Negotiating 1099

[bonedrone14]

Hi all. Thanks to everyone who posts job offers and gives thoughts on good vs bad and strategies. I'd have no idea what a realistic offer looked like without the advice here. Hopefully this can be a helpful reference for others down the road as well. I haven't seen this particular topic discussed yet.

I have a tentative offer (I spoke with the in house recruiter on the phone, will speak with the CMO about full details) that looks like this:

Salary 289k
Sign on 50k
Relocation 10k
CME 10 days/3600
"10 days sick leave and 6 holidays"
Generic retirement/vacation/medical benefits

The job itself is at a small rural hospital. Like, super rural. Town of 3k, county is maybe 30k. Which I like, but I just add that for reference. There is a 20 bed geri unit staffed by an NP. I'd supervise them and round "about" one weekend a month. There's also an FNP who just signed on to do outpatient, so I'd supervise them as well. My clinical role would be pretty generic outpatient (voiced flexibility that I could dictate appointment lengths) with about 10 (!) days of ED coverage a month. No word on whether that's just by phone or in person.

To me, this sounds pretty awful honestly. I'm not interested in supervising anyone. Also not jazzed to have to pull q3 call. However, the location is a place I really like, and because it's so rural, I'm assuming people aren't beating down their door to sign.

So, has anyone ever negotiated a 1099 contract from a W2 offer? I'd optimally like to contact for med/ED consults or a couple days of outpatient maybe. Is this a dead in the water idea? When I propose this to the CMO, should I also propose a rate and the whole enchilada, or wait to see what they propose? I'm finishing fellowship so I'm still in the "you'll eat it and you'll like it" mindset.

Thanks in advance!

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[TexasPhysician]

The job sounds reasonable without call, without supervising, without weekend rounds, and 2 extra weeks vacation.

Depending on the state, they may really need the supervision and coverage more than anything else. If so, I’d walk away. The above makes this terrible.

 

[bonedrone14]

Haha, my thoughts exactly. Which I guess is my suspicion: they wont be interested in contracting because all they need is supervision.

 

[Psych19]

So, has anyone ever negotiated a 1099 contract from a W2 offer? I'd optimally like to contact for med/ED consults or a couple days of outpatient maybe. Is this a dead in the water idea? When I propose this to the CMO, should I also propose a rate and the whole enchilada, or wait to see what they propose? I'm finishing fellowship so I'm still in the "you'll eat it and you'll like it" mindset.

Go for it. See what they say. Worst thing that happens is they say no. Propose an hourly rate if you're wanting 1099.

You're right in identifying that the initial offer is junk.

On a separate note, I'm curious about the interest in working in a rural community. I could see the appeal of living in such a place (picturesque, availability of outdoor activities, LCOL). I don't see the appeal of being a psychiatrist for a small community. Everyone you meet is going to be your patient (your barista, the guy who bags your groceries, the people you run into on the street when you go into town to go out to eat). I wouldn't want that kind of visibility.

 

[wolfvgang22]

What's the patient volume?
These places can't get applicants so they always want heavy call coverage, it's almost their #1 need. I wouldn't sign a contract unless hours, max call, and max patient volume are carefully set. There is also going to be some frustration with lack of nearby therapists and programs for patients. These places burn out clinicians quickly, even faster than you would think because the social and cultural scene is limited. Just don't get stuck in a long contract. Don't get me wrong, it could be a good job, but only if you are able to set firm limits.

The small town visibility worries is actually not as bad as you might think. Generally, difficult patients will avoid you or actually are much nicer in public when you cross paths. Other patients or staff will surprise you with brief positive interactions and respectful expressed appreciation. Just my experience. I tell patients if I see them outside clinic I won't approach them or say hello to protect their privacy, not because I'm snobby.

 

[robellis]

Hi all. Thanks to everyone who posts job offers and gives thoughts on good vs bad and strategies. I'd have no idea what a realistic offer looked like without the advice here. Hopefully this can be a helpful reference for others down the road as well. I haven't seen this particular topic discussed yet.

