Compensation question

[Doc1401]

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What does it mean if a contract says that your total compensation can not be in excess of fair market value?

 

[FlowRate]

It means don't sign that contract.

 

[Doc1401]

It means don't sign that contract.

Why not? Say they offer a high base salary and then that is in the contract. Does it not refer to receiving excess charges in billing? Not clear to me

 

[clausewitz2]

It means that if it is not specified somewhere else there is an arbitrary ceiling on your compensation they will impose if they feel like it.

 

[wolfvgang22]

Why not? Say they offer a high base salary and then that is in the contract. Does it not refer to receiving excess charges in billing? Not clear to me

That's a good question for your prospective employer. Sounds like a way for them to get you to work for free. Perhaps you should have an attorney familiar with physician contracts and employment law look at it, too.

 

[Doc1401]

That's a good question for your prospective employer. Sounds like a way for them to get you to work for free. Perhaps you should have an attorney familiar with physician contracts and employment law look at it, too.

A colleague referenced this,
“Conservative physician employers may cap total compensation paid through an employment agreement at the 90th percentile of reported survey data. This, however, does not mean that physician compensation at or in excess of the 90th percentile cannot be fair market value (FMV). Metrics such as services provided, experience, total hours worked and production levels must be collectively considered. If a physician's hours and/or productivity are in excess of the 90th percentile of reported data, it may be reasonable and within FMV to pay compensation levels above the 90th percentile.”

 

[aim-agm]

A colleague referenced this,
“Conservative physician employers may cap total compensation paid through an employment agreement at the 90th percentile of reported survey data. This, however, does not mean that physician compensation at or in excess of the 90th percentile cannot be fair market value (FMV). Metrics such as services provided, experience, total hours worked and production levels must be collectively considered. If a physician's hours and/or productivity are in excess of the 90th percentile of reported data, it may be reasonable and within FMV to pay compensation levels above the 90th percentile.”

So in this case, his percentile of work will cap his percentile of payment. So that high base salary he mentioned might get slashed if he doesn't have high base work.

Anyway, I agree with @FlowRate . While there might be an honest reason to have that clause, if they want to they can abuse the hell out of it to screw you. The clause does nothing for you (e.g. they can't pay you more than you are worth but they sure as hell can pay you less) and unilaterally favors the employer.

 

[Extralong]

Just make sure you get paid around 300-350k regardless of anything.

 

[MdCompCare]

FMV restrains such as this are common in employment contracts to ensure employers have unilateral flexibility to address compensation to comport to changes in healthcare regulations or dramatic shifts in compensation being paid across the country.

The primary reason that this clause in present is to address the Stark regulation and the Anti Kickback statute which restrict how employers compensate physicians. To remain compliant with these laws, an employer must pay compensation that is considered Fair Market Value (which cannot take into account the volume or value of referrals). The employer must also ensure that the payment structure is commercially reasonable.

Long and short, you aren't going to be able to negotiate this language away but you should be able to address it by tying compensation to survey percentiles if you are concerned.

 

[notlucid]

Does FMV also have to do something with IRS rules regarding non profit status?

 

[Sushirolls]

FMV restrains such as this are common in employment contracts to ensure employers have unilateral flexibility to address compensation to comport to changes in healthcare regulations or dramatic shifts in compensation being paid across the country.

The primary reason that this clause in present is to address the Stark regulation and the Anti Kickback statute which restrict how employers compensate physicians. To remain compliant with these laws, an employer must pay compensation that is considered Fair Market Value (which cannot take into account the volume or value of referrals). The employer must also ensure that the payment structure is commercially reasonable.

Long and short, you aren't going to be able to negotiate this language away but you should be able to address it by tying compensation to survey percentiles if you are concerned.

This is a good summary.
You will find these clauses in the larger health entities that have greater fears of running afoul of Stark and Anti Kickback. This is why they heavily rely on the national salary surveys to anchor their pay rates or other magical compensation formulas to.

In theory you can hit those higher percentile incomes, but some suit some where will sit down and review your billings to make sure you aren't an outlier and should be getting paid what you are working/billing for. This is likely to be 75th percentile or even 90th percentile. At times it may not just be one suit but could be a whole committee that even includes other doctors in the health system who will "approve" or deny your pay past that point.

I just hit one of these magical thresholds at a past job by a few dollars but thankfully didn't trigger the committee... however, had I stayed and continued with certain service lines I likely would have. That was one of many factors leading to my decision to drop the big box shop entities and strike out for independence.

