Contract opinions?

[Paindude11]

I have been with a PP group 2yrs and it is time to renegotiate in the next few months. The group is set up as a clinic LLC and an ambulatory surgicenter LLC where we do all our procedures (no other docs doing cases there). I will probably do around 1800-2000 procedures for the year doing 2 days of procedures and 2 days of clinic per week (working 4days, 80% full time). There is an in house lab and PT services. My issue is they are not willing to cut me into my procedure productivity, citing stark laws as a conflict. I proposed wRVU incentivization which the attorneys were agreeable, but then they declined (my guess after crunching the numbers). They are offering to bonus me for my clinic side collections only (and those billed under me by the Mid levels), but still expect me to be super busy and productive procedurally. Personally, I feel the clinic side is overstaffed and not very profitable, so I do not see how this projected bonus would work out. In fact, the same bonus was offered when I signed on and I never saw a dime of it. I can get benefits from my spouse, so I am willing to let the insurance go. Current salary is 350k and located in southeast. I have about 10 years experience.

Option 1: Do I try to negotiate a higher base and just punt the bonus altogether? After my experience with the bonus the 1st go around and now looking at the numbers offered for this current proposal, I dont think I would ever comfortably know how transparent the numbers would be anyway at this point.

Option 2: do I offer to 1099 for procedures only and set a daily limit? If so, what is a reasonable rate for 1099 these days?

Or do I just walk and find another group willing to incentivize for my productivity? Advice?

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[Ronin1]

Are you a lifetime employee with no talk of partnership? Can you invest in the ASC?is this a pain only group?

If you are asking you are probably looking to leave. Sooner the better.

 

[drusso]

My issue is they are not willing to cut me into my procedure productivity, citing stark laws as a conflict. Or do I just walk and find another group willing to incentivize for my productivity? Advice?

If they let you buy-in to the practice and ASC, then there is no Stark issue.

 

[paindoc007]

You do 2k procedures a year, and make $350k? Jesus

 

[bedrock]

They need to let you buy into ASC or let you do WRVU.

Anything else is totally screwing you over. Time to walk if they won't do one of the first two options. Their offer of a clinic productivity bonus is total BS as 80% of our revenue comes from procedures.

 

[drusso]

Are you a lifetime employee with no talk of partnership? Can you invest in the ASC?is this a pain only group?

If you are asking you are probably looking to leave. Sooner the better.

Have you asked to look at your production reports, your cost allocation reports, profit and loss by provider, and profit and loss by whole enterprise?

I would take the approach, "I'm trying to determine what my value is to the whole organization and how I should be compensated relative to my value proposition to you."

 

[BobBarker]

Full partner or bust.

 

[Dr. Ice]

Is this a pain practice or surgical practice?

 

[Paindude11]

Thank you all for your replies and advice. This is a private pain practice, currently 3 MDs with 1 retiring. I was offered to buy out the retiring doc and declined. Their valuation was excessively high and none of my advisors could make the numbers work to make it a good ROI. This is also why I do not trust their transparency for the proposed clinic only bonus structure, as those numbers looked terrible. However, the ASC is killing it (and killing me). I dont mind being busy and productive, but I am not willing to do it without fair compensation.

Since partnership and buy in is not going to be an option this go around, I am back to staying on as an employee and asking for a base raise (knowing the bonus is total BS), or staying for a while 1099, or just cutting ties altogether. Eventually I will probably move on, but there are family considerations for the short term. What is a fair base or 1099 per diem rate in this situation?

 

[Dr. Ice]

Thank you all for your replies and advice. This is a private pain practice, currently 3 MDs with 1 retiring. I was offered to buy out the retiring doc and declined. Their valuation was excessively high and none of my advisors could make the numbers work to make it a good ROI. This is also why I do not trust their transparency for the proposed clinic only bonus structure, as those numbers looked terrible. However, the ASC is killing it (and killing me). I dont mind being busy and productive, but I am not willing to do it without fair compensation.

Since partnership and buy in is not going to be an option this go around, I am back to staying on as an employee and asking for a base raise (knowing the bonus is total BS), or staying for a while 1099, or just cutting ties altogether. Eventually I will probably move on, but there are family considerations for the short term. What is a fair base or 1099 per diem rate in this situation?

