Contract negotiations: everything but salary

[5andten]

working through some negotiations on contracts. What are some things that should be negotiated into contracts other than salary? Understand insurance, time off, cme etc. but what are some other non common ancillary things you’ve found beneficial to contracts? Any other general tips on negotiation?

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[PODIATRYCRAZE]

maternity/paternity leave, sign on bonus, relocation bonus, collections bonus, noncompete. I heard of one guy who was able to negotiate his salary down a little bit in order to completely eliminate his noncompete.

Does your contract mention how to request extra tools or employees? like vaccuum dremels or good podiatry chairs? Scribes and medical assistants. If that matters to you, negotiate that.

I am not an expert on this but malpractice insurance tail vs full coverage might be something to look into. Not sure how negotiable it is.

Other nonimportant things (at least to me and most other podiatrists) which not all contracts include are research rights. For instance mine says that if I conduct research and become a millionaire off of it I get to keep all rights to it. Some contracts will claim the rights to that knowledge and profits.

 

[PMG03470]

working through some negotiations on contracts. What are some things that should be negotiated into contracts other than salary? Understand insurance, time off, cme etc. but what are some other non common ancillary things you’ve found beneficial to contracts? Any other general tips on negotiation?

My first advice is get a lawyer involved no matter what, you will miss verbiage in the contract that can screw you. I didn’t do this on my first contract and realized the guy basically owned me and at any point in time could call me and tell me to do something, so be careful. Otherwise these are important:

1) non-compete, how far is it, could this screw you if you leave

2) maternity/family leave. Most PP are so small they do not have to provide FMLA. Therefore if you are planning on a family or let alone someone in your family becomes ill that you need to care for extended leave must be written in.

3) this may be less common, but if you are aiming at board certified have something written in that the owner must provide you with charts/XRs from your surgical cases in the event you leave. Some people have failed cert because they couldn’t get charts from prior jobs.

4)is the contract “at will” for both parties? My first contract there were very specific things I would have had to do (ie commit a felony etc.) in order to be fired before my contract was over and concurrently I couldn’t leave unless my boss broke something in the contract. My current contract is at will on both sides, he can decide he doesn’t like my eye color and fire me and concurrently I can just say bye if I want to without reason.

5) this is silly, but didn’t think about this initially. Make sure you are designated days for CME on top of your other PTO. If I didn’t catch this I would have only had 5 sick days and 5 PTO and I would have lost a week of my PTO to CME if I didn’t have written in separately 5 days for CME.


I know I’m forgetting a lot, these are just somethings I personally learned. PM me if you have any questions

 

[Feli]

Non-compete is far and away #1.
It's not so much that you negotiate it, but you have to know if it's enforced in the state/area (for physicians). An employer could put 20 or 50 or 100 miles in the contract, and many try, in a place that non-compete clauses never hold up at all (but you need to know this). Often, they will hold up for a reasonable radius, but they could put a larger one in your contract than the area typically allows (which might hold up to lesser area-standard radius, might hold up in excess, or could get tossed totally for being excessive... depends on locality!). It is seldom good to question or negotiate non-compete (raises alarm bells that you might become local competition), but you need to be crystal clear via attorney on how enforced or not allowed the non-competes are in the area you are potentially going to.

The situation you want to avoid when employed (PP pod... also MSG or ortho or large group ... but also even hospital employ) is having to move and/or find a new job under duress if terminated or not renewed. This is where having knowledge of the area non-compete laws (and an emergency fund) comes in. You'd much rather have the option to take your time with the job search and move... or just work nearby or start up nearby. If you have to move, that often means break a lease, sell a house, yank kids outta school, partner job change, change all kinds of addresses, etc. Those things cost much more - both money and stress - than some piddly increase in CME allow or an extra day off or a small sign bonus that you may have negotiated. Even worse, non-compete (especially one which is NOT valid yet you think it is since it's in the contract), might make you feel stuck at a dead end job just to avoid moving.

Attorney, as mentioned... employment or medical focus office.

