Help with contract specifics

[Jack Donaghy]

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2 year base of 250k.
wRVU after than, but it looks like they have a "total allowable payment" of 75%ile of your specialty.. they decided that would be 315k for FM.
non-compete that is 1 year and 10 miles of your office location.
giant medical group with a million offices but plenty of large-ish private practices in the area.

questions:
is it insane that they cap your pay at 315k?
if I sign a non-compete, is it enforceable? like what happens if I leave and join another practice down the road immediately?
is this too sour a deal to take?

more details: current resident, non-negotiable on wanting to live in that city, private practices haven't really been good about getting back to me with specifics or offers or even talking on the phone so this is sort of my only option at the moment at least

 

[VA Hopeful Dr]

My hospital used to do that, but it was capped at 400k 4 years ago. 3 years ago they did away with that. I think a cap at 315k is ridiculous personally, but if you know the maximum you can make then work just hard enough to hit that point. Makes for a much more relaxing work day.

Non-compete enforcement is state dependent. 1 year and 10 miles is pretty mild as non-competes go. Not every employer decides to enforce them anyway, but you won't know that until you test it.

Need more details to know about the overall deal:

- wRVU rate
- Hours/week you have to see patients
- How are days off managed

That would help.

 

[Jack Donaghy]

My hospital used to do that, but it was capped at 400k 4 years ago. 3 years ago they did away with that. I think a cap at 315k is ridiculous personally, but if you know the maximum you can make then work just hard enough to hit that point. Makes for a much more relaxing work day.

Non-compete enforcement is state dependent. 1 year and 10 miles is pretty mild as non-competes go. Not every employer decides to enforce them anyway, but you won't know that until you test it.

Need more details to know about the overall deal:

- wRVU rate
- Hours/week you have to see patients
- How are days off managed

That would help.

Thanks for your reply.

-wRVU is $41 per, with various quality incentives that raises it either to $42 or $45 per wRVU. This whole structure confuses me but it seems an average of $43 per wRVU is to be expected / don't expect more than 43. For reference, no one in my residency has signed for less than $47 per wRVU so I'm already weary of this rate.
-36 hours minimum patient contact time per week and 4 hours minimum in office admin time (charting, etc). So 40 hours per week - each office is flexible as far as 5 8's vs 4 10's.
-35 days off per year total allowed for vacation, CME, holidays, etc.

It definitely seems like a bad deal but sadly for me, I was a quick draw and already signed with them for that sweet, sweet residency stipend. Obviously I could pay back what I've already received, but the money does make a big difference in my life currently. It's the non-compete that I'm really worried about because I would just quit after 3 years and work for a private group nearby, but I just don't want to be limited by their 10 mile rule. Maybe I'm overthinking it, but that's where I'm at.

 

[VA Hopeful Dr]

Thanks for your reply.

-wRVU is $41 per, with various quality incentives that raises it either to $42 or $45 per wRVU. This whole structure confuses me but it seems an average of $43 per wRVU is to be expected / don't expect more than 43. For reference, no one in my residency has signed for less than $47 per wRVU so I'm already weary of this rate.
-36 hours minimum patient contact time per week and 4 hours minimum in office admin time (charting, etc). So 40 hours per week - each office is flexible as far as 5 8's vs 4 10's.
-35 days off per year total allowed for vacation, CME, holidays, etc.

It definitely seems like a bad deal but sadly for me, I was a quick draw and already signed with them for that sweet, sweet residency stipend. Obviously I could pay back what I've already received, but the money does make a big difference in my life currently. It's the non-compete that I'm really worried about because I would just quit after 3 years and work for a private group nearby, but I just don't want to be limited by their 10 mile rule. Maybe I'm overthinking it, but that's where I'm at.

So if we assume that they are actually strict about the hours and days off, this job sounds awful. You have to spend 40 hours in the office each week and are limited to around 7-8 patients per half day unless you like working and not getting paid for it.

If they don't actually mind if you take longer lunches, arrive late, leave early then it wouldn't be too bad. Or if you can take time off as you like so long as you earn what they're paying you.

