Contract benefits negotiation

[You shall know the Truth]

in signing your first contract post residency/fellowship can you negotiate with the PP/hospital to increase your base salary instead of having benefits (403b, insurance, etc)? I ask because spouse has great benefits and they are not needed. Thank you

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[Winged Scapula]

in signing your first contract post residency/fellowship can you negotiate with the PP/hospital to increase your base salary instead of having benefits (403b, insurance, etc)? I ask because spouse has great benefits and they are not needed. Thank you

Everything's negotiable but typically academic contracts are fairly inflexible. You can refuse health insurance if you have it elsewhere.

However, I would caution you not to give up things like retirement plans etc. It sounds awful but what if you and your spouse divorce, or they die? You need to protect yourself. Besides, retirement plan $$ are not taxed; an increase in salary is, so you'll be giving up the extra income to Uncle Sam.

 

[Smurfette]

You can negotiate your salary without giving up benefits. However, make sure you think ahead on this---if it's a job with a base salary that switches to production in 2-3 years, negotiating a higher salary only applies for that 2-3 year period and not beyond that.

Turning down a 403B or other retirement plan is foolish IMO. This is yours so if your spouse dies in a car crash or something, you may regret not starting a nest egg early. I've seen more than my share of people end up screwed financially. You can always fund it minimally, but if your combined incomes are high and you live a reasonable lifestyle, you should be maximizing your contribution annually as should s/he. Investments 101. And if you have an employer match, you should be trying to get the max return on that.

Same thing with life insurance benefits they may give you. You can always take the minimum if it's at no cost to you and not pay for more coverage.

Some employers will not allow you to be on your spouse's insurance if your employer offers it, so definitely check with your spouse's HR before turning down insurance (plus which insurance truly is better for you/most cost effective---maybe both are equal but yours is cheaper than your spouse doing a family plan).

 

[You shall know the Truth]

You can negotiate your salary without giving up benefits. However, make sure you think ahead on this---if it's a job with a base salary that switches to production in 2-3 years, negotiating a higher salary only applies for that 2-3 year period and not beyond that.

Turning down a 403B or other retirement plan is foolish IMO. This is yours so if your spouse dies in a car crash or something, you may regret not starting a nest egg early. I've seen more than my share of people end up screwed financially. You can always fund it minimally, but if your combined incomes are high and you live a reasonable lifestyle, you should be maximizing your contribution annually as should s/he. Investments 101. And if you have an employer match, you should be trying to get the max return on that.

Same thing with life insurance benefits they may give you. You can always take the minimum if it's at no cost to you and not pay for more coverage.

Some employers will not allow you to be on your spouse's insurance if your employer offers it, so definitely check with your spouse's HR before turning down insurance (plus which insurance truly is better for you/most cost effective---maybe both are equal but yours is cheaper than your spouse doing a family plan).

I appreciate this so thank you, I have been day trading since I was 18 and I would rather control my investemests. I have worked at hospitals before and their retirement plans are not great when juxtaposed to other investment vehicles. I am a Christian so there are insurance policies and investments that don’t violate deeply held beliefs.

My follow up for you is the negotiation part of a job offer, how does one go about doing this? Do people during residency help with this before you graduate?

 

[You shall know the Truth]

Everything's negotiable but typically academic contracts are fairly inflexible. You can refuse health insurance if you have it elsewhere.

However, I would caution you not to give up things like retirement plans etc. It sounds awful but what if you and your spouse divorce, or they die? You need to protect yourself. Besides, retirement plan $$ are not taxed; an increase in salary is, so you'll be giving up the extra income to Uncle Sam.

Thank you for your reply. Divorce is not an option, insurance policies are there for death. I will keep reflecting on these comments and see how negotiations go. Have a nice evening.

 

[Smurfette]

I appreciate this so thank you, I have been day trading since I was 18 and I would rather control my investemests. I have worked at hospitals before and their retirement plans are not great when juxtaposed to other investment vehicles. I am a Christian so there are insurance policies and investments that don’t violate deeply held beliefs.