As far as the office, you have to look at the things that are not in the black and white: how happy are docs working there (or worked for the group in the past... TALK TO THEM, as many as possible), how is staffing, how is refer supply and marketing, how are area payers, do you like the office supplies and location and appearance, do the hiring and managing docs/owners seem legit. Hint: just because they appear to have money does NOT mean they're in a hurry to share it with you.

 

[LossToFollowUp]

Definitely non-compete is the most important as others have stated.

Another consideration would be details of resignation. They could royally screw you by withholding checks or deduct fees if you break contract or improperly give notice. I would negotiate the notice timeframe to about 30-60 days. 90 days is way too long and just leaves you in a really awkward environment.

 

[podourology]

Non-compete is far and away #1.
It's not so much that you negotiate it, but you have to know if it's enforced in the state/area (for physicians). An employer could put 20 or 50 or 100 miles in the contract, and many try, in a place that non-compete clauses never hold up at all (but you need to know this). Often, they will hold up for a reasonable radius, but they could put a larger one in your contract than the area typically allows (which might hold up to lesser area-standard radius, might hold up in excess, or could get tossed totally for being excessive... depends on locality!). It is seldom good to question or negotiate non-compete (raises alarm bells that you might become local competition), but you need to be crystal clear via attorney on how enforced or not allowed the non-competes are in the area you are potentially going to.

The situation you want to avoid when employed (PP pod... also MSG or ortho or large group ... but also even hospital employ) is having to move and/or find a new job under duress if terminated or not renewed. This is where having knowledge of the area non-compete laws (and an emergency fund) comes in. You'd much rather have the option to take your time with the job search and move... or just work nearby or start up nearby. If you have to move, that often means break a lease, sell a house, yank kids outta school, partner job change, change all kinds of addresses, etc. Those things cost much more - both money and stress - than some piddly increase in CME allow or an extra day off or a small sign bonus that you may have negotiated. Even worse, non-compete (especially one which is NOT valid yet you think it is since it's in the contract), might make you feel stuck at a dead end job just to avoid moving.

Attorney, as mentioned... employment or medical focus office.

As far as the office, you have to look at the things that are not in the black and white: how happy are docs working there (or worked for the group in the past... TALK TO THEM, as many as possible), how is staffing, how is refer supply and marketing, how are area payers, do you like the office supplies and location and appearance, do the hiring and managing docs/owners seem legit. Hint: just because they appear to have money does NOT mean they're in a hurry to share it with you.

In NY, Conn, Mass this is illegal to enforce.

 

[Hybrocure]

In NY, Conn, Mass this is illegal to enforce.

Non competes are pretty hard to enforce in general no matter where you are. Anyone in a proper business job will tell you how much of a joke non competes are this isn’t something exclusive to doctors.

It’s essentially a scare tactic into hoping you don’t leave the job. And honestly, questioning the non compete for an application/interview will raise a major red flag for your chance at getting the job right off the bat, especially because new grads are notorious for job hopping after the first year or two.

 

[Feli]

In NY, Conn, Mass this is illegal to enforce.

Yeah, and way more than that... and adding more nearly every year (link below that is 2022 updated).
Cali, Colorado, NMex, Delaware and many others all don't enforce non-compete (for physicians) either. That absolutely does NOT mean that the employer won't try to put it in the contract anyways (and in those states, you can just ignore it since it'd get tossed... but still verify with lawyer).

NY and NJ are a bit of a gray area to my knowledge... ask a local attorney on them.

Some states - quite a few of them - hold up non-competes reasonably or very well, though. It's mostly the red states. It's important to know what the typical rulings are via local attorney and review of cases to see what radius were found reasonable or reduced/disregarded.

Non-compete really limits one's future job options and affects the amount of roots you want to lay in the area or how much time you want to spend actually getting to know the PCPs or hospital. And no wrong to give a group a decent try but then break off on your own or work for the local hospital or etc. It's common sense, and MDs do this stuff all the time too.

Non competes are pretty hard to enforce in general no matter where you are. Anyone in a proper business job will tell you how much of a joke non competes are this isn’t something exclusive to doctors.