I have a tentative offer (I spoke with the in house recruiter on the phone, will speak with the CMO about full details) that looks like this:

Salary 289k
Sign on 50k
Relocation 10k
CME 10 days/3600
"10 days sick leave and 6 holidays"
Generic retirement/vacation/medical benefits

The job itself is at a small rural hospital. Like, super rural. Town of 3k, county is maybe 30k. Which I like, but I just add that for reference. There is a 20 bed geri unit staffed by an NP. I'd supervise them and round "about" one weekend a month. There's also an FNP who just signed on to do outpatient, so I'd supervise them as well. My clinical role would be pretty generic outpatient (voiced flexibility that I could dictate appointment lengths) with about 10 (!) days of ED coverage a month. No word on whether that's just by phone or in person.

To me, this sounds pretty awful honestly. I'm not interested in supervising anyone. Also not jazzed to have to pull q3 call. However, the location is a place I really like, and because it's so rural, I'm assuming people aren't beating down their door to sign.

So, has anyone ever negotiated a 1099 contract from a W2 offer? I'd optimally like to contact for med/ED consults or a couple days of outpatient maybe. Is this a dead in the water idea? When I propose this to the CMO, should I also propose a rate and the whole enchilada, or wait to see what they propose? I'm finishing fellowship so I'm still in the "you'll eat it and you'll like it" mindset.

Thanks in advance!

Wait I’m confused, you’re a psychiatrist and they want you to supervise a family Med NP?? That’s insane..also they have a geriatrics unit that is staffed with an NP that you’re supervising!??? I actually don’t think I’ve heard of a worse job before...I’m not even going to discuss the call schedule..OP you are getting completely ripped off, if you have to do all of the above I would not do this job for less than 500k and even then I'm
Not sure if it’s worth it probably not honestly..I agree the only way this job works is 1099, no call, no supervision, more vacation.

 

[bonedrone14]

Theoretically from what the in house recruiter told me, I'd be able to dictate patient volume. However, my gut tells me that I'd be able to choose between a set of dictates.

Y'all's responses are reassuring; it's helpful to see I'm not being unreasonable in looking at this job with skepticism.

As for small town psychiatry, its encouraging to hear positive experiences. In residency I saw a few of my outpatients out and had taken the strategy of prepping them and setting the precedent that I wouldn't acknowledge them unless they did so first.

@Psych19, I suppose you're right. Nothing particularly to lose. I guess my biggest question is, anyone with negotiating skills (I have no experience), are there things you wish you'd know before your first attempt? Mistakes to avoid?

 

[Sushirolls]

As I've aged, the fears of small rural locations and patients interacting with you is less of an issue. You'll more into your own hobbies or chores or family that you won't really be out and about. You'll have other more pressing things to worry about.

The last review on SDN I think the 'acceptable' rate is 50k per ARNP supervision. Rare to see that, but if that's what they really need then you should set your self up as the medical director right from the start. That you get 50k per ARNP you supervise and you get the ability to drop supervision roles - and if that means the ARNP is fired is up the hospital/employer - but you have the right to drop supervision, no questions asked, no petition from anyone.

 

[wolfvgang22]

Wait I’m confused, you’re a psychiatrist and they want you to supervise a family Med NP?? That’s insane..also they have a geriatrics unit that is staffed with an NP that you’re supervising!??? I actually don’t think I’ve heard of a worse job before...I’m not even going to discuss the call schedule..OP you are getting completely ripped off, if you have to do all of the above I would not do this job for less than 500k and even then I'm
Not sure if it’s worth it probably not honestly..I agree the only way this job works is 1099, no call, no supervision, more vacation.

You may not have a lot of experience with rural job offers. Family med NPs can do additional training to specialize in psychiatry but are often utilized working in psychiatric clinics and hospitals even without additional training due to the lack of available more qualified staff like psychiatrists. Rural hospitals cannot afford to pay a psychiatrist $500k, neither can big city private clinics in general unless you open your own clinic and work your tail off.

Bottom line here: $289K with malpractice coverage and the benefits mentioned is a good salary if there is very little to no call, no weekends, no ER coverage and 10 patients per day, whether they are inpatient or outpatient. Supervision is easy and if the NP is seeing the same number of patients I'd ask for 10k to 20k add on fee for supervision or negotiate other bennies like more flexible schedule or vacation or CME time to travel to conferences, etc to make it work. I think it is worth $50k but I think most rural hospitals are going to balk at that. I might be wrong. Open with $50k and see what their interest level in negotiating is. Don't get sucked in to supervising an NP that is blowing through 40 patients or more on weekend rounds.

