Salaries

[PMR_doc]

Hey all,

I'm not in derm at all but really curious about derm salaries. It seems that many starting salaries are in the 400-500k range - is that real for derm? Again just curious. Is the typical dermie making like a million bucks a few years out of residency? It's surprising that the avg derm salary is listed as like 380k when it seems like most base salaries are in the 400k +. Thoughts?

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[asmallchild]

Hey all,

I'm not in derm at all but really curious about derm salaries. It seems that many starting salaries are in the 400-500k range - is that real for derm? Again just curious. Is the typical dermie making like a million bucks a few years out of residency? It's surprising that the avg derm salary is listed as like 380k when it seems like most base salaries are in the 400k +. Thoughts?

They're real in that they're typically located in high need areas and/or plan on giving you a heavy workload and/or are typically only guaranteed for 1-2 years before transitioning you into a % structure. Derm is no different than any other field of medicine. If they're offering a starting salary in the 400-500k range, you can bet it's because you are earning enough for the practice to warrant that kind of salary. No, the typical dermatologist is not making 1 million+ a few years out of residency.

 

[1dayatatime]

what is the hit for academics vs private practice (in a large city and in a rural area)?

oh and can you please explain % structure?

i never really thought that much about the money, just knew that it was good lol.

 

[Balderdash]

Too many factors to account for to get an accurate idea. There's a wide range out there. Work 5 or 6 days a week in a rural area, spend 5 minutes per patient and biopsy everything you see (there are snakes like this in every town), you can pull in 1.5 +. For the rest of the ethical folks out there, your range is going to be anywhere from 200 to 5 or 600. Wide range because a lot depends on what your overhead is, what you negotiated with insurance companies, how full your schedule is, how many biopsies you do, what ancillary services your office offers, etc. etc. etc.

The further in training I've come and the more people I've talked to, the number of variables and thus the range have increased. Overall, expect salaries across the board to gradually decrease compared to inflation for reasons beyond the scope of discussion in this thread. The only folks who will make money like derms used to will be those milking us on the private equity side (see Frontier Dermatology).

In reality, derms, like every other doc, make as much or as little as we choose to make based upon balancing our work load, happiness and ethics.

 

[spartan564]

Too many factors to account for to get an accurate idea. There's a wide range out there. Work 5 or 6 days a week in a rural area, spend 5 minutes per patient and biopsy everything you see (there are snakes like this in every town), you can pull in 1.5 +. For the rest of the ethical folks out there, your range is going to be anywhere from 200 to 5 or 600. Wide range because a lot depends on what your overhead is, what you negotiated with insurance companies, how full your schedule is, how many biopsies you do, what ancillary services your office offers, etc. etc. etc.

The further in training I've come and the more people I've talked to, the number of variables and thus the range have increased. Overall, expect salaries across the board to gradually decrease compared to inflation for reasons beyond the scope of discussion in this thread. The only folks who will make money like derms used to will be those milking us on the private equity side (see Frontier Dermatology).

In reality, derms, like every other doc, make as much or as little as we choose to make based upon balancing our work load, happiness and ethics.

Could you please expand on what you mean by Frontier dermatology? I googled but did not get a good answer. I am assuming you are referring to PE firms that are buying up derm practices and managing them?

 

[Balderdash]

Could you please expand on what you mean by Frontier dermatology? I googled but did not get a good answer. I am assuming you are referring to PE firms that are buying up derm practices and managing them?

Yes.

 

[sawtella]

Currently interviewing at several practices in the west coast. I would say, on average, going rate for a general dermatologist fresh out of residency working a full 4 day work schedule (25-35 patients day) is in the range of $350-400k. Kaiser pays about the same depending on how desirable the area you want to work is in (Southern California around 360k and Sacramento closer to 400k). Some PPs may offer a one-year guarantee but most will just pay you just on straight collections. As far as % collection, I can only speak on Southern California but most practices will pay anywhere from 40-55% of net collections depending on the overhead of the practice. Even if you're getting paid 40% of net collections, if you see 30-35 patients a day, 4-4.5 days/week, with a decent payor mix and do a reasonable amount of destructions, biopsies and excisions, you can pull in ~$450k. The other main compensation model is based on wRVUs, which is more common in multispeciality groups and universities. From my understanding, RVUs are not ideal for dermatologists and much more favorable for primary care physicians, but you can still do pretty well.

Now if you're doing full-time Mohs, which admittedly isn't all that easy to do these days, you'll be making significantly more. Some of the offers I've seen for Mohs' position has made me strongly consider doing a procedural fellowship even after I work as an attending for a year..

 

[spicysoup55]

Currently interviewing at several practices in the west coast. I would say, on average, going rate for a general dermatologist fresh out of residency working a full 4 day work schedule (25-35 patients day) is in the range of $350-400k. Kaiser pays about the same depending on how desirable the area you want to work is in (Southern California around 360k and Sacramento closer to 400k). Some PPs may offer a one-year guarantee but most will just pay you just on straight collections. As far as % collection, I can only speak on Southern California but most practices will pay anywhere from 40-55% of net collections depending on the overhead of the practice. Even if you're getting paid 40% of net collections, if you see 30-35 patients a day, 4-4.5 days/week, with a decent payor mix and do a reasonable amount of destructions, biopsies and excisions, you can pull in ~$450k. The other main compensation model is based on wRVUs, which is more common in multispeciality groups and universities. From my understanding, RVUs are not ideal for dermatologists and much more favorable for primary care physicians, but you can still do pretty well.

Now if you're doing full-time Mohs, which admittedly isn't all that easy to do these days, you'll be making significantly more. Some of the offers I've seen for Mohs' position has made me strongly consider doing a procedural fellowship even after I work as an attending for a year..

Why would the salary of a Mohs surgeon be?

 

[sawtella]

Why would the salary of a Mohs surgeon be?

