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C/L job or out patient job

sujalneuro

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Have multiple offers and now I need to decide. They have similar benefits but different salaries.
C/L job in a medium size metro seeing around 20 patients per day. Offered low 200 and wRVU model. What should be expected salary and wRVU rate.
O/p job in the same city seeing around 20-22 patents per day. 250k +wRVU model. what should be expected salary and wRVU rate. No partnership track or calls.
 

wolfvgang22

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You should be getting $50k to $100k more annually for that volume if you actually see that many patients on either job, depending on benefits, time, off, support staff, whether any call is involved, etc. I wouldn't touch those for less than $280k personally. I'd probably look elsewhere.
 
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Merovinge

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Both those offers sound really low unless you have a marked increase in the salary from the wRVUs. 20 patient CL service is ungodly busy, that sounds like 2+ FTE. 20-22 outpts a day is definitely on the heavy side as well, I'd make sure you are up for being a churn through psychiatrist before accepting either.

If you do feel comfortable seeing patients at that clip, it's important to understand how they structure your pay. Some places set a goal wRVU then pay you a $$ amount past that goal for each you go over. Others have a base salary with bonus bracket based on your RVU generation. Still others change your pay to match MGMA or other data sources based on your RVUs using percentile comparisons. If this area if new to you, I would definitely spend the money to use a contract review option.

 
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Mass Effect

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Yeah, you're getting hosed. You need at least $300K to even consider those offers, especially the CL one. That many patients a day is nowhere near 200K material. Just for reference, I see about 13 outpatients a day and make over 200K. A friend of mine works CL and his initial offer (I don't know what he negotiated to) was 230K to see 8 patients total a day WITH a resident.
 
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splik

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There is no way you can provide anything close to decent care on C-L for 20 patients a day regardless of how long the day is. That is just nuts. There is no amount of money that would make that acceptable. That is a job for multiple people and also requires good support from a dedicated SW and possibly an NP/PA. These patients are way more complicated than in most other settings.

C-L is not/should not be wRVU based. It is not possible to meet RVUs on consults (unless you were seeing that many pts a day) but you would struggle to hit the appropriate targets. It should be straight salary, an hourly amount, or on a per consult basis.
 
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Splenda88

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Yeah, you're getting hosed. You need at least $300K to even consider those offers, especially the CL one. That many patients a day is nowhere near 200K material. Just for reference, I see about 13 patients a day and make over 200K. A friend of mine works CL and his initial offer (I don't know what he negotiated to) was 230K to see 8 patients total a day WITH a resident.
This is why physicians should not be afraid to share their salary with their colleagues... That's one way to know that you are being taken advantage of.
 
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Merovinge

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Yeah, you're getting hosed. You need at least $300K to even consider those offers, especially the CL one. That many patients a day is nowhere near 200K material. Just for reference, I see about 13 outpatients a day and make over 200K. A friend of mine works CL and his initial offer (I don't know what he negotiated to) was 230K to see 8 patients total a day WITH a resident.

Just had an offer at a very desirable location for $280k at 14 patients/day with very good benefits/PTO for reference.
 
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NickNaylor

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Thanks for feedback.. I had a base + bonus component.
What does 5500 wRVU CL and 5150 wRVU O/p. How many patient I need to see in a day to get my bonus, around 100K

5500 wRVUs with 5 x 52 = 260 working days - (4 x 5 = 20 days off/year) = 5500 wRVUs/240 working days = ~23 wRVUs/day.

Let's assume that you are billing level 4 consults (99254) for each new consult. That probably isn't going to be true, but for a rough estimate I suppose it'll work. Each level 4 consult is 3.29 wRVUs, so that would mean you are going to need to see 7 new consults/day to meet that target. Assuming the average follow-up is billed as a 99232, that would make each new consult equivalent to ~2.5 follow-up consults. So, you would need to see a maximum of 7 new consults or a maximum of 18 follow-ups each day. I don't know about you, but that is 0% possible with anything approaching normal working hours. The time spent seeing patients would make that difficult much less the documentation, talking with primary teams, and simply walking from room to room.