You could probaly just do a split formula and ask them for a cash sheet to break down your monthly direct expenses vs your collections. You could determine base on that. Maybe something like 60/40 collections to you after direct expenses met.

 

[nvrsumr]

There is zero reason you should be doing procedures at an ASC that you cannot buy into. Get your base raise then take your patients to a different ASC or hospital. They will fire you but will be fun.

 

[Paindude11]

Is this a pain practice or surgical practice?

You could probaly just do a split formula and ask them for a cash sheet to break down your monthly direct expenses vs your collections. You could determine base on that. Maybe something like 60/40 collections to you after direct expenses met.

 

[Paindude11]

There is zero reason you should be doing procedures at an ASC that you cannot buy into. Get your base raise then take your patients to a different ASC or hospital. They will fire you but will be fun.

Good point. It seems that employing me and requiring my procedure referrals be directed only to their ASC would be a stark violation anyway.

 

[gasdoc77]

G

Good point. It seems that employing me and requiring my procedure referrals be directed only to their ASC would be a STARK VIOLATION anyway.

I believe you are correct regarding this being a stark violation. Therefore, if and when they would try to let you go, you will have an excellent case against them to walk with a nice parting gift....startup capital for your own practice. These small wins are the only way the new guard will overcome the predatory ways of our predecessors.

 

[drusso]

G

I believe you are correct regarding this being a stark violation. Therefore, if and when they would try to let you go, you will have an excellent case against them to walk with a nice parting gift....startup capital for your own practice. These small wins are the only way the new guard will overcome the predatory ways of our predecessors.

I think that you've also got a "reasonable-ness" argument on your side if you want to stay. They can't induce you to do procedures at the ASC and pay you in a manner related to volume/bonuses, etc (and you would never suggest that they compensate you in a manner that would put either party at risk), but they could pay you 85%tile of MGMA Pain as a straight salary--no bonus, etc.

That would be high, but not off the charts. Hospitals do this all the time. This is how the employed HOPD health system docs are making $450K+ per annum and doing 60 min CESI's in the hospital OR. Site of service arbitrage. Your employers would basically be doing the same thing---shifting revenue back from the ASC facility fee into your salary. Ask them to "think like a hospital."

 

[Paindude11]

You could probaly just do a split formula and ask them for a cash sheet to break down your monthly direct expenses vs your collections. You could determine base on that. Maybe something like 60/40 collections to you after direct expenses met.

That is an idea. However, we

I think that you've also got a "reasonable-ness" argument on your side if you want to stay. They can't induce you to do procedures at the ASC and pay you in a manner related to volume/bonuses, etc (and you would never suggest that they compensate you in a manner that would put either party at risk), but they could pay you 85%tile of MGMA Pain as a straight salary--no bonus, etc.

That would be high, but not off the charts. Hospitals do this all the time. This is how the employed HOPD health system docs are making $450K+ per annum and doing 60 min CESI's in the hospital OR. Site of service arbitrage. Your employers would basically be doing the same thing---shifting revenue back from the ASC facility fee into your salary. Ask them to "think like a hospital."

Yes, thank you. I will consider this approach as well. I did in fact ask them to "think like a hospital" and apply compensation the fairest way possible based on wRVUs, but that was shot down. I think the straight salary route with caps on my procedure numbers may be my best option for the short term. I dont understand their logic here if one physician is retiring and they will obviously need someone to absorb these patients and procedure load. I just feel the current proposal is abusive and unreasonable for industry standards and needed some good, unbiased feedback. Thanks again!

 

[Dr. Ice]

I’m curious as to what others may have encountered in terms of asc buy in. Is it normal to have worked for a group for a few years, doing all cases in asc that the group owned but not be offered a share until after a period of time? I have heard some docs being offered shares right away if all volume is going there and I have heard individuals having to “prove their worthiness” only being able to buy in after a few years. Just curious

 

[drrosenrosen]

The last place I worked that owned an ASC, it was part of the partnership buy-in after 2 years. This was in Oregon about 6 years ago.

