Negotiating new contract with boss

[painconfidential]

Hello I need some advice as I am at a crossing point in my career. I am currently a PMR pain and I joined an Anesthesia Pain private practice solo practicioner last year. He is getting older so he wants to meet with me and discuss a 2-3 year plan.

Right now I have a straight base salary. We are EXTREMELY busy though we do about 20-30 procedures half day in his ASC as well as on clinic days we see about 30+ patients a day (which for me is draining and a lot). The thing I don't like is I don't have any autonomy, I don't control my own schedule (for example I wanted to have clinic from 7AM to 3PM and no new patients scheduled after 2 but that was completely disregarded). I also am only doing procedures 1X a week which isn't horrible. My main issue too is I'm seeing way too many Personal Injury Patients and I want to see the insurance patients too. Overall I just feel like a glorified PA and I don't have any ownership over my patients or my practice.

So I have some specific questions:
1. My current base salary is 300,000 and will go up to 350,000 in a month. I know for a fact he is making a ton of money off of me and I don't necessarily mind being busy seeing 30-40 patients a day but I also have very little incentive. So I want to negotiate some sort of base and incentive package what kind of numbers would make sense?

2. How can I structure it so I have some autonomy and say in the practice?

3. How does one figure compensation with PI patients? Should I negotiate a percentage of the liens?

4. He also owns an ASC which he is the only one that does procedures in. To be honest I don't have any interest in owning an ASC because it seems like its a lot of headache and a lot of employees to manage. Is this stupid of me?

5. How else would you guys approach this? He is looking to retire in 3-4 years and he has a son who is another PMR doctor and he is interested in forming a medical group between us three.

Im just not really sure where to begin or what kinds of demands/requests to even make... All I know is I have a pretty decent base salary but Im making him a TON of money and seeing 30-40 patients a day in clinic which I find draining even though the hours aren't so bad. Id like a bigger piece of the pie or at least some incentive to being that busy.

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[lobelsteve]

Id replace you and keep the 1.2 million profit after ive paid you and covered your benefits.

 

[tmvguy03]

You must demand transparency or walk. Conservatively you are probably bringing in 1.5 million/yr in collections. In any other reasonable setting you should be bringing home 900k gross for how busy you are. I wouldn’t take a salary under 550k+incentives

 

[paindoc007]

Leave immediately. I do way less and make way more. He won’t be reasonable if he’s screwing you this hard already

 

[Tramadeezy]

Damn your job gives me anxiety. 40 patients a day making 300k, thats rough man. I work 50% less and make twice as much... You should be killing it with that kind of volume. I would demand some sort of new patient/procedure bonus structure and if he is really considering incorporating you and his son I would work out some deal where you eventually become part owner in the ASC.

 

[Agast]

You’re going to get screwed over to make way for the son. Here comes the son, do do do doo...

 

[callmeanesthesia]

Hello I need some advice as I am at a crossing point in my career. I am currently a PMR pain and I joined an Anesthesia Pain private practice solo practicioner last year. He is getting older so he wants to meet with me and discuss a 2-3 year plan.

Right now I have a straight base salary. We are EXTREMELY busy though we do about 20-30 procedures half day in his ASC as well as on clinic days we see about 30+ patients a day (which for me is draining and a lot). The thing I don't like is I don't have any autonomy, I don't control my own schedule (for example I wanted to have clinic from 7AM to 3PM and no new patients scheduled after 2 but that was completely disregarded). I also am only doing procedures 1X a week which isn't horrible. My main issue too is I'm seeing way too many Personal Injury Patients and I want to see the insurance patients too. Overall I just feel like a glorified PA and I don't have any ownership over my patients or my practice.

So I have some specific questions:
1. My current base salary is 300,000 and will go up to 350,000 in a month. I know for a fact he is making a ton of money off of me and I don't necessarily mind being busy seeing 30-40 patients a day but I also have very little incentive. So I want to negotiate some sort of base and incentive package what kind of numbers would make sense?

