Advice for compensation

[bimmer79]

Hey guys, I rarely post on the forum but really would appreciate some advice! I’m the solo interventional Pain Doc in a group of 11 Orthopaedics surgeons. I’m the first and only pain Doc, currently in my 5th year with them. Good payor mix with average yearly RVUs of 12000. Average 40 procedures a week and 200 clinic patients per week. I collect about 1.15 million on professional services and another 1.25 million on ancillaries (surgery center facility fees, PT, MRI,etc)
No partnership opportunity, just employed.
I do get various benefits, including health, dental, malpractice, profit sharing, 401K, etc. I honestly don’t feel fairly compensated based on annual income including bonus. They’ve changed my contract in the interim as they seem to not know how to structure my compensation fairly which has led to a drastic reduction in bonus.
Can you please give me a reasonable expected annual salary? I’m frustrated and feel under compensated. Thanks in advance for insights.

---

Members don't see this ad.

 

[thecentral09]

Im curious what others will have to say. I am a hospital employed doc so I don't have much to add regarding this as I am largely salary based, however looking at the 2016 MGMA info says the median total RVUs for 2016 for anesthesia pain was 15,931.
It sounds like you are working a lot more than most, as you are seeing 240 people per week. Which is an insanely high average if you ask me. That should produce much more than 12000 RVU/year.

 

[Timeoutofmind]

Hey guys, I rarely post on the forum but really would appreciate some advice! I’m the solo interventional Pain Doc in a group of 11 Orthopaedics surgeons. I’m the first and only pain Doc, currently in my 5th year with them. Good payor mix with average yearly RVUs of 12000. Average 40 procedures a week and 200 clinic patients per week. I collect about 1.15 million on professional services and another 1.25 million on ancillaries (surgery center facility fees, PT, MRI,etc)
No partnership opportunity, just employed.
I do get various benefits, including health, dental, malpractice, profit sharing, 401K, etc. I honestly don’t feel fairly compensated based on annual income including bonus. They’ve changed my contract in the interim as they seem to not know how to structure my compensation fairly which has led to a drastic reduction in bonus.
Can you please give me a reasonable expected annual salary? I’m frustrated and feel under compensated. Thanks in advance for insights.

Unbelievable. Your productivity is astounding.

You would be killing it so hard if you were a hospital employed at some reasonable amount like $60/RVU. Do the math

How do you see 200 people in a week!! That is 40 people a day five days a week. And then do 30 procedures on top of it?

 

[Victorinox]

Curious, are you PM&R?

 

[thecentral09]

I see. you mean wRVUs/year. not RVUs. Yea you are way over the 90th percent MGMA. should be a mill plus some in compensation

 

[Blitz2006]

Unbelievable. Your productivity is astounding.

You would be killing it so hard if you were a hospital employed at some reasonable amount like $60/RVU. Do the math

How do you see 200 people in a week!! That is 40 people a day five days a week. And then do 30 procedures on top of it?

Here in NYC area, average pp pain doc sees 40/day (15 procedures, 25 clinics per day)...so 200 TOTAL (clinic + procedures)/week is pretty normal I think (in the non-academic, PP world).

Is this not the case rest of the country?

 

[SSdoc33]

there are a lot of variables here.

if you really want to know whats fair, you need to give your location and what you are actually taking home. PM me if you dont want to post it on the forum. ill let you know how many RVUs i produce, my salary, etc.

without giving us ANY additional info, assuming you are practicing in a relatively desirable area, you should be bringing in >500k. some on this board will hoot and holler about percentages, and eat what you kill etc, but in the real world, the numbers dont always work out that way.

 

[Dr. Ice]

Pp in northeast. I see about 100 pts/week, 5-7 emgs/week, 20-25 procedures. I feel like that's a decent amount but that's nowhere near the op. I have no pa or np though. I actually feel that by myself with all the other things involved in patient care, I feel rushed with the ov.

 

[bimmer79]

Unbelievable. Your productivity is astounding.

