Job Search Mentorship?

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Hi all,

I am a PGY4 who will be starting my pain fellowship this upcoming summer. As I have been curious about the market and have a limited geographic interest in practice location, I have been looking into positions around my desired metropolitan area. While I know that I still have a substantial timeframe to find a position and some may claim that it is way too early to be searching, I have been fearful of missing an opportunity if it arises. I’ve become very interested in a hospital-based practice looking to hire and would like to run some of the specifics by someone knowledgeable to get honest feedback.

Hospital-based practice
$405k base
$68/wRVU beyond 5200 wRVU
Sign-on would be $90k given I will be a fellow
4-day work week consisting of 2days OR/2days clinic
Per the contact, providers make 75th-90th percentile earnings although unable to provide wRVU information. (I’m requesting this information currently)
Clinic is made up of 2 pain providers/2 NPs
No real inpatient services; call is only consultation during business hours M-F.

They’re hiring because one of the pain providers is relocating across the country for family reasons. I would inherit this provider’s patient load. They have a large referral network at the hospital and the surround areas.

Downside: this is approximately 50-60 miles from the metropolitan area I’m interested in living. This would equate to 2 hrs total in commuting each day, which is my biggest concern.

Most other practices I have seen hiring in the past 2 months have similar base salaries (400k) without productivity incentive for the first 2 years followed by no base and only productivity with 7-10% facility fees.

Any input would be greatly appreciated either on here or privately.

Thanks for your time!
 
Opioids? If so did last guy do <90 MME or are you inheriting a bunch of high MME work? Pumps? Was he stimming everyone?

Clinic and procedure volume per day? On procedure days, do they allow for rapid turnover (sounds like they do if hitting high earnings percentile).

I’m an anti commute person. When I started my current gig, I was commuting to a satellite location two days a week for a similar amount of time. I found that really grating, but lots of other people aren’t that bothered by it and do it regularly.

A cofellow signed a gig similar to yours except he decided to live closer to work rather than deal with commute. Money amazing, four day work week every week and four day weekend every other week. BUT, he hates living as rural/commuting as he is and will likely leave the gig in a few years.

If not much opioid and at least a stones throw from where you want to be and no better private practice partnership track gig available, I would probably take it and keep an eye out.

You can also decline the signing bonus/stipend and keep looking. That way if you find something better it’s not messy to get out of your current contract.
 
It's a great starter gig. Rent close to the job. Do 2-4 years. Enjoy long weekend trips into the city. Move into your desired location with some better clinical and business sense. Most people leave that first job so just make sure the noncompete allows you that flexibility. Ideally you're able to make a good nest egg to allow you some buffer and flexibility in the 2nd gig. Use the time to network and find the perfect forever home in your 2nd job where you want to live the next 20 years.
 
First thank you all for your input.

Living 50-60 miles from the medical center is already me compromising by not living in a different, more desirable part of the city. I don’t mind an hour commute as I find solace in driving and used to do ridesharing for some extra cash in medical school. However, I would want to be compensated a little extra to make up for it.

The practice is highly interventional with little opioid management although not zero. I plan to meet with the group again to discuss some finer details so I’m not sure if the opioid management that they have is >90 MME but I would think probably not.

I guess one of the biggest things perplexing me right now is compensation. A 4-day work week sounds desirable but also seems like lost income potential. Dealing with a commute of this size less often seems nice but I would also want my compensation to make up for that. Since I’m so new to this, I have no idea what 75th-90th percentile equates to but it seems like 600-800k? Given that this is a wRVU-based compensation package and it’s a 4-day work week with 2 days being clinic (averaging 20-25 patients/day), does this seem possible? I’m not sure what wRVUs one could expect from a schedule like this, but 8000+ is what I would hope?
 
Sounds like a damn good gig overall, though the 4 day thing (at least right off the bat) is possibly a detriment, as you correctly identified. Ideally you would be working 5 days starting out when your efficiency isn't there yet. The patient load the old guy saw in 4 days, you might need 5 days for. Is that negotiable? If everybody else there is just working 4 days, they probably won't change it for you (have to pay the MA more, or you may have some people quit if they suddenly were to get an extra day of work, so there may be systemic reasons they would be resistant to a 5th day, as it may be good for you but possibly bad for them, although that ignores the fact that that 5th day you're bringing in $$$$ for them).

