New Job Advice

[TeslaCoil]

Hello all,

I am looking for contract advice. I have been offered a position at a middle-of-nowhere hospital, which currently has one pain physician who is looking to retire. He is currently doing med mgmt and some injections but is not heavily procedural. The hospital is looking for somebody to come in and do mostly procedures, including injections, stim, and possibly pumps. The contract they are offering for this is $400k base plus "15% production bonus" (have not gotten the RVU details yet). What they said was that the guy who is there now has made up to 650k in years where he has "worked hard". The rest of the deal is 6 weeks PTO plus 1 week CME, Full benefits paid. Malpractice paid.

In your expert opinion, is this a decent deal? Also, what is a reasonable RVU number to shoot for, if you are doing stim, injections, minimal med management, +/- pump. I need to know what to ask for if they have a minimum RVU level before production kicks in. Another offer I had was 10k RVU before production even starts, that sounds hardly attainable with a reasonable 8-4pm, 5 days/wk.

Another question I had was regarding tail coverage. What is the current trend? Do employers pay this in the event of termination of contract? Or does the physician?

Many thanks in advance!

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[Laryngospasm]

Yes they should pay for tail coverage. Trust me you don’t want to get a bill for 20-60k if you decide to leave. Second if rvu based it should go off of mgma rvu numbers which are easy to find. I believe the current 50%tile is right at 6600 per year. You should shoot for being compensated fairly above this number. There are jobs out there that will do this.. if they won’t then move on unless you have a real reason to be there. The 10k rvu offer is insulting unless the base is really high.

 

[changeofheart2016]

Looking at jobs myself as well. What region of the country is this?

My gut feeling is that places are low balling fellows because of covid, so I'm taking the approach to wait until Nov and then negotiate for a better contract.

 

[Laryngospasm]

Also important to find out how the rvus are calculated and communicated to you and how often bonuses are paid as well as any issue that can keep you from getting bonuses. Some places have clauses based off of charts being completed in a certain time etc. interview with the current docs and let them show you how it works will be the most helpful thing. Pick their brains.

 

[TIVAndy]

hospital will benefit immensely from OR site of service fee from procedures. ideally you should keep 50% of collections above your salary

 

[TeslaCoil]

Yes they should pay for tail coverage. Trust me you don’t want to get a bill for 20-60k if you decide to leave. Second if rvu based it should go off of mgma rvu numbers which are easy to find. I believe the current 50%tile is right at 6600 per year. You should shoot for being compensated fairly above this number. There are jobs out there that will do this.. if they won’t then move on unless you have a real reason to be there. The 10k rvu offer is insulting unless the base is really high.

Yea I thought the 10k RVU mark was a little ridiculous. So based on what you're saying if the MGMA 50th %ile aligns with 6500 RVU's and ~$450K, then the base should be around this number? Basically just shoot for the percentile pay to align with how many RVU's I'm expected to be generating? Thanks!

 

[SommeRiver]

Remember total compensation and salary are not the same number. If they agree to pay you...450k, you're actually costing them far more...401k, benefits, insurance, etc...I may be wrong, but I think MGMA is total compensation, and if that is true the guy getting 450k is actually being paid less.

So keep that in mind.

 

[Ducttape]

don't think you can do that, ie directly asking for % collections by the facility. you wont get it, either.

this sounds like a heavily Medicare/Medicaid area. you will be forced eventually to take his patients, NUT over time you essentially will be building up the practice for yourself. this does give you the opportunity to make the program as you see fit, however, but it will take at least 2 years.

while the bonus pay may sound lucrative, in this population group it will PROBABLY be harder to attain.

make sure that the salary is at least MGMA 50%, and is locked in place for a couple of years.

they will probably tell you that the payment for wRVU will be a blended amount based on their current private insurance/government insurance rate. if it is primarily private practice (its rural, so it wont be), then you should expect closer to $65/wRVU. with a heavy Medicaid population, it will be much lower. much much lower. you might want to consider whether a full wRVU model will be worth it.... it may be best to ask for high base salary esp if they offer low $/wRVU.