You would be killing it so hard if you were a hospital employed at some reasonable amount like $60/RVU. Do the math

How do you see 200 people in a week!! That is 40 people a day five days a week. And then do 30 procedures on top of it?

I know, I'm feeling the pain! I have 1 mid-level working with me in clinic, which helps, but it's still rough. I don't mind working hard, but just don't wanna burn out if I don't have the incentive.

 

[bimmer79]

Pp in northeast. I see about 100 pts/week, 5-7 emgs/week, 20-25 procedures. I feel like that's a decent amount but that's nowhere near the op. I have no pa or np though. I actually feel that by myself with all the other things involved in patient care, I feel rushed with the ov.

That's a busy volume considering you don't have a mid-level provider. I do actually have a mid-level that helps me with the clinic, but after salary and benefits are deducted, it doesn't add much to the bottom line, but helps ease some burden.

 

[bimmer79]

I see. you mean wRVUs/year. not RVUs. Yea you are way over the 90th percent MGMA. should be a mill plus some in compensation

Yes, you are correct, wRVUs. I am definitely working in the 90th percentile but I read that it doesn't always equate to compensation in the 90th percentile.

 

[bimmer79]

Curious, are you PM&R?

Yes, PMR!

 

[bimmer79]

Unbelievable. Your productivity is astounding.

You would be killing it so hard if you were a hospital employed at some reasonable amount like $60/RVU. Do the math

How do you see 200 people in a week!! That is 40 people a day five days a week. And then do 30 procedures on top of it?

That's why I'm frustrated! I'm considering options based on research and feedback from you guys and colleagues/peers. I've always heard that working with orthopods was discouraged as others have had similar experiences. Maybe a hospital employed position would offer more incentives.

 

[bimmer79]

Im curious what others will have to say. I am a hospital employed doc so I don't have much to add regarding this as I am largely salary based, however looking at the 2016 MGMA info says the median total RVUs for 2016 for anesthesia pain was 15,931.
It sounds like you are working a lot more than most, as you are seeing 240 people per week. Which is an insanely high average if you ask me. That should produce much more than 12000 RVU/year.

Yes, averaging 200 clinic patients and 40 procedures is killing me! I do have a mid-level that helps, but it's still rough. I'm wondering if the 12,000 is accurate

 

[lobelsteve]

135 per week includes new pt, follow up, procedures. wrvu is 12500 or so.

 

[bimmer79]

135 per week includes new pt, follow up, procedures. wrvu is 12500 or so.

I personally see about 140 patients (new, follow up, procedures) with my NP seeing close to 100, therefore my personal wRVU is approximately what you calculated. However, my total compensation includes my NPs contribution to my collections since her salary and benefits are deducted from my gross totals

 

[drusso]

there are a lot of variables here.

if you really want to know whats fair, you need to give your location and what you are actually taking home. PM me if you dont want to post it on the forum. ill let you know how many RVUs i produce, my salary, etc.

without giving us ANY additional info, assuming you are practicing in a relatively desirable area, you should be bringing in >500k. some on this board will hoot and holler about percentages, and eat what you kill etc, but in the real world, the numbers dont always work out that way.

I'm curious what you mean? People don't "eat what they kill" in the real world? Every month I look at what my real collections (cash in the till) are, what my real expenses are (rent, payroll, equipment, supplies, health insurance, malpractice, taxes, disability, CME, MOC, etc), subtract one from the other and *IF* there's anything left over I get to keep the difference...

Is that not the way it works for you?

 

[Ligament]

How do you possibly see 240 people per week? Do you utter a single word to them? This averages to what 5 minutes per patient? How many midlevels? You should be gettting paid 7 figures per year with this volume, if you are not, you are being raped.

 

[Agast]

Do you have a non compete that prevents you from striking out on your own? Are all your referrals from the orthopedic surgeons?