 

[unchockey21]

I’m curious as to what others may have encountered in terms of asc buy in. Is it normal to have worked for a group for a few years, doing all cases in asc that the group owned but not be offered a share until after a period of time? I have heard some docs being offered shares right away if all volume is going there and I have heard individuals having to “prove their worthiness” only being able to buy in after a few years. Just curious

Part of partnership buy in for me. 2-3 years depending on productivity. Cost for ASC portion of partnership determined by independent valuation at time of purchase. Price is for an equal share. I do less than 1/3 of my procedures in the ASC.

 

[Paindude11]

I’m curious as to what others may have encountered in terms of asc buy in. Is it normal to have worked for a group for a few years, doing all cases in asc that the group owned but not be offered a share until after a period of time? I have heard some docs being offered shares right away if all volume is going there and I have heard individuals having to “prove their worthiness” only being able to buy in after a few years. Just curious

My situation was the latter obviously, and I was on board because i did know the volume was there and knew my skills were up to par. I assumed the buy in would go smoothly and i would sail off into the sunset as a co Now that being said, I have talked to ASCs in the past that will allow you to buy in from the start. Most of these I have encountered are multispecialty as opposed to a single speciality pain one such as this. Not sure if that is the usual, but just my experience

I think that you've also got a "reasonable-ness" argument on your side if you want to stay. They can't induce you to do procedures at the ASC and pay you in a manner related to volume/bonuses, etc (and you would never suggest that they compensate you in a manner that would put either party at risk), but they could pay you 85%tile of MGMA Pain as a straight salary--no bonus, etc.

That would be high, but not off the charts. Hospitals do this all the time. This is how the employed HOPD health system docs are making $450K+ per annum and doing 60 min CESI's in the hospital OR. Site of service arbitrage. Your employers would basically be doing the same thing---shifting revenue back from the ASC facility fee into your salary. Ask them to "think like a hospital."

What is current mgma data? Mine is outdated I think.

 

[Yo GabbaPentin]

I have been with a PP group 2yrs and it is time to renegotiate in the next few months. The group is set up as a clinic LLC and an ambulatory surgicenter LLC where we do all our procedures (no other docs doing cases there). I will probably do around 1800-2000 procedures for the year doing 2 days of procedures and 2 days of clinic per week (working 4days, 80% full time). There is an in house lab and PT services. My issue is they are not willing to cut me into my procedure productivity, citing stark laws as a conflict. I proposed wRVU incentivization which the attorneys were agreeable, but then they declined (my guess after crunching the numbers). They are offering to bonus me for my clinic side collections only (and those billed under me by the Mid levels), but still expect me to be super busy and productive procedurally. Personally, I feel the clinic side is overstaffed and not very profitable, so I do not see how this projected bonus would work out. In fact, the same bonus was offered when I signed on and I never saw a dime of it. I can get benefits from my spouse, so I am willing to let the insurance go. Current salary is 350k and located in southeast. I have about 10 years experience.

Option 1: Do I try to negotiate a higher base and just punt the bonus altogether? After my experience with the bonus the 1st go around and now looking at the numbers offered for this current proposal, I dont think I would ever comfortably know how transparent the numbers would be anyway at this point.

Option 2: do I offer to 1099 for procedures only and set a daily limit? If so, what is a reasonable rate for 1099 these days?

Or do I just walk and find another group willing to incentivize for my productivity? Advice?

My opinion? GTFO. How about stop loooking for groups who want to offer table scraps and work for yourself?

 

[Paindude11]

My opinion? GTFO. How about stop loooking for groups who want to offer table scraps and work for yourself?

Thanks for the candid advice. I am already out the door unless something drastically changes, and even then I know it will not be a long term solution. I wanted to give it a fair shake since I have kids in school, spouse who works, enjoy the staff there, etc. The scenario just became an entirely different animal when I didn't buy in, yet they want me to continue to stay on generating these insane numbers without fair compensation or incentivization. I'm guessing his think tank got together and figured out what 2100+ procedures roughly translates to in an rvu model. And to be honest... I really dont have an interest in that amount of volume regardless. #burnout

 

[BobBarker]

should have worked out the buy in..,
You are making them 3-5x what they are paying you.

