Hospitalist gig opinion

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JohnTraylor

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Was wondering what you all thought about this offer I am about to take. First gig out of residency here.

Location : Eastern desirable coastal city

Hospital : Nice Community Hospital

Shifts : Flexible (15-20 depending on how much you want to work) and no nights (big deal for me as I hate nights especially with family)

Compensation : Strictly production based as an independent contractor (you get to keep 80% of net collections). You pay your own benefits/insurances as an IC. Uninsured rates are reportedly <2% of overall billing as mainly upper class community. Quality bonus of 30k yearly (reportedly everyone attains this)

Structure: 15+ hospitalists in group, group is physician owned that subcontracts with hospital. People I met with seemed pretty happy. Not responsible for codes/procedures. Can leave hospital when work is done with.
 
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Sounds scary. You might have decent upside but your downside is huge.

I guess with that many in the group you have a general sense of how much they each tend to make.
 
Don’t underestimate how much benefits costs. My Employee roughly provides 6-7k in health insurance premiums, 8-10k in 401k Match, 20-25k in annual/PTO, plus malpractice. It adds up quickly. Will you be an employee or contractor as that makes difference with taxes.
 
Doc_Mcstuffins said:
Don’t underestimate how much benefits costs. My Employee roughly provides 6-7k in health insurance premiums, 8-10k in 401k Match, 20-25k in annual/PTO, plus malpractice. It adds up quickly. Will you be an employee or contractor as that makes difference with taxes.
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Indepent contractor so can obviously write off all benefits but still... the other employer’s in town were either national hospitalist groups or hospital employees and I am trying to avoid corporate medicine if possible.
 
Mama 2016 average rvu for hospitalist was 4500. If you get 100% collections (unrealistic) and a rate of 80 per wrvu (good pay or mix, not sure if this us realistic for your area), then 80% of that is 288000. You'll owe both halves of fica as well.

Even with deductions you'll be paying a lot for benefits too. Many Hospitalists are subsidized by hospitals because e/m billing makes them underperform their salary demand but they make up for it in opening beds and keeping the hospital full/open. You'll learn to hate the absolute **** e/m billing system for inpatients if your income relies so heavily on it. Especially new out of residency this seems like a lot of salary risk while you learn how to code, document, and manage patients independently.
 
chessknt87 said:
Mama 2016 average rvu for hospitalist was 4500. If you get 100% collections (unrealistic) and a rate of 80 per wrvu (good pay or mix, not sure if this us realistic for your area), then 80% of that is 288000. You'll owe both halves of fica as well.

Even with deductions you'll be paying a lot for benefits too. Many Hospitalists are subsidized by hospitals because e/m billing makes them underperform their salary demand but they make up for it in opening beds and keeping the hospital full/open. You'll learn to hate the absolute **** e/m billing system for inpatients if your income relies so heavily on it. Especially new out of residency this seems like a lot of salary risk while you learn how to code, document, and manage patients independently.
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This is exactly right. You also have value above and beyond what you actually bill. Even if you are not admitting the hospital can't be open without you there.

Your contract is a great deal for the hospital as there is zero downside for them. They have no risk as you are essentially free labor that they no matter what will make money on.
 
chessknt87 said:
Mama 2016 average rvu for hospitalist was 4500. If you get 100% collections (unrealistic) and a rate of 80 per wrvu (good pay or mix, not sure if this us realistic for your area), then 80% of that is 288000. You'll owe both halves of fica as well.

Even with deductions you'll be paying a lot for benefits too. Many Hospitalists are subsidized by hospitals because e/m billing makes them underperform their salary demand but they make up for it in opening beds and keeping the hospital full/open. You'll learn to hate the absolute **** e/m billing system for inpatients if your income relies so heavily on it. Especially new out of residency this seems like a lot of salary risk while you learn how to code, document, and manage patients independently.
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Thank you all for your helpful responses.