 

[bimmer79]

How do you possibly see 240 people per week? Do you utter a single word to them? This averages to what 5 minutes per patient? How many midlevels? You should be gettting paid 7 figures per year with this volume, if you are not, you are being raped.

I perform about 30 procedures on Monday and about 15-20 throughout the rest of the week. Tuesday through Friday, my mid level and I see an average of 50 clinic patients together. Salary wise, it's less than 500K working above the 90th percentile. I want to go back to negotiations soon and present a fair bonus structure, considering that I'm not a partner and won't be offered partnership.

 

[bimmer79]

Do you have a non compete that prevents you from striking out on your own? Are all your referrals from the orthopedic surgeons?

Yes, I do have a non-compete for 2 years! I would say that half are from the group and half are outside referrals from the group's affiliates. I'm super saturated and that's why it's frustrating. I'm grateful for the volume of patients, but just can't keep the pace without a good incentive!

 

[Agast]

Yes, I do have a non-compete for 2 years! I would say that half are from the group and half are outside referrals from the group's affiliates. I'm super saturated and that's why it's frustrating. I'm grateful for the volume of patients, but just can't keep the pace without a good incentive!

If you have a good relationship with your referring doctors I would consider striking out on your own and checking to see how enforceable the non compete is. We let a physician go and he joined the group next door and it wasn’t worth the legal hassle to go after him with the non compete. None of the partners wanted to put their own time and money into it. Anyways if you lose half your patients it sounds like you would still be making a cool million in collections provided you are able to invest in similar ancillaries. Do you own shares of an ASC?

 

[bimmer79]

If you have a good relationship with your referring doctors I would consider striking out on your own and checking to see how enforceable the non compete is. We let a physician go and he joined the group next door and it wasn’t worth the legal hassle to go after him with the non compete. None of the partners wanted to put their own time and money into it. Anyways if you lose half your patients it sounds like you would still be making a cool million in collections provided you are able to invest in similar ancillaries. Do you own shares of an ASC?

Yes, I wonder how enforceable the non-compete truly is. It just seems like a huge headache to go through all that too! No, I wasn't offered buy-in for the ASC either. Unfortunately, too many interventional pain docs have experienced what I am currently dealing with and I knew that going into this, but was taking a gamble that it would be different, however it's definitely not.

 

[gdub25]

If you're going to renegotiate, why not renegotiate for partnership? If you're doing that kind of volume and you're generating big revenue then I don't think anyone here would say it's unreasonable to be given a fair piece of the pie. It's crappy if they look at this as a way to make money off of you. Haven't you proven your worth?

To me, if you go in to negotiate and say "I'm generating 2mil in collections, I want a higher salary" it's the same as saying "thank you for the opportunity to work here and let you guys take half of my earnings, may I please have a little extra and I'll gladly let you continue". I am in a private group with one partner, each 50% owner, and each of us keep what we collect minus overhead so that's the world I'm used to for what it's worth. Because I see first hand what the real world numbers are in terms of billing, collections, and overhead I would encourage you to have these actual numbers (not estimations or rough figures) before you start your talks though. Real world math is often much different than you think. I have a similar volume to you and know what income we generate but without knowing you're overhead it's impossible to say what's fair for you to be taking home. Just based on averages across the country most of us agree that overhead is generally around 50% so if you're collecting 2 mil you should take home 1 mil but the overhead % in the ASC/PT/ancillary side of things is probably higher.

Bottom line for me would be: I want to be partner, don't want anyone making money off of me because I'm busy and bringing in good business for everyone, I'm equally valuable to the group as anyone else. If partnership isn't an option then I quit.

If that's not an option for you then my next idea would be find out how much money they are profiting off of you per year and ask for half of it. They'll still make money and you'll be a lot closer to getting all the money you're actually making.