It’s essentially a scare tactic into hoping you don’t leave the job. And honestly, questioning the non compete for an application/interview will raise a major red flag for your chance at getting the job right off the bat, especially because new grads are notorious for job hopping after the first year or two.

You have to be careful with this thinking. ^

In states where non-competes are clearly not enforced (red ones on slide 2 here ), you are right. It's a bluff... paper tiger.

In many other states, the employer can BURY you financially and literally block your business. It is all variable based on locality.

Even in states where non-competes are not enforced or minimally allowed, the former employer can still sue you for alllll kinds of crap to drain your time and money (solicitation of patients, solicitation of refers, intellectual theft, employee solicitation, false advertising, breach of contract, etc etc etc). They know their pockets are much deeper (esp if it's a hospital), and they know slowing you down from opening or ramping up will help them keep more of the patients/refers. I know too many DPMs who have found this out firsthand with frivolous lawsuits. I have received phone calls from docs' attorneys litigating against my former employers (asking about locations, my contract, etc). I was fully expecting it myself (and was well prepped for it with attorney and paperwork to quickly put it to bed). People get funny about money. Underestimate that at your own risk.

Bottom line is know what you are getting into, and attorney consult is $ well spent.
Too many podiatrists learn about their non-compete once they inevitably realize their employer is screwing them and they won't budge on money or partnership or whatever. Many of them took out a mortgage or laid roots in the city. Not good. I do agree not to generally question/negotiate non-compete with employer as I said above (that shows your hand)... just understand how it will play out and make the job accept/reject accordingly. Do not trust Google or SDN or anything.... it's too important, so verify with a competent area medical or employment attorney.

 

[HardRoadPaved]

Take non competes seriously. I've seen so many docs and dentists devastated when associate leaves and owner just wants to take it out on them.

Getting lucky is like testing your pull out game. Both haunt you for years to come if you lose.

 

[5andten]

Thanks for all the suggestions. Definitely will get a lawyer. Dogs you guys recommend a certain guy/girl? Does it make sense for them to practice in the same state or? I’ve seen some online companies as well. Any recs?

 

[Feli]

Thanks for all the suggestions. Definitely will get a lawyer. Dogs you guys recommend a certain guy/girl? Does it make sense for them to practice in the same state or? I’ve seen some online companies as well. Any recs?

100% needs to be in same state/locality and you want employment (employee side) or medical attorney.
They need ability to pull cases and rulings in your area (because that's what judgements and precedents are based on).
You want someone who has litigated local area separations and noncompetes and contract disputes before.
They need ability to appear for you in small claims or regular courts (which will be in city/county of employer office you work at).

This is not minor league stuff or a place to save a few bucks. Find one of the best ones in the area.
You're only talking $300 or so for an hour consult on a contract (which can save thousands or tens of K and headaches on the back end).

 

[5andten]

Got my contract today. 240k first year, 35% after 500k. then 35% collections year 2 and 3. 40k signing, 20k relocation. thoughts? I think it is pretty fair deal but definitely some things to negotiate on and further outline

 

[Hybrocure]

Got my contract today. 240k first year, 35% after 500k. then 35% collections year 2 and 3. 40k signing, 20k relocation. thoughts? I think it is pretty fair deal but definitely some things to negotiate on and further outline

That sounds great. But what do they expect of you?

 

[5andten]

It will be some work. Trauma call one week per month. General call 2 weeks per month. Operating 1-2 days per week once i get going. 30ish patients a day once I am up to full speed.

 

[heybrother]

Who is this with?

Do you believe your compensation structure truly reimburses you for the amount of call you are taking?

 

[5andten]

It is a private practice job. I think so... its a level 3 hospital so trauma call isnt a ton. the other is general prodiatry call. Inpatient is 1-5 people usually.

 

[Retrograde_Nail]

It is a private practice job. I think so... its a level 3 hospital so trauma call isnt a ton. the other is general prodiatry call. Inpatient is 1-5 people usually.

private practice podiatry or private practice with Ortho and/or MSG?