Quick question, don’t those surveys (e.g. MGMA) also include benefits in there wRVU/salary numbers? I feel like some of those salary numbers are overinflated based on offers i’ve been seeing.
 
JohnTraylor said:
Was wondering what you all thought about this offer I am about to take. First gig out of residency here.

Location : Eastern desirable coastal city

Hospital : Nice Community Hospital

Shifts : Flexible (15-20 depending on how much you want to work) and no nights (big deal for me as I hate nights especially with family)

Compensation : Strictly production based as an independent contractor (you get to keep 80% of net collections). You pay your own benefits/insurances as an IC. Uninsured rates are reportedly <2% of overall billing as mainly upper class community. Quality bonus of 30k yearly (reportedly everyone attains this)

Structure: 15+ hospitalists in group, group is physician owned that subcontracts with hospital. People I met with seemed pretty happy. Not responsible for codes/procedures. Can leave hospital when work is done with.
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Did the employer give you an estimate of what the median net collections is for a hospitalist? Focus on median number as I have heard places that gives wrvu bonuses for hospitalists who work 5-10 extra shifts per month compared to average hospitalist to give applicants false impression? More importantly, have you heard a quote number from other hospitalists in the group and how does that compare to the median salary in you area? If the quoted salary plus all benefits costs plus extra money to make up higher tax burden as independent contractor is not considerably higher since you are assuming a lot more of risk (no guaranteed base salary) than more traditional models of payment, I would think twice in taking the job. Of course, you need to decide how much “considerably higher” is but with a family, I would think a guaranteed, more traditional salary is better than the proposed model.
 
"Uncle Albert, post: 19575432, member: 634877"]270k I believe

So just to clarify this includes all salary, bonuses, productivity and benefit package?
 
Doc_Mcstuffins said:
Did the employer give you an estimate of what the median net collections is for a hospitalist? Focus on median number as I have heard places that gives wrvu bonuses for hospitalists who work 5-10 extra shifts per month compared to average hospitalist to give applicants false impression? More importantly, have you heard a quote number from other hospitalists in the group and how does that compare to the median salary in you area? If the quoted salary plus all benefits costs plus extra money to make up higher tax burden as independent contractor is not considerably higher since you are assuming a lot more of risk (no guaranteed base salary) than more traditional models of payment, I would think twice in taking the job. Of course, you need to decide how much “considerably higher” is but with a family, I would think a guaranteed, more traditional salary is better than the proposed model.
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I spoke to one or two of them and they said they take home gross anywhere between 300-350k. But I didnt ask how many shifts that constitutes. One guy reportedly making 400k was working like 20+ shifts a month.
 
JohnTraylor said:
I spoke to one or two of them and they said they take home gross anywhere between 300-350k. But I didnt ask how many shifts that constitutes. One guy reportedly making 400k was working like 20+ shifts a month.
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What is a "take home gross"? Are these guys not paying taxes?
 
JohnTraylor said:
I spoke to one or two of them and they said they take home gross anywhere between 300-350k. But I didnt ask how many shifts that constitutes. One guy reportedly making 400k was working like 20+ shifts a month.
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Try not to focus on how much the guy working 20+ shifts a month is making as I assume that’s not the average number of shifts each person actually works. It’s an outlier that shouldn’t influence your decision unless you plan on working that much.

I remember at one program, the director quoted me that one guy makes over 450k a year. Turns out he works 25 shifts a year and has no family or friends in this county. Cool fact but not representative of actual salary numbers or helpful to me at that time.

My recommendation if you truly want an apples to apples comparison: is take the 300-350k pre-tax expected income subtract all the benefits (401k match, health insurance premium paid usually by employee, disability insurance, malpractice insurance, salary for pto/sick/annual, etc.) that you’d get as an employee but won’t get as contractor, subtract out difference in taxes since you’ll be paying higher taxes as contractor and see how the two take Home pays compare.

Lastly, I see your hesitation to join National hospitalist companies but why against joining multi speciality practice like hospital employees group? I’ve had much better experience with them.
 