 

[NJPAIN]

Medicine has turned from a gentlemen's business to a shark pool. It is so so sad. We do not hesitate to eat our own.
I was driving through town yesterday with my wife. We passed countless chiropractors, dentists, podiatrists, psychologists, etc in successful solo practices. Along the way we passed several offices of the SAME large primary care morphing into a multispeciality group. I commented to my wife how sad it is that we cannot enjoy the same autonomy that these other healthcare practitioners do. These guys are flourishing and those of us outside of hospital employment or large groups are struggling to hang on. It is particularly ironic that many of these other practitioners chose those fields as a second choice to medicine. We laughed at them as rejects and now they are laughing at us and how we like idiots lost control of our profession.

 

[drusso]

Medicine has turned from a gentlemen's business to a shark pool. It is so so sad. We do not hesitate to eat our own.
I was driving through town yesterday with my wife. We passed countless chiropractors, dentists, podiatrists, psychologists, etc in successful solo practices. Along the way we passed several offices of the SAME large primary care morphing into a multispeciality group. I commented to my wife how sad it is that we cannot enjoy the same autonomy that these other healthcare practitioners do. These guys are flourishing and those of us outside of hospital employment or large groups are struggling to hang on. It is particularly ironic that many of these other practitioners chose those fields as a second choice to medicine. We laughed at them as rejects and now they are laughing at us and how we like idiots lost control of our profession.

I don't think that this has happened by accident. Instead, it has been engineered throughout the entire training process. The goal is to instill dependency and create "willing slaves" to commit themselves to an altruistic "higher calling," or to mercurial organizational missions and values.

First, pre-meds are groomed to be uber-competitive, conforming, and over-focused on obtaining a single goal. This is the first step in the weeding process. So many friends who started out "pre-med" discovered that they could be equally or more successful in other fields without the same level of bull$hit and sacrifice. They wanted to "discover," "invent," or "create" and pursued career avenues that afforded them those opportunities. Next, the medical school admission process selects for high-C (conscientious, rule followers) personality types. Then, the process literally indentures you to a form of debt bondage. Finally, you spend your 20's cloistered in hospitals and universities working 80 hours per week (or more for those cohorts like mine who trained before the work rules). Those crucially important developmental early-adult years end up being truncated--hence the reason why physicians emerge from their training in their 30's with so little real "life experience" or adult social skills and vulnerable (to hospital admins, predatory groups, seedy financial advisors selling whole life insurance policies, "doctored-approved" mortgages, etc.)

Thus, it's not surprising that most physicians end up un-moored and professionally dependent on hospital/health system employers to literally feed them and wipe their butts. That is what the goal was all along...

The epiphany for me occurred right around residency graduation when our program hosted a "Life Skills 101" or "Ready for Practice" night where a bunch or financial advisors, career coaches, real estate agents, etc came in and lectured the house-staff about "the real world." It was so bizarre. What was even worse was that many of the house-staff literally had no idea how to pick a life insurance policy or a retirement plan. Sure, they could pick a part a scientific study, but they couldn't explain the most basic financial principles or how to read an employment contract or P&L statement...And, don't get me started about the general naiveté among physicians about how politics work...that's another whole ball of yarn!

 

[Paindude11]

should have worked out the buy in..,
You are making them 3-5x what they are paying you.

I understand that. The buy in was just as insulting.

 

[Paindude11]

Medicine has turned from a gentlemen's business to a shark pool. It is so so sad. We do not hesitate to eat our own.
I was driving through town yesterday with my wife. We passed countless chiropractors, dentists, podiatrists, psychologists, etc in successful solo practices. Along the way we passed several offices of the SAME large primary care morphing into a multispeciality group. I commented to my wife how sad it is that we cannot enjoy the same autonomy that these other healthcare practitioners do. These guys are flourishing and those of us outside of hospital employment or large groups are struggling to hang on. It is particularly ironic that many of these other practitioners chose those fields as a second choice to medicine. We laughed at them as rejects and now they are laughing at us and how we like idiots lost control of our profession.