When you are the boss, you are the entity controlling Fair Market Value.

Fair Market Value stuff can get tricky. One poster on here described having a dirt cheap lease of ~$200/month with a health system. Depending on the square footage and going rate in the local area of medical office space, if that is a true financial steal, its possible that difference of market rate and actual lease rate could be considered a kick back as means to garner/induce referrals...

 

[nexus73]

How does FMV work in rural areas with chronic undersupply of psychiatry? Does it make sense for a hospital to hold fast to 75% or median pay rates? How would a hospital justify paying a psychiatrist more? How would a psychiatrist argue they should be getting paid at the 90th percentile or beyond, assuming they’re doing full time work?

 

[MdCompCare]

Nexus,

Hospital systems are holding fast at the 75th percentile because of guidance from the OIG that pay in excess of this can raise issues with the FMV of the transaction. That said, there are acceptable deviations from this as payment above the 75th% if often necessary. I will give you an example:

You bring on a new cardiologist for $450,000 guarantee for two years. The cardiologist isn't generating that many wRVUs in the first two years as he ramps up his business even if he is in clinic 5 days a week. If you were to take the guaranteed salary and divide by the wRVUs, the resulting $/wRVU would be in excess of the 90th%. Outside of this, most examples of 90th% pay is either [1] paid because of wRVUs generated in excess of the 90th% or [2] preeminent luminaries that you pay a premium for and the FMV is contingent on a multi factorial analysis.

Happy to discuss further if you want to PM me.

 

[Sushirolls]

A somewhat tangent, is that health systems will almost always have verbiage in the contracts that say they want you to refer everything internal BUT for the exception your clinical judgement says otherwise. You will always be able to maintain your clinical judgement to refer patients where you see fit (*in theory) and had those clauses not been in there I believe it would run afoul of physician independence and/or kick back clauses.

My understanding is the only exception to outside referrals are closed HMO entities like Kaiser.

*some suit will eventually sit down with you and say you can't do that, you will then respond yes I can, in my contract I can do what's clinically necessary for the best health interests of the patient. They will disagree with you, and then proceed to fire you for that, or find other things to make life difficult for you and fire you for that, or blow out of proportion the smaller personnel conflicts that happen here and there, and turn it into a disciplinary plan with correction elements, all towards the greater purpose of ticking you off and getting you to leave. Remember, the HR department doesn't work for you or in your best interest but is the CYA squad for the health system to reduce liability and fire people.

 

[dl2dp2]

Fair Market Value stuff can get tricky. One poster on here described having a dirt cheap lease of ~$200/month with a health system. Depending on the square footage and going rate in the local area of medical office space, if that is a true financial steal, its possible that difference of market rate and actual lease rate could be considered a kick back as means to garner/induce referrals...

This is very interesting and good to know. Obviously if nobody whistleblows everything is hunkydory, but if some regulatory is putting you under a microscope inadvertent "good deals" of this type becomes problematic.

 

[clausewitz2]

This is very interesting and good to know. Obviously if nobody whistleblows everything is hunkydory, but if some regulatory is putting you under a microscope inadvertent "good deals" of this type becomes problematic.

So what you're saying is use the savings to pay the retainer of a top-notch attorney.

 

[nexus73]

Nexus,

Hospital systems are holding fast at the 75th percentile because of guidance from the OIG that pay in excess of this can raise issues with the FMV of the transaction. That said, there are acceptable deviations from this as payment above the 75th% if often necessary. I will give you an example:

You bring on a new cardiologist for $450,000 guarantee for two years. The cardiologist isn't generating that many wRVUs in the first two years as he ramps up his business even if he is in clinic 5 days a week. If you were to take the guaranteed salary and divide by the wRVUs, the resulting $/wRVU would be in excess of the 90th%. Outside of this, most examples of 90th% pay is either [1] paid because of wRVUs generated in excess of the 90th% or [2] preeminent luminaries that you pay a premium for and the FMV is contingent on a multi factorial analysis.

Happy to discuss further if you want to PM me.