As the others have said, it's variable. If you're at a Kaiser and you're doing "full time" Mohs, which really is only 3.5-4 days / week with 5-8 cases a day and two half days of surgery consults/wound checks, you're looking at 450-500k. And keep in mind, this schedule is very chill and relatively low volume. Compare this to seeing 28 med derm patients at day and making 50-100k less as a general dermatologist there.

At another MSG out in the Washington, full time Mohs was offering closer to 550-600k. I've heard of gigs in Texas where people are making significantly more but at the same time they are working significantly harder. The most important determinant is the volume. It is very difficult these days to expect to do full time Mohs in a major metro area unless you are working in an employed position.

 

[doctalaughs]

Currently interviewing at several practices in the west coast. I would say, on average, going rate for a general dermatologist fresh out of residency working a full 4 day work schedule (25-35 patients day) is in the range of $350-400k. Kaiser pays about the same depending on how desirable the area you want to work is in (Southern California around 360k and Sacramento closer to 400k). Some PPs may offer a one-year guarantee but most will just pay you just on straight collections. As far as % collection, I can only speak on Southern California but most practices will pay anywhere from 40-55% of net collections depending on the overhead of the practice. Even if you're getting paid 40% of net collections, if you see 30-35 patients a day, 4-4.5 days/week, with a decent payor mix and do a reasonable amount of destructions, biopsies and excisions, you can pull in ~$450k. The other main compensation model is based on wRVUs, which is more common in multispeciality groups and universities. From my understanding, RVUs are not ideal for dermatologists and much more favorable for primary care physicians, but you can still do pretty well.

Now if you're doing full-time Mohs, which admittedly isn't all that easy to do these days, you'll be making significantly more. Some of the offers I've seen for Mohs' position has made me strongly consider doing a procedural fellowship even after I work as an attending for a year..

Agree with above in non-saturated areas: full time starting 300-375k, typically 400k+ after few years in practice with some making a lot more (either high volume cosmetics or mills churning patients). With the caveat that just like most other specialties there are now some saturated areas of the country where groups/practices are trying to screw new hires (ie 200k starting full time). This is becoming more common as economic pressures apply across all of medicine.

A good academic place you will take a 30% paycut. A bad academic place (ie poorly run) will cut 50%.

 

[MOHS_01]

You can expect incomes to taper more rapidly as the newer survey data (and CY accounting) starts filtering through; payer class shifts as a result of demographic changes, ACA impacts, expanding Medicaid access, high deductible plans, shifts away from traditional employer sponsored plans, and workforce trends all have combined and the result is fewer dollars in collections per unit work. It has been trending this way for the last two to three years, but the pace has accelerated since last Sept / Oct -- and I fully expect that to occur again this fall with open enrollment again. Awesome.

 

[dermiedermie]

how much does the average starting dermatologist make on the east coast?

 

[MOHS_01]

how much does the average starting dermatologist make on the east coast?

What they make today will have zero impact on what they make 8 or 9 years from now. Do not make plans for a decade from now based on current conditions; a decade ago any radiologist graduating residency had $500k 3d/week no nights no weekend 12 weeks vacation plus CME travel offers Anywhere, USA. Now they get to do multiple fellowships and half that. Path was good, too. Just be wise of the fact that things are changing -- and in ways you will not like.

BTW -- there is not enough information contained in your question to make it an answerable question.

 

[reno911]

BTW -- there is not enough information contained in your question to make it an answerable question.

This is the big problem with these salary questions. I imagine this is a problem in all medical specialties, but I know for sure it's a problem in Derm. The range is just so wide and there are tons of variables that affect compensation. So even if you look at survey data, any means or medians that you get are relatively useless as they apply to your very specific situation (they probably won't).

I don't work with residents as much as I used to when I was in full-time academia, but I have talked to many residents about this issue. Here's one thing I've learned: If you ask any resident how much money (i.e., annual salary) they would be happy with if they were going to be stuck with exactly that salary for the rest of their career, 100% of them will pick a number that is not that difficult to achieve.*. As Mohs01 correctly points out, that may eventually no longer be the case, but so far it has been.

*Of course, if you ask the same residents the very same question 5 yrs post-residency, nearly all of them will pick a different number than they picked as a resident. But that's an issue for another thread, I suppose.

 

[sawtella]

Sorry to hijack this thread, but can any of the attendings comment on partnerships? What is the average length of time it should take for one to be offered partnership and what is considered a fair buy-in?

 

[Balderdash]

Sorry to hijack this thread, but can any of the attendings comment on partnerships? What is the average length of time it should take for one to be offered partnership and what is considered a fair buy-in?

Again pretty variable. In my large town, from what I can gather 3 years is about right. I've heard figures from 250-500k for buy in.

All of this varies based on location, saturation of the market, perceived value of the practice, etc etc. Others may be able to chime in with numbers they've heard.

The other thing to consider is that, as medical practitioners, we have always considered the other party in any negotiation (e.g. The patient) to have the same interest as us. Once you enter the business world, this isn't the case so don't be afraid to bargain and negotiate for figures that work for you. Your buy in may be too high or duration too long. Tell them to reconsider. The good thing about Derm is there are always other opportunities available; you are not in as bad of a negotiating position as many new grads perceive themselves in.

 

[doctalaughs]

Sorry to hijack this thread, but can any of the attendings comment on partnerships? What is the average length of time it should take for one to be offered partnership and what is considered a fair buy-in?

Variable.

1-3 years for partner (3 is a little long though, 1-2 more common). 0-500k buy-in, often built into reducing your salary for first few years.

There are unfortunately many practices now that are stringing new grads along and not making them partner after the prescribed time (no matter what your contract says its easy for them to find a way around). Even more common there will remain a single/few "senior" partners who still take the majority of profits. Although you will be a "partner" your salary will only jump 1-200k (likely just to the level of what you are actually collecting minus overhead) while the senior partners continue to rake it in on any ancillary revenue streams like midlevels, cosmeceuticals, esthetician and pathology.