For outpatient work, assume you are billing a level 4 follow-up (99214), which is 1.50 wRVUs, for your typical follow-up patient and a level 4 new patient (99204), which is 2.43 wRVUs, for your typical new patient. That would net ~9.5 new patients each day or ~15 follow-up patients each day to meet your wRVU goal. That seems slightly more reasonable to me than the consult productivity that you have to do to meet that target, but still, that's a busy day - each and every working day.

Either way, I agree - you're getting totally hosed at that salary.

Edit to add: You should also clarify if your productivity target is RVUs billed or RVUs collected. If it's the latter, there's probably no way you're going to meet that productivity target without a huge increase in the volume numbers than what's listed above.
 
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Splenda88

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This thread illustrates how important it is for physicians to be somewhat open with their colleagues about compensation (not only salary) because the bean counter would want us to be secretive about salary so they can exploit some of us.
 
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Merovinge

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5500 wRVUs with 5 x 52 = 260 working days - (4 x 5 = 20 days off/year) = 5500 wRVUs/240 working days = ~23 wRVUs/day.

Let's assume that you are billing level 4 consults (99254) for each new consult. That probably isn't going to be true, but for a rough estimate I suppose it'll work. Each level 4 consult is 3.29 wRVUs, so that would mean you are going to need to see 7 new consults/day to meet that target. Assuming the average follow-up is billed as a 99232, that would make each new consult equivalent to ~2.5 follow-up consults. So, you would need to see a maximum of 7 new consults or a maximum of 18 follow-ups each day. I don't know about you, but that is 0% possible with anything approaching normal working hours. The time spent seeing patients would make that difficult much less the documentation, talking with primary teams, and simply walking from room to room.

For outpatient work, assume you are billing a level 4 follow-up (99214), which is 1.50 wRVUs, for your typical follow-up patient and a level 4 new patient (99204), which is 2.43 wRVUs, for your typical new patient. That would net ~9.5 new patients each day or ~15 follow-up patients each day to meet your wRVU goal. That seems slightly more reasonable to me than the consult productivity that you have to do to meet that target, but still, that's a busy day - each and every working day.

Either way, I agree - you're getting totally hosed at that salary.

Edit to add: You should also clarify if your productivity target is RVUs billed or RVUs collected. If it's the latter, there's probably no way you're going to meet that productivity target without a huge increase in the volume numbers than what's listed above.

That's a great breakdown, and for the outpatient, OP keep in mind that no-show = 0 RVUs. So you actually have to see 15 f/u which means scheduling about 17-18 depending on the practice, not to mention that intakes hurt your rate (almost always 2x or longer than established).
 

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I would only consider that C/L job if there was a limit I could put on total work per day, determined by me, and the hospital would have to just accept I couldn't see all the possible consults that come in. They'd have to either hire more psychiatrists or get telepsych. I'd also almost certainly insist on a straight salary (and some agreement on maximum number of patients per day). The other possibility would be a base salary guarantee, but then get paid by RVU's if you exceed your base. The RVU rate should be somewhere between $65-75. I'd want a quarterly "true up" to pay me for the excess RVUs. And this is billed RVUs not based on collections, and I'd insist they would count any and all psychotherapy codes I need to use or extended service codes as C/L can be very time consuming.

I doubt the job you mentioned would go for any of this. But C/L is a hard job and what I propose is totally reasonable. They probably won't get anyone except the most naive to accept the job otherwise.
 
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I'd want a quarterly "true up" to pay me for the excess RVUs. And this is billed RVUs not based on collections, and I'd insist they would count any and all psychotherapy codes I need to use or extended service codes as C/L can be very time consuming.
I've had one job claw back wRVUs because they didn't paid... The collections vs billed is an important factor.
 

comp1

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22 consults a day is for a truly massive hospital. That should be a service, not a single provider. The service should include multiple attendings, residents and probably even an NP for the more straightforward stuff.
 