 

[5andten]

private practice podiatry only. With plans to be half owner in 2 years. No F&A orthro in town.

 

[5andten]

What is typical percentage of collections?

 

[Retrograde_Nail]

private practice podiatry only. With plans to be half owner in 2 years. No F&A orthro in town.

def a diamond job. good work.

I honestly would do the guaranteed salary + 35% of commission after 500K for the first two years then go straight production. This could be hit or miss. Better to lock in guaranteed salary while you are still building your practice.

 

[Retrograde_Nail]

What is typical percentage of collections?

30-35% is typical for podiatry. But it really should be 40% or higher. What does it take to make partner?

 

[HardRoadPaved]

Is DME included in collection? Are DME costs withdrawn from your collections?

 

[heybrother]

It is a private practice job. I think so... its a level 3 hospital so trauma call isnt a ton. the other is general prodiatry call. Inpatient is 1-5 people usually.

A job's a job and good for you for getting something that starts at a good wage. Hopefully your trauma call will lend itself to getting cases for board certification. That said - I'm worried that you've essentially signed up for the "worst of both worlds".

You are essentially going to perform a fairly large amount of hospital based care (which is inefficient, irregular, often untimely, potentially not convenient) and you are going to be reimbursed for it at private practice levels instead of through RVUs. Let's forget the 35% for a second which is better than many but isn't amazing.

Many, many, many patients have payors that do not reimburse very well. You can look up Medicare online (Medicare fee schedule look up tool). You'll see that it reimburses less for procedures performed in a facility. Medicare advantage plans often reimburse less than Medicare. Medicaid reimburses less still. And unpaid likely reimburses least of all. So even if your group somehow has very good commercial rates there are still a lot of people out there where you'll be getting 35% of a very small number, but you'll potentially be putting a lot of effort into their care.

The whole arrangement is strange to me because most PP podiatry groups don't put up money before hand and don't start pay over $200K. It feels like this might be being subsidized by the hospital.

 

[LossToFollowUp]

I don't understand this trauma vs general podiatry call. It's either you are on call or you are not. Do you mean you are taking hospital call 1 week and the other calls are for the office? Or is there a unique situation you have going on? Typically associates would get funneled all the call.

That's a dang good base. Kudos to you. I hate that 35% from 500k aspect but we can't have it all. I would argue that straight percentage is iffy in your situation in your 2nd and 3rd year.

 

[Retrograde_Nail]

A job's a job and good for you for getting something that starts at a good wage. Hopefully your trauma call will lend itself to getting cases for board certification. That said - I'm worried that you've essentially signed up for the "worst of both worlds".

You are essentially going to perform a fairly large amount of hospital based care (which is inefficient, irregular, often untimely, potentially not convenient) and you are going to be reimbursed for it at private practice levels instead of through RVUs. Let's forget the 35% for a second which is better than many but isn't amazing.

Many, many, many patients have payors that do not reimburse very well. You can look up Medicare online (Medicare fee schedule look up tool). You'll see that it reimburses less for procedures performed in a facility. Medicare advantage plans often reimburse less than Medicare. Medicaid reimburses less still. And unpaid likely reimburses least of all. So even if your group somehow has very good commercial rates there are still a lot of people out there where you'll be getting 35% of a very small number, but you'll potentially be putting a lot of effort into their care.

The whole arrangement is strange to me because most PP podiatry groups don't put up money before hand and don't start pay over $200K. It feels like this might be being subsidized by the hospital.

This is a great comment. It's an odd set up. It could be the hospital is fronting the money for the guaranteed income for the first year then is just going to cash in on the discounted work after that.

 

[wakaflocka88]

Congrats OP. good advice from the above experienced posters, talk to them more privately. Remember to always look out for yourself, review your billings and collections weekly and monthly to make sure you have a good understanding. Don’t let them hide anything from you.

