Big Box Shop ROL

[Sushirolls]

Some one posted some where about what are the Big Box shops. I can't find that post to reply there, so here is a new thread. In the spirit of the system we know well by students and residents who ask for advice, "Help me rank my programs!", let's collectively define the best of the Big Box Shops.

I ask that only attendings post their rankings, but others comment freely.

1) Large multi-specialty health systems that are listed as non-profit with their tax structure spanning across a state or states (not physician run)
2) HMO multi-specialty health systems spanning across states
3) Large multi-state online telemedicine firms
4) For profit Psychiatry / Addiction hospital chains spanning across states
5) Large multi-specialty health systems that are listed as non-profit with their tax structure spanning across a state or states (physician run)
6) VA
7) University Academic Center
8) Community mental health centers (not for profit)
9) Community mental health centers (for profit)
10) State Hospitals
11) Large multispecialty clinics with numerous offices localized in a smaller geographic area but no hospital ownership (not physician owned)
12) Regional hospital +/- Psych unit, +/- outpatient clinic (not physician owned) in one location only typically serving a rural community
13) Large multispecialty clinics with numerous offices localized in a smaller geographic area but no hospital ownership (physician owned)
14) Private for profit niche clinics like Eating Disorders, residential depression clinics, other super niche populations
--------------------------(below this line, I believe these are not Big Box Shops)---------------------------
15) Group Psychiatrist +/- therapists, for profit, private practice insurance based
16) Group Psychiatrist +/- therapists, for profit, private practice cash based
17) solo practice insurance based
18) solo practice cash based

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[nexus73]

Where would you classify me, a psychiatrist, driving around in an old Ford econoline van, with some converted captains chairs in the back, plus all the medical supplies and meds for running a mobile ketamine clinic. A ketamine van if you will. Oh, structured as for profit.

 

[Sushirolls]

Where would you classify me, a psychiatrist, driving around in an old Ford econoline van, with some converted captains chairs in the back, plus all the medical supplies and meds for running a mobile ketamine clinic. A ketamine van if you will. Oh, structured as for profit.

Not anywhere near the top of the Big Box list. Closer to the bottom of the list, like #17-19. But if it is part of a large corporate private equity firm and you are part of a fleet, then much higher in the list.
/sarcasm

 

[Stagg737]

Some one posted some where about what are the Big Box shops. I can't find that post to reply there, so here is a new thread. In the spirit of the system we know well by students and residents who ask for advice, "Help me rank my programs!", let's collectively define the best of the Big Box Shops.

I ask that only attendings post their rankings, but others comment freely.

1) Large multi-specialty health systems that are listed as non-profit with their tax structure spanning across a state or states (not physician run)
2) HMO multi-specialty health systems spanning across states
3) Large multi-state online telemedicine firms
4) For profit Psychiatry / Addiction hospital chains spanning across states
5) Large multi-specialty health systems that are listed as non-profit with their tax structure spanning across a state or states (physician run)
6) VA
7) University Academic Center
8) Community mental health centers (not for profit)
9) Community mental health centers (for profit)
10) State Hospitals
11) Large multispecialty clinics with numerous offices localized in a smaller geographic area but no hospital ownership (not physician owned)
12) Regional hospital +/- Psych unit, +/- outpatient clinic (not physician owned) in one location only typically serving a rural community
13) Large multispecialty clinics with numerous offices localized in a smaller geographic area but no hospital ownership (physician owned)
14) Private for profit niche clinics like Eating Disorders, residential depression clinics, other super niche populations
--------------------------(below this line, I believe these are not Big Box Shops)---------------------------
15) Group Psychiatrist +/- therapists, for profit, private practice insurance based
16) Group Psychiatrist +/- therapists, for profit, private practice cash based
17) solo practice insurance based
18) solo practice cash based

Are these rankings from your best to worst, or from most-hated to least hated? (I'm assuming the latter)

If the latter, I'd drop the VA down a few positions purely d/t the benefits allotted.

 

[Sushirolls]

Are these rankings from your best to worst, or from most-hated to least hated? (I'm assuming the latter)

Whose at the top of the Big Box Shop list. I am not a fan of the Big Box Shops, but others are. So which direction the ranking goes is sort of relative. I prefer and recommend the bottom of the list for people.

 

[nexus73]

This is a great list by the way. I’m currently at a regional hospital #12 on the list. Far enough down I feel like physicians still have some leverage and a seat at the table to determine the direction of the organization. I can tell as we grow however the health system is going to rise up the big box shop hierarchy and not sure what I’ll do in the long run. Probably have to exit to private practice or move on to a smaller health system elsewhere once things get annoying enough.

 

[dl2dp2]

There are some newer models here you haven't counted, like 100% telepsych (chain vs. nonchain). I recently saw a full time non-chain job on this... (a ****ty job but still a job)...

 

[Sushirolls]

There are some newer models here you haven't counted, like 100% telepsych (chain vs. nonchain). I recently saw a full time non-chain job on this... (a ****ty job but still a job)...