Just make sure you know the details of the "partnership" being offered and talk to any docs that left the practice. Devils in the details. Take non-compete clauses seriously- consider adding a clause that non compete is nullified if you aren't made partner or fired.

Remember too that dermatology has the almost unique advantage that starting a solo practice is not hard (compared with other specialties the capital investment is low).

 

[MOHS_01]

Yeah - really far too many variables to succinctly answer that question.

 

[doctalaughs]

keep in mind, this schedule is very chill and relatively low volume. Compare this to seeing 28 med derm patients at day and making 50-100k less as a general dermatologist there.

By the way seeing 28 med-derm patients a day is actually fairly chill out in practice unless you have a very bad patient mix. Seeing more than 35 is my point where it's stressful. Some see 50 a day but I don't see how you can actually make patients feel like human beings (sure you can safely do the skin checks and biopsies but if you cant talk for 60 seconds seems like they will hate you).

 

[MOHS_01]

By the way seeing 28 med-derm patients a day is actually fairly chill out in practice unless you have a very bad patient mix. Seeing more than 35 is my point where it's stressful. Some see 50 a day but I don't see how you can actually make patients feel like human beings (sure you can safely do the skin checks and biopsies but if you cant talk for 60 seconds seems like they will hate you).

Yeah.... I saw more than 28 both morning and afternoon when doing general derm... and the gen derm comp was better per wRVU than Mohs has been since 2009.

 

[doctalaughs]

Yeah.... I saw more than 28 both morning and afternoon when doing general derm... and the gen derm comp was better per wRVU than Mohs has been since 2009.

You saw more than 28 total or for each half-day? Im always interested in talking to those few providers who see 50-60 a day to see if I can gain efficiency tips (if only to make my day easier for my 30 or so). I think if you see that many you need the following pieces in place:
- a scribe vs dictate everything
- MAs do all the numbing for you
- possibly someone entering billing codes for you
- hand written scripts (emr is always slower)
- an established practice where most patients are in for follow-up skin exams or spot checks (rashes can slow you down)
- 3 or ideally 4 rooms.

Im not really interested in seeing that volume (not fun to not talk to people and boring mix of cases) but always curious how people do it. Anyone else chime in on high volume practice?

 

[asmallchild]

You saw more than 28 total or for each half-day? Im always interested in talking to those few providers who see 50-60 a day to see if I can gain efficiency tips (if only to make my day easier for my 30 or so). I think if you see that many you need the following pieces in place:
- a scribe vs dictate everything
- MAs do all the numbing for you
- possibly someone entering billing codes for you
- hand written scripts (emr is always slower)
- an established practice where most patients are in for follow-up skin exams or spot checks (rashes can slow you down)
- 3 or ideally 4 rooms.

Im not really interested in seeing that volume (not fun to not talk to people and boring mix of cases) but always curious how people do it. Anyone else chime in on high volume practice?

I agree with you, 50-60 a day is doable but taxing. I prefer your pace of 30. When I was seeing 50-60, I had:

- MAs who did all my documentation for me (on paper at first, now on EMR, I just sign off on charts at the end of the day)
- MAs who would do numbing as I moved to another room or did all the explaining to the patient
- I always oversaw my own billing (although the sharper MAs are able to handle this too), our EMR handles this for us now
- we did use hand written scripts previously but with EMR, we instruct the patients that scripts are either sent out at noon or at the end of the day so they'll know it won't be available immediately
- I had a rather open schedule but many of the more established providers would refuse to see rashes (purely lesional derm) and others were even more restrictive of what they would see in terms of lesional derm (full body skin exams have a certain templated time, spot checks are much shorter visits)
- 3 rooms with 3 MAs at minimum

As you mentioned, that kind of volume is not my cup of tea either and I've cut down significantly on my gen derm time as a result

 

[doctalaughs]

I agree with you, 50-60 a day is doable but taxing. I prefer your pace of 30. When I was seeing 50-60, I had:

- MAs who did all my documentation for me (on paper at first, now on EMR, I just sign off on charts at the end of the day)
- MAs who would do numbing as I moved to another room or did all the explaining to the patient
- I always oversaw my own billing (although the sharper MAs are able to handle this too), our EMR handles this for us now
- we did use hand written scripts previously but with EMR, we instruct the patients that scripts are either sent out at noon or at the end of the day so they'll know it won't be available immediately
- I had a rather open schedule but many of the more established providers would refuse to see rashes (purely lesional derm) and others were even more restrictive of what they would see in terms of lesional derm (full body skin exams have a certain templated time, spot checks are much shorter visits)
- 3 rooms with 3 MAs at minimum

As you mentioned, that kind of volume is not my cup of tea either and I've cut down significantly on my gen derm time as a result

Interesting. I never have tried 50-60 (I feel drained at end of day seeing 40). The other thing that would always get me is the occasional patient that is a major talker, needy with a long list of (sometimes written) complaints. There are always 1-2 in your daily schedule. If I'm seeing 30-35 I feel like I can slow down a little, talk with them for 15 minutes and they leave pretty happy. If you are seeing 50 and have 6-7 minutes this strategy doesn't work so it seems you'd always have a couple angry patients a day.

If you have a good method of dealing with this efficiently I'd love to hear it.

 

[asmallchild]

Interesting. I never have tried 50-60 (I feel drained at end of day seeing 40). The other thing that would always get me is the occasional patient that is a major talker, needy with a long list of (sometimes written) complaints. There are always 1-2 in your daily schedule. If I'm seeing 30-35 I feel like I can slow down a little, talk with them for 15 minutes and they leave pretty happy. If you are seeing 50 and have 6-7 minutes this strategy doesn't work so it seems you'd always have a couple angry patients a day.

If you have a good method of dealing with this efficiently I'd love to hear it.