Thanks for the reply. I'm sort of interested in an example at the extreme end. If a hospital has an inpatient psych unit they want/need to keep open, but their psychiatrist(s) are leaving, how does Fair Market Value effect who they can hire. There is a hospital in the boondocks south of me that is currently staffed only by locums psychiatrists. They've been trying to hire a psychiatrist for at least the last 2 years and have been staffing with locums docs and I'd imagine paying through the nose for them. If a qualified psychiatrist showed interest in the job and insisted on a salary above the 75th%ile or above the median...for example an extra $50K above...could the hospital justify this pay given the "market" is basically speaking and dictating this is the cost of an employed psychiatrist for this hospital in this city? I'm sure they're paying the locums companies drastically more than this to keep a psychiatrist on the unit, and the hospital would probably be happy to pay even a large premium for an employed psychiatrist who intends to stay at the job and will not just be gone in 3 months. It seems Fair Market Value could drastically undervalue an employed psychiatrist in such as situation and prevents both the psychiatrist and hospital from coming to a fair economic agreement.

 

[Sushirolls]

It seems Fair Market Value could drastically undervalue an employed psychiatrist in such as situation and prevents both the psychiatrist and hospital from coming to a fair economic agreement.

Yep. Fair market value isn't really about the local pond. Its about not being an outlier for the whole ocean.

So consider not being employed, but setting up your own corporation and being a hired contractor at your desired rate. Still may have some FMV issues even for independent contractors. Not 100% sure on this one.

Or reach out to a locums agency be the locums who covers the hospital on an almost permanent basis. There are long locums contracts out there.

Or form a corporation and being an independent psychiatrist and collect the billings 100% for your self. The trouble with this on inpatient units is some insurance companies won't do traditional fee for service but give bundled payments to the hospital. So you'll have to have some sort payer specific contracts with the hospital to get paid - and rest assured these bundled arrangements the doctor gets the short stick...

The only way to enhance beyond FMV aspects of hospitals/health systems is with medical director stipends, but even those have scrutiny for how that part of the contract looks and what the hourly rate is or how the time sheets are done. But the Med Dir role could spice up the inpatient pay (and headaches).

 

[dl2dp2]

It seems Fair Market Value could drastically undervalue an employed psychiatrist in such as situation and prevents both the psychiatrist and hospital from coming to a fair economic agreement.

Duh. This happens ALL THE TIME. In fact, this happens MOST of the time with many facility based jobs that are chronically short staffed and have high turnover.

There are people who would fill these locum positions on a temporary basis, and it may or may not cost the hospital more depending. But for a variety of administrative reasons (including FMV based employee salary offer, government salary caps, etc etc) fully employed salaries are not matching actual market value, which causes shortage.

This is not different from any other pricing control causing a shortage. Of course, in our field, when there's a shortage, what ends up happening is 1) patients don't get hospitalized and treated in a timely way, so they go into the criminal justice system or come around to the ER. 2) they kill themselves or overdose on drugs. 3) underqualified (cheaper) clinicians get hired to deal with highly complex cases and mistreat them with inappropriate polypharmacy.

Nobody cares. The fact that there's a day to day shortage is not typically able to overcome administrative hurdles. To overcome admin hurdles you usually need advisory from the above not below.

 

[Sushirolls]

Duh. This happens ALL THE TIME. In fact, this happens MOST of the time with many facility based jobs that are chronically short staffed and have high turnover.

There are people who would fill these locum positions on a temporary basis, and it may or may not cost the hospital more depending. But for a variety of administrative reasons (including FMV based employee salary offer, government salary caps, etc etc) fully employed salaries are not matching actual market value, which causes shortage.

This is not different from any other pricing control causing a shortage. Of course, in our field, when there's a shortage, what ends up happening is 1) patients don't get hospitalized and treated in a timely way, so they go into the criminal justice system or come around to the ER. 2) they kill themselves or overdose on drugs. 3) underqualified (cheaper) clinicians get hired to deal with highly complex cases and mistreat them with inappropriate polypharmacy.

Nobody cares. The fact that there's a day to day shortage is not typically able to overcome administrative hurdles. To overcome admin hurdles you usually need advisory from the above not below.

TRUTH. Good summary.

 

[nexus73]

Outside of taking on medical director or other administrative duties, are there any other options to get paid above the median rate? Is there an accepted variance from the salary survey company median number? For example, say the hospital wants to pay every physician at the 75th %ile, is it common or acceptable (i.e. hospital not fearing government investigation/fines for perceived kickback) to pay hard to staff specialties at the 80th or 85th %ile?

