I forgot who originally posted this on SDN
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Anesthesia Private Practice Primer
Employment Models
-Employee: of the hospital, of the private group? Someone is almost assuredly making money off of your work. How are you paid? Salary? Hourly? Are your hours/responsibilities well defined or vague? Is everyone in the department an employee, or are there partners? Does everyone get paid the same? Mommy track/part time available?
-Employee with production: base salary plus production bonus (with either private group or hospital employment)
-Partnership track: how long? Is there a cash buy-in? Who decides (and what determines) if you become a partner? Are all partners equal (in salary, vacation, benefits, case mix, schedule, call schedule, voting rights)? What is the track record of the group with regards to making people partners? Lots of “two years and out” people in their history?
-Locums
-Solo Practitioner
Compensation
-Money: Salary? Hourly wage? Salary plus production? 100% production? Profit sharing? Is it equal? 1099 vs W2?
-Models:
-Straight salary
-Straight hourly wage
-Salary plus production (how is this calculated?)
-100% production aka “eat what you kill” (how is this calculated-units, hours? Are the units blended? Who makes the schedule?)
-Equal split of profits (everyone gets paid the same, but it varies each month depending on how much was billed. Does everyone do the same amount of work/hours/case mix?)
-Are there stipends for call, backup call, subgroup call, etc.
Benefits:
-insurance (malpractice, disability, life, health, dental, umbrella)
who covers malpractice tail/nose?
-Retirement-vehicles, time to 100% vesting, matching, profit sharing
-Vacation-how much? How chosen/assigned? How taken (i.e. day by day, hourly, week at a time)?
-Business expenses (licensing/DEA, society memberships/journal subscriptions, travel, CME, moving expenses, interview expenses, cell phone/internet, etc)-are they covered/reimbursed?
-Leave (maternity, FMLA, disability, sick days, personal emergencies)-how is it handled?
Practice Models
-MD only
-Medical direction of midlevels (AA, CRNA)
-meets the 7 criteria for med direction: pre-op eval, anesthetic plan, present for critical portions (induction, procedures, emergence, etc), immediately available, physically present for emergencies, monitor case at frequent intervals, post op care
-max 4:1 ratio
-reimbursed 50% of billing
-Medical supervision of midlevels
-does not meet the 7 criteria listed above, or participating in > 4 cases simultaneously
-reimbursed at lower rate
-“Collaborative” (side-by-side practice) with midlevels (who gets what cases and who decides this? Do you help each other out with emergencies? What is your liability for their cases? Is the surgeon “supervising” the midlevel (i.e. is this an opt-out state?)
Clinical Practice:
-Sites: how many? Do you practice at all of them? What kinds (hospital, office, ASC, pain clinic, ICU)? Does everybody practice everywhere? Are some sites “cushier” than others? Who decides who practices where?
-Case mix: General, OB, peds, CV, regional, thoracic, vascular, neuro, trauma, out-of –OR (radiology, GI, ED, cath lab, etc), ICU, pain
-How many OR’s? How many procedures/year? How many deliveries?
-are there “sub-groups” within the group/department? Who decides who’s in each group? Do subgroups require fellowship/certification?
-Does everybody do everything? Are there enough cases of each type to keep everybody’s skills up (especially peds, CV, TEE, procedures)?
-Is there high risk OB? High risk peds? Complex CV cases?
-Can you do ICU or pain as well as anesthesia? Does the group control or have anything to do with this? Does the group run the ICU? Does the group run a pain clinic? If so, how do they value your ICU/pain time? Will you be a solo ICU or pain practitioner outside of the group? Will the hospital employ you directly for these things while you remain a part of the group?
-Coverage: what are you responsible for?
-OR hours: what are they? How late can they go? Who runs the OR schedule? How many rooms are you contracted for at specific times of the day? Can the surgeons schedule whatever they want whenever they want (i.e. 3 am lap chole, Sunday morning total knee, etc)? How are emergencies handled? When are midlevels always available (do you have to relieve them at 3 pm, are they in-house at night, etc)?
-Who covers ICU? Codes? Airways (ED, code, ICU, etc)?
-Do you cover a pain service? Acute/chronic? Consults?
-Anesthesia schedule:
-who makes it (same person every day, third party scheduler, different person everyday, etc)? What determines when you leave? Who picks what rooms/cases you do? Do you finish your room(s) no matter what? Do you hand off cases?
-Call: where (in-house, from home)? What kind (general, subgroup, backup)?
-MD only groups may have many people on call each night, depending on services provided, number of rooms they are contracted to cover, OB/trauma service, etc.
-Equipment: Does the hospital/group have the equipment you need to do your job? US? TEE? Airway carts/equipment? Specialized peds instruments? Does everything work? Who fixes equipment (and how available/reliable are they)? Is there an EMR? Anesthesia EMR?
-How does the group practice?
-Where did they train? Are they BC/BE? Are they fellowship-trained? Are they dangerous? Are they spread too thin?
-Do they help each other out? Cover for each other? Start rooms for each other? Respond to emergencies? See your pre/post-op patients?
-How’s their relationship with the surgeons? What happens if you cancel cases?
Contracts:
-Employment Contracts:
-Do you get one? What are your duties/responsibilities?
-Is everyone’s the same?
-Compensation/benefits-get specifics
-Leaving: when/why/how can you be fired or quit? Is there a minimum time you have to stay? How much notice do you have to give prior to leaving? Is there a non-compete clause (and is it binding or ever enforced)? If you got a sign-on bonus, do you have to pay it back? Do they have to warn you before terminating you? Is there probation/remediation? Can you be fired with/without cause? Who makes hiring/firing decisions and how are they made?
-Have an employment lawyer look it over. Money well spent.
-Hospital Contracts:
-does the group have them? What are the coverage responsibilities? Are they exclusive to your group (or do other groups also provide anesthesia services at your facililties)? How long have they been in place? Are multiple facilities’ contracts tied together or negotiated separately? How long are they for? Who negotiates them for your group? Does the group contract with multiple hospital/clinic systems or just one? Does the group get a stipend from the hospital? If so, why and how much? Are there other anesthesia groups locally? How big are they? Do they get stipends? Do large anesthesia management companies (AMCs) provide anesthesia services locally?
Group Dynamics:
-Private Group: What is the group structure? Are their officers or an administrative board? How/how often are these selected? How are group decisions made (by officers, by full group vote, by board vote, by individuals, etc)? Who gets to vote (full partners, employees, locums)? Are there committees? Are you required to serve on them? How frequently does the group (or the board) meet? On a schedule, or only when they need to? How is discipline handled? Is the group collegial? Do they meet socially? How transparent is it? Can everyone see the books/schedule? Is the schedule flexible? Do partners work for each other? How is this reimbursed (fixed rate, personal negotiations, etc)?
-What is the relationship with midlevels (employed, subcontracted, hospital-employed, private group, etc)? Is it collegial/professional/adversarial/hostile?
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