True. So create a new ROL and place it where it belongs.

 

[dl2dp2]

True. So create a new ROL and place it where it belongs.

Maybe rate more tiers.

I would roughly rank in this way...

100% equity ownership
----
1. solo/ group cash
2. solo/ group insurance


<100% equity ownership
----
physician-owned small-medium sized multispecialty clinic
large multi-state HMO partial physician-owned (i.e. Permanente Group)
large regional HMOs partial physician-owned
some boutiquey physician ownership structure (i.e. private contract group, uncommon in this field, but very common in other fields like EM), or non-practice ownership (i.e. physician-owned treatment facility with outside clinical contract to avoid anti-kickback)



No equity ownership

Public salary lined jobs (actually lots of overlap below both in terms of funding stream and in terms of administrative arrangement)
---
VA
University
State hospitals
Nonprofit CMHC
Other academic-govt roles


Private salary jobs
--
nonprofit large chains
for-profit large chains
telemedicine chains


The last group is the most numerous and most corporate, and if you approach any large regional chain there are virtually an unlimited number of staff positions. These jobs are usually very average, and the quality of job improves more into administration.

 

[sloh]

Maybe rate more tiers.

I would roughly rank in this way...

100% equity ownership
----
1. solo/ group cash
2. solo/ group insurance


<100% equity ownership
----
physician-owned small-medium sized multispecialty clinic
large multi-state HMO partial physician-owned (i.e. Permanente Group)
large regional HMOs partial physician-owned
some boutiquey physician ownership structure (i.e. private contract group, uncommon in this field, but very common in other fields like EM), or non-practice ownership (i.e. physician-owned treatment facility with outside clinical contract to avoid anti-kickback)



No equity ownership

Public salary lined jobs (actually lots of overlap below both in terms of funding stream and in terms of administrative arrangement)
---
VA
University
State hospitals
Nonprofit CMHC
Other academic-govt roles


Private salary jobs
--
nonprofit large chains
for-profit large chains
telemedicine chains


The last group is the most numerous and most corporate, and if you approach any large regional chain there are virtually an unlimited number of staff positions. These jobs are usually very average, and the quality of job improves more into administration.

That's a pretty high ranking for Permanente Group. Do you feel that psychiatrists who work for them are generally content?

 

[dl2dp2]

That's a pretty high ranking for Permanente Group. Do you feel that psychiatrists who work for them are generally content?

People who partner at Kaiser don't quit. I've never heard of it. Similar with other Kaiser-like regional entities.

 

[Sushirolls]

People who partner at Kaiser don't quit. I've never heard of it. Similar with other Kaiser-like regional entities.

I've heard of it. And I've seen it in chart notes with certain Psych or Addiction names dropping off in the chart and not showing in other patients charts over time. I.e. they quit, fired, left, moved on...

 

[sloh]

I've heard of it. And I've seen it in chart notes with certain Psych or Addiction names dropping off in the chart and not showing in other patients charts over time. I.e. they quit, fired, left, moved on...

I'm curious how many leave before partnership. The golden handcuffs after making partnership really disincentive leaving even if the job is miserable.

 

[FlowRate]

I'm curious how many leave before partnership. The golden handcuffs after making partnership really disincentive leaving even if the job is miserable.

A lot of our recent departures were people who either weren't partner or would have just made partner.

I can't imagine a realistic better employed job with a large entity than the one I have now with Kaiser. Some of the perks as you get up there in years are really nice, like a total of 8 or 9 weeks of vacation. There are certainly some frustrations but they're not unique or commonly better in any other employed position e.g. not much panel management currently but that seems to be on the priority list for upcoming changes.

Each region is different and I'd imagine sub-regions and clinics are also different so YMMV.

 

[sloh]

There are certainly some frustrations but they're not unique or commonly better in any other employed position

That right there is 100% true!

 

[Old&InTheWay]

How about a highly exclusive concierge psychiatry practice where your panel consists of one BPD patient who gets unlimited access to you and you can never go on vacation?

 

[AD04]

How about a highly exclusive concierge psychiatry practice where your panel consists of one BPD patient who gets unlimited access to you and you can never go on vacation?

Are you talking about marriage?

 

[Sushirolls]

How about a highly exclusive concierge psychiatry practice where your panel consists of one BPD patient who gets unlimited access to you and you can never go on vacation?

Unless the patient is named Big Box Shop, probably not a Big Box Shop job.

 

[Merovinge]

Maybe rate more tiers.

I would roughly rank in this way...