 

[Malayil]

Depends on payor mix and what procedures you are referring to

I would say you should be making at least 500,000-600,000 after paying overhead and NP

 

[Disciple]

Hey guys, I rarely post on the forum but really would appreciate some advice! I’m the solo interventional Pain Doc in a group of 11 Orthopaedics surgeons. I’m the first and only pain Doc, currently in my 5th year with them. Good payor mix with average yearly RVUs of 12000. Average 40 procedures a week and 200 clinic patients per week. I collect about 1.15 million on professional services and another 1.25 million on ancillaries (surgery center facility fees, PT, MRI,etc)
No partnership opportunity, just employed.
I do get various benefits, including health, dental, malpractice, profit sharing, 401K, etc. I honestly don’t feel fairly compensated based on annual income including bonus. They’ve changed my contract in the interim as they seem to not know how to structure my compensation fairly which has led to a drastic reduction in bonus.
Can you please give me a reasonable expected annual salary? I’m frustrated and feel under compensated. Thanks in advance for insights.

This type of set-up is the trade-off for being fed lots of procedures.

If you're not bringing in a lot of business on your own, it gives leverage to your employer and makes you more easily replaceable.

You can go out on your own, but it will require a different practice model/mind-set.

 

[Disciple]

To clarify, if most of the referrals are internal, they can say, "We're not increasing your pay. Don't like it? Give us 60 days notice so we can find a new interventional guy".

 

[nvrsumr]

I thought I worked hard but some of u are animals.

 

[Victorinox]

Correct me if I am wrong, I don't mean to denigrate anyone. I am learning, starting fellowship next year.
But it seems that it is more PMR people that end up working for ortho groups.
still in residency but already I am determined to never work for a group of ortho surgeons.

 

[thecentral09]

I perform about 30 procedures on Monday and about 15-20 throughout the rest of the week. Tuesday through Friday, my mid level and I see an average of 50 clinic patients together. Salary wise, it's less than 500K working above the 90th percentile. I want to go back to negotiations soon and present a fair bonus structure, considering that I'm not a partner and won't be offered partnership.

MGMA would say you are getting less than half of what others are making for the same productivity according to 2016

 

[Taus]

I am in an Ortho group, do a similar amount of procedures per week, but only about 80 office visits a week. I couldn’t handle what you are seeing. Full partner or not, a fair bonus structure is needed. Take home isn’t going to be right at 50% collections in this type of set up, but shouldn’t be THAT far off. I’m just a little under 50% with bonuses and will be over 50% with the type of partnership I’m eligible for in a few years. Overall I’m very happy with the set up, but I know it’s not for everyone.

 

[hyperalgesia]

Yes, I do have a non-compete for 2 years! I would say that half are from the group and half are outside referrals from the group's affiliates. I'm super saturated and that's why it's frustrating. I'm grateful for the volume of patients, but just can't keep the pace without a good incentive!

When you say "group's affiliates", I assume these would dry up when the group replaces you? If that's the case, you're leverage is somewhat limited. Bringing steady quality pts to the clinic is the single hardest thing to do IMO. Retaining pts is relatively easy. So the group might think of you as an MRI machine that wants to become a partner...

 

[Dr. Ice]

Ortho groups will never view you as an equal and most of the time unless you are billing some degree of fraud, no matter how much you generate, they will always be able to generate more. Rarely, are pain docs and ortho docs made equal partners, and even if you are made an equal partner you still won't be equal because they will drag you into their overhead and you will get hit hard. It is very difficult to create a formula where surgical docs and non surgical docs can coexist in an equal formula because of the overhead issue. Trust me I am dealing with this right now and have a ton of experience with this stuff so you can pm me to discuss further.

 

[unchockey21]

Ortho groups will never view you as an equal and most of the time unless you are billing some degree of fraud, no matter how much you generate, they will always be able to generate more. Rarely, are pain docs and ortho docs made equal partners, and even if you are made an equal partner you still won't be equal because they will drag you into their overhead and you will get hit hard. It is very difficult to create a formula where surgical docs and non surgical docs can coexist in an equal formula because of the overhead issue. Trust me I am dealing with this right now and have a ton of experience with this stuff so you can pm me to discuss further.