Doc_Mcstuffins said:
Try not to focus on how much the guy working 20+ shifts a month is making as I assume that’s not the average number of shifts each person actually works. It’s an outlier that shouldn’t influence your decision unless you plan on working that much.

I remember at one program, the director quoted me that one guy makes over 450k a year. Turns out he works 25 shifts a year and has no family or friends in this county. Cool fact but not representative of actual salary numbers or helpful to me at that time.

My recommendation if you truly want an apples to apples comparison: is take the 300-350k pre-tax expected income subtract all the benefits (401k match, health insurance premium paid usually by employee, disability insurance, malpractice insurance, salary for pto/sick/annual, etc.) that you’d get as an employee but won’t get as contractor, subtract out difference in taxes since you’ll be paying higher taxes as contractor and see how the two take Home pays compare.

Lastly, I see your hesitation to join National hospitalist companies but why against joining multi speciality practice like hospital employees group? I’ve had much better experience with them.
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Thank you for your assistance here!

Sorry for this stupid question but how much higher is IC taxes vs salaried? My understanding was since you are able to deduct so much more you can potentially lower your tax bill or have about the same you’d pay if salaried?
 
JohnTraylor said:
Thank you for your assistance here!

Sorry for this stupid question but how much higher is IC taxes vs salaried? My understanding was since you are able to deduct so much more you can potentially lower your tax bill or have about the same you’d pay if salaried?
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You pay about another 6.2% fica, sometimes other stuff deplending on state unemployment insurance laws. It is true you can deduct all kinds of stuff like car insurance, mileage, home office etc but it has to be enough to make up that 6.2%. You can deduct benefits paid too.

What you need to do is get a competing offer in the same area salaried with benefits to do a true comparison. You are basically assuming all the risk and giving these guys 20% for overhead (which is probably a bit high). This group may be getting a subsidy from the hospital to keep it open So it would be interesting to see how this is utilized since none of it is going to overhead. Since nobody offered your partner I would make the assumption you are getting bent over by the group owners and pass.
 
chessknt87 said:
You pay about another 6.2% fica, sometimes other stuff deplending on state unemployment insurance laws. It is true you can deduct all kinds of stuff like car insurance, mileage, home office etc but it has to be enough to make up that 6.2%. You can deduct benefits paid too.

What you need to do is get a competing offer in the same area salaried with benefits to do a true comparison. You are basically assuming all the risk and giving these guys 20% for overhead (which is probably a bit high). This group may be getting a subsidy from the hospital to keep it open So it would be interesting to see how this is utilized since none of it is going to overhead. Since nobody offered your partner I would make the assumption you are getting bent over by the group owners and pass.
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Thank you for the info!

So I got an offer from the other hospital corporation that employees its own hospitalists and the starting salary was 200k with full benefits (401k match up to 4% I believe, health, dental, malpractice, CME) with minimum 16 shifts (including two nights per month where you cover rapid responses and codes..bleh). Pay per extra shifts were well below market value.
 
JohnTraylor said:
Thank you for the info!

So I got an offer from the other hospital corporation that employees its own hospitalists and the starting salary was 200k with full benefits (401k match up to 4% I believe, health, dental, malpractice, CME) with minimum 16 shifts (including two nights per month where you cover rapid responses and codes..bleh). Pay per extra shifts were well below market value.
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200k (including bonus?) with 16 shifts in major east coast city is low offer. I am very familiar with the hospitalist market for one of the more costly (lower paying) cities on east coast (may not be your desired city) and good non academic hospital owned groups are usually starting fresh out of residency around 215-240k including bonus and within 2-3 years, that usually goes up by 15-20k. Usually 7 on/7 off so around 15.5 shifts and usually no to 1 night a month. Would recommend you keep looking and at least see what else is out there in terms of employer jobs.
 
