Job Offer

[Pain321123]

New job offer: Hospital employed. 458K base guaranteed for 3 years. wRVU $64. Production after 3 years with no base salary or earlier if out earning the base.

80k student loan repayment over 5 years. 6 weeks vacation. 15k per year quality bonus. 5K per year cme. Sounds like great built in primary and neurosurg referral base.

Would like to negotiate a higher wRVU as this is in the Midwest.

Thoughts?

Newer grad < 5 years out. Currently in private practice looking at the cost of buy ins, ASC ownership which already sold to VC years ago. Not sure if it is worth the stress my current boss seems to go through.

My one big concern with hospital based practice will the insurance companies continue to pay these facility fees for a lot of the basic pain procedures that can be done in office or ASC? This will be HOPD with ASC designated as HOPD.

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[Dr. Ice]

Lol drusso is getting hot just reading this offer..keep juicing the SOS for as long as possible. Everything is going private equity or hopd. No one can predict the direction but it seems as though the politics of healthcare continues to drive employment and controllable systems. I’d imagine the cervical esi in hopd will continue to pay for 10x office injection for forseeable future

 

[lobelsteve]

Most could hit the salary match (7156) in 7-8 months.

 

[Ducttape]

that depends on the patient population.

if it is a high medicaid population, good luck with getting to salary match. id guess it would take 2+ years to get past 7000...

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seems like a pretty good deal. salary isnt that bad considering your benefits.

what is the noncompete?

let me guess.... 2 years and 25 miles...

 

[lobelsteve]

3766 level 4 visits in a year.
230 days work.
16.4 patients per day.

 

[Pain321123]

that depends on the patient population.

if it is a high medicaid population, good luck with getting to salary match. id guess it would take 2+ years to get past 7000...

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seems like a pretty good deal. salary isnt that bad considering your benefits.

what is the noncompete?

let me guess.... 2 years and 25 miles...

that depends on the patient population.

if it is a high medicaid population, good luck with getting to salary match. id guess it would take 2+ years to get past 7000...

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seems like a pretty good deal. salary isnt that bad considering your benefits.

what is the noncompete?

let me guess.... 2 years and 25 miles...

Haha exactly

 

[drusso]

New job offer: Hospital employed. 458K base guaranteed for 3 years. wRVU $64. Production after 3 years with no base salary or earlier if out earning the base.

80k student loan repayment over 5 years. 6 weeks vacation. 15k per year quality bonus. 5K per year cme. Sounds like great built in primary and neurosurg referral base.

Would like to negotiate a higher wRVU as this is in the Midwest.

Thoughts?

Newer grad < 5 years out. Currently in private practice looking at the cost of buy ins, ASC ownership which already sold to VC years ago. Not sure if it is worth the stress my current boss seems to go through.

My one big concern with hospital based practice will the insurance companies continue to pay these facility fees for a lot of the basic pain procedures that can be done in office or ASC? This will be HOPD with ASC designated as HOPD.

Hospitals are in the facility fee/room cover charge business. They would if they could figure out how to charge a facility fee for a naturopathic nurse practitioner to do Reiki therapy. Recognize that is the moral rudder of your new boss. They don't give a S hit about you, your training, or the fact that you sunk 14 years of your life into learning to be good at what you do and take good care of patients. They want the SOS facility fee. They are nakedly practicing the art of site of service arbitrage and kicking you back some Vig on the SOS. They will never love you back.

At least your new VC overlords are business people. They know that hogs get fed, and pigs get slaughtered. Negotiate hard with them and negotiate for a REAL piece of the action. Their BATNA is to go out and find new doctors to turn the crank to keep the lights on and burn down their powder. You have leverage in that discussion. You have no leverage with the hospital CEO.

 

[Ferrismonk]

My one big concern with hospital based practice will the insurance companies continue to pay these facility fees for a lot of the basic pain procedures that can be done in office or ASC? This will be HOPD with ASC designated as HOPD.

Next year CMS HOPD/ASC fees are going up and professional fees are going down. That should tell you everything you want to know.

 

[drusso]

Next year CMS HOPD/ASC fees are going up and professional fees are going down. That should tell you everything you want to know.

Do you know why? It's not an accident or simple error.

 

[Ronin1]

Do what’s best for you. This sos train isn’t going anywhere. If you have the stones to launch and be your own boss do that. Otherwise cash the checks. They will keep coming long after I’m retired.

 

[drusso]

Do what’s best for you. This sos train isn’t going anywhere. If you have the stones to launch and be your own boss do that. Otherwise cash the checks. They will keep coming long after I’m retired.

There's a movement afoot for SOS equity.

 

[deleted131481]

There's a movement afoot for SOS equity.

What other specialties are significantly affected by SOS besides pain? I know surgeries/GI done at ASC vs HOPD but specifically I'm thinking clinic vs HOPD. Derm procedures perhaps?

 

[Pain321123]

Hospitals are in the facility fee/room cover charge business. They would if they could figure out how to charge a facility fee for a naturopathic nurse practitioner to do Reiki therapy. Recognize that is the moral rudder of your new boss. They don't give a S hit about you, your training, or the fact that you sunk 14 years of your life into learning to be good at what you do and take good care of patients. They want the SOS facility fee. They are nakedly practicing the art of site of service arbitrage and kicking you back some Vig on the SOS. They will never love you back.