I agree that with all else being equal you’d pay more than your fair share of overhead given how much stuff ortho needs. However, wouldn’t ancillaries make up for it if they go into an evenly split pot since they’d be contributing more PT, DME, and imaging?

 

[DODOCSS]

work smarter, not harder

 

[NJPAIN]

To clarify, if most of the referrals are internal, they can say, "We're not increasing your pay. Don't like it? Give us 60 days notice so we can find a new interventional guy".

Unfortunately, I fear that this is EXACTLY how a group of orthopedic surgeons would respond. Let's face it, most of them are a bunch of self-absorbed bone heads who don't truly value what any other physician does. This entire practice model where they hire a non orthopedic physician who works for them just stinks and is a license to abuse.

 

[Dr. Ice]

I agree that with all else being equal you’d pay more than your fair share of overhead given how much stuff ortho needs. However, wouldn’t ancillaries make up for it if they go into an evenly split pot since they’d be contributing more PT, DME, and imaging?

Depends on what they decide to do with ancillaries. Don't forget you also have to factor in call. So in an ortho group as a non ortho you may have to some how pay tax for call since you can't take it and they hate it. There are so many other factors though too like insurance contracts, payor mix, patient distribution amongst the group. These all have an impact on bottom line. Also, in a massive group like I used to be a part of, the playing field is not level as some offices maybe more productive with a better payor mix, better demographics, more efficient staff, etc. So what happens if you aren't a part of those more productive offices or don't have enough access to them?

 

[clubdeac]

Being the sole guy in your specialty in a big group practice can suck. I was in a big neuro group and they leached off my revenue for 2 years before I said enough is enough. I did not have a mid level and was therefore doing about 1/2 as much as your volume. I was also probably taking home half of your income. Needless to say we both are/were getting royally screwed. My overhead as a percent of total collections turned out to be ~75%

 

[promethius]

I perform about 30 procedures on Monday and about 15-20 throughout the rest of the week. Tuesday through Friday, my mid level and I see an average of 50 clinic patients together. Salary wise, it's less than 500K working above the 90th percentile. I want to go back to negotiations soon and present a fair bonus structure, considering that I'm not a partner and won't be offered partnership.

Pros and cons of a musculoskeletal/pain physician working for an orthopedic group:

Pros:
Tons of "easy" musculoskeletal patient referrals and injections
Easier to avoid chronic pain management if you so choose

Cons:
Lack of a true partnership. Even if the orthopedic group offers you a true partnership, you will only be a partner in name because there are more orthopedic surgeons in the group than musculoskeletal/pain physicians, and you will always be out-voted on any issues that affect you.
Extremely high overhead. This point cannot be overemphasized based on what you mentioned above and as many other posters have commented on. Sounds like you are paying at least $615K in overhead costs a year and that's just based on $1.15 million of collections for professional fees and a salary of less than $500K (and that's not even including ancillaries, which are another $1.25 million). Most orthopedic practices have extremely high overheads, averaging probably in the range of $700-$800K a year per provider. Maybe that's reasonable for an orthopedic surgeon because of the equipment and facilities they use for operations, but that is a huge chunk of money for someone who is mainly office-based with a day or two a week in the procedure room/ASC. I mean seriously, are the prescriptions, pens, and needles you are using plated with gold?

If you do chronic pain management, that will probably slow down your volume because those patients take more time to see than simple musculoskeletal patients, but chronic pain patients will be yours rather than the practice's. With orthopedic practices, your service is not replaceable, as orthopods want to operate and do not want to have to manage the conservative aspects of spine/joint pain, but you are. They will lose a lot of money if no physiatrist with interventional skills will join their practice, and they have to refer those services out. You also may be a bit less replaceable if you see chronic pain patients, as fewer and fewer physicians want to manage those patients, and those patients come specifically to see you rather than the orthopedic surgeons.