 

[TeslaCoil]

don't think you can do that, ie directly asking for % collections by the facility. you wont get it, either.

this sounds like a heavily Medicare/Medicaid area. you will be forced eventually to take his patients, NUT over time you essentially will be building up the practice for yourself. this does give you the opportunity to make the program as you see fit, however, but it will take at least 2 years.

while the bonus pay may sound lucrative, in this population group it will PROBABLY be harder to attain.

make sure that the salary is at least MGMA 50%, and is locked in place for a couple of years.

they will probably tell you that the payment for wRVU will be a blended amount based on their current private insurance/government insurance rate. if it is primarily private practice (its rural, so it wont be), then you should expect closer to $65/wRVU. with a heavy Medicaid population, it will be much lower. much much lower. you might want to consider whether a full wRVU model will be worth it.... it may be best to ask for high base salary esp if they offer low $/wRVU.

well... it is rural but it is actually private practice. Medicare yes, Medicaid, no. My question is more so in reference to the RVU's. What would be reasonable for me to ask of the practice as far as 1) The RVU level at which the production bonus begins to kick in, and 2) how much money per RVU to ask for.

 

[Laryngospasm]

Shoot for bonus above 50%tile mid to upper 60$ per rvu. Of course this may change based on base guarantee. Some of the established folks have really high guarantee with no bonus.

 

[drusso]

don't think you can do that, ie directly asking for % collections by the facility. you wont get it, either.

this sounds like a heavily Medicare/Medicaid area. you will be forced eventually to take his patients, NUT over time you essentially will be building up the practice for yourself. this does give you the opportunity to make the program as you see fit, however, but it will take at least 2 years.

while the bonus pay may sound lucrative, in this population group it will PROBABLY be harder to attain.

make sure that the salary is at least MGMA 50%, and is locked in place for a couple of years.

they will probably tell you that the payment for wRVU will be a blended amount based on their current private insurance/government insurance rate. if it is primarily private practice (its rural, so it wont be), then you should expect closer to $65/wRVU. with a heavy Medicaid population, it will be much lower. much much lower. you might want to consider whether a full wRVU model will be worth it.... it may be best to ask for high base salary esp if they offer low $/wRVU.

As long as the OP is stuck in an RVU-based, "fixed-pie," "distributive bargaining," "Price-Is-RIght," frame, it is not a negotiation as much as it is a stick-up. "I think it should be $64/RVU; No, $63/RVU; Okay, let's settle for $63.50..." It's garbage. Ditto for MGMA. Garbage. These are sleight-of-hand tricks that more experienced HR and hiring managers use to distract physicians from having the REAL conversation: "How much is my work worth to you?" In order to answer that you need to know Enterprise Value. What is the value of ALL the activity the doctor is going to bring to the hospital: Facility fees, $O$, downstream revenue, labs, PT, etc, etc, etc.

If a doctor's employer is going to bill government payers (and of course most do), then the employer has to demonstrate that the compensation arrangement is "fair market value." It doesn't have to be RVU-based, MGMA-based, etc. There are a ton of creative ways they can work above and beyond FMV and still be compliant. It can be any method the EMPLOYER chooses. And, it is completely discretionary. Moreover, it is not up to the employee to make sure that the method is compliant.

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it. Then, I would say, "Okay are you ready to talk like adults now? How much money do you think I will bring in and how much of it do you think that I'm entitled to keep?" Once you have that number, the employer can backward engineer any comp method they want to drive the process to that result. That's the conversation that needs to happen here.

 

[SommeRiver]

As long as the OP is stuck in an RVU-based, "fixed-pie," "distributive bargaining," "Price-Is-RIght," frame, it is not a negotiation as much as it is a stick-up. "I think it should be $64/RVU; No, $63/RVU; Okay, let's settle for $63.50..." It's garbage. Ditto for MGMA. Garbage. These are sleight-of-hand tricks that more experienced HR and hiring managers use to distract physicians from having the REAL conversation: "How much is my work worth to you?" In order to answer that you need to know Enterprise Value. What is the value of ALL the activity the doctor is going to bring to the hospital: Facility fees, $O$, downstream revenue, labs, PT, etc, etc, etc.