I never found a way around this. I remember being told as a medical student to seize the list as soon as you enter the room to streamline the visit but in truth, that only shaves a few minutes off. I agree that at the pace of 50-60/day, the provider will feel drained and patients will definitely pick up on the fact that they're being milled in and out of rooms as quickly as possible

 

[sawtella]

By the way seeing 28 med-derm patients a day is actually fairly chill out in practice unless you have a very bad patient mix. Seeing more than 35 is my point where it's stressful. Some see 50 a day but I don't see how you can actually make patients feel like human beings (sure you can safely do the skin checks and biopsies but if you cant talk for 60 seconds seems like they will hate you).

I meant 28 the entire day. I know that sounds like pretty low volume, and it is, even compared to our academic attendings who see on average 15-20 in a half day, but as a general dermatologist at Kaiser, you work out of only two rooms, have only one MA that can be very hit or miss, write ALL of your own notes/scripts on Epic, which is a terrible EMR for derm, and see TONS of rashes, because most of the other kaisers in the area will refer them to us as we're considered the most "academic" in the area. Yes, 28 is still 28 but the point I was trying to make was that compare to the Mohs surgeon who makes about 100k more doing 5-7 cases a day for only 2.5 days out of the week with the other two half days doing consults and wound checks, you can see why Mohs is so appealing.

As an aside, I really appreciate the insight that some of the attendings have been sharing about clinic efficiency and would to love to keep them coming.

 

[MOHS_01]

You saw more than 28 total or for each half-day? Im always interested in talking to those few providers who see 50-60 a day to see if I can gain efficiency tips (if only to make my day easier for my 30 or so). I think if you see that many you need the following pieces in place:
- a scribe vs dictate everything
- MAs do all the numbing for you
- possibly someone entering billing codes for you
- hand written scripts (emr is always slower)
- an established practice where most patients are in for follow-up skin exams or spot checks (rashes can slow you down)
- 3 or ideally 4 rooms.

Im not really interested in seeing that volume (not fun to not talk to people and boring mix of cases) but always curious how people do it. Anyone else chime in on high volume practice?

Yes, scheduled 60+ per day, sometimes more. I did not do many FSE's -- mostly acne, rashes, lumps, bumps. It really was not that taxing to be honest; I ran four rooms and used my two surg techs as MA's. They would do any non-eyelid anesthesia that needed to be done; I would enter the room, mark if any biopsy needed to be done, flip on the door light, go to the next room and see the next patient and continue doing so until I saw the light was back out meaning they were ready. There was a cry-ac in every room. I used an exam template that I scribbled on and would be scanned into the chart, any complicated history was dictated immediately, and I would dictate (Dragon) into the EMR after everyone else had gone home for the day. I did handwritten Rx's as they were faster. I'm telling you -- it was not all that hectic, either. Busy, but not hectic. I chit chatted about farming and housing and whatever else rather a lot, rarely ran more than 10 minutes behind, always had lunch, and was done with seeing patients by 4-4:15 every day. I can promise you that my 7 Mohs cases and 10-15 general derm (plus s/r's, surgical f/u's) that I do per day now is wayyyyyyyy more taxing and more difficult. Way.

I meant 28 the entire day. I know that sounds like pretty low volume, and it is, even compared to our academic attendings who see on average 15-20 in a half day, but as a general dermatologist at Kaiser, you work out of only two rooms, have only one MA that can be very hit or miss, write ALL of your own notes/scripts on Epic, which is a terrible EMR for derm, and see TONS of rashes, because most of the other kaisers in the area will refer them to us as we're considered the most "academic" in the area. Yes, 28 is still 28 but the point I was trying to make was that compare to the Mohs surgeon who makes about 100k more doing 5-7 cases a day for only 2.5 days out of the week with the other two half days doing consults and wound checks, you can see why Mohs is so appealing.

As an aside, I really appreciate the insight that some of the attendings have been sharing about clinic efficiency and would to love to keep them coming.

To be perfectly honest -- and I'm not trying to be a dick -- there is no way in hell that I would work the way I do now for only 100k more than doing general derm. Maybe your Mohs guys are not having to dig out the utter **** that I get referred, I don't know. That would help a lot, I'm sure. Another thing worth mentioning is that seeing 28 a day in my neck of the woods would not earn a person more that maybe $250k/yr -- and that is a big maybe. Our reimbursement schedule is abysmal as is our demographics; volume is a necessity if you hope to earn median. People on the outside looking in (recruiters, potential docs) look at the volume and wait times in the area and think that the area is grossly underserved and ripe for the picking; what they soon learn is that the number of providers is low because of the poor demographics and payer mix.

 

[doctalaughs]

I meant 28 the entire day. I know that sounds like pretty low volume, and it is, even compared to our academic attendings who see on average 15-20 in a half day, but you work out of only two rooms, have one MA that can be very hit or miss, write ALL of your own notes/scripts on Epic, which is a terrible EMR for derm, and see TONS of rashes, because most of the other kaisers in the area will refer them to us as we're considered the most "academic" in the area. Yes, 28 is still 28 but the point I was trying to make was that compare to the Mohs surgeon who makes about 100k more doing 5-7 cases a day for only 2.5 days out of the week with the other two half days doing consults and wound checks, you can see why Mohs is so appealing.

As an aside, I really appreciate the insight that some of the attendings have been sharing about clinic efficiency and would to love to keep them coming.

Yea, I've done work at kaiser and agree really 28 is about all you can see there (2 rooms, 1 MA, all your own note writing and numbing, fairly complex patient mix compared to PP). The mohs surgeons there would also probably argue they get larger tumors though since every effort is made to take care of them in genderm though, to be fair.