 

[Vandalia]

The FTC is actually considering a rule change right now that outlaws non competes. Theoretically this only applies to the private sector (i.e. for-profit groups) but I suspect the nonprofit sector would follow suit soon after if it goes through.

A 10 mile noncompete seems pretty non-onerous to me but it depends where you are. 10 miles is a 10 minute drive for me in the rural area where I'll be practicing (and my noncompete is 30 miles/18mo for comparison), it could be an hour in a major city. If you think you might leave, be conscious of where you decide to live in comparison to your office location. Would you be willing to do locums or telehealth or something until the year is up? You can also talk to a contract lawyer and see how enforceable the noncompete actually is based on your local/state laws and regulations.

One point to keep in mind is that with or without a non compete provision, there is a separate tort if you steal business (I.e. patients) from your previous employer. That exists whether or not non compete clauses are enforceable in the employment contract.

For most specialties this is pretty much impossible in that anesthesiology, EM, pathology the physician doesn’t have any patients that can be stolen. However, family medicine is probably the one specialty where it could happen.

So if you do move two miles down the road you need to be careful when your old patients show up. Specifically make sure they can’t accuse you of actively recruiting them for your new practice while you worked for the old.

 

[FrustratedFamDoc]

$315,000 and you have complete control over your schedule… cheesy but not a 100% deal breaker.

$315,000 max and 0.00% autonomy for your schedule or work hours? Let’s walk through this one.

So quick math: say you see 100 patients a week for 48 weeks = 4800 patients on the year.

100 patients in a 4.5 day week is 22.2/day
RVU per patient maybe 1.6-7 ish.
1.6 gets you 7680 RVU
1.7 gets you 8160 RVU

7680 RVU x $41 = $314,880
8160 RVU x $41 = $334,560

This is also before quality/performance bonuses are awarded.

What is the compensation for an NP that they may be able to force on you?

Schedule control is now the way corporate medicine operates.

If you have 3 work in double books a day forced on you, it’s not 38 patient contact hours to you, but it is to them. See, it’s not really ‘patient contact hours’ at all. It’s forcing you to be in office 4.5 days a week seeing whomever they put on your schedule.

If you don’t take your maximum time off allotted for the year, you could easily exceed your RVU to meet your max allowed salary. 100 patients a week could become 110 a week

110 x 48 weeks = 5280 patients/yr
5280 patients x 1.6 RVU = 8448
8448 x $41 = $346,368

You’ll be a brand new attending with a brand new patient panel. They are a giant system, which means they have a ton of patients, and providers with full panels and full schedules. Their patients will need to be worked in frequently for ‘acute’ visits. Patients are also allowed to book their own visits now through the app, directly on to your schedule.

“Hey, where the hell did that 2:15 new patient double book come from??” “I’ve already got a hospital follow up scheduled at 2:45.” Game over for that afternoon because you also have a new patient booked at 3:30. Call your wife and let her know you’re running late again and you’ll try to be at your kid’s ball game before halftime. Pro tip: Don’t you dare take your laptop home.

Are there any currently older ‘don’t have to take this ish anymore’ attendings? There may all of a sudden be 3,000 patients who need a new doc, asap. Med refills on patients whom you’ve never even seen? Enjoy that one.

Could they be nice to you and not crush you with what I just said? Sure they could, but you are putting the cards in their hand.

Now if they are willing to pay you the full compensation for the RVU you’re generating? Ok, fair enough, but you are trusting them to do what’s right.

Control, and who gets it is the new game. If they own your schedule and how long you have to be in office, and force NP oversight on you… they own you. At least it’s only a 10 mile noncompete. That’s pretty awesome for you, but how much guaranteed salary are you on the hook to pay back if you leave?

Ask to do a walk through of the offices during business hours. Are all of the staff in the back in haul ass mode? Observe staff faces. “Do you like it here?” Will get you nowhere. Do you hear them doing 200 mouse clicks just to triage 1 patient? Do the MAs have several huge stacks of papers on their desks (guess where all of that is going to end up eventually)? How backed up is the waiting room at 10 am? Do the patients appear frustrated? How many rooms are still waiting to be seen for each provider?