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oldiebutgoodie1211

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22 consults a day is for a truly massive hospital. That should be a service, not a single provider. The service should include multiple attendings, residents and probably even an NP for the more straightforward stuff.

yeah seriously they would need a 700k budget for that type of service yet the OP is considering it for less than 300k..absolutely nuts these hospitals can get away with this type of stuff it’s like blatant scamming but docs are uninformed and sign up for this slavery
 
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Splenda88

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yeah seriously they would need a 700k budget for that type of service yet the OP is considering it for less than 300k..absolutely nuts these hospitals can get away with this type of stuff it’s like blatant scamming but docs are uninformed and sign up for this slavery
New docs don't know any better (myself included).
 

Techmed07

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Can somebody describe a good outpatient job and a good CL job?


I have an offer for an outpatient job

275k
At least 10 patient a day (not RVU based).
Occasional call (not compensated)
Crazy non compete
36k loan forgiveness
10k moving expensive
FQHC, small town, terrible schools
 

TexasPhysician

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@Techmed07

Any sign on bonus? Everyone that I know got a sign on bonus (between 20-35k). Then again it's IM. Things my be different for psych.

A sign-on bonus is initially thought of as a positive thing. After all, you get the money up front. If you think about it though, it’s a bad thing.

It is often found when some bureaucracy caps salary. If you can’t get the salary to market rate, some agencies will allow a sign-on bonus that disappears after day 1. They hope you just stick around after as many people don’t change jobs often. Kids make friends and like their school, etc. People in high debt may consider a county job that pays $225k with $30k sign on bonus when they are in a crunch for money over a job that pay $275k annually. After day 1, you are now yearly $50k behind the other job unless you leave job 1. Some jobs randomly allow a retention bonus to stay, but you’ll often need to

It is taxed the same. After 1 year, the employer is out the same amount of money.

The only difference is that bonuses are subject to disappearing.
 
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oldiebutgoodie1211

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Can somebody describe a good outpatient job and a good CL job?


I have an offer for an outpatient job

275k
At least 10 patient a day (not RVU based).
Occasional call (not compensated)
Crazy non compete
36k loan forgiveness
10k moving expensive
FQHC, small town, terrible schools

Ok so let’s go through it, uncompensated call is a deal breaker, crazy non compete is meh depending on your goals, 275 can be negotiated up to 300k as you should never ever ever accept the first number they tell you because it’s always always always lower than they’re willing to offer, 10 patients per day is reasonable just make sure it’s not 10 one day and 20 the next day since you won’t be paid extra if they get you very busy,
 
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Splenda88

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A sign-on bonus is initially thought of as a positive thing. After all, you get the money up front. If you think about it though, it’s a bad thing.

It is often found when some bureaucracy caps salary. If you can’t get the salary to market rate, some agencies will allow a sign-on bonus that disappears after day 1. They hope you just stick around after as many people don’t change jobs often. Kids make friends and like their school, etc. People in high debt may consider a county job that pays $225k with $30k sign on bonus when they are in a crunch for money over a job that pay $275k annually. After day 1, you are now yearly $50k behind the other job unless you leave job 1. Some jobs randomly allow a retention bonus to stay, but you’ll often need to

It is taxed the same. After 1 year, the employer is out the same amount of money.

The only difference is that bonuses are subject to disappearing.
I was talking about sign on bonus with generous base salary. For instance, a friend signed a nocturnist contract (340k base + 35k sign on + 10k relocation + RVU and incentive)
 
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Techmed07

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Ok so let’s go through it, uncompensated call is a deal breaker, crazy non compete is meh depending on your goals, 275 can be negotiated up to 300k as you should never ever ever accept the first number they tell you because it’s always always always lower than they’re willing to offer, 10 patients per day is reasonable just make sure it’s not 10 one day and 20 the next day since you won’t be paid extra if they get you very busy,

So I should ask for a cap on patients I see?
 

sluox

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Can somebody describe a good outpatient job and a good CL job?


I have an offer for an outpatient job

275k
At least 10 patient a day (not RVU based).
Occasional call (not compensated)
Crazy non compete
36k loan forgiveness
10k moving expensive
FQHC, small town, terrible schools

Can somebody give a description of a realistic outpatient psych job that they believe is ideal.