100% equity ownership
----
1. solo/ group cash
2. solo/ group insurance


<100% equity ownership
----
physician-owned small-medium sized multispecialty clinic
large multi-state HMO partial physician-owned (i.e. Permanente Group)
large regional HMOs partial physician-owned
some boutiquey physician ownership structure (i.e. private contract group, uncommon in this field, but very common in other fields like EM), or non-practice ownership (i.e. physician-owned treatment facility with outside clinical contract to avoid anti-kickback)



No equity ownership

Public salary lined jobs (actually lots of overlap below both in terms of funding stream and in terms of administrative arrangement)
---
VA
University
State hospitals
Nonprofit CMHC
Other academic-govt roles


Private salary jobs
--
nonprofit large chains
for-profit large chains
telemedicine chains


The last group is the most numerous and most corporate, and if you approach any large regional chain there are virtually an unlimited number of staff positions. These jobs are usually very average, and the quality of job improves more into administration.

This would be almost exactly my ranking as well. Probably University>VA, but could easily see VA>university.

Private salary jobs (nonprofit large chains, for-profit large chains, telemedicine chains) are where so many people are going these days and are a complete race to the bottom. I'd expect many psychiatrists to be happy anywhere above these on the list.

 

[brazilianpsych]

Hey, I have question. I always like reading this forum, however sometimes I get sad because it seems to me that the only good job available for psych is private practice. I don't really like PP and outpatient is not my favorite thing in psych either. I imagine myself doing PP just for the money but not really enjoying it.

Question is, can you get a good pay working inpatient? I know 200k/y is not bad for the average person, but if I am earning 200k/y as inpatient vs 350-400k/y as PP owner, then I may do the PP even though I hate it.

PS: haven't even started residency, but I had my own practice in Brazil and hated it.

 

[Merovinge]

Hey, I have question. I always like reading this forum, however sometimes I get sad because it seems to me that the only good job available for psych is private practice. I don't really like PP and outpatient is not my favorite thing in psych either. I imagine myself doing PP just for the money but not really enjoying it.

Question is, can you get a good pay working inpatient? I know 200k/y is not bad for the average person, but if I am earning 200k/y as inpatient vs 350-400k/y as PP owner, then I may do the PP even though I hate it.

PS: haven't even started residency, but I had my own practice in Brazil and hated it.

Yes, you can absolutely make 300k a year inpatient with semi-reasonable patient loads/hours. There will, of course, be on-call requirements as well as horrendous fights with insurance companies on a daily basis to justify why the patient needs more than 14 seconds inpatient, but if you like the work it will be readily available. You'll have to pick from working for a large employer, state facility, forensic facility, or for profit hospital chain but it's not as though doing so is untenable.

 

[Bartelby]

Also consider VA inpatient. It will not quite get you to $300k but tends to offer a reasonable workload.

 

[jbomba]

Yes, you can absolutely make 300k a year inpatient with semi-reasonable patient loads/hours. There will, of course, be on-call requirements as well as horrendous fights with insurance companies on a daily basis to justify why the patient needs more than 14 seconds inpatient, but if you like the work it will be readily available. You'll have to pick from working for a large employer, state facility, forensic facility, or for profit hospital chain but it's not as though doing so is untenable.

My goal is to take one of these jobs but negotiate to leave and take calls by phone after done rounding. Then do outpatient in the afternoon. Hoping this combination could get me to 500k a year.

 

[dl2dp2]

Hey, I have question. I always like reading this forum, however sometimes I get sad because it seems to me that the only good job available for psych is private practice. I don't really like PP and outpatient is not my favorite thing in psych either. I imagine myself doing PP just for the money but not really enjoying it.

Question is, can you get a good pay working inpatient? I know 200k/y is not bad for the average person, but if I am earning 200k/y as inpatient vs 350-400k/y as PP owner, then I may do the PP even though I hate it.

PS: haven't even started residency, but I had my own practice in Brazil and hated it.

If you prefer inpatient clinically there are plenty of "good" jobs that pay more than 300k as described above. The main mark is equity ownership. You want to choose a facility where you are one of a group of owners of the facility that has some control over your work. This is common in tier 2 jobs.

The other way to think about inpatient is that you can be an inpatient doc with 100% 1099. This can easily exceed 300k, especially if you rotate at several facilities, some of which might be Big Box. This way you essentially have a private inpatient practice (except your clients are institutions, not patients), which allows all the benefits of private practice without issues associated with the outpatient practice. Your negotiation power is much higher because if one of your BigBox clients are lackluster, you can negotiate it up to market parity, in every aspect. People do this all the time in psychiatry. It's much rarer in other fields like EM/Hospitalist medicine because they usually need to be part of a larger group to negotiate a favorable contract against hospitals ("private contract group", many examples), due to higher overhead. Psychiatry units also resist consolidation. This aspect I find fascinating. I'm not sure why this is the case. I suspect the large availability of flexible alternatives (i.e. if you organize a hospitalist group you'd be fairly certain that most of them will stay in this line of work, but if you organize an inpatient psychiatrist group, half of the group will drop out to outpatient 5 years out).

Also -- be careful of inpatient: a large number of these jobs, 1099 or not, will very soon consist of "medical director" roles where you supervise mid-levels to care for a much larger caseload. This is again FINE in theory and can be very lucrative if you own equity, but the clinical content can be dramatically different.