2. How can I structure it so I have some autonomy and say in the practice?

3. How does one figure compensation with PI patients? Should I negotiate a percentage of the liens?

4. He also owns an ASC which he is the only one that does procedures in. To be honest I don't have any interest in owning an ASC because it seems like its a lot of headache and a lot of employees to manage. Is this stupid of me?

5. How else would you guys approach this? He is looking to retire in 3-4 years and he has a son who is another PMR doctor and he is interested in forming a medical group between us three.

Im just not really sure where to begin or what kinds of demands/requests to even make... All I know is I have a pretty decent base salary but Im making him a TON of money and seeing 30-40 patients a day in clinic which I find draining even though the hours aren't so bad. Id like a bigger piece of the pie or at least some incentive to being that busy.

First and biggest question for you to ask yourself is, how willing are you to walk? Is your geographic area very attractive? Do you have a strict noncompete, and if so can you leave the area? If you are willing and able to walk you have negotiating power. If there is something keeping you in this job, you are a supplicant in the conversation.

It sounds like you are being screwed hard. With how busy you are, you should be making a lot more (and generating a lot more than a day of procedures - does he have you doing a lot of med management or something?). Get your wRVU data if you can - compare it to one of the data sets available on here to see what you should be making.

If you can leave this job, it’s time to start making some discreet inquiries in other groups. You will be in a strong negotiating position but you absolutely must be willing and able to walk. Know your contract inside and out going in to that discussion. Make sure you have enough saved for tail coverage and moving/credentialing expenses. Hopefully he’s on the up and up and really does want to cut you in at this point, but based on what you have described it sounds like you are being used.

 

[nvrsumr]

Lots of auto in asc is millions and millions

 

[blockstar]

Partnership man...youve paid the price turning and burning.

 

[drusso]

Hello I need some advice as I am at a crossing point in my career. I am currently a PMR pain and I joined an Anesthesia Pain private practice solo practicioner last year. He is getting older so he wants to meet with me and discuss a 2-3 year plan.

Right now I have a straight base salary. We are EXTREMELY busy though we do about 20-30 procedures half day in his ASC as well as on clinic days we see about 30+ patients a day (which for me is draining and a lot). The thing I don't like is I don't have any autonomy, I don't control my own schedule (for example I wanted to have clinic from 7AM to 3PM and no new patients scheduled after 2 but that was completely disregarded). I also am only doing procedures 1X a week which isn't horrible. My main issue too is I'm seeing way too many Personal Injury Patients and I want to see the insurance patients too. Overall I just feel like a glorified PA and I don't have any ownership over my patients or my practice.

So I have some specific questions:
1. My current base salary is 300,000 and will go up to 350,000 in a month. I know for a fact he is making a ton of money off of me and I don't necessarily mind being busy seeing 30-40 patients a day but I also have very little incentive. So I want to negotiate some sort of base and incentive package what kind of numbers would make sense?

2. How can I structure it so I have some autonomy and say in the practice?

3. How does one figure compensation with PI patients? Should I negotiate a percentage of the liens?

4. He also owns an ASC which he is the only one that does procedures in. To be honest I don't have any interest in owning an ASC because it seems like its a lot of headache and a lot of employees to manage. Is this stupid of me?

5. How else would you guys approach this? He is looking to retire in 3-4 years and he has a son who is another PMR doctor and he is interested in forming a medical group between us three.

Im just not really sure where to begin or what kinds of demands/requests to even make... All I know is I have a pretty decent base salary but Im making him a TON of money and seeing 30-40 patients a day in clinic which I find draining even though the hours aren't so bad. Id like a bigger piece of the pie or at least some incentive to being that busy.

Negotiate a production-based compensation arrangement--preferably a percent of collections.

Ask questions about succession planning. Ask him what he would do without you? The next prospect might not have the same work ethic you do. That's a terrible risk for him to take.

Millionaire Doctor Dying From Cancer Warns That Money, Nice Things Bring 'No Joy' in the End

A Singaporean physician who lived his life in the “fast lane” had learned one critical lesson after his days became numbered: there’s more to life than money. Dr. Richard Teo Keng Siang, a cosmetic surgeon, managed to spread his message before succumbing to lung cancer in October 2012.