At least your new VC overlords are business people. They know that hogs get fed, and pigs get slaughtered. Negotiate hard with them and negotiate for a REAL piece of the action. Their BATNA is to go out and find new doctors to turn the crank to keep the lights on and burn down their powder. You have leverage in that discussion. You have no leverage with the hospital CEO.

I tend to agree with that. As far as a real piece of the action PE owns 60% of the ASC. Physicians the other 40%. There are already 4 orthopedics surgeons. I’m guessing it would be 5%ish. Won’t know that offer for another couple of months.

 

[DOctorJay]

can you buy into any of the real estate?

 

[Ducttape]

There's a movement afoot for SOS equity.

im betting that will run head on in to the problems with increasing hospital closures.


i disagree completely with your assessment on PE vs hospital CEO. you may not trust HOPD executives, but there is at least a modicum of accountability from hospital boards, etc. not so with private equity. for them, the only juice is the $$.

https://publichealth.berkeley.edu/wp-content/uploads/2021/05/Private-Equity-I-Healthcare-Report-FINAL.pdf#:~:text=Private%20equity%20companies%20seek%20to%20consolidate%20health%20care,used%20to%20bargain%20against%20suppliers%2C%20payors%2C%20and%20patients.

 

[Pain321123]

can you buy into any of the real estate?

Yes, I could buy into the real estate. He will likely retiring in the next 5 years so I would end up buying the office building and his 50% share of the practice. I would be buying into the practice, 50% ownership, in the next couple of months around 75k to 100k for whatever the practice, equipment etc is currently valued. No idea about the ASC real estate.

 

[drusso]

Yes, I could buy into the real estate. He will likely retiring in the next 5 years so I would end up buying the office building and his 50% share of the practice. I would be buying into the practice, 50% ownership, in the next couple of months around 75k to 100k for whatever the practice, equipment etc is currently valued. No idea about the ASC real estate.

So...why are you NOT doing this?

 

[Pain321123]

So...why are you NOT doing this?

That is really what I am trying to figure out. He made on average over the last 20 years around 450 to 500k. To me taking on all this risk, business debt and stress of running a business, I would want to be making closer to 800k+. I am starting to do my own scs implants, spacers, mild, in office kypho etc. So I do feel an ASC would be a great option for this minus the kypho. I just can’t get past that 450K number in private practice.

 

[drusso]

That is really what I am trying to figure out. He made on average over the last 20 years around 450 to 500k. To me taking on all this risk, business debt and stress of running a business, I would want to be making closer to 800k+. I am starting to do my own scs implants, spacers, mild, in office kypho etc. So I do feel an ASC would be a great option for this minus the kypho. I just can’t get past that 450K number in private practice.

Make the number bigger. Work smarter, not harder. If you're the Boss, you can make the machine run any way you want if you're the Cog, not so much. Besides, there's a difference between $450K as a K-1/S-Corp owner versus $450K as a W-2.

 

[Ducttape]

if you are choosing between buying up a practice or going hospital employed - those are two different career paths with completely different headaches.

both are risky. the hospital employed job sounds decent. the stress will come with your perceived lack of control over circumstances.

buying up your bosses practice will entail you having to devote a lot of energy to the business side of things and take on significantly more responsibility

im an old guy. for me, hospital employed is a far better option than private practice.

as a young guy <5 years out, buying up the practice would probably be the better way to go.

 

[mid|ine]

If the practice has failed to generate more than the base for hospital pay and the hospital job is in a location that works for you, I would choose not taking on debt and a more secure income stream.

 

[SSdoc33]

If the practice has failed to generate more than the base for hospital pay and the hospital job is in a location that works for you, I would choose not taking on debt and a more secure income stream.

or, you could be a better doc doing more stuff than the previous owner.

for drusso say "work smarter, not harder" is pretty rich, seeing as how he claims to work 5 a.m. to 9 p.m.

 

[Ferrismonk]

Do you know why? It's not an accident or simple error.

Of course. Politics and money.

 

[drusso]

or, you could be a better doc doing more stuff than the previous owner.

for drusso say "work smarter, not harder" is pretty rich, seeing as how he claims to work 5 a.m. to 9 p.m.

 

[lobelsteve]

View attachment 362342

Quoting Tim Deer's LinkedIn again?

 

[Ligament]

Besides, there's a difference between $450K as a K-1/S-Corp owner versus $450K as a W-2.

That is a good point. Would you mind explaining that to those who don't understand?

 

[drusso]

That is a good point. Would you mind explaining that to those who don't understand?

The K-1 saves over W2 if you take the less (but still competitive) salary and a higher profit-sharing contribution, where the profit sharing isn't subject to self-employment tax. The other benefit of the K-1 is company losses can pass through to you as well, but if it's a partnership or LLC, then the partners get to decide how losses pass through. (If it's an s-corp, it's strictly pro-rata.) So it can be a possible tax advantage if you're helping grow the business (possible home office deduction, etc.) and they pass through your contributed losses to you.

Being a partner can mean a lot of flexibility in other areas. You can look into setting up a deferred income system to save on taxes now and be paid back from the company later(at retirement/when you leave/after X years, whatever you want.) if the company defaults; however, you'd be considered a general creditor.

 

[nvrsumr]

I would take the hospital gig. 450k/yr which I assume includes the six figures he should be making off u is bad risk-reward. there are likely reasons beyond your control that he isn’t doing better.

If he’s working 20 hour weeks and making 500+k off u and the asc that’s a different story.