 

[TexasPhysician]

Outside of taking on medical director or other administrative duties, are there any other options to get paid above the median rate? Is there an accepted variance from the salary survey company median number? For example, say the hospital wants to pay every physician at the 75th %ile, is it common or acceptable (i.e. hospital not fearing government investigation/fines for perceived kickback) to pay hard to staff specialties at the 80th or 85th %ile?

You can pay physicians whatever you want.

 

[dl2dp2]

Outside of taking on medical director or other administrative duties, are there any other options to get paid above the median rate? Is there an accepted variance from the salary survey company median number? For example, say the hospital wants to pay every physician at the 75th %ile, is it common or acceptable (i.e. hospital not fearing government investigation/fines for perceived kickback) to pay hard to staff specialties at the 80th or 85th %ile?

This is a confusing question. Trivially, if there's an 80%tile it means by definition 20% of the facilities are paying more.

The original question has to do with FMV in a contract. Many (most?) facility contracts do not explicitly contain FMV clauses.

 

[VA Hopeful Dr]

You can pay physicians whatever you want.

True, but if they aren't earning what you're paying them (or at least close) you run the risk of drawing the government's attention.

As for the OP, my current FP job has a maximum pay per year. Not sure what it is in terms of percentile nationally but its about $540k/year. I'm not particularly worried about ever hitting that mark.

I do work for a publicly owned hospital, which is why this is the first contract I've ever had that contained a maximum pay clause.

 

[TexasPhysician]

True, but if they aren't earning what you're paying them (or at least close) you run the risk of drawing the government's attention

Of course it’ll look weird if you start paying a psychiatrist $500k for 20 hours of work to treat Medicaid patients and the psychiatrist isn’t terminated, because the company is going under with that math. The government only looks to be sure the job isn’t kept because the psychiatrist is doing unethical things to get that $500k like running 5k UDS’s, 4,000 labs, and thousands of internal referrals.

The problem with this argument is that the unethical things above will draw attention regardless of what you pay the psychiatrist. It isn’t the psychiatrists job to earn below a given threshold. It is the administrators job to demonstrate why the psychiatrist creates value if the government ever asks.

 

[nexus73]

This is a confusing question. Trivially, if there's an 80%tile it means by definition 20% of the facilities are paying more.

The original question has to do with FMV in a contract. Many (most?) facility contracts do not explicitly contain FMV clauses.

Sorry I'll try to clarify. I'll use my employer as an example. It's a hospital with many employed doctors across lots of specialties. I haven't found any exceptions, all doctors are getting the median RVU rate (for their specialty based on national physician salary survey data) and almost all are on an RVU only contract with no base salary. For psychiatry the median RVU rate is about 75th%ile...which is about $65 and something like 3800 RVUs per year. My hospital doesn't explicitly have FMV language in contracts, but frequently mentions the FMV when sticking to the median pay rates during pay negotiation. My question is basically is there an industry accepted way to determine FMV besides just sticking to the median? How much variance up from the this rate is reasonable to negotiate for...or how much weight should the hospital's argument about avoiding government investigation carry? Is a psychiatrist getting paid at the 80th%ile RVU rate for producing the median number of RVUs (3800/year) realistically going to bring an investigation to the hospital?

Another issue I've learned about recently is that hospitals get much larger facility fees than doctors in private practice. This is why our cardiology group for example sold out to the hospital. Doing echocardiograms in the office was reimbursed so much lower they'd be losing money... but the hospital facility fee is so much higher echos are still a money maker. I've recently seen several posts on social media reemphasizing the amount of money a doctor brings into a hospital outside of physician fees by ordering labs, imaging, operating room use, and just patients being admitted to a bed makes money for the hospital. Doctors do not get any of this money. The government and hospitals almost seem complicit in paying large facility fees to hospitals and "threatening" hospitals with investigation and fines if they use the facility fees to pay doctors larger salaries. So why is the facility fee so large and why haven't physician fees increased instead? Hospital lobbyists? What can we as physicians do to change this? I'd imagine hospitals are happy to have this pay ceiling in place, because they can keep pay levels down and shift blame to the government, while still making money from the physician. These kind of price controls seem like they should be illegal.