Just for fun, here are some of my efficiency tips (I'm not claiming to be the most efficient out there, others please chime in too). I do know you learn almost all your efficiency AFTER residency. It's nearly impossible to be efficient as a resident when you have to staff everything, move from attending to attending and EMR to EMR:

1. Talk to them while doing your exam. You get good at making small talk and taking additional HPI while checking them. I actually do sit down (for no more than 1 minute) with my 30-or-so schedule because I think it makes them feel happier, but if I was seeing 50 I wouldn't probably do that.
2. Get good at documenting/billing efficiently. There are good systems and bad systems but no matter what, it shouldn't take you more than 2 minutes total to document 95% of your patient notes.
3. If you don't have a scribe see 2-3 patients, then document all the notes together. Rinse and repeat.
4. Never let more than 3 notes pile up. Documenting at the end of a half day makes all the notes take double the time (because you don't remember things as well).
5. When you are in a patient room after hearing their story you need to make a definitive decision early, which basically will "end" 95% of visits. Almost always you are only going to do one of a few things: do a biopsy, prescribe some medications, draw some labs, do some counseling/reassurance. Make your decision and you are done.
6. If they do have multiple complaints take care of each one on the spot. For example, they bring a list of 15 lesions (and god forbid a diagram) they want to show you. They point out an AK- tell them what it is, freeze it. They point out a keloid and want it injected do it on the spot before moving on. Exception being biopsies. Mark them all and do them at the end.
7. Time outside of the exam/patient room can be optimized but that's based mainly on the system you are in. The more work/callbacks/call screening the staff can do for you the more time you will have to see patients.
8. Get good at breaking down a complex presentation into a quick action and a follow-up visit. Bullous eruption? Biopsy/DIF, steroids, see you in 1-2 weeks done. Vasculitis? Biopsy/Labs/UA possible steroids see you in 1-2 weeks done. 20 visible skin cancers? Biopsy 4-5 most nasty looking, explain to them and document there are many more, see you in 2 months, done.
9. Know when to say no to patients. If they have 4 skin cancers and are asking you to freeze a bunch of SKs tell them (politely) you can't. If they need a full skin exam with biopsies and then add a iffy alopecia complaint at the end say they need another appointment.

 

[doctalaughs]

Yes, scheduled 60+ per day, sometimes more. I did not do many FSE's -- mostly acne, rashes, lumps, bumps. It really was not that taxing to be honest; I ran four rooms and used my two surg techs as MA's. They would do any non-eyelid anesthesia that needed to be done; I would enter the room, mark if any biopsy needed to be done, flip on the door light, go to the next room and see the next patient and continue doing so until I saw the light was back out meaning they were ready. There was a cry-ac in every room. I used an exam template that I scribbled on and would be scanned into the chart, any complicated history was dictated immediately, and I would dictate (Dragon) into the EMR after everyone else had gone home for the day. I did handwritten Rx's as they were faster. I'm telling you -- it was not all that hectic, either. Busy, but not hectic. I chit chatted about farming and housing and whatever else rather a lot, rarely ran more than 10 minutes behind, always had lunch, and was done with seeing patients by 4-4:15 every day. I can promise you that my 7 Mohs cases and 10-15 general derm (plus s/r's, surgical f/u's) that I do per day now is wayyyyyyyy more taxing and more difficult. Way.

To be perfectly honest -- and I'm not trying to be a dick -- there is no way in hell that I would work the way I do now for only 100k more than doing general derm. Maybe your Mohs guys are not having to dig out the utter **** that I get referred, I don't know. That would help a lot, I'm sure. Another thing worth mentioning is that seeing 28 a day in my neck of the woods would not earn a person more that maybe $250k/yr -- and that is a big maybe. Our reimbursement schedule is abysmal as is our demographics; volume is a necessity if you hope to earn median. People on the outside looking in (recruiters, potential docs) look at the volume and wait times in the area and think that the area is grossly underserved and ripe for the picking; what they soon learn is that the number of providers is low because of the poor demographics and payer mix.

I can understand how you'd see 50-60 with that system for acne, and lesion-checks (with biopsies). Can't really understand how you do it with rashes mixed in though. Maybe it's just the system I'm in, but I'd say 50% of the rashes I see are easy (slam dunk diagnosis, prescription, done) but the other 50% require lots of hand-holding and workup (you know, those ones seen by multiple providers, chronic for a year, no one knows why they have it, patient is itchy miserable and frustrated). Those I can't do in 5 minutes- I really need a full 15 which doesn't fly seeing 60 patients a day.

Also, when you were doing general dermatology how did you prevent the common visits that took more time (full body skin exams, female alopecia, laundry-list of lesions to look at, occasional psych derm stuff etc).

It sounds like you have a bad payor mix and hard cases. I do think some mohs guys (ours probably) don't have to dig the stuff out you do. How many cases do you do a day and what percentage of those would you deem "large/complex" (ie would be totally inappropriate for an excision by a good general dermatologist)

 

[username456789]

- I had a rather open schedule but many of the more established providers would refuse to see rashes (purely lesional derm)

I . . . never realized this was a thing.

 

[asmallchild]

I . . . never realized this was a thing.

Neither did I.

A dermatologist refusing to see rashes, oh the things you'll see

I lost a lot of respect for my colleagues that did this. To be fair, I don't think they cared as their clinic was typically more efficient and more profitable with that rule in place.

 

[MOHS_01]

I can understand how you'd see 50-60 with that system for acne, and lesion-checks (with biopsies). Can't really understand how you do it with rashes mixed in though. Maybe it's just the system I'm in, but I'd say 50% of the rashes I see are easy (slam dunk diagnosis, prescription, done) but the other 50% require lots of hand-holding and workup (you know, those ones seen by multiple providers, chronic for a year, no one knows why they have it, patient is itchy miserable and frustrated). Those I can't do in 5 minutes- I really need a full 15 which doesn't fly seeing 60 patients a day.

Also, when you were doing general dermatology how did you prevent the common visits that took more time (full body skin exams, female alopecia, laundry-list of lesions to look at, occasional psych derm stuff etc).