There are other more boutiquey inpatient jobs that are pretty awesome, i.e. inpatient jobs for people are residential/voluntary facilities, etc. State hospitals/prisons can also be good if you know what you are doing.

Remember -- ownership of equity is the most important. You want as much control over every aspect of your job as possible, which allows you to tailor the job in a way that works for you. Clinical content of the job is secondary and can change. The main issue with "Box Box" is the lack of control. Short of ownership of equity, the next tier jobs are those that occupy "hard salary lines" (i.e. tenure, VA lines, govt lines). Typically you make less money but your control level, which is imputed by systemic stricture of job security, is very high.

 

[psychacad]

Where does doing random per diem moonlighting shifts fit in? It's a viable way of making a full time salary even higher than full time salaried positions. It's technically a Big Box Shop work but doesn't really work like that. You can call all the shots in terms of scheduling, you don't really "belong" to the institution, can walk out anytime you want, get paid for being a sleeping warm body...etc.

 

[Sushirolls]

Moonlighting is moonlighting. Separate category.

 

[AD04]

I view work as more fluid. The type of work and entity you work for isn't as important as the people you work with. The lack of flexibility is a double-edge sword. In some cases, you are more competent than the people in control and it is infuriating to see that affect your patient care and income in a negative way. On the other hand, you want people more competent than you to be in control as that will affect your patient care and income in a positive way. That is what allows people in great systems to make outsized income, such as in FAANG.

Being in control is it's own reward and will not necessary pay off in terms of $. This is why the range of income in solo private practice is so broad. How many software engineers or investment bankers, if starting their own business, could make the income they make outside the institutions they work in? Not many and I would say that would be the same for psychiatrists. (And anyways, the best way to make top 0.1% money is outside of clinical medicine. Clinical medicine is certainly a valid stepping stone though.)

If you are capable in many different aspects of psychiatry and can decipher a good deal from a bad deal and are nimble enough to take advantage of opportunities wherever they may be, you'll have a monetarily and emotionally rewarding career in psychiatry.

 

[robellis]

I view work as more fluid. The type of work and entity you work for isn't as important as the people you work with. The lack of flexibility is a double-edge sword. In some cases, you are more competent than the people in control and it is infuriating to see that affect your patient care and income in a negative way. On the other hand, you want people more competent than you to be in control as that will affect your patient care and income in a positive way. That is what allows people in great systems to make outsized income, such as in FAANG.

Being in control is it's own reward and will not necessary pay off in terms of $. This is why the range of income in solo private practice is so broad. How many software engineers or investment bankers, if starting their own business, could make the income they make outside the institutions they work in? Not many and I would say that would be the same for psychiatrists. (And anyways, the best way to make top 0.1% money is outside of clinical medicine. Clinical medicine is certainly a valid stepping stone though.)

If you are capable in many different aspects of psychiatry and can decipher a good deal from a bad deal and are nimble enough to take advantage of opportunities wherever they may be, you'll have a monetarily and emotionally rewarding career in psychiatry.

You were the guy that said 50k was a rounding error so I’m interested in the specifics of what you do if you would be kind enough to share with us

 

[AD04]

You were the guy that said 50k was a rounding error so I’m interested in the specifics of what you do if you would be kind enough to share with us

You're quite persistent. Fine, I'll tell you why I wrote what I did.

I work for an institution run by very competent people. The psychiatric department is especially well-run clinically and financially. People travel from other states for care because of the reputation. The inpatient unit is actually profitable, unlike most. I do outpatient, inpatient, C&L, ECT. This institution has me working above-average hours for above-average $ / hour. That translates to good money.

What I make in a month is more than my annual expense. So I take all that extra money and dump it into investments. All that money compounds, but fluctuates as well. So my net worth can fluctuate by six-figures on a month by month basis. Therefore, it doesn't matter much to me if I'm up or down by $50k.

 

[brazilianpsych]

Thank you for everyone that replied me! I am more relieved after reading everything, really helped me with the incoming perspectives. I know that right now it's more of curiosity, but I like to have an idea about the market.

 

[robellis]

You're quite persistent. Fine, I'll tell you why I wrote what I did.

I work for an institution run by very competent people. The psychiatric department is especially well-run clinically and financially. People travel from other states for care because of the reputation. The inpatient unit is actually profitable, unlike most. I do outpatient, inpatient, C&L, ECT. This institution has me working above-average hours for above-average $ / hour. That translates to good money.

What I make in a month is more than my annual expense. So I take all that extra money and dump it into investments. All that money compounds, but fluctuates as well. So my net worth can fluctuate by six-figures on a month by month basis. Therefore, it doesn't matter much to me if I'm up or down by $50k.

