Joining a practice, looking for a job. Basic questions to ask

[oreosandsake]

saw some older threads on this in other forums but not a ton here.

was wondering if anyone had some advice.

Thank you

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[lonelobo]

1st Question and most important:
How are you guys trying to F'ck Me?

 

[oreosandsake]

1st Question and most important:
How are you guys trying to F'ck Me?

keep em' coming!

I'm gonna have to figure out how to ask that one... visiting Wednesday. ANY HELP would be most useful before then!

 

[lobelsteve]

Where did you bury the last guy?

Or you can ask have there been any staff changes in the past 3 years?

How soon are you looking for the doc to start?

Job is secondary to the community. Dont take a great job in a lousy area or you will be miserable. School systems, culture, (monster truck rally), etc.

Is there time to a ludicrous amount of research?

 

[oreosandsake]

thanks for the advice Steve.

I like the neighborhood. private practice job. the guy is consolidating two practices, and moving to a larger office (remodeling now, to open at the end of this month) he hired another guy just a year or so ago.


I'd like to keep a part of my time in scholarly activities... but I'm not sure if any pp employers are really interested in doing studies unless they are funded by industry.

 

[bronchospasm]

Most important thing is to know what you want.
If you don't know what you are looking for, it can get really confusing.
Location and whether your family will be happy there is key. School, kids, community etc is equally important as percentage of collections, etc

Went through this last year and finally decided to start my own.
You will come across a lot of Dbags.. That's for sure.

 

[Paddington]

As far as compensation goes, the only real compensation is salary. Production bonus can be calculated in a number of screwy ways, all very unfavorable to you.

Sometimes they'll offer you part ownership. But the question is, ownership of what? Often times their one practice is setup as 3-4 different businesses, and the real profit is going to some business with an obscure name that you'll never get any ownership in.

 

[clubdeac]

As far as compensation goes, the only real compensation is salary. Production bonus can be calculated in a number of screwy ways, all very unfavorable to you.

Sometimes they'll offer you part ownership. But the question is, ownership of what? Often times their one practice is setup as 3-4 different businesses, and the real profit is going to some business with an obscure name that you'll never get any ownership in.

So you're saying the only compensation is base? I've always been told the lower the base the better with better options for productivity. Many of the jobs I looked at had a base of x with productivity bonus kicking in typically after I doubled x. Therefore the lower the base the better

 

[gaseous_clay]

So you're saying the only compensation is base? I've always been told the lower the base the better with better options for productivity. Many of the jobs I looked at had a base of x with productivity bonus kicking in typically after I doubled x. Therefore the lower the base the better

Yes, in theory, taking a lower base salary usually entitles one to better production-based incentives. However, as stated by another poster earlier, there are numerous factors that come into play in terms of how your production can be calculated. First of all, will the practice open up the books and actually show you your true monthly revenue generated and not simply hand you a piece of paper with your supposed production numbers? Are you required to pay overhead (indirect and direct expenses)? Are you supervising mid-levels? If so, is their production counted toward your numbers if the practice is billing their services incident to you? Are you doing clinic based procedures or taking them to the practice's ASC? The site of service differential can be very large for some procedures which will definitely affect your numbers. By no means is this an exhaustive list of questions, but these are just a few things to consider.

 

[clubdeac]

Yes, in theory, taking a lower base salary usually entitles one to better production-based incentives. However, as stated by another poster earlier, there are numerous factors that come into play in terms of how your production can be calculated. First of all, will the practice open up the books and actually show you your true monthly revenue generated and not simply hand you a piece of paper with your supposed production numbers? Are you required to pay overhead (indirect and direct expenses)? Are you supervising mid-levels? If so, is their production counted toward your numbers if the practice is billing their services incident to you? Are you doing clinic based procedures or taking them to the practice's ASC? The site of service differential can be very large for some procedures which will definitely affect your numbers. By no means is this an exhaustive list of questions, but these are just a few things to consider.

So how does one have them "open the books" rather than have them hand me a piece of paper with my production numbers? My practice manager hands me a printout with a breakdown of monthly revenue from procedures, RFA, stim and clinic visits. How is "opening the books" any different than this? Shall I ask to sit down at her computer and show me where these numbers come from? I'm guessing she'll look at me a little confused...

 

[gaseous_clay]

So how does one have them "open the books" rather than have them hand me a piece of paper with my production numbers? My practice manager hands me a printout with a breakdown of monthly revenue from procedures, RFA, stim and clinic visits. How is "opening the books" any different than this? Shall I ask to sit down at her computer and show me where these numbers come from? I'm guessing she'll look at me a little confused...