My follow up for you is the negotiation part of a job offer, how does one go about doing this? Do people during residency help with this before you graduate?

You can generally pick the funds of your 403b.

For negotiation, once you get a contract, you review it and contact them asking for what changes you want. So you can ask for salary X, call schedule Y, etc. The worst they can say is no. They may meet you in the middle or give you what you ask.

Also, have a lawyer look at your contract before you sign. This is extremely important and cannot be overstated. You need to understand non-competes, reasons why they can fire you, and other parameters to your employment.

Your residency program will probably not help with this at all. My GME office did have a list of contract attorneys that offered discounts for new grads as well as a basic handout explaining non-competes and types of malpractice insurance. Otherwise we were on our own.

 

[You shall know the Truth]

You can generally pick the funds of your 403b.

For negotiation, once you get a contract, you review it and contact them asking for what changes you want. So you can ask for salary X, call schedule Y, etc. The worst they can say is no. They may meet you in the middle or give you what you ask.

Also, have a lawyer look at your contract before you sign. This is extremely important and cannot be overstated. You need to understand non-competes, reasons why they can fire you, and other parameters to your employment.

Your residency program will probably not help with this at all. My GME office did have a list of contract attorneys that offered discounts for new grads as well as a basic handout explaining non-competes and types of malpractice insurance. Otherwise we were on our own.

Wow, this was tremendously helpful. I don’t understand why they don’t teach use this stuff in school. Thank you for all of your help.

 

[mimelim]

You can generally pick the funds of your 403b.

For negotiation, once you get a contract, you review it and contact them asking for what changes you want. So you can ask for salary X, call schedule Y, etc. The worst they can say is no. They may meet you in the middle or give you what you ask.

Also, have a lawyer look at your contract before you sign. This is extremely important and cannot be overstated. You need to understand non-competes, reasons why they can fire you, and other parameters to your employment.

Your residency program will probably not help with this at all. My GME office did have a list of contract attorneys that offered discounts for new grads as well as a basic handout explaining non-competes and types of malpractice insurance. Otherwise we were on our own.

Wow, this was tremendously helpful. I don’t understand why they don’t teach use this stuff in school. Thank you for all of your help.

To add to Smurfette, what I have found is that more important than what is in a contract is what isn't. That is a fundamental problem with you or a standard contract lawyer looking at the contract. You don't know what you can or can't get put into writing. That is where getting a physician contract specific lawyer will help. I would also highly recommend trying to attend in person or through the web society oriented sessions about this. I was at SCVS and SVS and there were specific panels about contract negotiation and how to deal with this whole process. Also, in general the salary is the hardest thing to negotiate and typically hospitals or practices tie their salaries to something fixed, so they won't budge much. Actual medical stuff people are far more flexible on.

 

[You shall know the Truth]

To add to Smurfette, what I have found is that more important than what is in a contract is what isn't. That is a fundamental problem with you or a standard contract lawyer looking at the contract. You don't know what you can or can't get put into writing. That is where getting a physician contract specific lawyer will help. I would also highly recommend trying to attend in person or through the web society oriented sessions about this. I was at SCVS and SVS and there were specific panels about contract negotiation and how to deal with this whole process. Also, in general the salary is the hardest thing to negotiate and typically hospitals or practices tie their salaries to something fixed, so they won't budge much. Actual medical stuff people are far more flexible on.

Thank you, I will look into this. Why would you say the salary is the hardest thing to negotiate? Are there that many surgeons where the employer can be unwilling to change. Or do they just do without a surgeon until one comes along willing to accept their offer?

 

[mimelim]

Thank you, I will look into this. Why would you say the salary is the hardest thing to negotiate? Are there that many surgeons where the employer can be unwilling to change. Or do they just do without a surgeon until one comes along willing to accept their offer?

Hospitals and practices will tie their salaries to MGMA or other data. They will offer local 50th percentile or some other number because that is what Merritt Hawkins or someone else told them to do. The larger the group or institution, the more firm those numbers tend to be. If a hospital can't fill the position then they will increase this amount, but that can take a lot of time. Simply put, while there are some surgical practices where the people offering the job have the authority to offer more, they are the minority.