I may edit and add more as it comes to me but I’m out of coffee right now.

Trust me on this.

 

[Appellatelove]

$315,000 and you have complete control over your schedule… cheesy but not a 100% deal breaker.

$315,000 max and 0.00% autonomy for your schedule or work hours? Let’s walk through this one.

So quick math: say you see 100 patients a week for 48 weeks = 4800 patients on the year.

100 patients in a 4.5 day week is 22.2/day
RVU per patient maybe 1.6-7 ish.
1.6 gets you 7680 RVU
1.7 gets you 8160 RVU

7680 RVU x $41 = $314,880
8160 RVU x $41 = $334,560

This is also before quality/performance bonuses are awarded.

What is the compensation for an NP that they may be able to force on you?

Schedule control is now the way corporate medicine operates.

If you have 3 work in double books a day forced on you, it’s not 38 patient contact hours to you, but it is to them. See, it’s not really ‘patient contact hours’ at all. It’s forcing you to be in office 4.5 days a week seeing whomever they put on your schedule.

If you don’t take your maximum time off allotted for the year, you could easily exceed your RVU to meet your max allowed salary. 100 patients a week could become 110 a week

110 x 48 weeks = 5280 patients/yr
5280 patients x 1.6 RVU = 8448
8448 x $41 = $346,368

You’ll be a brand new attending with a brand new patient panel. They are a giant system, which means they have a ton of patients, and providers with full panels and full schedules. Their patients will need to be worked in frequently for ‘acute’ visits. Patients are also allowed to book their own visits now through the app, directly on to your schedule.

“Hey, where the hell did that 2:15 new patient double book come from??” “I’ve already got a hospital follow up scheduled at 2:45.” Game over for that afternoon because you also have a new patient booked at 3:30. Call your wife and let her know you’re running late again and you’ll try to be at your kid’s ball game before halftime. Pro tip: Don’t you dare take your laptop home.

Are there any currently older ‘don’t have to take this ish anymore’ attendings? There may all of a sudden be 3,000 patients who need a new doc, asap. Med refills on patients whom you’ve never even seen? Enjoy that one.

Could they be nice to you and not crush you with what I just said? Sure they could, but you are putting the cards in their hand.

Now if they are willing to pay you the full compensation for the RVU you’re generating? Ok, fair enough, but you are trusting them to do what’s right.

Control, and who gets it is the new game. If they own your schedule and how long you have to be in office, and force NP oversight on you… they own you. At least it’s only a 10 mile noncompete. That’s pretty awesome for you, but how much guaranteed salary are you on the hook to pay back if you leave?

Ask to do a walk through of the offices during business hours. Are all of the staff in the back in haul ass mode? Observe staff faces. “Do you like it here?” Will get you nowhere. Do you hear them doing 200 mouse clicks just to triage 1 patient? Do the MAs have several huge stacks of papers on their desks (guess where all of that is going to end up eventually)? How backed up is the waiting room at 10 am? Do the patients appear frustrated? How many rooms are still waiting to be seen for each provider?

I may edit and add more as it comes to me but I’m out of coffee right now.

Trust me on this.

How can you prevent this from happening? Any ways to work no double bookings into contract?

 

[VA Hopeful Dr]

How can you prevent this from happening? Any ways to work no double bookings into contract?

This sort of thing is rarely put into writing. What you want is an employer that lets you have control of your schedule.

 

[NeuroticByN8ure]

$315,000 and you have complete control over your schedule… cheesy but not a 100% deal breaker.

$315,000 max and 0.00% autonomy for your schedule or work hours? Let’s walk through this one.

So quick math: say you see 100 patients a week for 48 weeks = 4800 patients on the year.

100 patients in a 4.5 day week is 22.2/day
RVU per patient maybe 1.6-7 ish.
1.6 gets you 7680 RVU
1.7 gets you 8160 RVU

7680 RVU x $41 = $314,880
8160 RVU x $41 = $334,560

This is also before quality/performance bonuses are awarded.

What is the compensation for an NP that they may be able to force on you?

Schedule control is now the way corporate medicine operates.