It is so true. I think DC school must be entrepreneurialism 101. Look at these "doctors" pouring through your fb feed peddling their supplements and wisdom (dr. Axe, dr Weill, etc etc.... I use the term dr loosely here). How in the hell do you get advanced nutritional training in DC school? Several DCs in the area claiming to be "pain doctors", which is actually illegal to have a licensed pain clinic in the state unless you are BC'd. It is sad. I think the biggest difference with medicine is our dependence on the man and insurers, where as these other practices exist mostly cash pay. The funny thing is that the same patient who complains about their $25 co pay in your office is the same one with dental veneers, a face full of fillers, a therapist, and goes to their chiropractor every other week for their "adjustments". Smh.

 

[Paindude11]

I don't think that this has happened by accident. Instead, it has been engineered throughout the entire training process. The goal is to instill dependency and create "willing slaves" to commit themselves to an altruistic "higher calling," or to mercurial organizational missions and values.

First, pre-meds are groomed to be uber-competitive, conforming, and over-focused on obtaining a single goal. This is the first step in the weeding process. So many friends who started out "pre-med" discovered that they could be equally or more successful in other fields without the same level of bull$hit and sacrifice. They wanted to "discover," "invent," or "create" and pursued career avenues that afforded them those opportunities. Next, the medical school admission process selects for high-C (conscientious, rule followers) personality types. Then, the process literally indentures you to a form of debt bondage. Finally, you spend your 20's cloistered in hospitals and universities working 80 hours per week (or more for those cohorts like mine who trained before the work rules). Those crucially important developmental early-adult years end up being truncated--hence the reason why physicians emerge from their training in their 30's with so little real "life experience" or adult social skills and vulnerable (to hospital admins, predatory groups, seedy financial advisors selling whole life insurance policies, "doctored-approved" mortgages, etc.)

Thus, it's not surprising that most physicians end up un-moored and professionally dependent on hospital/health system employers to literally feed them and wipe their butts. That is what the goal was all along...

The epiphany for me occurred right around residency graduation when our program hosted a "Life Skills 101" or "Ready for Practice" night where a bunch or financial advisors, career coaches, real estate agents, etc came in and lectured the house-staff about "the real world." It was so bizarre. What was even worse was that many of the house-staff literally had no idea how to pick a life insurance policy or a retirement plan. Sure, they could pick a part a scientific study, but they couldn't explain the most basic financial principles or how to read an employment contract or P&L statement...And, don't get me started about the general naiveté among physicians about how politics work...that's another whole ball of yarn!

1000000x YES to this. And dont forget the large academic centers gobbling up all the private guys/competition. Our market has been completely saturated with a pop up clinic under the academic umbrella. I guess that is easy to do when you have deep pockets and an endless supply of cheap/free labor.

 

[wmc24]

Anyone have the most recent MGMA data, northeast data in particular? Thanks.

 

[RM38]

Due to various reasons I am looking to leave my current practice and I am starting to negotiate with a practice in a different state in the SE. I have a question about where people think the bonus should kick in. Practice is a small multidisciplinary PP group with one older pain guy that is only working part time and preparing to retire. Area is not all that desirable, but there is little competition in the area and they have a several month wait for new patients, so I will be very busy. They also a very conservative with opioids so I won't be coming into a bad situation there. My family and I would live about an hour away in a very desirable area with great public schools and also where we have a lot of friends. My wife could also get her old job back which would make her happy. I am in my second year out from fellowship. Starting is 350K with no health, dental, vision or retirement, but malpractice, license and cost of 1 conference is included. Partnership is up for negotiation after 1 year. Ultimately I was thinking about asking for 35% above 900K in collections. Am I too low in this thinking or does that sound about fair? There is no onsite UDS lab or ASC to invest in as all procedures are done in office. They do own their own building that has around 10000 sq ft and they rent the downstairs out to another practice. Other docs seem very friendly and thought I would get along well with them.

 

[lobelsteve]

50% over 750k

 

[jsaul]

I understand that. The buy in was just as insulting.

So about how much was this buy in to the practice ?

Also what are most of you paying for buy in per share for ASCs nowadays

 

[clubdeac]

Not to toot my own horn but I was doing about 2400-2500 procedures/year at the VA. Just left to do that same volume but get paid for it