 

[dtrack22]

Got my contract today. 240k first year, 35% after 500k. then 35% collections year 2 and 3. 40k signing, 20k relocation. thoughts? I think it is pretty fair deal but definitely some things to negotiate on and further outline

The call situation will suck as a private, non-facility employed podiatrist. You will do more work that won’t count towards your $500k collections than you would like. I also don’t understand the “trauma” call and “general” call distinctions. Community, level 3 hospitals don’t do that.

I would at least be asking for 40% once there is no more guarantee. Your base is great. But once again, you have a “bonus” structure that makes no sense. Because podiatry. This employer is ok paying you a guaranteed $240k for $500k in collections. Math time everyone. Your base is worth 48% of collections, at worst. After you’ve met that $500k threshold (where you theoretically have covered your cost to the practice), you go from getting 48 cents of every dollar you bring in to only 35 cents of every dollar you bring in. And you could say that the owner is gambling on you sticking around and making them money in year 2, 3, 4, 5, etc. but then you get to partner in year 2? Likely before they even broke even on you? Ok. It makes no sense, but you won’t find better pay working in a podiatry group so I would try and squeeze a higher % of collections out of them when you are straight production and consider myself fortunate. Even though there are things you’ve said about this contract that don’t add up…

 

[Hybrocure]

Also just consider your quality of life. If it’s 3 weeks of call a month you will hate it regardless of how busy it is. Even if it’s slow, you still have to be ready at any time and that can wear on you mentally.

That being said at least you’re compensated enough for it. There are pods out there doing that call for 100k

 

[5andten]

Is DME included in collection? Are DME costs withdrawn from your collections?

It is not included in collections.

A job's a job and good for you for getting something that starts at a good wage. Hopefully your trauma call will lend itself to getting cases for board certification. That said - I'm worried that you've essentially signed up for the "worst of both worlds".

You are essentially going to perform a fairly large amount of hospital based care (which is inefficient, irregular, often untimely, potentially not convenient) and you are going to be reimbursed for it at private practice levels instead of through RVUs. Let's forget the 35% for a second which is better than many but isn't amazing.

Many, many, many patients have payors that do not reimburse very well. You can look up Medicare online (Medicare fee schedule look up tool). You'll see that it reimburses less for procedures performed in a facility. Medicare advantage plans often reimburse less than Medicare. Medicaid reimburses less still. And unpaid likely reimburses least of all. So even if your group somehow has very good commercial rates there are still a lot of people out there where you'll be getting 35% of a very small number, but you'll potentially be putting a lot of effort into their care.

The whole arrangement is strange to me because most PP podiatry groups don't put up money before hand and don't start pay over $200K. It feels like this might be being subsidized by the hospital.

It’s a PP job but the hospital subsidizes salary first year and signing bonus as it’s a smaller town so they are helping recruit.

I don't understand this trauma vs general podiatry call. It's either you are on call or you are not. Do you mean you are taking hospital call 1 week and the other calls are for the office? Or is there a unique situation you have going on? Typically associates would get funneled all the call.

That's a dang good base. Kudos to you. I hate that 35% from 500k aspect but we can't have it all. I would argue that straight percentage is iffy in your situation in your 2nd and 3rd year.

There is an ortho group in town so they take the foot and ankle trauma every other week. I would be splitting the 2 weeks a month of foot and ankle trauma with another guy. Then general hospital/office call for infections etc would be 2 weeks a month. The trauma week and general week would be together so essentially 2 weeks of call a month for now

This is a great comment. It's an odd set up. It could be the hospital is fronting the money for the guaranteed income for the first year then is just going to cash in on the discounted work after that.

The hospital is subsidizing pay first year

 

[5andten]

The call situation will suck as a private, non-facility employed podiatrist. You will do more work that won’t count towards your $500k collections than you would like. I also don’t understand the “trauma” call and “general” call distinctions. Community, level 3 hospitals don’t do that.