Very interesting, I haven’t seen many people getting paid hourly across all of those settings, usually it’s a salary with a bonus or 1099 or something, sounds like a good gig you got going

 

[jbomba]

If you prefer inpatient clinically there are plenty of "good" jobs that pay more than 300k as described above. The main mark is equity ownership. You want to choose a facility where you are one of a group of owners of the facility that has some control over your work. This is common in tier 2 jobs.

The other way to think about inpatient is that you can be an inpatient doc with 100% 1099. This can easily exceed 300k, especially if you rotate at several facilities, some of which might be Big Box. This way you essentially have a private inpatient practice (except your clients are institutions, not patients), which allows all the benefits of private practice without issues associated with the outpatient practice. Your negotiation power is much higher because if one of your BigBox clients are lackluster, you can negotiate it up to market parity, in every aspect. People do this all the time in psychiatry. It's much rarer in other fields like EM/Hospitalist medicine because they usually need to be part of a larger group to negotiate a favorable contract against hospitals ("private contract group", many examples), due to higher overhead. Psychiatry units also resist consolidation. This aspect I find fascinating. I'm not sure why this is the case. I suspect the large availability of flexible alternatives (i.e. if you organize a hospitalist group you'd be fairly certain that most of them will stay in this line of work, but if you organize an inpatient psychiatrist group, half of the group will drop out to outpatient 5 years out).

Also -- be careful of inpatient: a large number of these jobs, 1099 or not, will very soon consist of "medical director" roles where you supervise mid-levels to care for a much larger caseload. This is again FINE in theory and can be very lucrative if you own equity, but the clinical content can be dramatically different.



There are other more boutiquey inpatient jobs that are pretty awesome, i.e. inpatient jobs for people are residential/voluntary facilities, etc. State hospitals/prisons can also be good if you know what you are doing.

Remember -- ownership of equity is the most important. You want as much control over every aspect of your job as possible, which allows you to tailor the job in a way that works for you. Clinical content of the job is secondary and can change. The main issue with "Box Box" is the lack of control. Short of ownership of equity, the next tier jobs are those that occupy "hard salary lines" (i.e. tenure, VA lines, govt lines). Typically you make less money but your control level, which is imputed by systemic stricture of job security, is very high.

Can you talk more about ownership of equity? As a new grad, what am I looking for/where am I looking for it/what do I ask for? If I approach a for profit psych hospital, how would i arrange this? I'm woefully naive to this, so I apologize if this question doesnt even make sense.

 

[AD04]

People who partner at Kaiser don't quit. I've never heard of it. Similar with other Kaiser-like regional entities.

What is partnership at Kaiser like? Why don't people leave?

 

[dl2dp2]

You're quite persistent. Fine, I'll tell you why I wrote what I did.

I work for an institution run by very competent people. The psychiatric department is especially well-run clinically and financially. People travel from other states for care because of the reputation. The inpatient unit is actually profitable, unlike most. I do outpatient, inpatient, C&L, ECT. This institution has me working above-average hours for above-average $ / hour. That translates to good money.

What I make in a month is more than my annual expense. So I take all that extra money and dump it into investments. All that money compounds, but fluctuates as well. So my net worth can fluctuate by six-figures on a month by month basis. Therefore, it doesn't matter much to me if I'm up or down by $50k.

Well you are kind of winning aren't you. But yes, the gestalt of what you wrote is exactly right.

You own equity. It's just not equity in the institutions with which you have some contract. In fact, such institutions may not have equity to own (non-profit). Diversified ownership of equity is still equity.

When people own equity, they start to realize that the problem of budgeting becomes the problem of asset allocation. This mindset is really what differentiates the employers from the owners. I just happen to prefer that a good chunk of my net worth is allocated to equity of my own business.

Can you talk more about ownership of equity? As a new grad, what am I looking for/where am I looking for it/what do I ask for? If I approach a for profit psych hospital, how would i arrange this? I'm woefully naive to this, so I apologize if this question doesnt even make sense.

You can't own equity in a for-profit hospital and be an employee of that hospital. This is double-dipping and forbidden by anti-kickback/Stark/ACA. That's actually the entire point of this whole discussion. The reason Kaiser is superior is that Kaiser physicians are organized separately into an entity called Permanente Group, within which you CAN own equity.

It's hard to explain what ownership of equity means without actual practice. This is why I recommend everyone to start a practice. Equity is the valuation of the net cash flow after subtracting the cost of your labor (and other costs) from the income (aka, profit). It's an asset rather than a liability. Understanding why this is important basically makes it much easier to understand things like the stock market and the different types of financial derivatives. This also seems very abstract until you've seen the practice balance sheet and P&L statement to file for your schedule C for your accountant. For me there's definitely an aha moment. It's hard for me to mindfully being an employee without understanding the perspectives of my employers.


Try to figure out why a publicly-traded company is worth $X. Ownership of equity and legal control of the business are equivalent ways to say the same thing.


Another practical way to understand this is to buy a rental property. I personally don't have one, but I understand why people have rental properties. If you own a house, you have the control to do what you want with it, within reason. If you own a job, you have control over what you do with the job. If you own company, you have control over everyone in it. Etc. In particular, when you have control you can control what you do with the profit. That's the foundation. I feel like running my practice is basically equivalent to an executive MBA.