It sounds like you have a bad payor mix and hard cases. I do think some mohs guys (ours probably) don't have to dig the stuff out you do. How many cases do you do a day and what percentage of those would you deem "large/complex" (ie would be totally inappropriate for an excision by a good general dermatologist)

I'd say >90% of the rashes were less than 2 minute diagnoses, but I was never really scheduled a ton of weird rashes anyway. Quick history and review of meds, what have you tried, etc --> Rx, light, or straight to patch, rarely a biopsy. It's not that I would not do FSE's -- those had a set number of appointment slots in the day. I actually did ban female alopecia after a couple of years in practice -- no apologies for that. Ha. They still lied and snuck in occasionally, though. Neuroderm was and is annoying, but we would order some blood work, only do a biopsy if they insisted (and usually could talk them out of that), give them a Rx for TAC/mupirocin mix and maybe an antihistamine and told them flat out that picking was the cause of their scarred leopard spots. Most of them actually are aware.

Yes, poor state with a poor payer mix. We reside at the floor of the geographic price adjustment scale and suffer from a duopoly in the private market. When you have that background, there exists very little to no pricing power with insurance companies for reimbursements as the state's DoI has to be "insurance friendly" (i.e., they do not adopt, champion, or otherwise enforce strict provider panel requirements). My entire (almost) practice is external referrals; everything is either recurrent, infiltrating, immunosuppressed (transplant or CLL or lymphoma, etc), or located in a difficult anatomic area. When I started almost a decade ago (wow!) I had many referrals for easy things on helical rim, cheek, small spots on the lip or dorsal hand, etc; in the past 3-5 years these have virtually disappeared as everyone is trying to keep everything they might not get sued for in house. Awesome.

I . . . never realized this was a thing.

Definitely a thing. I no longer have that rule, but I did for three years when I was trying to establish a surgical practice; now everyone requires a referral and everyone knows to direct those elsewhere. In my mind it is no different than the pulmonologist who decides to limit his/her practice and not follow pulmonary hypertension patients.... or, in my case, the cardiologist who decides that he is not going to manage diabetes.

 

[sore eye asses]

Wow, love this thread, best in years.

Appreciate the insight from the "senior" folks.

I'm nearly 1 year out and my situation most resembles the 28 pt/day, complex derm, tons of rashes, can't imagine seeing a single extra pt a day. Find myself yearning for a simpler schedule, but I think if I told my supervisor I no longer see rashes he'd laugh in my face and say I no longer work there.

I haven't figured out why, but within my practice, referrals from PA and ANP are the lions share, and they're almost universally terrible/inappropriate. Also, the primary docs are doing (poorly) their own biopsies, and then sending the mistakes/results to me. Makes for minimal lesional derm and maximum hand-holding. Fun fun fun.

 

[Zummie]

https://www.aad.org/dw/monthly/2014/may/work-rvu-contracts-have-pitfalls-for-dermatologists#allpages Work RVU's explained by the former president of the AAD.

 

[sawtella]

https://www.aad.org/dw/monthly/2014/may/work-rvu-contracts-have-pitfalls-for-dermatologists#allpages Work RVU's explained by the former president of the AAD.

Yup, I saw this. Thanks for posting this though. Interestingly, the general dermatologists at a MSG I was interviewing at that are paid on a wRVU contract seem to be making more than those at the derm-only practice I also interviewed at (%40 net collections). However, the rub on a wRVU contract is that they can always adjust that conversion factor if your department is doing well and the others (esp primary care) is not. This may be acceptable to some but the idea of some your earnings being siphoned off to subsidize the other less profitable specialities makes me not rest easy. I guess you can make the argument that they are providing you with a referral base but I think that a straight % net collections is much cleaner. Would love to hear other's thoughts...

 

[sawtella]

Wow, love this thread, best in years.

Appreciate the insight from the "senior" folks.

I'm nearly 1 year out and my situation most resembles the 28 pt/day, complex derm, tons of rashes, can't imagine seeing a single extra pt a day. Find myself yearning for a simpler schedule, but I think if I told my supervisor I no longer see rashes he'd laugh in my face and say I no longer work there.

I haven't figured out why, but within my practice, referrals from PA and ANP are the lions share, and they're almost universally terrible/inappropriate. Also, the primary docs are doing (poorly) their own biopsies, and then sending the mistakes/results to me. Makes for minimal lesional derm and maximum hand-holding. Fun fun fun.

If you don't mind me asking, what type of practice setting are you in? Sounds like a MSG

 

[MOHS_01]

Wow, love this thread, best in years.

Appreciate the insight from the "senior" folks.

I'm nearly 1 year out and my situation most resembles the 28 pt/day, complex derm, tons of rashes, can't imagine seeing a single extra pt a day. Find myself yearning for a simpler schedule, but I think if I told my supervisor I no longer see rashes he'd laugh in my face and say I no longer work there.

I haven't figured out why, but within my practice, referrals from PA and ANP are the lions share, and they're almost universally terrible/inappropriate. Also, the primary docs are doing (poorly) their own biopsies, and then sending the mistakes/results to me. Makes for minimal lesional derm and maximum hand-holding. Fun fun fun.

One of the reasons I left a multi specialty group after one year.

 

[reno911]

Yup, I saw this. Thanks for posting this though. Interestingly, the general dermatologists at a MSG I was interviewing at that are paid on a wRVU contract seem to be making more than those at the derm-only practice I also interviewed at (%40 net collections). However, the rub on a wRVU contract is that they can always adjust that conversion factor if your department is doing well and the others (esp primary care) is not. This may be acceptable to some but the idea of some your earnings being siphoned off to subsidize the other less profitable specialities makes me not rest easy. I guess you can make the argument that they are providing you with a referral base but I think that a straight % net collections is much cleaner. Would love to hear other's thoughts...

This is another one of those questions that is unanswerable without more detail. You can't really say that $/wRVU contracts are better or worse than percentage collection contracts unless you know a lot of other things. From the employer's perspective, it is easy to make either type of contract unfavorable to the dermatologist if they so desire.