I would at least be asking for 40% once there is no more guarantee. Your base is great. But once again, you have a “bonus” structure that makes no sense. Because podiatry. This employer is ok paying you a guaranteed $240k for $500k in collections. Math time everyone. Your base is worth 48% of collections, at worst. After you’ve met that $500k threshold (where you theoretically have covered your cost to the practice), you go from getting 48 cents of every dollar you bring in to only 35 cents of every dollar you bring in. And you could say that the owner is gambling on you sticking around and making them money in year 2, 3, 4, 5, etc. but then you get to partner in year 2? Likely before they even broke even on you? Ok. It makes no sense, but you won’t find better pay working in a podiatry group so I would try and squeeze a higher % of collections out of them when you are straight production and consider myself fortunate. Even though there are things you’ve said about this contract that don’t add up…

Good points. Good math to think about also. What else doesn’t add up?

 

[LossToFollowUp]

I don't mean to speak for dtrack22, but I think you have a unique situation with the hospital subsidizing pay along with this trauma call situation. To most of us private private dudes, it just sounds a bit odd how the math works out in terms of your collections/earning potential.

But to clarify your situation, are you able to take on pilon fractures in your state, if not who would it go to if it comes in during your week? Who would handle the tib/fib fracture? Is there a general ortho trauma also taking call at the same time? You sharing call with F/A ortho doesn't mean you can fully share the responsibilities.

 

[HardRoadPaved]

No dme, no deal. Great enjoy making 35% of an ankle ORiF at $275 net. Meanwhile boss sells that cam boot post op for nearly as much and no risk.

 

[5andten]

No dme, no deal. Great enjoy making 35% of an ankle ORiF at $275 net. Meanwhile boss sells that cam boot post op for nearly as much and no risk.

after looking closer, I think I misread-DME is included. Having a lawyer review so I will be sure this is outlined properly.

 

[5andten]

I don't mean to speak for dtrack22, but I think you have a unique situation with the hospital subsidizing pay along with this trauma call situation. To most of us private private dudes, it just sounds a bit odd how the math works out in terms of your collections/earning potential.

But to clarify your situation, are you able to take on pilon fractures in your state, if not who would it go to if it comes in during your week? Who would handle the tib/fib fracture? Is there a general ortho trauma also taking call at the same time? You sharing call with F/A ortho doesn't mean you can fully share the responsibilities.

Yes can do pilons.

I think you all bring up some good points that I need more clarification on so I appreciate that.

 

[LossToFollowUp]

From my experience, the orthos doing tib/fib fractures tend to take the pilons/ankles as well. Most ERs don't care to learn what you can or can't do. It is much easier to consult ortho trauma that will do it all.
You also have to consider this point which many have brought up before. You are getting 250K+ base for everything you described but an ortho trauma is getting 700-800K+. Is taking these calls worth your time?

 

[GreenHousePub]

From my experience, the orthos doing tib/fib fractures tend to take the pilons/ankles as well. Most ERs don't care to learn what you can or can't do. It is much easier to consult ortho trauma that will do it all.
You also have to consider this point which many have brought up before. You are getting 250K+ base for everything you described but an ortho trauma is getting 700-800K+. Is taking these calls worth your time?

ER Call for "trauma" is going to be for 95% diabetic foot infections, 4% non-op fractures and 1% operable pathology.

 

[air bud]

We determined this call overlaps correct?

 

[HardRoadPaved]

I'm more convinced this job is just a great initial do surgery and do the grunt work for a group. All the meanwhile the owners are reaping in the real office work + dme 9-5. I cant imagine the "free care" you'll have to take on to keep the ER docs calling too.

#fasttracktoburnout

 

[MoostashPod]

I'm more convinced this job is just a great initial do surgery and do the grunt work for a group. All the meanwhile the owners are reaping in the real office work + dme 9-5. I cant imagine the "free care" you'll have to take on to keep the ER docs calling too.

#fasttracktoburnout

I agree. The owner benefits this tremendously while the associate works to the bone 🦴. Tread carefully and go over the contract word for word, question everything now before signing it.

 

[Feli]

The whole point of PP is not taking call (among other things).

If you want to take call, I'd work for the hospital.
The facility would clearly be suggestible if fronting the salary and bonuses and employing other docs. Simply contact them directly and find out? Sure, that steps on the PP pod group a bit, but you have to get the best deal for you. You have no current allegiance or non-compete with the group. Do you.