 

[You shall know the Truth]

Hospitals and practices will tie their salaries to MGMA or other data. They will offer local 50th percentile or some other number because that is what Merritt Hawkins or someone else told them to do. The larger the group or institution, the more firm those numbers tend to be. If a hospital can't fill the position then they will increase this amount, but that can take a lot of time. Simply put, while there are some surgical practices where the people offering the job have the authority to offer more, they are the minority.

Thank you, I highly respect you insight. What would you suggest to residents/fellows that are looking for competitive benefits that accurately reflect their abilities? Or do you recommend any job out if training and then a more aggressive avenue with some work history.

 

[VA Hopeful Dr]

Thank you, I highly respect you insight. What would you suggest to residents/fellows that are looking for competitive benefits that accurately reflect their abilities? Or do you recommend any job out if training and then a more aggressive avenue with some work history.

There's no one right answer (other than not taking a bad job).

My general rule of thumb is you want a job that pays you well for the work you do. I know that seems obvious, but you'd be surprised how often that doesn't work out.

 

[You shall know the Truth]

There's no one right answer (other than not taking a bad job).

My general rule of thumb is you want a job that pays you well for the work you do. I know that seems obvious, but you'd be surprised how often that doesn't work out.

I know the MGMA is a guide line that is used, but what about rural areas? How would a prudent physician analyze a less desirable market’s offer?

 

[VA Hopeful Dr]

I know the MGMA is a guide line that is used, but what about rural areas? How would a prudent physician analyze a less desirable market’s offer?

Decide how much above the median for your specialty it would take to get you to work rural. For me, the 100k signing bonus offered wasn't enough so now I don't work in a rural area.

 

[Winged Scapula]

I know the MGMA is a guide line that is used, but what about rural areas? How would a prudent physician analyze a less desirable market’s offer?

You also have to analyze the market and your resources.

If you're a rural general surgeon without anyone to take call/cover vacation or someone who is "difficult" to coordinate with, then maybe all the money in the world is not enough.

If you're a rural general surgeon and your spouse is miserable because of a dearth of social and professional opportunities, then what does it matter what they pay you?

If you're a rural general surgeon and they pay you $750K salary guarantee for 2 years but after that you struggle to meet your RVUs with lipomas, breast biopsies and cholecystectomies, then are you going to be able to sustain the practice and survive?

Are the patients the kind that stay in town for services or do they not trust small town doctors. For example, here in AZ we have a lot of remote communities. Many of those residents drive several hours to come here because they firmly believe they will get better care in the big city, even if they have a surgeon capable of caring for them in town. As one told me, " rural doctors are those that can't compete in the big city with all the other doctors". Maybe so, probably not, but the impression is most important. It doesn't matter if you like the town, or if your spouse does, or how much they pay you, if everyone either is referred or self-refers out of town.

These contracts are NOT written to benefit you. You can bet if they pay you X, they (your employer) is making X + Y.

 

[mimelim]

Thank you, I highly respect you insight. What would you suggest to residents/fellows that are looking for competitive benefits that accurately reflect their abilities? Or do you recommend any job out if training and then a more aggressive avenue with some work history.

As others have said, it all depends on what you are looking for and how YOU perceive your value. I'll give you some real world numbers... From job offers that I'm personally considering and those that my co-residents have accepted in the last 3 months...

280k VA, middle of major city
350k PP, middle of major city
220k Academics, middle of major city
320k Academics, medium sized city, but one in a state hurting for vascular surgeons
320k Hybrid, 30 miles outside major city
450k Hospital employed, 60 miles outside medium sized city
700k Hospital employed, 80 miles outside medium sized city