Well good for you that your practice offers you a monthly report like that. Either you are an owner or your employer is unusually transparent with you. If it's the former, then you missed the point of the original post. If it's the latter, then you must live in a bubble because most practices do not provide that level of transparency to their new hires. Some do not get any information about how much they have produced until the end of the contract year and often without the detailed breakdown you described.

 

[SSdoc33]

So how does one have them "open the books" rather than have them hand me a piece of paper with my production numbers? My practice manager hands me a printout with a breakdown of monthly revenue from procedures, RFA, stim and clinic visits. How is "opening the books" any different than this? Shall I ask to sit down at her computer and show me where these numbers come from? I'm guessing she'll look at me a little confused...

my guess is that they are showing you your professional fees only. if you do your shots at an ASC or hospital, i doubt they show you the facility fees as well. i could be wrong.

 

[drusso]

I'm curious if posters believe that hospital-based or hospital-employed opportunities are "fairer" than independent single-specialty or multi-specialty practice opportunities. I've always felt the hospital-employed jobs or academic jobs looked better on paper but were actually a bigger rip-off...especially when you consider earning over an entire life-time.

 

[Ducttape]

personally, i have i believe almost all the relevant numbers. Visits, number of procedures by RVU, amount billed, wRVU per procedure, no show rates, charges, denials, collection, AR, net cash, etc...

now, its a HOPD, so the take home message is that it all depends on the job. all that info is not what i expected when i insisted on seeing the numbers, but they are very open.


fyi, the reason i think they are willing to be open is that the system doesnt have to try to screw over me financially, unlike what might happen when there is 1 owner or practice partner who is looking to keep his piece of the pie. they own the whole kit-and-kaboodle (sic), so they can screw me any which way they want, if they wanted to 😉

 

[gaseous_clay]

my guess is that they are showing you your professional fees only. if you do your shots at an ASC or hospital, i doubt they show you the facility fees as well. i could be wrong.

You are right. Unless you own shares in the facility, no one will show you the the revenue from facility fees. The only thing you can do is estimate what the center is getting per procedure based on the Medicare fee schedule.

 

[SSdoc33]

I'm curious if posters believe that hospital-based or hospital-employed opportunities are "fairer" than independent single-specialty or multi-specialty practice opportunities. I've always felt the hospital-employed jobs or academic jobs looked better on paper but were actually a bigger rip-off...especially when you consider earning over an entire life-time.

I think you generally get a higher percentage of what you collect in PP than in a hospital setting. 'Fair' is in the eye of the beholder. Guaranteed referrals, good benefits, limited administrative work, and job security are the trade off for less money/unit of work

 

[Yo GabbaPentin]

I think you generally get a higher percentage of what you collect in PP than in a hospital setting. 'Fair' is in the eye of the beholder. Guaranteed referrals, good benefits, limited administrative work, and job security are the trade off for less money/unit of work

It took me one year of getting lied to and watching books get cooked to desire LESS of a PP scenario. The guaranteed referrals, limited administrative work and job security are worth a LOT to me after going through that first year. I was always worried about if the practice would keep getting referrals since all of the PCPs and surgeons were owned by the major hospitals. There were constant concerns about staffing, advertising, kissing referring doc a$$, buy in price, practice sustainability, etc, etc, etc. It was way more stress than it was worth (especially since I made no money). I am not a hospital employee but in a large multi specialty group consisting mostly of PCPs. Now I get a monthly statement related to productivity and who knows if that's cooked. At least it doesn't put my overhead at >80K per month like the last place!!!!

For what it's worth, NONE of my co fellows over multiple classes for the past several years make almost ANY productivity bonus at all and there is always some BS excuse for why they were stuck at that low base salary. But don't worry, because invariably, "next year will be better."

 

[hyperalgesia]

The VA is kind of it's own animal. I'm doing both right now and there is more administrative crap at the VA than in PP. Imagine the same people who wrote Obamacare, HIPPA and the "Meaningful Use" criteria are your bosses.

 

[drusso]

I think that the perception of "fairness" versus "equality" is crucial: You know when you're employed by a big hospital system, that the deal isn't fair--the hospital is taking a huge chunk of *YOUR* revenue and paying for administrators, cost-shifting activities, the C-Suite strategic planning junkets, etc...but you also know that everyone else around you is getting screwed EQUALLY. And, that makes all the difference...everyone from the pediatric cardiothoracic surgeon down to the nurse practitioner is getting the same size chunk taken from their hide to pay "the man." On the other hand, when you take a PP deal, you also know that the deal isn't necessarily fair, but you also know that it's an inherently UNEQUAL arrangement. The partners have different stakes (let alone associates), different interests, and likely different compensation deals from different sources of activity based upon when they came into the game. That's the part I think that drives people crazy: In the PP enviroment, not all physician-owners are created EQUAL.