I will say that it's probably easier to take advantage of a dermatologist on a wRVU contract because they are so poorly understood (which is weird, because it is not really that difficult). In my experience, even the people in charge trying to negotiate the contract don't understand some of the intricacies well enough for you to be able to have an intelligent discussion with them. I actually know a handful of people that have taken advantage of this and have such good wRVU-based contract that no reasonable percentage-collections-based contract could possibly compete. However, this is very rare. Most of the time it is the other way around.

The bottom line is that it is perfectly possible to construct a fair wRVU-based contract. However, in practice this is probably not done as often as it should be.

 

[sore eye asses]

One of the reasons I left a multi specialty group after one year.

Yeah, this is not sustainable for the long run. Highly stressful and relatively poor reimbursement. Live and learn.

Sawtella, yes, it's an MSG.

 

[doctalaughs]

Wow, love this thread, best in years.

I haven't figured out why, but within my practice, referrals from PA and ANP are the lions share, and they're almost universally terrible/inappropriate. Also, the primary docs are doing (poorly) their own biopsies, and then sending the mistakes/results to me. Makes for minimal lesional derm and maximum hand-holding. Fun fun fun.

I see this too (I think everyone does). While it's annoying, the upside is that frequently they are short/easy visits (ie yeah thats an obvious SK, no I'm not cutting out your ganglion cyst, your "rash" not responding to steroids is actually all confluent AKs).

Sometimes thats actually a relief compared to another interesting but time-consuming erythrodermic patient.

 

[MOHS_01]

Yup, I saw this. Thanks for posting this though. Interestingly, the general dermatologists at a MSG I was interviewing at that are paid on a wRVU contract seem to be making more than those at the derm-only practice I also interviewed at (%40 net collections). However, the rub on a wRVU contract is that they can always adjust that conversion factor if your department is doing well and the others (esp primary care) is not. This may be acceptable to some but the idea of some your earnings being siphoned off to subsidize the other less profitable specialities makes me not rest easy. I guess you can make the argument that they are providing you with a referral base but I think that a straight % net collections is much cleaner. Would love to hear other's thoughts...

This is another one of those questions that is unanswerable without more detail. You can't really say that $/wRVU contracts are better or worse than percentage collection contracts unless you know a lot of other things. From the employer's perspective, it is easy to make either type of contract unfavorable to the dermatologist if they so desire.

I will say that it's probably easier to take advantage of a dermatologist on a wRVU contract because they are so poorly understood (which is weird, because it is not really that difficult). In my experience, even the people in charge trying to negotiate the contract don't understand some of the intricacies well enough for you to be able to have an intelligent discussion with them. I actually know a handful of people that have taken advantage of this and have such good wRVU-based contract that no reasonable percentage-collections-based contract could possibly compete. However, this is very rare. Most of the time it is the other way around.

The bottom line is that it is perfectly possible to construct a fair wRVU-based contract. However, in practice this is probably not done as often as it should be.

Yes, it is very difficult to make broad generalizations that ring true more often than not; for example, I know of high volume practices that would fare very poorly by the comp/wRVU metric yet the docs do very well and much of the work is delegated. Similarly, I know of small practices with low overhead and low volume that would fare very well according to a wRVU breakdown, but the doc does not make as much due to lower collections.

Eventually all systems come back to basic finance / economics, though. One cannot do volume without increased space and staffing requirements which means higher direct costs.... so ultimately you are either going to be in one of three situations:

- eating what you kill
- subsidizing others (most likely case in a MSG, possibly not the case in a SSG unless you are Mohs or path or patch)
- getting subsidized (part time gen derm in SSG is almost always a subsidized position, but don't tell them that -- they get pissed and whine like no other)​

Unfortunately, there's no free lunch to be had for most of us. If you want to earn at your potential, you are going to have to be a volume provider in a conducive setting. Since the economics of practice is one of largely minimally variable costs, revenue (i.e., volume) drives compensation (ultimately).

 

[sawtella]

This is another one of those questions that is unanswerable without more detail. You can't really say that $/wRVU contracts are better or worse than percentage collection contracts unless you know a lot of other things. From the employer's perspective, it is easy to make either type of contract unfavorable to the dermatologist if they so desire.

I will say that it's probably easier to take advantage of a dermatologist on a wRVU contract because they are so poorly understood (which is weird, because it is not really that difficult). In my experience, even the people in charge trying to negotiate the contract don't understand some of the intricacies well enough for you to be able to have an intelligent discussion with them. I actually know a handful of people that have taken advantage of this and have such good wRVU-based contract that no reasonable percentage-collections-based contract could possibly compete. However, this is very rare. Most of the time it is the other way around.

The bottom line is that it is perfectly possible to construct a fair wRVU-based contract. However, in practice this is probably not done as often as it should be.

Yes, it is very difficult to make broad generalizations that ring true more often than not; for example, I know of high volume practices that would fare very poorly by the comp/wRVU metric yet the docs do very well and much of the work is delegated. Similarly, I know of small practices with low overhead and low volume that would fare very well according to a wRVU breakdown, but the doc does not make as much due to lower collections.

Eventually all systems come back to basic finance / economics, though. One cannot do volume without increased space and staffing requirements which means higher direct costs.... so ultimately you are either going to be in one of three situations:

- eating what you kill
- subsidizing others (most likely case in a MSG, possibly not the case in a SSG unless you are Mohs or path or patch)
- getting subsidized (part time gen derm in SSG is almost always a subsidized position, but don't tell them that -- they get pissed and whine like no other)​

Unfortunately, there's no free lunch to be had for most of us. If you want to earn at your potential, you are going to have to be a volume provider in a conducive setting. Since the economics of practice is one of largely minimally variable costs, revenue (i.e., volume) drives compensation (ultimately).