If you have 3 work in double books a day forced on you, it’s not 38 patient contact hours to you, but it is to them. See, it’s not really ‘patient contact hours’ at all. It’s forcing you to be in office 4.5 days a week seeing whomever they put on your schedule.

If you don’t take your maximum time off allotted for the year, you could easily exceed your RVU to meet your max allowed salary. 100 patients a week could become 110 a week

110 x 48 weeks = 5280 patients/yr
5280 patients x 1.6 RVU = 8448
8448 x $41 = $346,368

You’ll be a brand new attending with a brand new patient panel. They are a giant system, which means they have a ton of patients, and providers with full panels and full schedules. Their patients will need to be worked in frequently for ‘acute’ visits. Patients are also allowed to book their own visits now through the app, directly on to your schedule.

“Hey, where the hell did that 2:15 new patient double book come from??” “I’ve already got a hospital follow up scheduled at 2:45.” Game over for that afternoon because you also have a new patient booked at 3:30. Call your wife and let her know you’re running late again and you’ll try to be at your kid’s ball game before halftime. Pro tip: Don’t you dare take your laptop home.

Are there any currently older ‘don’t have to take this ish anymore’ attendings? There may all of a sudden be 3,000 patients who need a new doc, asap. Med refills on patients whom you’ve never even seen? Enjoy that one.

Could they be nice to you and not crush you with what I just said? Sure they could, but you are putting the cards in their hand.

Now if they are willing to pay you the full compensation for the RVU you’re generating? Ok, fair enough, but you are trusting them to do what’s right.

Control, and who gets it is the new game. If they own your schedule and how long you have to be in office, and force NP oversight on you… they own you. At least it’s only a 10 mile noncompete. That’s pretty awesome for you, but how much guaranteed salary are you on the hook to pay back if you leave?

Ask to do a walk through of the offices during business hours. Are all of the staff in the back in haul ass mode? Observe staff faces. “Do you like it here?” Will get you nowhere. Do you hear them doing 200 mouse clicks just to triage 1 patient? Do the MAs have several huge stacks of papers on their desks (guess where all of that is going to end up eventually)? How backed up is the waiting room at 10 am? Do the patients appear frustrated? How many rooms are still waiting to be seen for each provider?

I may edit and add more as it comes to me but I’m out of coffee right now.

Trust me on this.

Trust him/her on this.

I left my hospital-owned job, and due to my noncompete, I had to work part-time all of 2021 in order to balance being away from my family (2 young kids and my wife works full-time) and the need to make income. It sucked emotionally and financially for all of us because I made the mistake of not asking the questions posed by FrustratedFamilyDoc. I also wish I asked the additional questions:

1. What is your PCP's average patient panel size?
2. Who decides when I can close my patient panel, and what metrics do I need to meet to do this?

I was stuck establishing care for patients, and I wasn't able to get them in for follow up for their uncontrolled HTN/DMII and X,Y,Z random complaints for 4-5 months. When patients got sick, we didn't have any acute slots, so they would go to our hospitals ED, where they would get a CT scan for a tummy ache and the hospital could maximize their revenue. My job was to keep establishing patients to help generate more referrals, hospitalizations and ED visits for my local hospital. It took a while for me to understand this, because I was able to see my patients back and get them in when I first started working.

I understand that I was naive in my approach to my first job, but I'm still baffled by how blind I was. In retrospect, it makes sense that hospital systems would employ these tactics, as it maximizes revenue for this "non-profit." Do most people just understand this intuitively, and that's why most residents aren't coached explicitly about this?

Any resident (or attending) interested in learning about how to avoid my blunders, please feel free to DM me.

 

[VenusinFurs]

I don't like noncompetes in general. I'm doing locums now so I have to sign specific ones for those companies, but generally speaking I think it is a very bad thing. (Locums companies all seem to have a boilerplate noncompete that states you will not contract with any of their clients for the next two years without going through them).

 

[Sardonix]

The FTC is actually considering a rule change right now that outlaws non competes. Theoretically this only applies to the private sector (i.e. for-profit groups) but I suspect the nonprofit sector would follow suit soon after if it goes through.