Despite that variability, I honestly think that I can make an argument that each of those jobs are offering about right (except that last one, which will need to go to 900k+ before someone fills it). The reality is that your job title or training is NOT what matters in job offerings. That isn't a medicine/physician thing, that is just a global marketplace thing. The question is how much value do you bring to a practice. While RVUs as @Winged Scapula points out is important to consider for post guaranteed salary, they aren't the only 'value' that surgeons bring to the table, especially vascular surgery. One of the ancillary benefits of vascular surgery is the other income they bring to the hospital via testing, but also their ability to back up other surgeons allowing them to do bigger/riskier operations. As exemplified by the last hospital I listed, they had a horrific outcome after an elective, routine knee operation that could have been avoided with the available vascular surgery. Their cardiac surgeon functions as their vascular 'backup', but as he was tied up in a long valve/cab case and was the only surgeon in the hospital that 'could' help, the an elective knee turned into an AKA. Hence why they have significant pressure to get someone and quick.

 

[Psai]

I swear to god I've read this exact thread before

 

[Winged Scapula]

While RVUs as @Winged Scapula points out is important to consider for post guaranteed salary, they aren't the only 'value' that surgeons bring to the table

Excellent point which I felt was beyond the scope of our HS or pre-med OP.

The same is true in my field: we bring in money via imaging, radiation and medical oncology because we drive the referrals. Its long been a bargaining chip in the world of breast surgery.

 

[VA Hopeful Dr]

Excellent point which I felt was beyond the scope of our HS or pre-med OP.

The same is true in my field: we bring in money via imaging, radiation and medical oncology because we drive the referrals. Its long been a bargaining chip in the world of breast surgery.

Don't say that too loudly as that's might close to a Stark violation...

 

[Winged Scapula]

Don't say that too loudly as that's might close to a Stark violation...

Not unless there is an ownership or investment interest and only for Medicare patients.

If you pay me more by the # or value of referrals to your oncologists, then that's a problem (falls afoul of the Indirect Compensation Exemption) and you must pay me Fair Market value.

NB: I am self-employed and IANAL

 

[You shall know the Truth]

As others have said, it all depends on what you are looking for and how YOU perceive your value. I'll give you some real world numbers... From job offers that I'm personally considering and those that my co-residents have accepted in the last 3 months...

280k VA, middle of major city
350k PP, middle of major city
220k Academics, middle of major city
320k Academics, medium sized city, but one in a state hurting for vascular surgeons
320k Hybrid, 30 miles outside major city
450k Hospital employed, 60 miles outside medium sized city
700k Hospital employed, 80 miles outside medium sized city

Despite that variability, I honestly think that I can make an argument that each of those jobs are offering about right (except that last one, which will need to go to 900k+ before someone fills it). The reality is that your job title or training is NOT what matters in job offerings. That isn't a medicine/physician thing, that is just a global marketplace thing. The question is how much value do you bring to a practice. While RVUs as @Winged Scapula points out is important to consider for post guaranteed salary, they aren't the only 'value' that surgeons bring to the table, especially vascular surgery. One of the ancillary benefits of vascular surgery is the other income they bring to the hospital via testing, but also their ability to back up other surgeons allowing them to do bigger/riskier operations. As exemplified by the last hospital I listed, they had a horrific outcome after an elective, routine knee operation that could have been avoided with the available vascular surgery. Their cardiac surgeon functions as their vascular 'backup', but as he was tied up in a long valve/cab case and was the only surgeon in the hospital that 'could' help, the an elective knee turned into an AKA. Hence why they have significant pressure to get someone and quick.

Thank for the help, understanding a surgeons worth seems to be multifaceted and more complex than previously thought.

 

[You shall know the Truth]

Excellent point which I felt was beyond the scope of our HS or pre-med OP.

The same is true in my field: we bring in money via imaging, radiation and medical oncology because we drive the referrals. Its long been a bargaining chip in the world of breast surgery.

This is a great point. Can maximizing patient care/outcomes and increasing hosptial revenue be opposed to each other or can they in concert to benefit all parties?

 

[doc05]

This is a great point. Can maximizing patient care/outcomes and increasing hosptial revenue be opposed to each other ...?

Yes. They are diametrically opposed.

 

[You shall know the Truth]

Yes. They are diametrically opposed.

Thank you, i Would like to do right by the patient in all circumstances. This thread has been a big help, thank you to all who have contributed.