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[painconfidential]

Yeah I think I have a lot of leverage because I have been setting up some fall back options and honestly I don’t think he’d want to lose me. He said he wants to make a plan to eventually fade a way but he doesn’t want to consider giving up the ASC which to be honest is fine with me. Just too much of a hassle.


I do agree that I need some kind of productivity model because I’m getting burnt out not being able to spend time with patients for no reason.

I know what he’s going to say:
1. He can’t tell me what my collections are because I see mostly PI patients in the satellite clinics

2. Running a practice is already very expensive so it’s not like he’s keeping all that money.

3. I can’t just expect him to handover the keys after he’s spent years building the practice

4. He may try to negotiate a higher base maybe like 500,000k which for me is a lot but I’m still working my ass of for it.

Btw guys all this makes me hate private practice but then I see how little the hospital system or academic guys make so I feel like it’s a no win situation :-/

 

[lobelsteve]

Yeah I think I have a lot of leverage because I have been setting up some fall back options and honestly I don’t think he’d want to lose me. He said he wants to make a plan to eventually fade a way but he doesn’t want to consider giving up the ASC which to be honest is fine with me. Just too much of a hassle.


I do agree that I need some kind of productivity model because I’m getting burnt out not being able to spend time with patients for no reason.

I know what he’s going to say:
1. He can’t tell me what my collections are because I see mostly PI patients in the satellite clinics

2. Running a practice is already very expensive so it’s not like he’s keeping all that money.

3. I can’t just expect him to handover the keys after he’s spent years building the practice

4. He may try to negotiate a higher base maybe like 500,000k which for me is a lot but I’m still working my ass of for it.

Btw guys all this makes me hate private practice but then I see how little the hospital system or academic guys make so I feel like it’s a no win situation :-/

You have no leverage because you are his biotch. Stop being a sheep. Base needs to be 650,000. You deserve 50% of net after 1.5x collections. That covers your nut and you can walk when you want to. No ownership.

 

[drusso]

Yeah I think I have a lot of leverage because I have been setting up some fall back options and honestly I don’t think he’d want to lose me. He said he wants to make a plan to eventually fade a way but he doesn’t want to consider giving up the ASC which to be honest is fine with me. Just too much of a hassle.


I do agree that I need some kind of productivity model because I’m getting burnt out not being able to spend time with patients for no reason.

I know what he’s going to say:
1. He can’t tell me what my collections are because I see mostly PI patients in the satellite clinics

2. Running a practice is already very expensive so it’s not like he’s keeping all that money.

3. I can’t just expect him to handover the keys after he’s spent years building the practice

4. He may try to negotiate a higher base maybe like 500,000k which for me is a lot but I’m still working my ass of for it.

Btw guys all this makes me hate private practice but then I see how little the hospital system or academic guys make so I feel like it’s a no win situation :-/

You'll never be happier than being your own boss and owning something. When you work as an employee, you're just an "at-will" employee. Hospitals can't love you. Institutions can't love you. Do what our forefathers in medicine did: Build something from the ground up.

 

[painconfidential]

Damn thanks guys this was really helpful actually. Yeah you’re right I need to stop being a sheep. Meeting this weekend gonna be aggressive

 

[lobelsteve]

Damn thanks guys this was really helpful actually. Yeah you’re right I need to stop being a sheep. Meeting this weekend gonna be aggressive

You have nothing to lose, everything to gain.

 

[SSdoc33]

ok, pump the brakes.

the opinions you have heard come from a board that is overwhelming pro-private practice and basically tells everyone to leave every job all the time.

we all agree that you arent getting paid enough. ok. fine.

comparing salaries is sort of meaningless b/c take home pay in manhattan is very different than arkansas or montana or BFE.

the real money here is facility fees from the ASC. you say you dont want to be owner or have shares in it, so you really shouldnt be entitled to all of the spoils from it.

if you dont want the hassle of being a part-owner of an ASC, then do you really want to run your own private practice (spending half of your time on administrative stuff).