A 10 mile noncompete seems pretty non-onerous to me but it depends where you are. 10 miles is a 10 minute drive for me in the rural area where I'll be practicing (and my noncompete is 30 miles/18mo for comparison), it could be an hour in a major city. If you think you might leave, be conscious of where you decide to live in comparison to your office location. Would you be willing to do locums or telehealth or something until the year is up? You can also talk to a contract lawyer and see how enforceable the noncompete actually is based on your local/state laws and regulations.

Don't worry, the AHA is hard at work lobbying to make an exception to physicians so that non-competes can still be allowed. Why? Because.

 

[cj_cregg]

Don't worry, the AHA is hard at work lobbying to make an exception to physicians so that non-competes can still be allowed. Why? Because.

My current hospital system actually sent out an email from executive leadership to all employees encouraging them to advocate against the adoption of this rule as well as a similar state law. Not a peep from them when our newly elected local government officials started stripping away existing funding/resources for mental health services, pregnancy support/care, and essential health department functions. Lol.

 

[Cranjis McBasketball]

Arent non-competes dependent on the state you're in? I know for my home state they are not enforceable at all. Companies wont vocalize that, of course.

 

[cj_cregg]

Arent non-competes dependent on the state you're in? I know for my home state they are not enforceable at all. Companies wont vocalize that, of course.

Yes, there are some state laws that affect whether noncompetes are permitted/enforceable.

 

[Sardonix]

My current hospital system actually sent out an email from executive leadership to all employees encouraging them to advocate against the adoption of this rule as well as a similar state law. Not a peep from them when our newly elected local government officials started stripping away existing funding/resources for mental health services, pregnancy support/care, and essential health department functions. Lol.

Man, that is even more tone deaf than getting an (unblockable) email from the VP of Window Dressing Projects (salary likely +$300k) asking employees to donate to whatever garden/wing/courtyard they have going on. It's really astounding that they use the argument of, "This is a bad idea... Physicians should be exempt because, well, yeah, we don't like the idea of them not being exempt."

Arent non-competes dependent on the state you're in? I know for my home state they are not enforceable at all. Companies wont vocalize that, of course.

They are very state and contract dependent. And like you said, companies probably know it. But they also know doctors are easily exploited people pleasers who like to follow rules. It's more the threat of using the contract against a physician and the POTENTIAL legal/financial headache it would cause that is the deterrent.

 

[cabinbuilder]

The bad thing about contracts is they can always fire you at anytime they want if you don't do what they want you to do or you complain too much. On the flip side there should be a clause in there about (irreconcilable differences) so you can part ways. Learned that the hard way many times and that's how I ended up doing locums for so long. Been at my current job for 7 years. I don't send emails, I don't complain, I don't let them have anything in writing. I go to work, I see the patients, I go home. I'm in urgent care, I have seen as little at 24 in a 12 hour shift and I have the record at 100. The trick is being in a contract that is acceptable for your monetary needs and your lifestyle. Always have a back up plan (more than one state license, savings in the bank if you have to pay back sign-on or tail coverage) so if you need to throw down the gauntlet and quit, you can. I had to do that about 2 years ago when they fired my colleague about being too vocal and writing emails about virtual visits. I was vocal too, just not in any way they could track me and prove it. I called my boss and told him I was giving 2 weeks notice because I don't agree with virtual visits in urgent care and it was never discussed with us and we see the most volume. Some director of virtual just shows up in clinic one day to install cameras and telling me that "oh, you didn't get the memo?". So I gave my 2 weeks, they back pedaled real quick since I see the most patients of all the providers and we are 3 doctors short. They leave me alone now. Its best to have the upper hand.

 

[Vandalia]

This is an important point to remember: "Noncompetes" may or may not be enforceable, or there may be restrictions on them in certain jurisdictions.

However, even where "noncompetes" do not exist, it is still a tort to "steal" business from a previous employer. (I use that term in a nontechnical sense.)

So if you move down the road, and any of your old patients follow you, your previous employer can still sue you for that. Whether they will win or not depends on the specific details.