Doc_Mcstuffins said:
200k (including bonus?) with 16 shifts in major east coast city is low offer. I am very familiar with the hospitalist market for one of the more costly (lower paying) cities on east coast (may not be your desired city) and good non academic hospital owned groups are usually starting fresh out of residency around 215-240k including bonus and within 2-3 years, that usually goes up by 15-20k. Usually 7 on/7 off so around 15.5 shifts and usually no to 1 night a month. Would recommend you keep looking and at least see what else is out there in terms of employer jobs.
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No sorry, bonus is 20k based off quality.

The not having to do any nights is the big sell for me on the IC side.
 
JohnTraylor said:
Non-compete is very reasonable. Thanks!
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Define "very reasonable".

For the job you first described, anything further than "you can throw a rock and break another hospital CEOs corner office window" or a time frame longer than it will take you to drive to the other hospital during rush hour, is a screw job and completely unreasonable.

Also, the concept of a non-compete for a hospitalist is laughable. The whole point of a non-compete is to keep you from packing up your patient panel and taking them all somewhere else. How is that relevant for a hospitalist (or EM doc for that matter)? "Thanks for coming to University Hospital for your CHF exacerbation. Next time you feel like you're drowning in your own breath, be sure to tell 911 to take you to Community General instead."
 
gutonc said:
Define "very reasonable".

For the job you first described, anything further than "you can throw a rock and break another hospital CEOs corner office window" or a time frame longer than it will take you to drive to the other hospital during rush hour, is a screw job and completely unreasonable.

Also, the concept of a non-compete for a hospitalist is laughable. The whole point of a non-compete is to keep you from packing up your patient panel and taking them all somewhere else. How is that relevant for a hospitalist (or EM doc for that matter)? "Thanks for coming to University Hospital for your CHF exacerbation. Next time you feel like you're drowning in your own breath, be sure to tell 911 to take you to Community General instead."
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Non-compete for the IC gig is non-existent.

10 miles for the salaried gig.

I agree it is ridiculous.
 
JohnTraylor said:
Was wondering what you all thought about this offer I am about to take. First gig out of residency here.

Location : Eastern desirable coastal city

Hospital : Nice Community Hospital

Shifts : Flexible (15-20 depending on how much you want to work) and no nights (big deal for me as I hate nights especially with family)

Compensation : Strictly production based as an independent contractor (you get to keep 80% of net collections). You pay your own benefits/insurances as an IC. Uninsured rates are reportedly <2% of overall billing as mainly upper class community. Quality bonus of 30k yearly (reportedly everyone attains this)

Structure: 15+ hospitalists in group, group is physician owned that subcontracts with hospital. People I met with seemed pretty happy. Not responsible for codes/procedures. Can leave hospital when work is done with.
Click to expand...

So I came across one of these groups in my search for a job close to home. I forget the %, but it was all based on what I billed for. They informed me that one of the other docs was making ~300K while doing "part time."

In short, I was going to be expected to see 30-40 a day. I would absolutely have been PAID. But If I go to any hospital and see 30-40 a day, I get PAID. That's a lot of work. A lot more than "normal." The people I interviewed with that worked as hospitalists for the group seemed happy. And when you inquired as to how they saw so many..."Well, the ones in the unit we consult critical care and they manage the patient. The heart patients, cardiology basically does everything." You don't want to come out of residency and let other doctors do all the doctoring.

The flip-side is what if you aren't seeing a lot of patients. It makes sense that if they don't have a lot of patients, they won't have a lot of doctors working at a given time. But if everything is only production based, there is no downside.

TL;DR--be skeptical
 
jm192 said:
So I came across one of these groups in my search for a job close to home. I forget the %, but it was all based on what I billed for. They informed me that one of the other docs was making ~300K while doing "part time."

In short, I was going to be expected to see 30-40 a day. I would absolutely have been PAID. But If I go to any hospital and see 30-40 a day, I get PAID. That's a lot of work. A lot more than "normal." The people I interviewed with that worked as hospitalists for the group seemed happy. And when you inquired as to how they saw so many..."Well, the ones in the unit we consult critical care and they manage the patient. The heart patients, cardiology basically does everything." You don't want to come out of residency and let other doctors do all the doctoring.