your boss may not know exactly how much money you are making him (although he should be able to figure it out) -- but he knows how much he is bringing in overall, and he knows the percentage of patients you see / percentage of shots you do vs. the rest of the practice.

it sounds like you just want more money with no risk. i think we all would want that. you should get either a higher salary or incentive-based production. also, you need to have a say in the running of the practice -- which patients you see, how many days a week you do injections, your overall schedule. this may make you more happy than a higher salary. if you have no say in how you run your practice, then that is a recipe for burnout. especially at the volume you are talking about.

if the boss doesnt go for your plea, then will you be able to get a job right away in the area you want to be at an equal or higher salary? what does your significant other have to say? mine would shoot me if i told her we had to move to indiana for my job.

think about what you really want, and if you want to be a part of this practice, make a reasonable offer. my guess is that your boss will budge slightly, but probably not all that much. if you "buy-in" to the practice and put up some of your own money in one way or another, then he cant push you around as much

 

[painconfidential]

Got it thanks yeah I think at the root of it all is I want to feel some sense of ownership and all the sense of freedom and responsibility that entails. I hate not being in control of my schedule. And although I’m not upset about the money I think the principle that he’s making way more money off me (which is fine 1st year out he put trust in me and fed me patients) combined with not being in control of the schedule and how things are run bothered me.

I like the idea of potentially sacrificing pay for more flexibility but I think incentive based production would solve a lot of that.

 

[nvrsumr]

You need a piece of the ASC. You will never be compensated properly with only your professional fee no matter how you incentivize it.

 

[Ducttape]

aggression works if you want to get out of the practice.

if it were me, id try to work on an amicable solution that the boss sees as a win for him - a more engaged employee looking to expand the practice.

now, I am hospital employed, so take my suggestion with a grain of salt:

1. get shares in the ASC. tell him that this will encourage you to do more procedures at the ASC, and make more money.

2. ask for a second day at the ASC doing procedures.

3. ask for wRVU production based salary instead of the set salary.

 

[DOctorJay]

what's a reasonable percentage of collections to ask for? should it increase after certain thresholds?

 

[painconfidential]

The thing is he does 25-30 procedures a day himself in the morning at the ASC and then goes to clinic after and sees like 20-30 patients. I think where my real value to him is taking pressure off of him and also I go to a bunch of satellite clinics and chiropractor clinics and see like 30 PI patients daily. I only do procedures 1x a week but it’s usually fully booked and they aren’t necessarily my patients as opposed to the practices overall.

 

[painconfidential]

I think incentive based is a win win for everyone right?

 

[painconfidential]

Also I know if I say I dont want to be so busy and have like 4 new patients quadruple booked at 5pm hell say the problem is in private practice
You have to go where and when the patients are available.

When I started I wanted clinic to be from 7AM to 3PM with no new patient after 2 but I know he’ll say that’s not realistic because a lot of patients want to come after work etc

 

[SommeRiver]

The thing is he does 25-30 procedures a day himself in the morning at the ASC and then goes to clinic after and sees like 20-30 patients. I think where my real value to him is taking pressure off of him and also I go to a bunch of satellite clinics and chiropractor clinics and see like 30 PI patients daily. I only do procedures 1x a week but it’s usually fully booked and they aren’t necessarily my patients as opposed to the practices overall.

You go to chiro clinics? Wut you mean?

25 to 30 procedures in the AM and then a similar number of clinic pts in the afternoon? How is that even possible?

 

[Ducttape]

I’m not sure how anyone - ie myself - can competently do a procedure in 8 minutes, especially RFAs or CESI...

You could probably get a lot of business if you went private and actually spent some time - like 10 minutes - with each of them. Individualized care per se.

 

[Ligament]

You need a piece of the ASC. You will never be compensated properly with only your professional fee no matter how you incentivize it.

Be cautious, ASCs are not all gold mines. I get nothing from mine.

 

[SommeRiver]

I’m not sure how anyone - ie myself - can competently do a procedure in 8 minutes, especially RFAs or CESI...