 

[FlowRate]

Sorry I'll try to clarify. I'll use my employer as an example. It's a hospital with many employed doctors across lots of specialties. I haven't found any exceptions, all doctors are getting the median RVU rate (for their specialty based on national physician salary survey data) and almost all are on an RVU only contract with no base salary. For psychiatry the median RVU rate is about 75th%ile...which is about $65 and something like 3800 RVUs per year. My hospital doesn't explicitly have FMV language in contracts, but frequently mentions the FMV when sticking to the median pay rates during pay negotiation. My question is basically is there an industry accepted way to determine FMV besides just sticking to the median? How much variance up from the this rate is reasonable to negotiate for...or how much weight should the hospital's argument about avoiding government investigation carry? Is a psychiatrist getting paid at the 80th%ile RVU rate for producing the median number of RVUs (3800/year) realistically going to bring an investigation to the hospital?

Another issue I've learned about recently is that hospitals get much larger facility fees than doctors in private practice. This is why our cardiology group for example sold out to the hospital. Doing echocardiograms in the office was reimbursed so much lower they'd be losing money... but the hospital facility fee is so much higher echos are still a money maker. I've recently seen several posts on social media reemphasizing the amount of money a doctor brings into a hospital outside of physician fees by ordering labs, imaging, operating room use, and just patients being admitted to a bed makes money for the hospital. Doctors do not get any of this money. The government and hospitals almost seem complicit in paying large facility fees to hospitals and "threatening" hospitals with investigation and fines if they use the facility fees to pay doctors larger salaries. So why is the facility fee so large and why haven't physician fees increased instead? Hospital lobbyists? What can we as physicians do to change this? I'd imagine hospitals are happy to have this pay ceiling in place, because they can keep pay levels down and shift blame to the government, while still making money from the physician. These kind of price controls seem like they should be illegal.

Reading up about the Anti-Kickback Statute, Stark Law, and whichever CFR statute, which is where FMV is relevant, an average doc employed by a hospital or company should be able to be paid literally anything as long as they're not being paid an egregious amount for the purpose of running up charges to Medicare or other federal programs (via referrals, tests, etc.) It seems to me that FMV fear-mongering is an advertising tactic by MD compensation consultants (such as the one posting here), data warehouses (MGMA), and the corporate healthcare industry (who would love to freeze physician comp by paying everyone at the median per RVU.)

 

[Sushirolls]

This is a confusing question. Trivially, if there's an 80%tile it means by definition 20% of the facilities are paying more.

The original question has to do with FMV in a contract. Many (most?) facility contracts do not explicitly contain FMV clauses.

FMV takes into consideration all psychiatry pay. So the doc at the VA, the doc at the community mental health center, the doc at the large "non-profit health system", and private practice taking insurance and the cash only doctors who fill out the surveys, etc. So yes, there are doctors making more, but they are in different venues then the non-profit health system. A health system isn't going to care enough to pay one psychiatrist more to go above the FMV. Collectively all of them don't want to, because they don't want to deal with a ton of contract re-negotiations. Part of the issue of FMV for psych is the diversity of practice locations that the other specialties don't have. Other specialists don't have Community mental health, or prison/jail jobs pulling down the salary median.

Facility fees are part of how the hospital keeps the lights on and supports their bloated bureaucracy. I can't recall if it was state article I glimpsed or a national one but I recall something about the neighboring medical buildings that were linked as 'part of the hospital' and charging facility fees is going to be stopped. The money from facility fees goes to the multimillion dollar CEO pay, the nurses union demands, the other union demands, and actual facility maintenance which is really expensive (how many hospitals are new shiny buildings? most are old dilapidated with expensive HVAC issues).

The solutions you seek are more systemic of the entirety of the dying American health system for physicians. The tug of war between hospitals, hospital associations, insurance companies, mid level expansion, mid level scope of practice creep through legislation, overt devotion to cookbook protocols (medicare driving this with never events, meaningful use, MIPS, and the general ceding of physician authority to others). The only way to solve this is to enter more politics, and join more assertive grass root societies that intend to advocate for physicians unlike the existing entrenched organizations that don't.

Psychiatry, with its ability to do simple cash only practices will be one of the last hold outs for the death of the American Health system. I wish everyone has the opportunity to experience the life changing education of a physician degree, but I doubt once my kids are older I will recommend a health care career, sadly.

 

[Sushirolls]

Reading up about the Anti-Kickback Statute, Stark Law, and whichever CFR statute, which is where FMV is relevant, an average doc employed by a hospital or company should be able to be paid literally anything as long as they're not being paid an egregious amount for the purpose of running up charges to Medicare or other federal programs (via referrals, tests, etc.) It seems to me that FMV fear-mongering is an advertising tactic by MD compensation consultants (such as the one posting here), data warehouses (MGMA), and the corporate healthcare industry (who would love to freeze physician comp by paying everyone at the median per RVU.)