If a doctor's employer is going to bill government payers (and of course most do), then the employer has to demonstrate that the compensation arrangement is "fair market value." It doesn't have to be RVU-based, MGMA-based, etc. There are a ton of creative ways they can work above and beyond FMV and still be compliant. It can be any method the EMPLOYER chooses. And, it is completely discretionary. Moreover, it is not up to the employee to make sure that the method is compliant.

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it. Then, I would say, "Okay are you ready to talk like adults now? How much money do you think I will bring in and how much of it do you think that I'm entitled to keep?" Once you have that number, the employer can backward engineer any comp method they want to drive the process to that result. That's the conversation that needs to happen here.

...and then they're like, "Oh...Well, you've never done a single case by yourself have you? You can strong arm us when you've earned that right...You're not only replaceable you're easily replaceable."

 

[drusso]

...and then they're like, "Oh...Well, you've never done a single case by yourself have you? You can strong arm us when you've earned that right...You're not only replaceable you're easily replaceable."

Then, you had them the spinal needle/trochar/Jamshidi and say, "Here, go do it your-f*cking-self." Remember, people who go into hospital administration are night school MBA, 2.80 GPA state college, sociology majors...not Jeff Bezos."

 

[bedrock]

...and then they're like, "Oh...Well, you've never done a single case by yourself have you? You can strong arm us when you've earned that right...You're not only replaceable you're easily replaceable."

Though we should remember that this is not a highly desirable area, but in the OPs words-- "middle of nowhere"

He can definitely ask and should receive more than 50% MGMA to practice in BFE.

The hospital won't necessarily find it easy to find someone else. If they were in highly desirable ares, things would be different.

 

[paindoc007]

As long as the OP is stuck in an RVU-based, "fixed-pie," "distributive bargaining," "Price-Is-RIght," frame, it is not a negotiation as much as it is a stick-up. "I think it should be $64/RVU; No, $63/RVU; Okay, let's settle for $63.50..." It's garbage. Ditto for MGMA. Garbage. These are sleight-of-hand tricks that more experienced HR and hiring managers use to distract physicians from having the REAL conversation: "How much is my work worth to you?" In order to answer that you need to know Enterprise Value. What is the value of ALL the activity the doctor is going to bring to the hospital: Facility fees, $O$, downstream revenue, labs, PT, etc, etc, etc.

If a doctor's employer is going to bill government payers (and of course most do), then the employer has to demonstrate that the compensation arrangement is "fair market value." It doesn't have to be RVU-based, MGMA-based, etc. There are a ton of creative ways they can work above and beyond FMV and still be compliant. It can be any method the EMPLOYER chooses. And, it is completely discretionary. Moreover, it is not up to the employee to make sure that the method is compliant.

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it. Then, I would say, "Okay are you ready to talk like adults now? How much money do you think I will bring in and how much of it do you think that I'm entitled to keep?" Once you have that number, the employer can backward engineer any comp method they want to drive the process to that result. That's the conversation that needs to happen here.

Wait this is a serious question. Isn’t all that illegal? Downstream revenue from imaging, referrals, therapy, etc and using that in the equation for income to an employed physician ?

this sort of thing:

Feds accuse hospitals of using big salaries to lure specialists

Hospitals are eager to get particular specialists on staff because they bring in business that can be highly profitable.

www.google.com

 

[SommeRiver]

Though we should remember that this is not a highly desirable area, but in the OPs words-- "middle of nowhere"

He can definitely ask and should receive more than 50% MGMA to practice in BFE.

The hospital won't necessarily find it easy to find someone else. If they were in highly desirable ares, things would be different.

Of course, and one should always negotiate and stick up for yourself but we're talking about fellowship graduates who've never actually been pain doctors rolling in there tryna wear V neck tee shirts and pleated pants...

 

[Laryngospasm]

While I agree with Dr. Russo on a fundamental level the reality is going in with that attitude as a new grad won’t get you very far. My hospital is largely physician run and we recently worked out a new way for people to get their Bonus payments earlier and more consistently with transparency. To think a new grad is going to come in and get special treatment different than everyone else is a little nuts. If you are going to push for things you should consider things which will make a big difference financially for you that the hospital will possibly consider such a loan assistance, tail coverage, etc.