At that volume you're running what...3 procedure rooms with Nurse Ratchet turning over the room? If I do 20 in a half day I'm totally spent afterwards, and there is a 0% chance I'm moving on to a 25 person clinic afterwards.

 

[painconfidential]

Just one procedure suite but turnover is fast. So typically clinic day is average 16 news 19 follow ups. Typical procedure day is 20 procedures in the AM and then 20 patients in clinic afternoon. Just FYI pretty much all clinic patients are personal injury

 

[painconfidential]

After taking everyone’s advice this is gonna be my request:
1. Complete transparency into the earnings of the practices
2. Incentive structure or 650k base or keep it at 350 with control over how many patients per day (not more than 30 patients scheduled as well as 2 procedure days.
3. A specific written out plan for partnership and buy in including the ASC (seems like this is what you guys recommend.
4. Two of my clinic days have to be non personal injury cases.

Does that seem fair? Anything else I should consider?

 

[SommeRiver]

I don't understand how you are seeing that many clinic pts and only generating enough procedural volume to float one half of a procedure day.

 

[SommeRiver]

You avg 640 clinic pts per month and 80 procedures?

What am I missing?

Edit - You're doing ONLY personal injury? How and why is that? I would leave that practice ASAP. You're getting hosed.

 

[painconfidential]

I don't understand how you are seeing that many clinic pts and only generating enough procedural volume to float one half of a procedure day.

It’s because when we do procedures it’s not just my patients or his. We have procedures 5days a week 20-30 but he just does them 4 days a week I do them 1 day.

 

[SommeRiver]

It’s because when we do procedures it’s not just my patients or his. We have procedures 5days a week 20-30 but he just does them 4 days a week I do them 1 day.

Yep...Later dude. I'd be outta there.

 

[drusso]

After taking everyone’s advice this is gonna be my request:
1. Complete transparency into the earnings of the practices
2. Incentive structure or 650k base or keep it at 350 with control over how many patients per day (not more than 30 patients scheduled as well as 2 procedure days.
3. A specific written out plan for partnership and buy in including the ASC (seems like this is what you guys recommend.
4. Two of my clinic days have to be non personal injury cases.

Does that seem fair? Anything else I should consider?

You're not going to get complete transparency until you're a partner. Employed hospital MD's don't get transparency. Why would an owner want to share proprietary information with you?

You need to consider "tactical empathy" in these situations and look for opportunities to "grow the pie." Buying shares in the ASC is a fact-specific decision and depends upon the valuation, the payor-mix, etc.[/QUOTE]

 

[drusso]

ok, pump the brakes.

the opinions you have heard come from a board that is overwhelming pro-private practice and basically tells everyone to leave every job all the time.

we all agree that you arent getting paid enough. ok. fine.

comparing salaries is sort of meaningless b/c take home pay in manhattan is very different than arkansas or montana or BFE.

the real money here is facility fees from the ASC. you say you dont want to be owner or have shares in it, so you really shouldnt be entitled to all of the spoils from it.

if you dont want the hassle of being a part-owner of an ASC, then do you really want to run your own private practice (spending half of your time on administrative stuff).

your boss may not know exactly how much money you are making him (although he should be able to figure it out) -- but he knows how much he is bringing in overall, and he knows the percentage of patients you see / percentage of shots you do vs. the rest of the practice.

it sounds like you just want more money with no risk. i think we all would want that. you should get either a higher salary or incentive-based production. also, you need to have a say in the running of the practice -- which patients you see, how many days a week you do injections, your overall schedule. this may make you more happy than a higher salary. if you have no say in how you run your practice, then that is a recipe for burnout. especially at the volume you are talking about.

if the boss doesnt go for your plea, then will you be able to get a job right away in the area you want to be at an equal or higher salary? what does your significant other have to say? mine would shoot me if i told her we had to move to indiana for my job.

think about what you really want, and if you want to be a part of this practice, make a reasonable offer. my guess is that your boss will budge slightly, but probably not all that much. if you "buy-in" to the practice and put up some of your own money in one way or another, then he cant push you around as much

I hate to see people stay in a bad deal because they're "afraid" of alternatives. Doctors have become so risk-averse and cuckolded. My wife would support whatever decision I make in the best interest of my career and our family.