Percentile is usually determined by region, there's a few different regions, the most recent data for my region has 75th-90th %ile as 14k-17k RVU. So if you hit 14k RVU you're looking at just under $600k productivity in addition to $405k base. Do they have a cap on your earnings?

Do you have any midlevel supervision responsibilities and if so have they delineated them clearly, including compensation for such?

They already are compensating you to make up for the commute, this job would definitely either be lower paying or have already been filled by somebody practicing for a while if it weren't out in the sticks.

Overall it sounds extremely similar to the job I took (minus the 4 day thing), and I took that job in a heartbeat (well actually after like a month of due diligence, but you get what I mean).
 
mdo1738 said:
Sounds like a damn good gig overall, though the 4 day thing (at least right off the bat) is possibly a detriment, as you correctly identified. Ideally you would be working 5 days starting out when your efficiency isn't there yet. The patient load the old guy saw in 4 days, you might need 5 days for. Is that negotiable? If everybody else there is just working 4 days, they probably won't change it for you (have to pay the MA more, or you may have some people quit if they suddenly were to get an extra day of work, so there may be systemic reasons they would be resistant to a 5th day, as it may be good for you but possibly bad for them, although that ignores the fact that that 5th day you're bringing in $$$$ for them).

Percentile is usually determined by region, there's a few different regions, the most recent data for my region has 75th-90th %ile as 14k-17k RVU. So if you hit 14k RVU you're looking at just under $600k productivity in addition to $405k base. Do they have a cap on your earnings?

Do you have any midlevel supervision responsibilities and if so have they delineated them clearly, including compensation for such?

They already are compensating you to make up for the commute, this job would definitely either be lower paying or have already been filled by somebody practicing for a while if it weren't out in the sticks.

Overall it sounds extremely similar to the job I took (minus the 4 day thing), and I took that job in a heartbeat (well actually after like a month of due diligence, but you get what I mean).
Click to expand...
Thank you for the very thought out reply and the data to help understand . I’m surprised by those numbers to be honest though. I’ll certainly be sure to bring up the 5-day work week as a potential. My understanding is that it’s currently set up so that one provider is M-Th and the other is T-F, so I could see it being a possibility to be 5-day/week.

As far as mid levels, I believe the model is that I would see new patients and complex follow-ups while the mid level sees simple follow-ups. I’m not sure how they’re compensated though to be honest.

Thanks so much!
 
Sounds like a very solid offer. If you're okay with the commute, I'd go for it. For me, the commute would be a deal breaker. I commuted 30-45 minutes most days for fellowship, and quickly tired of it. Currently live 5 minutes from work and am loving life.

I'm also hospital employee, working 4 days per week. Had 1 year salary of $400k, now pure production, $65/RVUs. Took me about a year to get up to full speed. Currently seeing about 45 patients in clinic, 35-40 procedures, per week. Excluding vacation weeks, will be around $650k this year. I'm busy enough I could open up my 5th day and increase to maybe $780k? I'm happy with current salary and more time with the fam.

You could always start at 4 days until those 4 days get packed, then open up a 5th day. Might be preferable to starting with 5 days that are only 60% full.
 
The downside of being 60 miles away from where you want to live, is probably the reason this job has such an attractive offer. They’re paying for what they think people will move for.

Are you single? The only thing that would seriously make me pause on this offer would be if I thought there was zero chance of meeting a potential partner in that town.
 
stsa84 said:
Sounds like a very solid offer. If you're okay with the commute, I'd go for it. For me, the commute would be a deal breaker. I commuted 30-45 minutes most days for fellowship, and quickly tired of it. Currently live 5 minutes from work and am loving life.

I'm also hospital employee, working 4 days per week. Had 1 year salary of $400k, now pure production, $65/RVUs. Took me about a year to get up to full speed. Currently seeing about 45 patients in clinic, 35-40 procedures, per week. Excluding vacation weeks, will be around $650k this year. I'm busy enough I could open up my 5th day and increase to maybe $780k? I'm happy with current salary and more time with the fam.

You could always start at 4 days until those 4 days get packed, then open up a 5th day. Might be preferable to starting with 5 days that are only 60% full.
Click to expand...

Absolutely mind boggling the difference between private practice and HOPD in certain markets. As per my 40-50 patients per day thread, a private ortho group I interviewed with wanted 40-50 patients in clinic per day 3 days a week and 30 procedures two days per week to hit a slightly higher than your 780 if you were to open up to 5 days a week.
 
agolden1 said:
Absolutely mind boggling the difference between private practice and HOPD in certain markets. As per my 40-50 patients per day thread, a private ortho group I interviewed with wanted 40-50 patients in clinic per day 3 days a week and 30 procedures two days per week to hit a slightly higher than your 780 if you were to open up to 5 days a week.
Click to expand...
It’s all RVU, and HOPD facility fee.