 

[robellis]

Well you are kind of winning aren't you. But yes, the gestalt of what you wrote is exactly right.

You own equity. It's just not equity in the institutions with which you have some contract. In fact, such institutions may not have equity to own (non-profit). Diversified ownership of equity is still equity.

When people own equity, they start to realize that the problem of budgeting becomes the problem of asset allocation. This mindset is really what differentiates the employers from the owners. I just happen to prefer that a good chunk of my net worth is allocated to equity of my own business.




You can't own equity in a for-profit hospital and be an employee of that hospital. This is double-dipping and forbidden by anti-kickback/Stark/ACA. That's actually the entire point of this whole discussion. The reason Kaiser is superior is that Kaiser physicians are organized separately into an entity called Permanente Group, within which you CAN own equity.

It's hard to explain what ownership of equity means without actual practice. This is why I recommend everyone to start a practice. Equity is the valuation of the net cash flow after subtracting the cost of your labor (and other costs) from the income (aka, profit). It's an asset rather than a liability. Understanding why this is important basically makes it much easier to understand things like the stock market and the different types of financial derivatives. This also seems very abstract until you've seen the practice balance sheet and P&L statement to file for your schedule C for your accountant. For me there's definitely an aha moment. It's hard for me to mindfully being an employee without understanding the perspectives of my employers.


Try to figure out why a publicly-traded company is worth $X. Ownership of equity and legal control of the business are equivalent ways to say the same thing.


Another practical way to understand this is to buy a rental property. I personally don't have one, but I understand why people have rental properties. If you own a house, you have the control to do what you want with it, within reason. If you own a job, you have control over what you do with the job. If you own company, you have control over everyone in it. Etc. In particular, when you have control you can control what you do with the profit. That's the foundation. I feel like running my practice is basically equivalent to an executive MBA.

I still don’t understand how you own “equity” when you work at a hospital as an inpatient doc as it seems the poster you quoted does. How does he own equity? It seems he just works a lot and has a high hourly wage..obviously if you own a practice you have “equity” although psych practices aren’t as profitable as say a surgery practice but that’s a different discussion

 

[dl2dp2]

I still don’t understand how you own “equity” when you work at a hospital as an inpatient doc as it seems the poster you quoted does. How does he own equity? It seems he just works a lot and has a high hourly wage..obviously if you own a practice you have “equity” although psych practices aren’t as profitable as say a surgery practice but that’s a different discussion

He buys a bunch of SPY and owns equity in the largest companies of the world.

When you own a lot income-generating assets, the question is no longer how much you make per hour and how much you spend per month. The relevant question is what type of assets you own and what's the respective risk-adjusted return of the assets. This is what I mean by you convert the budget question to an asset allocation question.

But the first step to that is spending much less than what you make, which if you think of running your household as a business, literally means that it's a very profitable business. The pattern and habit of his life itself has value. By the way this is not me just pulling junk out of my ass--there are very sophisticated analyses pioneered by people like Gary Becker that showed that much of certain sociological phenomena can be understood by modeling households as businesses.

You need to own equity, whether in your own business, or income-generating real estate, or financial derivatives (i.e. stocks and bonds and index funds). Owning equity is the pathway to true power and control in life. When you own a lot of SPY you can say oh yes I don't own my own business because I made an asset allocation calculus that owning my own business has a lower risk-adjusted return than owning SPY. If you don't own any equity, your life is one that's being held hostage by your employer.

 

[robellis]

He buys a bunch of SPY and owns equity in the largest companies of the world.

When you own a lot income-generating assets, the question is no longer how much you make per hour and how much you spend per month. The relevant question is what type of assets you own and what's the respective risk-adjusted return of the assets. This is what I mean by you convert the budget question to an asset allocation question.

You need to own equity, whether in your own business, or income-generating real estate, or financial derivatives (i.e. stocks and bonds and index funds). Owning equity is the pathway to true power and control in life. When you own a lot of SPY you can say oh yes I don't own my own business because I made an asset allocation calculus that owning my own business has a lower risk-adjusted return than owning SPY. If you don't own any equity, your life is one that's being held hostage by your employer.

Ohhh lol so you’re just talking about investments..ok that makes sense..i thought there was some mysterious way to own equity in the inpatient unit that I wasn’t understanding

 

[AD04]

@sluox

What is your background? You're quite well-versed in business.

 

[dl2dp2]

@sluox

What is your background? You're quite well-versed in business.

I literally have 0 business background. All learned on the job.

 

[psychacad]

What is partnership at Kaiser like? Why don't people leave?

From what I know you get some extra-income from profit sharing. People supposedly don't leave because of the "golden handcuffs". A really nice retirement package that includes a pension that can pay in the 7-8k/month if you spend your career there on top of a 401k, a sign-on loan of 100k in some cases that is forgiven after 7-8 years, help with mortgage...etc. Essentially you are held hostage, lol.