 

[nvrsumr]

So this guy has a wildly successful practice with 3X Medicare PI reimbursement at his asc. Plus 3X on anesthesia. We are talking ridiculous $ at 125pts/week at asc then 200/week in clinic.

You are in the best position to know if this is an ethical practice you want to be a part of.

If ethical you should go eat what you kill and try for 25% share of asc.

Dinners 3 nites a week with PI attorney and chiros for the rest of your life is a fringe benefit.

 

[Ducttape]

I hate to see people stay in a bad deal because they're "afraid" of alternatives. Doctors have become so risk-averse and cuckolded. My wife would support whatever decision I make in the best interest of my career and our family.

do you think the fact that your wife is a working professional factors in to her willingness to support you? you have to admit that, when family is involved, it takes guts to give up everything to try to make improvements.


looks like your boss is in bed with PI. personally, I agree with your disdain. I do no PI work. the yoke around my neck is Medicaid...
if you do decide to leave and set up practice in the area, make sure he is aware that you wont do PI, and that might appease him enough to not hold you to any non-compete clause you have in your contract...

 

[drusso]

do you think the fact that your wife is a working professional factors in to her willingness to support you? you have to admit that, when family is involved, it takes guts to give up everything to try to make improvements.

Well, I just asked her and she said, "No. it's because you know the biz better than anyone and if you saw a better alternative we'd just buck up and support you. Kids are more resilient than people give them credit for. Life is an adventure. Stay nimble and light on your feet. Follow your bliss."

 

[Ducttape]

nice!

course, she is a psychologist.

my wife would just ask "why? are you going to make less money?"

 

[anonperson]

After taking everyone’s advice this is gonna be my request:
1. Complete transparency into the earnings of the practices
2. Incentive structure or 650k base or keep it at 350 with control over how many patients per day (not more than 30 patients scheduled as well as 2 procedure days.
3. A specific written out plan for partnership and buy in including the ASC (seems like this is what you guys recommend.
4. Two of my clinic days have to be non personal injury cases.

Does that seem fair? Anything else I should consider?

I'm not in pain but when I finished training I joined a practice as an employee with the physician-owner running a similar type of practice. My contract indicated I would make a bonus when I generated 2x my salary in collections. You know how often I got any information regarding my collections?

Zero.

He is under no obligation to be transparent to you. And you can never know you are getting full access to the financial records even if he says so. You are just an employee and to him you are replaceable.

Also, joining a practice where a father son function is a recipe for disaster. Let me guess, is his wife on the payroll or the office manager? You think you will have any standing with daddy and son outvoting you in any issues?

This guy is the equivalent of a slum lord and is running a predatory practice. Happens in all specialties. Pure greed.

 

[deleted993114]

Yeah I think I have a lot of leverage because I have been setting up some fall back options and honestly I don’t think he’d want to lose me. He said he wants to make a plan to eventually fade a way but he doesn’t want to consider giving up the ASC which to be honest is fine with me. Just too much of a hassle.


I do agree that I need some kind of productivity model because I’m getting burnt out not being able to spend time with patients for no reason.

I know what he’s going to say:
1. He can’t tell me what my collections are because I see mostly PI patients in the satellite clinics

2. Running a practice is already very expensive so it’s not like he’s keeping all that money.

3. I can’t just expect him to handover the keys after he’s spent years building the practice

4. He may try to negotiate a higher base maybe like 500,000k which for me is a lot but I’m still working my ass of for it.

Btw guys all this makes me hate private practice but then I see how little the hospital system or academic guys make so I feel like it’s a no win situation :-/

1. Start looking at other jobs and interviewing so that you have options in place. If you remain in state, consider your no-compete range. If out of state, you will need a license, which can take 3 months. DO NOT get fired- this will be a "black mark" against you when looking for other practices, regardless of who is right or wrong.

2. If moving, consider the payer mix to which you will be moving. A high medicare/Medicaid area will generate lots of work, but no revenue. There is a HUGE difference in reimbursement around the country.