Thanks for your insights. So if you were guaranteed to be fully busy within the first month of starting and you could maintain that volume indefinitely, would you prefer a wRVU contract or a straight % of net collections? I was also under the impression that the wRVU conversion factor can be changed periodically to reflect the market conditions and the needs of the practice, so that was something that concerned me as well.

 

[MOHS_01]

Thanks for your insights. So if you were guaranteed to be fully busy within the first month of starting and you could maintain that volume indefinitely, would you prefer a wRVU contract or a straight % of net collections? I was also under the impression that the wRVU conversion factor can be changed periodically to reflect the market conditions and the needs of the practice, so that was something that concerned me as well.

What we are both trying to say (I think) is that it really does not matter - you can be a winner or loser with either method. This is where MGMA data becomes worth its high price tag - it breaks everything down by percentile.

The one thing that I like about wRVU arrangements - at least initially and assuming that the $ per wRVU is solid - is that it shields you from both collection and payer mix risks.

Again, no free lunch. If your payer mix is crap or if collections are lacking, the conversion factor will be adjusted to reflect that at some point. If the conversion factor is low out of the gates they are tacitly admitting that some problem exists.

 

[reno911]

Thanks for your insights. So if you were guaranteed to be fully busy within the first month of starting and you could maintain that volume indefinitely, would you prefer a wRVU contract or a straight % of net collections? I was also under the impression that the wRVU conversion factor can be changed periodically to reflect the market conditions and the needs of the practice, so that was something that concerned me as well.

That's still not nearly enough information to be able to judge which option is better. Sure the conversion factor could be changed. But you could attempt to negotiate some sort of floor beyond which it couldn't go. Moreover, the percentage of collections that they pay you is not some immutable constant. You don't think that could be changed "periodically to reflect the market conditions [i.e., declining reimbursements] and the needs of the practice"?

 

[sawtella]

That's still not nearly enough information to be able to judge which option is better. Sure the conversion factor could be changed. But you could attempt to negotiate some sort of floor beyond which it couldn't go. Moreover, the percentage of collections that they pay you is not some immutable constant. You don't think that could be changed "periodically to reflect the market conditions [i.e., declining reimbursements] and the needs of the practice"?

Point well taken. However, how can a practice change the net % collection on you if the contract explicitly states that this is the % you'll get if you generate x amount of money, etc?

Not to be annoying, but what other type of information would I need other than payer mix to determine whether a wRVU contract w a MSG is more favorable than a % net collections from a SSG? I have access to MGMA data for the area that I'm interested in. Thanks!

 

[MOHS_01]

Point well taken. However, how can a practice change the net % collection on you if the contract explicitly states that this is the % you'll get if you generate x amount of money, etc?

Not to be annoying, but what other type of information would I need other than payer mix to determine whether a wRVU contract w a MSG is more favorable than a % net collections from a SSG? I have access to MGMA data for the area that I'm interested in. Thanks!

More when I can post from a keyboard rather than this phone...

Not to be a dick, but this is why I think every doc turned out should be forced into solo practice for a while - there is so much that goes into this and so little education on it... and the trend toward employed positions for everyone is a root contributor to the fall of the profession.

Bottom line - you will rarely get paid more than what you contribute to the organization's bottom line regardless of the formula with the sole caveat of a desperate institution or kickbacks for referrals to more lucrative specialties. You will often get paid less than that contribution, though (you will be the subsidizer of others).

 

[MOHS_01]

Oh - one more thing - contracts are for a finite period of time, often one year - then adjustments are made.

 

[sawtella]

More when I can post from a keyboard rather than this phone...

Not to be a dick, but this is why I think every doc turned out should be forced into solo practice for a while - there is so much that goes into this and so little education on it... and the trend toward employed positions for everyone is a root contributor to the fall of the profession.

Bottom line - you will rarely get paid more than what you contribute to the organization's bottom line regardless of the formula with the sole caveat of a desperate institution or kickbacks for referrals to more lucrative specialties. You will often get paid less than that contribution, though (you will be the subsidizer of others).

I can't argue with that. I've tried my best to be somewhat educated on the business side of medicine, even read a book with that exact title written by one of the ophthalmologists who posts on this on forum regularly, but clearly there is no replacement for actually working in solo practice. I think moonlighting in the practices here have also helped but all of them have paid on a % net collections, which is why I'm so unfamiliar with the wRVU model (other than what I read from that one article by Brett Colidron).

But thank you to all of you who have contributed to this thread. You have helped tremendously.

 

[Member1]

What type of % collections contracts has the group encountered for residents entering the private world, as it relates to overhead? Certainly a difficult question to answer based on numerous variables, but I'm just polling the audience. What seems to be a reasonable % collections for first year out? Assuming 50% overhead by practice, is 40% (maybe~30% in higher overhead practices) collections the common number offered? (meaning the practice profits 10% collections off new hires, avg ~100K if your avg. gen dermatologist collects 1m).

 

[MOHS_01]

What type of % collections contracts has the group encountered for residents entering the private world, as it relates to overhead? Certainly a difficult question to answer based on numerous variables, but I'm just polling the audience. What seems to be a reasonable % collections for first year out? Assuming 50% overhead by practice, is 40% (maybe~30% in higher overhead practices) collections the common number offered? (meaning the practice profits 10% collections off new hires, avg ~100K if your avg. gen dermatologist collects 1m).

A total pay package of 40% of collections is not unreasonable; collecting 1m in year one may be a little more ambitious. Collections are harder to realize than you might imagine... and you'll be working with an 11 month calendar.

 

[Member1]

A total pay package of 40% of collections is not unreasonable; collecting 1m in year one may be a little more ambitious. Collections are harder to realize than you might imagine... and you'll be working with an 11 month calendar.

What about % collections 1st year out of Mohs fellowship? Single specialty med. sized practice. Slightly less than gen derm given higher overhead of most Mohs practices?