.s, LMFT’s / N
Duluth/Berkeley Lake 30 20 50
Suwanee 18 38 56
Johns Creek 12 20 32
Norcross 22 21 43
Lawrenceville 23 35 58
Dacula 7 9 16
Lilburn 13 9 22
Snellville 11 19 30
Buford/Sugar Hill 4 14 18
____ ____ ____
Totals 140 185 325
We found a total of 322 psychotherapists in private practice within a 10 mile radius of my office. That is a staggering number. That does not include the psychiatrists. I thought there were perhaps 10 in the area, yet our search turned up 46. Even the new communities of Suwanee and Johns Creek are saturated. The population in Gwinnett County has grown fivefold since I opened an office in 1980. However, the number of mental health providers in private practice has grown 53 fold, or more than ten times as fast as the population growth. This area might sustain the practices of the 140 psychologists. However, we are competing with 182 master’s level counselors who have hung out their shingles and are operating next door to us. We simply cannot all make a living here.
I write this article with an interest in hearing from other psychologists about what is happening in their areas. I would expect that the same trend is occurring all over the country. Recently I read Jerrold Pollak’s gloomy but sobering article in the May/June 2014 issue of The National Psychologist titled “Does Psychology Have a Viable Future?” He gives a brief overview of the history of the clinical practice of psychology which I won’t review here. He concludes, “With the exception of testing skills (possessed by a relatively small number of practitioners), our competencies cannot be reliably differentiated from mental health practitioners with considerably less education/training.” This is the same statement which was made to me by a colleague at the recent GPA conference in Athens. He whispered it to me lest someone overhear him.
However, it is true. From what I see and hear in my practice, the public is flocking to masters level providers whom they call “counselors.” I would say that half or most are satisfied with the services they get. I have started to get the occasional call from a parent who is seeking some testing for their child to help the counselor figure out what’s wrong with their child. A few parents seem to know that a psychologist has more training and across a broader area than a social worker, but they are a minority in my geographic area.
Pollak concludes that the solution for us is to align ourselves further with primary care physicians. To do so we should provide future clinical psychologists with training in medical psychology and continue to push for prescriptive authority. In other words he sees the psychotherapy field as eventually being taken over by the M.Ed.’s and the LMFT’s and MSW’s, so we may as well retreat. Pollak is coordinator of the Program in Medical and Forensic Neuropsychology and a staff clinician in emergency services at Seacoast Mental Health Center in Portsmouth, New Hampshire. His recommendations reflect his own survival strategy.
No doubt many of my colleagues would disagree and protest that they are doing well. If so, I would surmise that they have a boutique, part-time practice in an affluent area of Atlanta and don’t accept insurance from their wealthy clientele. I, however, am practicing in middle America where patients choose a provider based on the low co-pay (or no co-pay on their EAP or Medicaid plan) and how far they have to drive in traffic. And they don’t want to drive very far.
My view of this picture is that if we are to have a viable future we are going to have to bring what marketing strategists call “value” to the table. We are going to have to offer services that are different from the “counselors,” and we are going to have to clearly differentiate ourselves this way to the public and to our referral sources. At this time those skills appear to be: psychoeducational and pediatric evaluations, forensic evaluations, both civil and criminal, neuropsychological evaluations, pain management programs, and possibly geriatric evaluations. I have specialized in the first two categories over the years and have been able to have a full practice most weeks, despite the fifty fold increase in providers. I have also increased my marketing efforts which were already intensive.
I have only a few years to go before I retire, but I, too, have concerns about the viability of private practice for psychologists who are in early or mid career phases of life. I look forward to your responses to this article.
Elizabeth Ellis, Ph.D., is the author of: Raising a Responsible Child (Birchlane press, 1995) and Divorce Wars (APA, 2000), along with 33 papers in peer-reviewed journals.