 

[Louisville04]

The VA is kind of it's own animal. I'm doing both right now and there is more administrative crap at the VA than in PP. Imagine the same people who wrote Obamacare, HIPPA and the "Meaningful Use" criteria are your bosses.

Yes but in the VA you get a set salary whether you're doing administrative crap or seeing patients. It's not a eat what you kill mentality.

 

[bedrock]

Yes but in the VA you get a set salary whether you're doing administrative crap or seeing patients. It's not a eat what you kill mentality.

True but isn't the VA salary for a fellowship trained pain doc around 180k?

Maybe clubdeac and hyperalgesia can fill us in on that. I'm not sure if the VA pays a different salary to pain docs depending on whether their primary residency is PM&R or Anesthesia like Kaiser does in CA.

 

[clubdeac]

True but isn't the VA salary for a fellowship trained pain doc around 180k?

Maybe clubdeac and hyperalgesia can fill us in on that. I'm not sure if the VA pays a different salary to pain docs depending on whether their primary residency is PM&R or Anesthesia like Kaiser does in CA.

Yes the VA will base your pay on your primary specialty. There are various tiers of reimbursement with neurosurgery/cardiothoracic surgery/interventional rads at the top and primary care/psych etc. at the bottom. PMR was in the middle but below anesthesia. Doing strictly interventional pain including stims and kypho, I personally thought that was bs and negotiated a pretty great deal. I've mentioned exact numbers in another thread somewhere. Your negotiation power however all depends on the need in that particular VISN. If they are fee basing out a lot and losing beaucoup bucks then you'll obviously have more leverage. That was my situation. Let's just say I was making a hell of a lot more in the VA than I made in my first year out in pp. Things better change pretty quickly....

 

[bedrock]

Yes the VA will base your pay on your primary specialty. There are various tiers of reimbursement with neurosurgery/cardiothoracic surgery/interventional rads at the top and primary care/psych etc. at the bottom. PMR was in the middle but below anesthesia. Doing strictly interventional pain including stims and kypho, I personally thought that was bs and negotiated a pretty great deal. I've mentioned exact numbers in another thread somewhere. Your negotiation power however all depends on the need in that particular VISN. If they are fee basing out a lot and losing beaucoup bucks then you'll obviously have more leverage. That was my situation. Let's just say I was making a hell of a lot more in the VA than I made in my first year out in pp. Things better change pretty quickly....

deac,

What state was your VA? What numbers are we talking for that underserved VA , 350K or so? I think you mentioned you made about 240K your first year working in private practice in NC.

 

[hyperalgesia]

True but isn't the VA salary for a fellowship trained pain doc around 180k?

Maybe clubdeac and hyperalgesia can fill us in on that. I'm not sure if the VA pays a different salary to pain docs depending on whether their primary residency is PM&R or Anesthesia like Kaiser does in CA.

Initial salary at the VA is based on a national pay table with primary specialties with 5 tiers each. Pain Management is not ANYWHERE on the table, only primary specialties. So, for PM&R, I believe the tiers are something like from 170 - 250k. To go higher, your Service Chief (boss) can fill out some forms and request the regional VA to approve a higher salary. This can be quite political because the salary for a Service chief tops out at about 250k, regardless of the specialty. So you really need have the right people and the right situation to be able to successfully negotiate a higher salary. Sometimes saving massive amounts of money won't cut it -unless you are truly walking out the door. But some people (like clubdeac) can do it. Anesthesia pay scale is something like 250-350k.

Most people who stay at the VA long term are either demoralized or completely okay with being told what to do. I have a neurology colleague at the VA who is thrilled about the system. She's making under 200k and freely admits, "I just want someone to tell me what to do [and security]." The VA was made for this type of personality.

-edit: just to add, I don't think there's anything wrong with the people who like working for the VA. My inability to function under authority is more a weakness than a strength. Ideally, a person could function at their highest in any situation. Just not me...

 

[drusso]

Most people who stay at the VA long term are either demoralized or completely okay with being told what to do. I have a neurology colleague at the VA who is thrilled about the system. She's making under 200k and freely admits, "I just want someone to tell me what to do [and security]." The VA was made for this type of personality.

I think that this is spot on: Increasingly the medical school selection process and residency training programs are actively SELECTING for this kind of personality style. It helps hospital managers and administrators better control their medical staff.