The flip-side is what if you aren't seeing a lot of patients. It makes sense that if they don't have a lot of patients, they won't have a lot of doctors working at a given time. But if everything is only production based, there is no downside.

TL;DR--be skeptical
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30- 40 pts per day as a hospitalist??!! Waaay too many pts...that is just not safe.
 
rokshana said:
30- 40 pts per day as a hospitalist??!! Waaay too many pts...that is just not safe.
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Yeah. At the point we're talking numbers, it was the CEO and his assistant. The assistant says "Think about how much you could make though." I bit my tongue, but my first thought "How long does it take for me to get sued though."

My current gig we run close to 20-22 with 2-3 admits. At it's craziest I've seen 28 in a day.
 
The high census model maximizes charge capture through consultation while keeping the line item expense of hospitalist to a minimum. Ideal scenario for any hospital but for the people in the trenches not so much, even with a mid level of good quality.

At the same time smaller hospittals often have to pull shenanigans like this to stay afloat in a world of declining reimbursement for bundled care, increasing regulation, and bloated admin salaries
 
You can always do a salaried spot without nights and moonlight outside a few days with time off, just make sure to get that ability to moonlight added in your contract. That way, you're getting your benefits and making extra somewhere that probably pays more per hour but might not be sustainable to work at 14 shifts a month. Some places have swing shifts from like 3pm to 10pm that can pay as much as a day shift and those are a good supplement. If you get an extra 3 shifts a month at 1500 a shift then you're looking at over 50k gross and you're still averaging less than 20 shifts a month.
 
Anything over 20 patients a day is unsustainable, unreasonable, and a recipe for disaster. You will make enough money regardless. Don't risk your wellbeing and your license chasing money.

$200k is low pay for a hospitalist anywhere. You make more than that as a primary care doctor.

Open ICU - Nice for the intensivist (less paperwork), sucks for the hospitalist. You are an internist, not CC.

Consult away when you have a doubt. Make your life easier, keep everybody happy. The allure of doing everything for the patient quickly wears off in favor of expediency and making things manageable for yourself.

Try to have the non compete clause removed. Understand the definition as well. Is it ten miles from the hospital alone or ten miles from any hospital owned facility? In some cases, the latter will put you out of the city due to many satellite clinics.

$200k is low. I can't stress that enough.
 
PlutoBoy said:
Anything over 20 patients a day is unsustainable, unreasonable, and a recipe for disaster. You will make enough money regardless. Don't risk your wellbeing and your license chasing money.

$200k is low pay for a hospitalist anywhere. You make more than that as a primary care doctor.

Open ICU - Nice for the intensivist (less paperwork), sucks for the hospitalist. You are an internist, not CC.

Consult away when you have a doubt. Make your life easier, keep everybody happy. The allure of doing everything for the patient quickly wears off in favor of expediency and making things manageable for yourself.

Try to have the non compete clause removed. Understand the definition as well. Is it ten miles from the hospital alone or ten miles from any hospital owned facility? In some cases, the latter will put you out of the city due to many satellite clinics.

$200k is low. I can't stress that enough.
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200k was for the salaried position with excellent benefits and quality bonus opportunities. Other salaried groups had similar bases in the area.

With regards to the CC work I don’t mind the open ICU as under productivity only model I can bill for critical care time.
 
JohnTraylor said:
200k was for the salaried position with excellent benefits and quality bonus opportunities. Other salaried groups had similar bases in the area.

With regards to the CC work I don’t mind the open ICU as under productivity only model I can bill for critical care time.
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You'll mind if there is a crashing patient you have to care for while your pager is blowing up with RN calls and er admits and you finish your shift with only half of your documentation done.

You also have to be realistic about what you can and can't do--if you miss something and someone gets hurt and sues your lack of board certification in CCM will weigh very heavily against you.
 
chessknt87 said:
You'll mind if there is a crashing patient you have to care for while your pager is blowing up with RN calls and er admits and you finish your shift with only half of your documentation done.