3. Hospital system/employed practices are not as bad as you think. I have an offer for one with a $600K base and $75 RVU bonus which equates to about $800K per year at a leisurely pace. The hospital systems can charge 7X as much as an office and more than a surgery center, so they can afford the higher salaries. I made about $1.3 million for 20 years in an office, but the overhead over $1 million and rising was too much of a stressor to deal with. PRP has been viewed as a "salvation" by the office based practice, but we did that over 20 years ago and it did not work then. It's time will be over (again) soon.

4. Office base and surgery center bases practices will be getting "the squeeze". Larger groups are making more and more money from quality contracts, rather than direct patient contact. Thus they are seeking to use individuals with the lowest possible costs to make more money from their ACOs. Unless you participate in those contracts (The Blues just started using back pain as a quality metric this year), you will be a target of cost reduction, not expansion, particularly with the high (and many times inappropriate) use of imaging by pain clinics/spine clinics.

The world is changing to a quality based payment system and that does not bode well for those cranking out a ton of procedures every day.

5. The surgery center is a loadstone and hard asset that you don't want to own going forward. A partnership track with the guy will force you to buy into the assets (part of which will be the surgery center).

6. That guy is never going to willingly give you a square deal. Figure out how many RVUs you are generating (if you want to stay) and give yourself a base of $500k with an RVU bonus over 8,000 RVUs per year at $75 per RVU. That is fair. However, the arrangement he has is forcing you to do the lower RVU stuff, which will not change.

7. The practice is making you hate work. CHANGE! The money would not be worth it if you were actually getting paid for all the work you do. However, you are doing a lot of work and not getting paid as well. Would a reasonable, honest guy do that to a fellow physician? Think about your longevity in practice- at such a pace, you will want to quit early and will burn out. There is more to life than slaving away.

 

[drusso]

3. Hospital system/employed practices are not as bad as you think. I have an offer for one with a $600K base and $75 RVU bonus which equates to about $800K per year at a leisurely pace. The hospital systems can charge 7X as much as an office and more than a surgery center, so they can afford the higher salaries. I made about $1.3 million for 20 years in an office, but the overhead over $1 million and rising was too much of a stressor to deal with. PRP has been viewed as a "salvation" by the office based practice, but we did that over 20 years ago and it did not work then. It's time will be over (again) soon.

If you work for as an employed MD for a hospital, you're an "at-will" employee. And, you would be participating in a corrupt system of site-of-service arbitrage. Everyone knows that cushy hospital compensation is a bubble...what happens to the employed MD when the contract resets?

The real question is, "Did you go to medical school to be some hospital admin's little Biotch?"

"As private-practice physicians will attest, rising personnel costs with declining reimbursement rates lead to concerns of insolvency. For decades, hospital systems have been able to use economies of scale to absorb the mismatch in the physician compensation and physician productivity curves despite declining reimbursement; but with most hospital systems’ operating margins currently at about 3 percent and falling, these employers eventually will run out of ways to reallocate funds to cover physician compensation subsidies."

The Physician Compensation Bubble Is Looming

Physician salary has evolved the hands of many market forces, with changes in inflation rates perhaps the most significant threat to compensation rates.

www.physicianleaders.org

 

[lobelsteve]

If you work for as an employed MD for a hospital, you're an "at-will" employee. And, you would be participating in a corrupt system of site-of-service arbitrage. Everyone knows that cushy hospital compensation is a bubble...what happens to the employed MD when the contract resets?

The real question is, "Did you go to medical school to be some hospital admin's little Biotch?"

"As private-practice physicians will attest, rising personnel costs with declining reimbursement rates lead to concerns of insolvency. For decades, hospital systems have been able to use economies of scale to absorb the mismatch in the physician compensation and physician productivity curves despite declining reimbursement; but with most hospital systems’ operating margins currently at about 3 percent and falling, these employers eventually will run out of ways to reallocate funds to cover physician compensation subsidies."