Of course the flip side is you will never do therapy again in your life, your patient panel will keep growing till the end of your career with no limit, you will work hard though the details vary depending on the site. The whole Kaiser system is set up in some way to reduce access because physicians are paid from insurance premiums rather than service so your services are prepaid. There has been some pretty bad publicity recently particularly for mental health care. Essentially, it's glorified Big Box Shop.

. Some of the perks as you get up there in years are really nice, like a total of 8 or 9 weeks of vacation.

That's interesting. The SoCal and NoCal vacation packages frankly weren't all that great but I guess that is dependent on site? 3/4 weeks first 5 years and then it maxes out at 6, I believe.

 

[sloh]

From what I know you get some extra-income from profit sharing. People supposedly don't leave because of the "golden handcuffs". A really nice retirement package that includes a pension that can pay in the 7-8k/month if you spend your career there on top of a 401k, a sign-on loan of 100k in some cases that is forgiven after 7-8 years, help with mortgage...etc. Essentially you are held hostage, lol.

Of course the flip side is you will never do therapy again in your life, your patient panel will keep growing till the end of your career with no limit, you will work hard though the details vary depending on the site. The whole Kaiser system is set up in some way to reduce access because physicians are paid from insurance premiums rather than service so your services are prepaid. There has been some pretty bad publicity recently particularly for mental health care. Essentially, it's glorified Big Box Shop.



That's interesting. The SoCal and NoCal vacation packages frankly weren't all that great but I guess that is dependent on site? 3/4 weeks first 5 years and then it maxes out at 6, I believe.

Don't forget about the inbox messages and patient satisfaction scores.

 

[Merovinge]

From what I know you get some extra-income from profit sharing. People supposedly don't leave because of the "golden handcuffs". A really nice retirement package that includes a pension that can pay in the 7-8k/month if you spend your career there on top of a 401k, a sign-on loan of 100k in some cases that is forgiven after 7-8 years, help with mortgage...etc. Essentially you are held hostage, lol.

Of course the flip side is you will never do therapy again in your life, your patient panel will keep growing till the end of your career with no limit, you will work hard though the details vary depending on the site. The whole Kaiser system is set up in some way to reduce access because physicians are paid from insurance premiums rather than service so your services are prepaid. There has been some pretty bad publicity recently particularly for mental health care. Essentially, it's glorified Big Box Shop.



That's interesting. The SoCal and NoCal vacation packages frankly weren't all that great but I guess that is dependent on site? 3/4 weeks first 5 years and then it maxes out at 6, I believe.

I suppose this may vary for mental health but this is the exact opposite of my SO's experience with Kaiser offers. The primary pay incentive was for short access times, although there is obviously a tension with how many patient's one wants to see in a day vs the number on the total panel/population. In some sense paying for short access time is a lot like paying for productivity/RVU but sounds different and is likely harder to compare offers with outside of Kaiser.

 

[psychacad]

I suppose this may vary for mental health but this is the exact opposite of my SO's experience with Kaiser offers. The primary pay incentive was for short access times, although there is obviously a tension with how many patient's one wants to see in a day vs the number on the total panel/population. In some sense paying for short access time is a lot like paying for productivity/RVU but sounds different and is likely harder to compare offers with outside of Kaiser.

This is actually not very different, from what I understand from your post. Essentially the more doctors you hire and services per patient you provide, the bigger the waste. Given the huge demand in psych, this translates to large ever-expanding panels with poor follow up (i.e short access times). Hence, a lot of the service ends up being dependent on emails and phone calls. This kind of model works well in preventive medicine but sounds like a disaster for fields like psych, where close follow-up is important.

 

[nexus73]

This is actually not very different, from what I understand from your post. Essentially the more doctors you hire and services per patient you provide, the bigger the waste. Given the huge demand in psych, this translates to large ever-expanding panels with poor follow up (i.e short access times). Hence, a lot of the service ends up being dependent on emails and phone calls. This kind of model works well in preventive medicine but sounds like a disaster for fields like psych, where close follow-up is important.

luckily healthcare administrators understand this /s

 

[Merovinge]

This is actually not very different, from what I understand from your post. Essentially the more doctors you hire and services per patient you provide, the bigger the waste. Given the huge demand in psych, this translates to large ever-expanding panels with poor follow up (i.e short access times). Hence, a lot of the service ends up being dependent on emails and phone calls. This kind of model works well in preventive medicine but sounds like a disaster for fields like psych, where close follow-up is important.

SO is definitely not in primary care and poor f/u is a disaster in her field as well (for some of the patients). It seemed like the Kaiser docs saw markedly less patients/day than other private practice docs (talking like around 50%) and the mechanisms to entice seeing more patients was paying you for extra hours spent in clinic and bonus pay for shorter wait times. Their call sounded absolutely slammed packed along with quite low initial salary as the downsides. This was in the Pacific NW so not sure if this would vary elsewhere.