 

[TeslaCoil]

While I agree with Dr. Russo on a fundamental level the reality is going in with that attitude as a new grad won’t get you very far. My hospital is largely physician run and we recently worked out a new way for people to get their Bonus payments earlier and more consistently with transparency. To think a new grad is going to come in and get special treatment different than everyone else is a little nuts. If you are going to push for things you should consider things which will make a big difference financially for you that the hospital will possibly consider such a loan assistance, tail coverage, etc.

This is exactly why Im asking for applicable real world advice and thank you for the well-grounded responses! Will definitely come in handy. Im not looking to strike oil, just want to avoid being taken complete advantage of as a fresh grad of fellowship.

 

[drusso]

While I agree with Dr. Russo on a fundamental level the reality is going in with that attitude as a new grad won’t get you very far. My hospital is largely physician run and we recently worked out a new way for people to get their Bonus payments earlier and more consistently with transparency. To think a new grad is going to come in and get special treatment different than everyone else is a little nuts. If you are going to push for things you should consider things which will make a big difference financially for you that the hospital will possibly consider such a loan assistance, tail coverage, etc.

You're right. As a new grad, there is less leverage. But look at the things you mentioned: Loan assistance, tail coverage, etc. I would add: Moving assistance, CME, technology allowances, child care allowance, etc. I know one doctor who negotiated private school tuition for his kids!

My larger point is that Doctors get no training in how to have these conversations in medical school, residency, fellowship, etc. But, the 2.80 GPA MBA Night School Grad actually does! They attend classes where they role model and play negotiate low-balling doctors the same way we learn how to take an STD history...

How old were you when you learned about physician enterprise value and facility fees?

 

[cowboydoc]

You're right. As a new grad, there is less leverage. But look at the things you mentioned: Loan assistance, tail coverage, etc. I would add: Moving assistance, CME, technology allowances, child care allowance, etc. I know one doctor who negotiated private school tuition for his kids!

My larger point is that Doctors get no training in how to have these conversations in medical school, residency, fellowship, etc. But, the 2.80 GPA MBA Night School Grad actually does! They attend classes where they role model and play negotiate low-balling doctors the same way we learn how to take an STD history...

How old were you when you learned about physician enterprise value and facility fees?

That’s more nuanced. With the utmost respect, I believe your experience and demeanor has made you “unemployable.”

 

[gdub25]

Can you please clarify if this is a hospital employee position or if you will be employed by a private practice group. The answer to this question alone completely changes the negotiation and the job offer in general.

 

[TeslaCoil]

Can you please clarify if this is a hospital employee position or if you will be employed by a private practice group. The answer to this question alone completely changes the negotiation and the job offer in general.

Its private hospital employed. Non-partnership.

 

[Agast]

Did you contact the retiring physician and ask him what his base salary and production bonus are? If you’re taking over his clinic the schedule should already be full, so at the very least it’s reasonable to ask for exactly what he has if not more.

 

[SommeRiver]

I don't recommend taking over an established doctor's clinic schedule until you've been on your own for at least a month or two.

 

[Laryngospasm]

I don't recommend taking over an established doctor's clinic schedule until you've been on your own for at least a month or two.

Or six!

 

[Pain Applicant1]

...and then they're like, "Oh...Well, you've never done a single case by yourself have you? You can strong arm us when you've earned that right...You're not only replaceable you're easily replaceable."

I don't know about that. I was straight out of fellowship and I convinced the local hospital to fund my practice start-up completely and guarantee me a salary on top of it. I had to borrow zero dollars on my own and was guaranteed to earn at least a minimum amount, even if I saw zero patients. The minimum amount was greater than 50% MGMA at the time. All I had to do was stay in the area for a couple of years and agree not to build a surgical center for 6 years and they forgave the loan. I initially cold-called different hospitals until finding one who was interested in my proposition of an income guarantee and loan forgiveness. I then gave a presentation to the CEO, CFO, and some others in the hospital and it worked. Never discount your ability and potential.