When your institution is paid so much more in facility fees for HOPD procedures, you don’t have to work like a dog.
 
im thinking they do not want to hire extra help for the 5th day if possible.


when i started as an youngling, i worked 2 jobs with long commutes.

for both jobs, the commute was 45 minutes. 12 hour shifts, a tiny bit under 4 per week, but rarely 5 days a week.

i found no issues with the commute, and lived in a location that was quite favorable. helps to have a car you like to drive. (at that time, an Eagle Talon turbo)

i would buy audio books and audio reviews - i had used Dannemiller - to listen/study for boards while driving.

bedrock said:
It’s all RVU, and HOPD facility fee.

When your institution is paid so much more in facility fees for HOPD procedures, you don’t have to work like a dog.
Click to expand...
HOPD physicians are encouraged to work like a dog. but they are less likely to be fired (or go broke) for not doing so...


yet hospitals are doing very poorly lately.

yes, part is due to the exorbitant amounts of money given to admin.

i would suspect that if facility fees were eliminated from HOPD practices, a significant number of hospitals would go belly up.

www.aha.org

The Current State of Hospital Finances: Fall 2022 Update | AHA

Since the onset of the COVID 19 pandemic in March 2020, our nation’s hospitals and health systems have coped with intense pressure on staff and resources. Hospitals also are facing a host of other related challenges, including workforce shortages, supply disruptions, and rising expenses. These...
www.aha.org www.aha.org
 
Ducttape said:
i found no issues with the commute, and lived in a location that was quite favorable. helps to have a car you like to drive. (at that time, an Eagle Talon turbo)
Click to expand...

Did you not get a good deal on the Plymouth Laser? I'm sure the Eclipse would have been more.
 
Good job offer if the practice isn’t toxic
Lot of great advice already
You will appreciate being able to work 4 days I’m sure they’d oblige you if you wanted to work a fifth

Money is not everything. It seems that way when you first start but soon becomes much, much lower on your priorities list
 
Is the 90k sign on up-front when you start fellowship year? Or monthly stipend during fellow year? Or it's given end of fellowship/before starting job?
 
bedrock said:
It’s all RVU, and HOPD facility fee.

When your institution is paid so much more in facility fees for HOPD procedures, you don’t have to work like a dog.
Click to expand...

This has always confused me. If you look at the facility fee charges for procedures, it's always way less than non-facility fee charges.

ex, VTP in a facility (i.e. HOPD) = $407.66... VTP in non facility (i.e. office) = $1,851.26

Can anyone explain to me how facilities ultimately get paid more??
 
not sure you are reading that correctly..

you have to add on the facility fee to your calculation


for vertebroplasty, that is $2782 from the 2020 ASIPP fee schedule.

so vertebroplasty to patient at faciliity is $407.66 + $2782 for grand total of $3190.

vs office based, the total fee is the physician fee or $1855 (again, 2020 numbers).

 
lmsanscafe said:
This has always confused me. If you look at the facility fee charges for procedures, it's always way less than non-facility fee charges.

ex, VTP in a facility (i.e. HOPD) = $407.66... VTP in non facility (i.e. office) = $1,851.26

Can anyone explain to me how facilities ultimately get paid more??
Click to expand...
i think you're mixing pro fees and facility fee numbers.
 
Ducttape said:
not sure you are reading that correctly..

you have to add on the facility fee to your calculation


for vertebroplasty, that is $2782 from the 2020 ASIPP fee schedule.

so vertebroplasty to patient at faciliity is $407.66 + $2782 for grand total of $3190.

vs office based, the total fee is the physician fee or $1855 (again, 2020 numbers).

Click to expand...

I got the numbers using the CPT code on the CMS website for 2023. But I guess what I’m hearing is that facilities will also be paid a facility fee in addition to the payment for the procedure, ultimately resulting in a higher reimbursement overall. Do I have that correct?
 
lmsanscafe said:
I got the numbers using the CPT code on the CMS website for 2023. But I guess what I’m hearing is that facilities will also be paid a facility fee in addition to the payment for the procedure, ultimately resulting in a higher reimbursement overall. Do I have that correct?
Click to expand...
yes
 
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