Correct me if I am wrong, but adjusting for collections and actually utilized overhead, orthopedic surgeons and pain physicians will probably have comparable salaries. Question you have to ask yourself is would you be happier seeing half the volume of patients you are currently seeing and still making the same amount? As much as they want you to believe that you are "replaceable," you do not need them as much as they need you (or someone with your skill set).

 

[hyperalgesia]

Is it plausible to take "primary" call for an ortho group? We're not gonna operate, but couldn't we field calls and decide what's urgently operable, start abx, etc? Some of us were surgical residents at one time and "took call". Just wondering if this could be on the table (pardon the pun) when negotiating with ortho groups. I seem to remember an ortho group asking me if I would be willing to do this at one time...

 

[Dr. Ice]

Is it plausible to take "primary" call for an ortho group? We're not gonna operate, but couldn't we field calls and decide what's urgently operable, start abx, etc? Some of us were surgical residents at one time and "took call". Just wondering if this could be on the table (pardon the pun) when negotiating with ortho groups. I seem to remember an ortho group asking me if I would be willing to do this at one time...

You could do this if you work for a large enough group where that type of triage work is done but not too often. I used to do this also. When I did it, non surgical docs were on call and took care of all triage for entire practice including all joints spine foot ankle service not to mention all the non op calls that would come in. They have since created a much more "Cush" call which is by non surgical specialty and it's related surgical speciality. It gets annoying and some of it will inevitably be beyond your comfort zone even to triage. Ultimately if you are not a physical presence for call, your triage ability is still not viewed as that valuable. Honestly the only value that I see in an ortho or neurosurg group as non op is potential ownership in surgical center if the practice has ownership particularly if it is a multispecialty center with different revenue streams. This is pretty much the sole reason I am staying right now...

 

[powermd]

This entire practice model where they hire a non orthopedic physician who works for them just stinks and is a license to abuse.

Well, "protective pairing" has it's benefits, provided you don't mind being the little spoon.

 

[emd123]

Hey guys, I rarely post on the forum but really would appreciate some advice! I’m the solo interventional Pain Doc in a group of 11 Orthopaedics surgeons. I’m the first and only pain Doc, currently in my 5th year with them. Good payor mix with average yearly RVUs of 12000. Average 40 procedures a week and 200 clinic patients per week. I collect about 1.15 million on professional services and another 1.25 million on ancillaries (surgery center facility fees, PT, MRI,etc)
No partnership opportunity, just employed.
I do get various benefits, including health, dental, malpractice, profit sharing, 401K, etc. I honestly don’t feel fairly compensated based on annual income including bonus. They’ve changed my contract in the interim as they seem to not know how to structure my compensation fairly which has led to a drastic reduction in bonus.
Can you please give me a reasonable expected annual salary? I’m frustrated and feel under compensated. Thanks in advance for insights.

If you were in private practice, you'd likely be keeping 50% of what you collect, i.e., $2.35 million divided by 2 = $1.17 million. I end up able to keep about half of what I collect. In other words, my overhead is about 50% of collections. Rough ballpark. +/-
I collect nowhere near your $2.35 million, by the way. It would take two of me, to do that.

 

[BobBarker]

Yes, but he wouldn’t have PT/MRI, expensive ancillaries if he left this huge group. He realistically will just have his professional fees.

 

[drusso]

Well, "protective pairing" has it's benefits, provided you don't mind being the little spoon.

SAGE Journals: Your gateway to world-class journal research

Donaldson (2001, 2003) defines protective pairing as a form of prison rape in which men protect weaker inmates in exchange for sex. He explains how this occurs: The senior partner, or “man” in prisoner slang (also called “daddy,” “old man,” “jocker,” “pitcher,” and other terms), in a protective pair is most often not a rapist himself, though he may take advantage of the consequences of a rape by offering protection to a new punk. Sometimes a rapist will try to hook up with his victim. In any case, he obligates himself to provide complete protection for his punk or junior partner (also called “kid,” “boy,” “sweet boy,” “f*ckboy,” “catcher,” and other terms) from further sexual assaults from anyone else, from violence, from theft, and from other forms of disrespect. (Donaldson, 2001, p. 349)

 

[Blitz2006]

Is it plausible to take "primary" call for an ortho group? We're not gonna operate, but couldn't we field calls and decide what's urgently operable, start abx, etc? Some of us were surgical residents at one time and "took call". Just wondering if this could be on the table (pardon the pun) when negotiating with ortho groups. I seem to remember an ortho group asking me if I would be willing to do this at one time...