 

[vistaril]

My goal is to take one of these jobs but negotiate to leave and take calls by phone after done rounding. Then do outpatient in the afternoon. Hoping this combination could get me to 500k a year.

you can definately do this....

As for 'negotiating to leave'....it sounds like you just need to get a contract with the hospital where you get a stipend and then bill yourself. You do that and they can't tell you when you show up, leave,etc....thats going to be far better than being an employee at 280k or whatever.

 

[vistaril]

The other way to think about inpatient is that you can be an inpatient doc with 100% 1099. This can easily exceed 300k, especially if you rotate at several facilities, some of which might be Big Box. This way you essentially have a private inpatient practice (except your clients are institutions, not patients), which allows all the benefits of private practice without issues associated with the outpatient practice. Your negotiation power is much higher because if one of your BigBox clients are lackluster, you can negotiate it up to market parity

your clients are generally both. Because in most of these arraingments you are going to get an inpatient stipend + be responsible for billing and collecting the inpatient codes. The stipend will generally fluctuate with how much can generally be expected from inpatient collections.

I work in a group where the owner of the group has a large inpatient practice with all the inpatient contracts(maybe 7-8 hospitals across the state), and Im one of the psychs that service those contracts. There is also an outpt component to the group, but I don't do any of that.

There is another even larger group in this area(one of the largest in the country) with a similar model but there are like 6 equity partners. The group I work for just has one owner(Im one of maybe 7 psychs in the area. We have 20 or so nps as well, and counting everyone maybe 100 employees)

 

[AD04]

From what I know you get some extra-income from profit sharing. People supposedly don't leave because of the "golden handcuffs". A really nice retirement package that includes a pension that can pay in the 7-8k/month if you spend your career there on top of a 401k, a sign-on loan of 100k in some cases that is forgiven after 7-8 years, help with mortgage...etc. Essentially you are held hostage, lol.

Of course the flip side is you will never do therapy again in your life, your patient panel will keep growing till the end of your career with no limit, you will work hard though the details vary depending on the site. The whole Kaiser system is set up in some way to reduce access because physicians are paid from insurance premiums rather than service so your services are prepaid. There has been some pretty bad publicity recently particularly for mental health care. Essentially, it's glorified Big Box Shop.

I don't see how this is better than the VA.

 

[dl2dp2]

your clients are generally both. Because in most of these arraingments you are going to get an inpatient stipend + be responsible for billing and collecting the inpatient codes. The stipend will generally fluctuate with how much can generally be expected from inpatient collections.

I work in a group where the owner of the group has a large inpatient practice with all the inpatient contracts(maybe 7-8 hospitals across the state), and Im one of the psychs that service those contracts. There is also an outpt component to the group, but I don't do any of that.

There is another even larger group in this area(one of the largest in the country) with a similar model but there are like 6 equity partners. The group I work for just has one owner(Im one of maybe 7 psychs in the area. We have 20 or so nps as well, and counting everyone maybe 100 employees)

Interesting. So there's no partnership track? What happens when the owner wants to retire? Or is the owner already institutional? I'm overall not a huge fan of this type of arrangement--ownership is very important to me with a job, but I suppose if they pay well you can do what AD04 does.

 

[vistaril]

Interesting. So there's no partnership track? What happens when the owner wants to retire?

Not at this group no...which is a good thing imo. It cuts out the bs and makes the decisions about work vs compensation clear. And makes the
job expectations clear.

I pointed this out when the owner and COO(two different people) are always brainstorming how we should 'come together' to cover stuff various times and get everything done...for example when the owner is out. I'm like "look, I'm an employee so I know exactly what I'm going to cover...what my contract says". Since I'm an employee it's not my responsibility to make sure it all comes together.

A lot of times he will reference this other group in terms of how they do things and I'm like "thats great. but they have 6 partners...you can't compare how they assign work in that group to how we assign work here"

When I did my new contract, I made sure to make the work expectations part fairly well defined. You can't do it perfectly because units partially close, switch around, etc so some flexibility is required. But I improved things a lot. No longer does my day consist of "whatever the owner says I should do".....

Now the nps in the group have a lot less leverage(market is different for them.....seemingly 40 million of them graduate in this area every semester ugh) so they have to do more and be more flexible.

When the owner wants to retire my guess is the inpatient contracts will either:

1) be bid for and won by other local groups and their people will do them
2) be bid for and won by other local groups and someone like me will do them just like now but working for that group
3) something will be worked out with the people who do them now whereas someone like me signs on to do it...of course billing may be a little tricky as
I wouldnt have my own billing aparatus but could work that out

But i think any of those three would work out. There are a lot of downsides to my current gig(some upsides too), but I'd much rather work
here than the larger group in town that has 6 partners. I wouldnt have a chance to make partner there either in reality but they would get more work out of me for less money in the meantime....no thanks.