Take anything an in house recruiter says with a grain of salt. I again advise against taking a job like this unless a limit on responsibilities are spelled out specifically in writing, because they will ask you to do more and more after you get started. That is a constant of the universe in clinical medicine. When they are trying to hire you they are being as accommodating as they will ever be. They may stay that way, but may not.

Find out what they want from you with that 50K sign on bonus. If you plan to stay longer than a year or two negotiate a higher salary and lower bonus, it's more money in the long run and gives you a higher base for future increases. I personally feel it is better to get them to pay for relocation, and very small bonus or even no bonus with no repayment required so you can walk away if the job truly sucks. Bonuses are used to trap doctors into bad situations a lot - "stay here for 3 years or owe us the 50K back and cannot practice within 500 miles" type stuff. These places often go through a bunch of recent graduates and foreign trained doctors on visas and locums doctors with varying skill sets.

Another thought: who is going to cover you when you are on vacation? Also, 6 holidays is nothing. 11 holidays plus 3 weeks vacation and 1 additional week CME time with a stipend is standard from my experience.

 

[Merovinge]

Hi all. Thanks to everyone who posts job offers and gives thoughts on good vs bad and strategies. I'd have no idea what a realistic offer looked like without the advice here. Hopefully this can be a helpful reference for others down the road as well. I haven't seen this particular topic discussed yet.

I have a tentative offer (I spoke with the in house recruiter on the phone, will speak with the CMO about full details) that looks like this:

Salary 289k
Sign on 50k
Relocation 10k
CME 10 days/3600
"10 days sick leave and 6 holidays"
Generic retirement/vacation/medical benefits

The job itself is at a small rural hospital. Like, super rural. Town of 3k, county is maybe 30k. Which I like, but I just add that for reference. There is a 20 bed geri unit staffed by an NP. I'd supervise them and round "about" one weekend a month. There's also an FNP who just signed on to do outpatient, so I'd supervise them as well. My clinical role would be pretty generic outpatient (voiced flexibility that I could dictate appointment lengths) with about 10 (!) days of ED coverage a month. No word on whether that's just by phone or in person.

To me, this sounds pretty awful honestly. I'm not interested in supervising anyone. Also not jazzed to have to pull q3 call. However, the location is a place I really like, and because it's so rural, I'm assuming people aren't beating down their door to sign.

So, has anyone ever negotiated a 1099 contract from a W2 offer? I'd optimally like to contact for med/ED consults or a couple days of outpatient maybe. Is this a dead in the water idea? When I propose this to the CMO, should I also propose a rate and the whole enchilada, or wait to see what they propose? I'm finishing fellowship so I'm still in the "you'll eat it and you'll like it" mindset.

Thanks in advance!

Just so we're clear, you are taking on:
1) A >1 FTE coverage in 20 inpatient geri beds in which you are ultimately responsible for all the patients regardless of having an NP write the notes
2) 1 FTE outpatient psych supervision of an undertrained FNP doing outpatient psych
3) Covering consults/ED 10 days/month
4) AND your own clinic
for around 300k/year?

I don't think 500k with a sign on bonus of a Lambo + it's insurance would make this worth it to me. Some of the mental health care in my region is provided like this, I find it truly substandard care, but if you feel this is an acceptable system to be part of I would really want a different compensation model. The guy I know who covers an inpatient unit, several nursing homes, and >50 outpatients a day is at least looking around 1MM in annual compensation for it.

 

[robellis]

You may not have a lot of experience with rural job offers. Family med NPs can do additional training to specialize in psychiatry but are often utilized working in psychiatric clinics and hospitals even without additional training due to the lack of available more qualified staff like psychiatrists. Rural hospitals cannot afford to pay a psychiatrist $500k, neither can big city private clinics in general unless you open your own clinic and work your tail off.

Bottom line here: $289K with malpractice coverage and the benefits mentioned is a good salary if there is very little to no call, no weekends, no ER coverage and 10 patients per day, whether they are inpatient or outpatient. Supervision is easy and if the NP is seeing the same number of patients I'd ask for 10k to 20k add on fee for supervision or negotiate other bennies like more flexible schedule or vacation or CME time to travel to conferences, etc to make it work. I think it is worth $50k but I think most rural hospitals are going to balk at that. I might be wrong. Open with $50k and see what their interest level in negotiating is. Don't get sucked in to supervising an NP that is blowing through 40 patients or more on weekend rounds.