Somewhat related but not really, if you join an ortho group, can you get OR privileges (for pain docs who are interseted in doing stuff like stims, pumps, MILD, etc.)?

 

[lobelsteve]

Somewhat related but not really, if you join an ortho group, can you get OR privileges (for pain docs who are interseted in doing stuff like stims, pumps, MILD, etc.)?

No, you have to join a hospital for that.

 

[bimmer79]

This type of set-up is the trade-off for being fed lots of procedures.

If you're not bringing in a lot of business on your own, it gives leverage to your employer and makes you more easily replaceable.

You can go out on your own, but it will require a different practice model/mind-set.

Unfortunately, I believe you're correct. I get fed tons of internal referrals plus external referrals from the relationships that the group has established. I have an over-abundance for which I'm again very grateful for, however, I still feel that I need to be incentivized considering I'm taking home a salary approximately less than 25% of my total active/passive collections. Nonetheless, I feel like asking to negotiate would be all in vain and they would just attempt to replace me.

 

[bimmer79]

Yes, but he wouldn’t have PT/MRI, expensive ancillaries if he left this huge group. He realistically will just have his professional fees.

Yes, you are correct. My professional fees account for about half.

 

[bimmer79]

Pros and cons of a musculoskeletal/pain physician working for an orthopedic group:

Pros:
Tons of "easy" musculoskeletal patient referrals and injections
Easier to avoid chronic pain management if you so choose

Cons:
Lack of a true partnership. Even if the orthopedic group offers you a true partnership, you will only be a partner in name because there are more orthopedic surgeons in the group than musculoskeletal/pain physicians, and you will always be out-voted on any issues that affect you.
Extremely high overhead. This point cannot be overemphasized based on what you mentioned above and as many other posters have commented on. Sounds like you are paying at least $615K in overhead costs a year and that's just based on $1.15 million of collections for professional fees and a salary of less than $500K (and that's not even including ancillaries, which are another $1.25 million). Most orthopedic practices have extremely high overheads, averaging probably in the range of $700-$800K a year per provider. Maybe that's reasonable for an orthopedic surgeon because of the equipment and facilities they use for operations, but that is a huge chunk of money for someone who is mainly office-based with a day or two a week in the procedure room/ASC. I mean seriously, are the prescriptions, pens, and needles you are using plated with gold?

If you do chronic pain management, that will probably slow down your volume because those patients take more time to see than simple musculoskeletal patients, but chronic pain patients will be yours rather than the practice's. With orthopedic practices, your service is not replaceable, as orthopods want to operate and do not want to have to manage the conservative aspects of spine/joint pain, but you are. They will lose a lot of money if no physiatrist with interventional skills will join their practice, and they have to refer those services out. You also may be a bit less replaceable if you see chronic pain patients, as fewer and fewer physicians want to manage those patients, and those patients come specifically to see you rather than the orthopedic surgeons.

Correct me if I am wrong, but adjusting for collections and actually utilized overhead, orthopedic surgeons and pain physicians will probably have comparable salaries. Question you have to ask yourself is would you be happier seeing half the volume of patients you are currently seeing and still making the same amount? As much as they want you to believe that you are "replaceable," you do not need them as much as they need you (or someone with your skill set).

Very well composed Promethius! I don't want to come across contentious or have any unusual tension among the partners, however, being the solitary pain doctor doesn't give me much leverage. Talking with the orthopods about my situation thus far has yielded no results; they seem oblivious to my value...they insist that they aren't profiting from me at all.