 

[drusso]

I don't know about that. I was straight out of fellowship and I convinced the local hospital to fund my practice start-up completely and guarantee me a salary on top of it. I had to borrow zero dollars on my own and was guaranteed to earn at least a minimum amount, even if I saw zero patients. The minimum amount was greater than 50% MGMA at the time. All I had to do was stay in the area for a couple of years and agree not to build a surgical center for 6 years and they forgave the loan. I initially cold-called different hospitals until finding one who was interested in my proposition of an income guarantee and loan forgiveness. I then gave a presentation to the CEO, CFO, and some others in the hospital and it worked. Never discount your ability and potential.

That's inspiring!

 

[SommeRiver]

I don't know about that. I was straight out of fellowship and I convinced the local hospital to fund my practice start-up completely and guarantee me a salary on top of it. I had to borrow zero dollars on my own and was guaranteed to earn at least a minimum amount, even if I saw zero patients. The minimum amount was greater than 50% MGMA at the time. All I had to do was stay in the area for a couple of years and agree not to build a surgical center for 6 years and they forgave the loan. I initially cold-called different hospitals until finding one who was interested in my proposition of an income guarantee and loan forgiveness. I then gave a presentation to the CEO, CFO, and some others in the hospital and it worked. Never discount your ability and potential.

Great job, and like I said earlier in the thread, always negotiate and stick up for yourself.

Most new grads do not have the ability to do what you did, and most need to get some experience in the real world before trying to make demands bc all of us DEFINITELY ARE REPLACEABLE.

Maybe you're better than 95% of other doctors in your field, but at the end of the day that probably doesn't matter to a CFO/CEO.

 

[drusso]

Maybe you're better than 95% of other doctors in your field, but at the end of the day that probably doesn't matter to a CFO/CEO.

My experience has been that the C-suite folks just want an RVU-slut...anyone who a turn facility-fee trick for a payday. Quality, integrity, or entrepreneurial spirit are WAY down on their list.

 

[SommeRiver]

My experience has been that the C-suite folks just want an RVU-slut...anyone who a turn facility-fee trick a payday. Quality, integrity, or entrepreneurial spirit are WAY down on their list.

Exactly my point.

It doesn't matter how "good" you are at your job in most circumstances. Perhaps it matters if you're on faculty somewhere and going after grant money and publishing...Maybe...

Most doctors are just doctors, and when it comes to hiring it doesn't really matter.

 

[TeslaCoil]

I don't recommend taking over an established doctor's clinic schedule until you've been on your own for at least a month or two.

There would be overlap of about a year.

 

[SommeRiver]

There would be overlap of about a year.

Cool. I was given the option of jumping in deep off the bat but didn't, and it was immensely beneficial. It just isn't the same when you're "the guy."

Everything takes longer for the first several months. Everything...

 

[Pain Applicant1]

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it.

Then, you had them the spinal needle/trochar/Jamshidi and say, "Here, go do it your-f*cking-self."

This man is hysterical!!!! I love it!

 

[Pain Applicant1]

Great job, and like I said earlier in the thread, always negotiate and stick up for yourself.

Most new grads do not have the ability to do what you did, and most need to get some experience in the real world before trying to make demands bc all of us DEFINITELY ARE REPLACEABLE.

Maybe you're better than 95% of other doctors in your field, but at the end of the day that probably doesn't matter to a CFO/CEO.

I agree, it doesn't matter. People tend to care only about how they benefit. I knew that and when I presented it to the hospital I incorporated it. Of course, I told them how I would benefit the community, improve care, blah blah blah but really I knew what they were thinking. I told them about patients I can bring to the community, referrals to their orthopods, the needs for MRIs, my procedures in their surgery center. etc. I used their surgery center for 3 months before bringing the procedures in-house. This way worked for me back then but I still like DRUSSO's approach much better!!!!

As I mentioned to some of you, if you guys have questions please post them here and don't PM me. This site really helped me when I was starting out and I should try to give back a bit at this point. I'm not sure if there is any interest in my experience, but if there is, the questions may be helpful to others.