I think your job offer is not unusual for an FQHC in small town. You might be able to negotiate away a few things (i.e. 300k+ salary, no non-compete), but the basics are there (fixed, below-market salary, little cross-coverage, salary not related to performance, no control over your schedule, geography). These jobs are usually reserved for people who have a connection to the area and/or people who don't have other options. They also have high turnover.

Generally, the best outpatient jobs carry ownership stakes, either as a solo practice owner or partner at a large group practice. A second tier are very lax state government or VA jobs, or jobs that are part of some very large system (typically academic) and carry a high no-show rate or low caseload, typically due to an increase in activities unrelated to clinical care (i.e. teaching, etc). Some FQHCs are profitable businesses. If the owners of that practice are willing to talk about partnership track and profit-sharing, then that's different. The reason that psychiatry is a good job in general is that in a good outpatient job scenario you will have an extremely high degree of control and autonomy, including schedule, compensation, mix of patients, style of practice (i.e. therapy vs. meds, etc), ancillary support. A good job should let you specify and change any of these components at any time. This is not feasible in other fields in medicine.

Salaried CL jobs are uniformly awful. The most desirable CL jobs are either private hospital-contracted independent practice groups working as an owner (I've heard practices grossing 1M billing per physician in the Midwest in such an arrangement--though typically the overhead is quite a bit higher than a community outpatient practice, possibly > 50%) or large academic staff with a lax schedule.
 
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wolfvgang22

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Can somebody describe a good outpatient job and a good CL job?


I have an offer for an outpatient job

275k
At least 10 patient a day (not RVU based).
Occasional call (not compensated)
Crazy non compete
36k loan forgiveness
10k moving expensive
FQHC, small town, terrible schools
  • Salary is fine
  • Patient load ok, but tell them how many you are willing to see. Don't ask, tell them "I would feel comfortable seeing up to X per day." I'd say 10 to 12 max, personally. Make sure you have sufficient paperwork/phone/admin time. Don't let them saddle you with a "walk in" clinic unless it is scheduled and part of your regular patient load.
  • Good employers/jobs don't need draconian non competes. Negotiate this down/away or walk.
  • Negotiate higher salary in lieu of loan forgiveness. The less tied down you are, the better, and if you stick around you get more money in the long run.
  • Standard relocation
  • You really do not want to be stuck in a small town with bad schools. You may love it afer all, but who knows? Make sure you can leave within 90 days at most.
  • These jobs need you more than you need them, they are plentiful. Negotiate what you want nicely. If they won't budge, move on. If they won't negotiate in good faith now, they won't later.
  • About call: either get compensated for it or don't do it.
  • A lot of these places have salary limitations.If acceptable to you, negotiate lower work load, more time off, CME, time to teach, etc in lieu of more money is often a good tactic.
 
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Splenda88

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How long was your friend’s contract? What’s the stipulation of the sign on bonus? Who wants to be a nocturnist?—-I am talking 8-5 M-F
2 yrs... I agree that most do not want to be nocturnists (myself included). Some don't want to work a 9-5 M-F job and prefer 7 days on/off... I don't know the stipulation of her contract. But financially she is doing well as she always got over 30k (RVU + incentive) every quarter.
 

Techmed07

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  • Salary is fine
  • Patient load ok, but tell them how many you are willing to see. Don't ask, tell them "I would feel comfortable seeing up to X per day." I'd say 10 to 12 max, personally. Make sure you have sufficient paperwork/phone/admin time. Don't let them saddle you with a "walk in" clinic unless it is scheduled and part of your regular patient load.
  • Good employers/jobs don't need draconian non competes. Negotiate this down/away or walk.
  • Negotiate higher salary in lieu of loan forgiveness. The less tied down you are, the better, and if you stick around you get more money in the long run.
  • Standard relocation
  • You really do not want to be stuck in a small town with bad schools. You may love it afer all, but who knows? Make sure you can leave within 90 days at most.
  • These jobs need you more than you need them, they are plentiful. Negotiate what you want nicely. If they won't budge, move on. If they won't negotiate in good faith now, they won't later.
  • About call: either get compensated for it or don't do it.
  • A lot of these places have salary limitations.If acceptable to you, negotiate lower work load, more time off, CME, time to teach, etc in lieu of more money is often a good tactic.