Take anything an in house recruiter says with a grain of salt. I again advise against taking a job like this unless a limit on responsibilities are spelled out specifically in writing, because they will ask you to do more and more after you get started. That is a constant of the universe in clinical medicine. When they are trying to hire you they are being as accommodating as they will ever be. They may stay that way, but may not.

Find out what they want from you with that 50K sign on bonus. If you plan to stay longer than a year or two negotiate a higher salary and lower bonus, it's more money in the long run and gives you a higher base for future increases. I personally feel it is better to get them to pay for relocation, and very small bonus or even no bonus with no repayment required so you can walk away if the job truly sucks. Bonuses are used to trap doctors into bad situations a lot - "stay here for 3 years or owe us the 50K back and cannot practice within 500 miles" type stuff. These places often go through a bunch of recent graduates and foreign trained doctors on visas and locums doctors with varying skill sets.

Another thought: who is going to cover you when you are on vacation? Also, 6 holidays is nothing. 11 holidays plus 3 weeks vacation and 1 additional week CME time with a stipend is standard from my experience.

Supervision is easy? Have you ever done geriatric psychiatry?? These are the most complicated patients with a ton of medical comorbidities, you want to supervise an NP seeing 20 of them?? Good luck with that one..this is a recipe to lose your license

 

[robellis]

Just so we're clear, you are taking on:
1) A >1 FTE coverage in 20 inpatient geri beds in which you are ultimately responsible for all the patients regardless of having an NP write the notes
2) 1 FTE outpatient psych supervision of an undertrained FNP doing outpatient psych
3) Covering consults/ED 10 days/month
4) AND your own clinic
for around 300k/year?

I don't think 500k with a sign on bonus of a Lambo + it's insurance would make this worth it to me. Some of the mental health care in my region is provided like this, I find it truly substandard care, but if you feel this is an acceptable system to be part of I would really want a different compensation model. The guy I know who covers an inpatient unit, several nursing homes, and >50 outpatients a day is at least looking around 1MM in annual compensation for it.

This is exactly right

 

[wolfvgang22]

Supervision is easy? Have you ever done geriatric psychiatry?? These are the most complicated patients with a ton of medical comorbidities, you want to supervise an NP seeing 20 of them?? Good luck with that one..this is a recipe to lose your license

I do it every day. I've never had so much as a complaint against my license. But, everyone has their own abilities and tolerances.
Also, if you read my post I didn't say 20. I said 10, max.

 

[psychacad]

I've seen some similar obnoxious offers. They want MDs to take all the liability but hire NPs for the job. One such offer was a weekly rounding telepsych on an acute geri unit and signing daily NP notes on all the patients. LOL

 

[bonedrone14]

Just so we're clear, you are taking on:
1) A >1 FTE coverage in 20 inpatient geri beds in which you are ultimately responsible for all the patients regardless of having an NP write the notes
2) 1 FTE outpatient psych supervision of an undertrained FNP doing outpatient psych
3) Covering consults/ED 10 days/month
4) AND your own clinic
for around 300k/year?

I don't think 500k with a sign on bonus of a Lambo + it's insurance would make this worth it to me. Some of the mental health care in my region is provided like this, I find it truly substandard care, but if you feel this is an acceptable system to be part of I would really want a different compensation model. The guy I know who covers an inpatient unit, several nursing homes, and >50 outpatients a day is at least looking around 1MM in annual compensation for it.

Very well stated. I might have to use this when I talk with the CMO. And to be clear, I agree that setups like this lead to bad care and the doc is the patsy should anything happen. Not my kind of a deal.

And thinking of it the way someone alluded to above, I guess they may really not be able to pay what that should be worth. Plus, if the NP's are checking the boxes why go with a more expensive option in a psychiatrist. Which I guess may lead them to turn down any of my negotiations since I don't plan on supervising anyone.

 

[calvnandhobbs68]

Just so we're clear, you are taking on:
1) A >1 FTE coverage in 20 inpatient geri beds in which you are ultimately responsible for all the patients regardless of having an NP write the notes
2) 1 FTE outpatient psych supervision of an undertrained FNP doing outpatient psych
3) Covering consults/ED 10 days/month
4) AND your own clinic
for around 300k/year?