Hospitals that require call by docs are generally ones with no DPMs on staff or on-call, aside from their employees.... and they get little/no elective from area PP docs (who go elsewhere or do "courtesy staff" status to avoid call... or find associates dumb enough to do the call).

 

[heybrother]

In rural areas - family medicine doctors sometimes sign multi-year contracts with a great starting base, switch to RVUs, and then sometimes find that they are taking a paycut with years of contract to come and a signing bonus to pay back if they try to leave. RVUs are substantially more fair than collections - they don't take into account payors, the patient actually paying their bill etc. They are what they are - if your RVUs are low you didn't do enough.

How long is your signing bonus contingent on you staying?

What would you say if I told you that you're in danger of taking a (massive) paycut in year 2? At 35% you'll need collections of $686K to maintain your starting year pay. Call me a pessimist, but I don't believe you'll reach that number. There are some very succesful people on this forum and there's a tendency to throw big numbers around and act like they are no big deal. That doesn't mean you'll be able to do it your second year. The volume may not be there, the contracts may not be there, your owner may not be willing to add the services. When you hear someone has big collections - you really need to know how they got there. Is it grafts? Diabetic shoes? Hard sell on cash services ie. offer shockwave at 1st visit for plantar fasciitis and refuse to offer anything else until they comply. Maybe its CAM boots for every mechanical ailment and ulceration.

Do you have a connection to the area? Family nearby? What does your spouse think?

...wait a second. Why am I writing this. I already wrote this post.

Forum Members - Official: Job Offer Thread

... if ortho is really upset about elevating osteotomies, kellers, Gastroc lengthenings I&Ds/amps then ortho is really not busy. ... Yeah, exactly. But, just because ortho (or gen or vasc) is too busy now, that doesn't mean they always will be. If they're ever not busy, they will then start to...

forums.studentdoctor.net

And I wrote it to you!

I stand by everything I said. I think its great you are getting some money year 1, but I think you are making a big commitment contingent on the idea of being owner when this might not be for you as time passes. The call requirement is also just ridiculous.

 

[Shiyuan]

Any one have thoughts on the “physician enterprise value” (hospital employed mostly)?

 

[5andten]

In rural areas - family medicine doctors sometimes sign multi-year contracts with a great starting base, switch to RVUs, and then sometimes find that they are taking a paycut with years of contract to come and a signing bonus to pay back if they try to leave. RVUs are substantially more fair than collections - they don't take into account payors, the patient actually paying their bill etc. They are what they are - if your RVUs are low you didn't do enough.

How long is your signing bonus contingent on you staying?

What would you say if I told you that you're in danger of taking a (massive) paycut in year 2? At 35% you'll need collections of $686K to maintain your starting year pay. Call me a pessimist, but I don't believe you'll reach that number. There are some very succesful people on this forum and there's a tendency to throw big numbers around and act like they are no big deal. That doesn't mean you'll be able to do it your second year. The volume may not be there, the contracts may not be there, your owner may not be willing to add the services. When you hear someone has big collections - you really need to know how they got there. Is it grafts? Diabetic shoes? Hard sell on cash services ie. offer shockwave at 1st visit for plantar fasciitis and refuse to offer anything else until they comply. Maybe its CAM boots for every mechanical ailment and ulceration.

Do you have a connection to the area? Family nearby? What does your spouse think?

...wait a second. Why am I writing this. I already wrote this post.

Forum Members - Official: Job Offer Thread

... if ortho is really upset about elevating osteotomies, kellers, Gastroc lengthenings I&Ds/amps then ortho is really not busy. ... Yeah, exactly. But, just because ortho (or gen or vasc) is too busy now, that doesn't mean they always will be. If they're ever not busy, they will then start to...

forums.studentdoctor.net

And I wrote it to you!

I stand by everything I said. I think its great you are getting some money year 1, but I think you are making a big commitment contingent on the idea of being owner when this might not be for you as time passes. The call requirement is also just ridiculous.