This is great! Thanks Wolfgang can you in bullet tell us what are the characteristics of a good outpatient job. For example,

Salary
Call
Relocation
Patient load
etc

just want a good baseline.
 
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TexasPhysician

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I was talking about sign on bonus with generous base salary. For instance, a friend signed a nocturnist contract (340k base + 35k sign on + 10k relocation + RVU and incentive)

Id still negotiate for $385k/year without the bonuses. That way I get an automatic bump in year 2 compared to the current arrangement. Also $10k relocation in the fine print is often only allowed with demonstrating receipts of $10k costs. I’d rather move cheaper and keep the cash. The employer gets some benefit from the interest by not paying the $45k up front.
 
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Splenda88

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Id still negotiate for $385k/year without the bonuses. That way I get an automatic bump in year 2 compared to the current arrangement. Also $10k relocation in the fine print is often only allowed with demonstrating receipts of $10k costs. I’d rather move cheaper and keep the cash. The employer gets some benefit from the interest by not paying the $45k up front.
Will employer commit to paying 45k/yr above your salary forever? it's not in their advantage... most will not do that.
 
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TexasPhysician

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Will employer commit to paying 45k/yr above your salary forever? it's not in their advantage... most will not do that.

Smart employers aren’t taking a guaranteed loss in year 1 because you can’t guarantee someone will stay long-term. You need to hire someone at a rate that will quickly be profitable or sustainable. If the extra $45k is sustainable in year 1, it should certainly be sustainable in future years. In the instances where it isn’t available to negotiate, there is often a pension as a carrot to stay long-term. Im not sure if this applies to the VA or not, but I could see them offering starting bonuses and a few retention bonuses for the first few years. When a pension comes at year 20 and you are already in 7 years, many will stay without a bonus to get the pension.

Without the carrot, you should constantly sign short-term contracts with bonuses and then leave for the next bonus. Businesses would constantly be paying the bonuses in lump sums at the beginning which is financially detrimental.
 
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whopper

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CL?!?!?!?

A lot of whether or not I'd take the job is if the institution actually respected the consults. E.g. while as a resident I'd do a consult, the reason in the chart only being "psych consult" ordered. So I'd ask the nurse why there was a consult, she didn't know, I asked the patient, he/she didn't know, so then I'd beep the attending and the attending wouldn't answer for about 25 minutes while I sat there wasting my time.

Or then the attending would then call and after being asked tell me "well I ordered it cause the nurse on night shift said she needed one." So I'd ask why and he'd be like, "I don't know." So then the nurse on duty is like, "well I'm not that nurse."

So by the time I figured out why a consult was ordered in the effin first place (we'd call the nurse at home or ask the nurse manager, or hear 3rd hand "I think she wanted it cause the patient said she was sad," aside that many of them were completely BS consults, I'd end up wasting over an hour on the consult.

Less than 1/3 of the consults I did as a resident were relevant. Most of them were irrelevant. E.g. a patient is stable on their Escitalopram 10 mg daily and they wanted me to talk to the patient and do a complete consult cause they were on that dosage and already stable?

The attendings had no desire to fix the problem cause they weren't actually doing the work themselves. The residents couldn't fix the problem cause if we complained we were ignored.

So I'd only do CL in a hospital if they had their act together in the first place or if they were paying me A LOT OF MONEY to have my time wasted over parsing through 1 real consult for every 3 that were BS. They want to waste my time on a BS consult? Fine! PAY ME BY THE HOUR.

This problem happened in every institution I've worked in with consults. At least as an attending I'd tell the nurse, "we're not going to do the consult to begin with unless you specify why we are supposed to do it and it just can't say psych consult ordered." I'd protect the residents from having their time wasted. I'd tell the nurse "we're not doing them until you tell us why, and when you find out you call us and document it in the chart, otherwise we're not doing it." If they put in some more information but it still didn't give me enough data, I'd say "still not enough data, not doing it yet."
 
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