I don't think 500k with a sign on bonus of a Lambo + it's insurance would make this worth it to me. Some of the mental health care in my region is provided like this, I find it truly substandard care, but if you feel this is an acceptable system to be part of I would really want a different compensation model. The guy I know who covers an inpatient unit, several nursing homes, and >50 outpatients a day is at least looking around 1MM in annual compensation for it.

Perfect way of spelling that out. Cut this down to 2 of those (most reasonably doing your own clinic + supervising outpatient NP) and they’re coming closer to a more usual offer. The ED coverage alone would kill that for me, what are you supposed to be doing taking calls in between patients in your clinic vs killing your weekends covering the ED? No way.

 

[psychacad]

It's utter craziness. Whatever you do please don't take offers like that. I'm sure theres a poor soul somewhere who needs to be on a visa or something getting forced to take a job like that one, but we really need to respect our profession and our patients. You're better opening your PP in a rural area and taking insurance.

 

[bonedrone14]

It's utter craziness. Whatever you do please don't take offers like that. I'm sure theres a poor soul somewhere who needs to be on a visa or something getting forced to take a job like that one, but we really need to respect our profession and our patients. You're better opening your PP in a rural area and taking insurance.

I'm leaning more and more towards this. I've traditionally disliked outpatient. But I think my residency clinic and all its trappings played a big role in that. I'm wondering if being my own boss would make a world of difference.

 

[Sushirolls]

Being your own boss is Priceless. Once you taste the independence and freedom, so hard to ever go back.

 

[Candidate2017]

Who covers clinic patients while you are doing 10 days' ED consults? Who supervises NPs while you are in clinic? Probably you?

Working in three different settings (clinic, gero unit supervision, ED consults) for one paid position seems terribly inefficient from your end but a good deal for the hospital. Outside residency, you are free to tell The Man that in return for an agreed upon amount of cash, you are happy to do A or B or C clinical duty for him, but he can pick only one.

 

[Stagg737]

I do it every day. I've never had so much as a complaint against my license. But, everyone has their own abilities and tolerances.
Also, if you read my post I didn't say 20. I said 10, max.

Is this at the VA though? There’s a pretty significant difference in liability between VA jobs and everything else. Anywhere else, if the person you’re supervising screws up you’re going to be the one held liable, I’ve unfortunately heard of some nightmarish situations through PPP regarding physicians who were supervising mid levels. I legitimately don’t understand the willingness of most people to supervise and put their license on the line. Especially if they have not worked with the person they’re supervising.

 

[TexasPhysician]

Is this at the VA though? There’s a pretty significant difference in liability between VA jobs and everything else. Anywhere else, if the person you’re supervising screws up you’re going to be the one held liable, I’ve unfortunately heard of some nightmarish situations through PPP regarding physicians who were supervising mid levels. I legitimately don’t understand the willingness of most people to supervise and put their license on the line. Especially if they have not worked with the person they’re supervising.

Having known someone that lost their medical license from supervision, I won’t consider a midlevel unless I’m hiring them in my clinic in which I can see any/all of their patients every day.

 

[Merovinge]

Having known someone that lost their medical license from supervision, I won’t consider a midlevel unless I’m hiring them in my clinic in which I can see any/all of their patients every day.

And gero psych inpatient has got to be the absolute worst place to do that when you are not even on the unit. I can't even...

 

[bonedrone14]

I figured I'd close the loop here for anyone who may find this helpful in their own job negotiations.

I spoke with the CMO, who was more than happy to discuss contracting rather than hiring me as a W2 employee. So happy, in fact, that she admitted that they really "just need someone for medical directorship," just as many above were speculating.

For those interested in this type of role, she mentioned paying a yearly stipend plus a per-chart rate. I didn't get specifics because I have no interest in doing that type of work.

 

[dl2dp2]

I spoke with the CMO, who was more than happy to discuss contracting rather than hiring me as a W2 employee. So happy, in fact, that she admitted that they really "just need someone for medical directorship," just as many above were speculating.

I recently was contacted by someone also for a "medical director" job, which I initially thought was to do more institutional policy/systems-level work, which might have been a match. After a 10 min discussion, it became apparent that these days "medical director" literally means signing 100 NP charts. No thanks.

 

[Sushirolls]

Or it means being the enforcer to the CEO of a for profit hospital.
Or it means being the yes man to a non-profit hospital system that wants to continue inefficiently doing things and preserving the CEO / top admin salary structure by continuing the facade of things 'looking good on paper.'