You also have to be realistic about what you can and can't do--if you miss something and someone gets hurt and sues your lack of board certification in CCM will weigh very heavily against you.
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agreed...when i first came out of residency, i was comfortable enough with an open icu...had a great deal of icu (and with VA micu, you get a lot of autonomy)in residency and icu wasn't the crazy crazy sick (that life flighted to the mother ship) so doable, but now knowing what i know now...it can be a scary proposition and a medico-legal minefield.
 
chessknt87 said:
You'll mind if there is a crashing patient you have to care for while your pager is blowing up with RN calls and er admits and you finish your shift with only half of your documentation done.

You also have to be realistic about what you can and can't do--if you miss something and someone gets hurt and sues your lack of board certification in CCM will weigh very heavily against you.
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In this scenario don’t you just consult CC and have them take over care of the patient especially if respiratory failure is impending? In residency currently that is how we operate and seems to work out just fine.
 
JohnTraylor said:
In this scenario don’t you just consult CC and have them take over care of the patient especially if respiratory failure is impending? In residency currently that is how we operate and seems to work out just fine.
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hqdefault.jpg
 
gutonc said:
hqdefault.jpg
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Lmao it’s true and standard of care. Outside of non-invasive ventilation there is no role for the general internist to handle intubated amd ventilated patient’s. Pressor’s are easy to initate and don’t necessarily need an intensivist involved. What am I missing? CC medicine is just general hospital medicine with way more acuity and either the addition of vasopressors or mechanical ventilation.
 
JohnTraylor said:
Lmao it’s true and standard of care. Outside of non-invasive ventilation there is no role for the general internist to handle intubated amd ventilated patient’s. Pressor’s are easy to initate and don’t necessarily need an intensivist involved. What am I missing? CC medicine is just general hospital medicine with way more acuity and either the addition of vasopressors or mechanical ventilation.
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The fact that you think pressors are just turned on prn and CCM fellowship is just management of a ventilator is quite concerning
 
JohnTraylor said:
Lmao it’s true and standard of care. Outside of non-invasive ventilation there is no role for the general internist to handle intubated amd ventilated patient’s. Pressor’s are easy to initate and don’t necessarily need an intensivist involved. What am I missing? CC medicine is just general hospital medicine with way more acuity and either the addition of vasopressors or mechanical ventilation.
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A disturbing amount.

But good luck to you...and your patients.
 
chessknt87 said:
The fact that you think pressors are just turned on prn and CCM fellowship is just management of a ventilator is quite concerning
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I don’t recall saying that at all in my post... I have nothing but the utmost respect for CCM physicians, and I am only expressing my opinion of what I have observed over the years. It appears to me that the majority of CCM (pure CCM not the pulm component) comprises taking care of shock and respiratory failure. Also CCM physicians appear to consult subspecialists just as much if not more often than hospitalists (appropriately so). Dealing with these issues is obviously extremely stressful and by no means simple but from a pure physiological standpoint please correct me if I am wrong.
 
JohnTraylor said:
I don’t recall saying that at all in my post... I have nothing but the utmost respect for CCM physicians, and I am only expressing my opinion of what I have observed over the years. It appears to me that the majority of CCM (pure CCM not the pulm component) comprises taking care of shock and respiratory failure. Also CCM physicians appear to consult subspecialists just as much if not more often than hospitalists (appropriately so). Dealing with these issues is obviously extremely stressful and by no means simple but from a pure physiological standpoint please correct me if I am wrong.
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Pressors
Lines/tubes
Codes
Being able to make decisions quickly as to what is going on with a crashing patient
Mechanical support management if in a CCU (IABP, Impella, etc)
Bedside ultrasound
Thoras, Paras, bronchoscopy
Mechanical ventilation
CRRT management in conjunction with renal

There’s a LOT more to critical care than just pressors and vents.
 
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