The Physician Compensation Bubble Is Looming

Physician salary has evolved the hands of many market forces, with changes in inflation rates perhaps the most significant threat to compensation rates.

www.physicianleaders.org

Or $ell$tem$ells.

 

[Ligament]

Was that 800k offer in a reasonable metropolitan area or rustic?

 

[Laryngospasm]

You are really getting screwed. PI work is extremely lucrative. I had a practice where I did that only and in one day a week doing 12 or so procedures made way more than you are making total. If he is hosing you that bad you will not be very likely to get him to stop. Get a good business manager and attorney and figure out a plan to go out on your own.

 

[painconfidential]

Hey all,

I wanted to updated everyone on the situation. This forum has been extremely helpful.

So after I met with my Boss he agreed to some sort of base salary + productivity incentive. He stated the reason we are so busy is because of marketing costs and we have a lot of costs associated with maintaining an ASC and multiple offices. One issue I have is he isn't being completely transparent. He tells me they are paying 50,000 a month on marketing which I find to be excessive. Also, he said he is ok with some sort of productivity incentive BUT it certainly won't be 50:50 after costs because he feels like the patients are being handed to me on a platter. I don't get why 50/50 wouldn't be fair or at least 55/45 AFTER costs. That's just pure money in his pocket. Also, if im going to make a longer term commitment I want to have some say in terms of how business is run. For example, how many patients I see in a day, who are these marketers and why are we paying the so much, etc. Is that a fair expectation? He is also making me see a ton of PI which I kind of hate because I can't do any newer procedures on these patients and overall they are not very medically complicated so I feel like I'm not honing my skills which is important for me as a fresh grad.


I have another option of joining this internal medicine doctor who is now an administrator. He is offering me a 2 year guarantee salary of $350,000 first year and $400,000 the second with 50:50 split after costs. I asked him what would costs be defined as on contract and he replied that it would be mutually agreed upon. Is this a sufficient answer? I feel like there should be a cold hard number. Also he said that he is ok with all hiring and firing decisions to be made mutually. He is ok to limiting the practice to being 20% Personal Injury. His idea is eventually growing a pain/neurology/rehab practice with me starting it. The thing is this would probably be more work as its something I would have to grow but Ill have the stability of salary and all of his resources and network (He is very well connected and has been a doctor in the area for a very long time).

I am planning on using the two against eachother to get the best possible deal. The thing is I am honestly not looking for an easy way out or to make money off of someone. I just want a fair deal and to practice in a setting where I have some degree of control and can practice ethically under my terms. I still think pain practices can make a lot of money operating this way.

 

[Ducttape]

Go solo...

 

[deleted993114]

Was that 800k offer in a reasonable metropolitan area or rustic?

Well...................... I am somewhat white trash, so my definition of a nice place differs from that of a normal human. Midwest town of 60K with a small university. High employment rate and not run down; so I think it is a nice place, but others probably would not. I really do not like large metro areas, however.

My previous job was in a town of about 600K and I made $1.3 million per year for 15-16 years. It was exclusively an office based practice- 75% commercial insurance/25% medicare. However, it was part of a multi-specialty clinic and admin was horrible, despite it being physician owned. The CEO gained control of the clinic and is destroying it- I "escaped" and am glad to be away. Volumes are down 30%. The doc who took over my position is a new grad who can only see 15 pts per day and do 6-7 procedures. I saw 32-35 pts per day and did 24-25 procedures.

With that volume, my overhead was $1 million; things can get squeezed with just minor changes in volume/reimbursement, so it was too much of a rat race.

There are trade offs with every job as well as pros and cons. The CMS is implementing site neutral reimbursement for E&M codes; perhaps in the future they will drive pain procedures away from the hospitals with site neutral procedure reimbursement.

 

[lobelsteve]

I saw 32-35 pts per day and did 24-25 procedures.

Please explain.

 

[Laryngospasm]

That’s a lot of procedures per day while seeing patients. Also from my experience it will be unlikely for you to get more than a 50:50 split. I suppose it is possible and some may have done it and want to chime in here if they have but overhead is high and reimbursement especially on the procedural side sucks now if it’s not personal injury or WC.