You have been very helpful and I appreciate all the points you have made. Lots of things to consider. I will be working through this offer in the next couple weeks and see what points I can negotiate

 

[HardRoadPaved]

the sad part is one of your colleagues will say omg 240k and blindly jump on this job. most do not do any due diligence and this why we live in the 100-125k base era. if you pass on this opportunity and feel bad that everything else out there is a low base, you can thank oversaturation.

 

[5andten]

Curious what you all would think is an ideal contract for someone fresh out? What's the gold standard in our profession that everyone is chasing? I know there is a lot of variability but what are some things one should strive for.

 

[heybrother]

Any one have thoughts on the “physician enterprise value” (hospital employed mostly)?

Obviously I had to create a meme. That said - every hospital podiatrist I've ever spoken to has at some point described not only the collections that they've generated through OR use and facility fees, but also quality of the referrals into the system that feed the virtuous loop of hospital profiteering - referrals for MRI, doppler, cardiology, ultrasound, PT etc. Theoretically the podiatrist's value to the system is increased through this self referral that would in the past have referrals to other local community doctors that you held in high regard. This is all essentially the vertical integration of healthcare that happened in other industries. At different points in time through history the perception was that the quality of healthcare would be improved through this unified approach. All of the doctors in the system can see all of the test results, all of the imagery, all of the other doctors notes. Outside EHRs were supposed to deliver this - but they never did. That moment in private practice where a patient has no idea whether the cardiologist did a venous doppler or an arterial doppler - its terrible. The problem is that everything rendered in a hospital is overpriced and the government and the press are starting to notice. There are now front page articles in major newspapers showing that when hospitals buy up cardiology practices the cost of basic testing explodes. Its good for hospitals bottom lines but its not ideal for society. Paying $1000 for a hospital to perform a stress test that a PP cardiologist would have performed for $200 is going to be one of those pressure points that's going to make CMS do something. There are already things coming down the pipe to reduce Medicare reimbursement for free standing hospital facilities that aren't on hospital grounds and individual states are going after facility fees because they don't produce value.

 

[Feli]

Any one have thoughts on the “physician enterprise value” (hospital employed mostly)?

I didn't watch Star Trek.

 

[Feli]

Curious what you all would think is an ideal contract for someone fresh out? What's the gold standard in our profession that everyone is chasing? I know there is a lot of variability but what are some things one should strive for.

It's diff for everyone.

• Many want a comfortable base +/- benefits and that's it (why any hospital DPM job not in horrid places gets hundreds of apps).
• Others want some incentive (RVU/bonus chances).
• Quite a few will go almost anywhere to get the cases/scope they want (try to be a mini F&A ortho).
• Some portion wants to set their own sched, staff, supplies, pts/marketing style (PP owner/partner).
• A few are completely tied to a certain location... and will just take the best they can find there.
• Some have such a rough time (failed boards, trouble at hospitals, etc) that they'll literally take anything.

...In reality, I know a pretty tiny number of ppl who stayed at their first job for 10+ years (under 5% of DPMs that I know). There are that VERY few who gel well and don't get (totally) ripped off by a PP boss or get good admins at hospital/MSG and don't get bored or overworked or underpaid. It's definitely under half that make it even 3-5yrs after training without switching. Big MSGs (Kaiser, Sutter, etc) seem to have a fairly high stick rate; they are comfort jobs (avg pay, reasonable/no call) with a good fit for the first bullet above. The husband/wife DPM teams who take employed jobs same/nearby tend to fare particularly bad (or good) as they will have real trouble moving states/jobs.

Most pod grads simply stay at their first stop job until they get ABFAS cert or until they get real frustrated with boss/pay/etc, and then they're done at the first job and on to a higher pay job or starting own PP. Nothing wrong with just finding the best gig you can, figure it probably won't be as good as hoped, and be pleasantly surprised if it does end up roses. Look at nearly any good surgical DPM or PP owner or residency director or just any pod you resepect... they've probably moved a few times. It's really hard to start and stay perfect on pod jobs... the flooded market sucks, and admins change.