Yes.
They have no desire to budge, either through willful intent, or just bureaucratic bloat. They would rather look to hire Locums briefly or just shut down the psych service, or run the existing docs into the ground with burn out (all the while sending emails and hosting meetings to talk about physician burn out, or hand out books to every doctor in the hospital) when they are the largest cause of the burn out.

I've fought this battle before at a place the continually failed to fill its 1-2 open psych positions in a very small department and emphasis on salary increase was ignored for several years, and real recruitment happened. The adherence to the physician comp plan, proposed by the outside consultants, reviewed/ratified every few years by hospital admin, medical group admin and trustees, couldn't be tinkered with.

So the best solution for hospital health systems is to hire the new fresh young grad who they can whisper into their ears. "You know nothing Jon Snow."

 

[dl2dp2]

Sorry I'll try to clarify. I'll use my employer as an example. It's a hospital with many employed doctors across lots of specialties. I haven't found any exceptions, all doctors are getting the median RVU rate (for their specialty based on national physician salary survey data) and almost all are on an RVU only contract with no base salary. For psychiatry the median RVU rate is about 75th%ile...which is about $65 and something like 3800 RVUs per year. My hospital doesn't explicitly have FMV language in contracts, but frequently mentions the FMV when sticking to the median pay rates during pay negotiation. My question is basically is there an industry accepted way to determine FMV besides just sticking to the median? How much variance up from the this rate is reasonable to negotiate for...or how much weight should the hospital's argument about avoiding government investigation carry? Is a psychiatrist getting paid at the 80th%ile RVU rate for producing the median number of RVUs (3800/year) realistically going to bring an investigation to the hospital?

Another issue I've learned about recently is that hospitals get much larger facility fees than doctors in private practice. This is why our cardiology group for example sold out to the hospital. Doing echocardiograms in the office was reimbursed so much lower they'd be losing money... but the hospital facility fee is so much higher echos are still a money maker. I've recently seen several posts on social media reemphasizing the amount of money a doctor brings into a hospital outside of physician fees by ordering labs, imaging, operating room use, and just patients being admitted to a bed makes money for the hospital. Doctors do not get any of this money. The government and hospitals almost seem complicit in paying large facility fees to hospitals and "threatening" hospitals with investigation and fines if they use the facility fees to pay doctors larger salaries. So why is the facility fee so large and why haven't physician fees increased instead? Hospital lobbyists? What can we as physicians do to change this? I'd imagine hospitals are happy to have this pay ceiling in place, because they can keep pay levels down and shift blame to the government, while still making money from the physician. These kind of price controls seem like they should be illegal.

OH I see...

1) The answer to the first question is unknowable because it depends too much on local conditions (i.e. how much does a particular system need an additional psychiatrist for their particular set of issues). Hospitals are willing to lose money if you can provide a valuable service either due to clinical needs or regulatory needs. So it's hard to make blanket statements about "how much more should I ask". The most reasonable answer is if you can get multiple comparable offers, you can take the highest offer and tag on another 10-15% as the starting counter, and generally have people to match the highest bid.

2) Sushirolls had a pretty good discussion facilities fees. The bottom line is the gold rush using facilities fees will eventually end, at which point hospitals will start selling off private practices again or have a very loose franchise model. This is happening already with large NE academic practices as the facility fees there are really no longer covering the ever increasing facility expense bloat. There is an economy of scale---systems like Kaiser, Northwell, Harvard Pilgrim, etc. have advantages--they tend to pay higher fixed salary and negotiate with large payers directly with much better rates. However, you certainly lose autonomy and have more "burn out". Secondarily, economy of scale works if your aim is to provide scaled service en masse -- i.e. if you do insurance based or even Medicaid practice, it's likely that you'll get paid more net-net if you work for Kaiser or Northwell (using one of their managed Medicaid programs) than if you set up your own little Medicaid clinic (though even in that scenario interesting exceptions have emerged through semi-legit methods i.e. urine drug testing). However, it's basically impossible for even Northwell to up-negotiate your rates to the actual market rate, especially if you have the right kind of training, which is why in general cash practices in most markets are still more lucrative on a per wRVU basis. This disparity between maximal insurance vs. cash market is now so large that academic medical centers are starting to charge cash for their faculty members, especially for sub-sub-specialty consults... so in that case, your first question finds another answer.