 

[Ligament]

As long as the OP is stuck in an RVU-based, "fixed-pie," "distributive bargaining," "Price-Is-RIght," frame, it is not a negotiation as much as it is a stick-up. "I think it should be $64/RVU; No, $63/RVU; Okay, let's settle for $63.50..." It's garbage. Ditto for MGMA. Garbage. These are sleight-of-hand tricks that more experienced HR and hiring managers use to distract physicians from having the REAL conversation: "How much is my work worth to you?" In order to answer that you need to know Enterprise Value. What is the value of ALL the activity the doctor is going to bring to the hospital: Facility fees, $O$, downstream revenue, labs, PT, etc, etc, etc.

If a doctor's employer is going to bill government payers (and of course most do), then the employer has to demonstrate that the compensation arrangement is "fair market value." It doesn't have to be RVU-based, MGMA-based, etc. There are a ton of creative ways they can work above and beyond FMV and still be compliant. It can be any method the EMPLOYER chooses. And, it is completely discretionary. Moreover, it is not up to the employee to make sure that the method is compliant.

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it. Then, I would say, "Okay are you ready to talk like adults now? How much money do you think I will bring in and how much of it do you think that I'm entitled to keep?" Once you have that number, the employer can backward engineer any comp method they want to drive the process to that result. That's the conversation that needs to happen here.

Beautiful post and should be stickied forever.

 

[au bon pain]

I don't know about that. I was straight out of fellowship and I convinced the local hospital to fund my practice start-up completely and guarantee me a salary on top of it. I had to borrow zero dollars on my own and was guaranteed to earn at least a minimum amount, even if I saw zero patients. The minimum amount was greater than 50% MGMA at the time. All I had to do was stay in the area for a couple of years and agree not to build a surgical center for 6 years and they forgave the loan. I initially cold-called different hospitals until finding one who was interested in my proposition of an income guarantee and loan forgiveness. I then gave a presentation to the CEO, CFO, and some others in the hospital and it worked. Never discount your ability and potential.

Wow, well done!

How did you get your foot in the door at these places? Did you just call the hospital and ask to speak to the CEO/CMO? Also, how did you negotiate and successfully sell the admins on your desired setup?

 

[Pain Applicant1]

Wow, well done!

How did you get your foot in the door at these places? Did you just call the hospital and ask to speak to the CEO/CMO? Also, how did you negotiate and successfully sell the admins on your desired setup?

First, I did what I call a poor man's demographic analysis. It was like I was going to war. I printed out massive google maps and taped the pieces together. I searched around the area I needed to be in. Then I marked all the pain docs in the area and the population of each area. The population numbers came from Wikipedia. This way, I was able to target an area with good catchment and low competition. I called each pain doctor to see how busy they were and how long it would take to make an appointment. I called primary care docs asking if they needed a pain doc to refer to. I finally pinpointed and settled on a location. I then called the physician recruiters from different hospitals in the area. One hospital took my idea and tried to hire their own pain doc. They were not successful so the recruiter contacted me a few weeks later and they flew me down and put me up in a nice hotel. It was about a decade ago so I don't remember exactly what I did but I believe I made a PowerPoint presentation to several of the top brass. I remember the CFO, CEO, some admins, and some doctors were there. I mentioned what I noted in my previous post. Not that it matters but I'm a graduate of both Harvard and Hopkins so I think they liked that. More importantly, I spoke confidently like I knew what I was doing which I did not. I attribute my lack of intimidation and confidence at the time to have grown up in NYC in the 80s and 90s. I fought a bit as a kid so I wasn't really scared of a few guys in suits. I brought them MGMA numbers and used them as a starting point for negotiations. I convinced them to fund my startup. My practice was profitable somewhere between the 2nd and 3rd months and I terminated the contract with the hospital after 10 months as I broke through the minimum income guarantee. I can't give out specific numbers but the hospital ended up dishing out quite a bit of moolah to me, more so than has been discussed in this post so far. The irony of the whole thing is that if they refused to offer me the income guarantee and loan forgiveness, I still would have started my practice there. Of course, I never let them know that.

 

[au bon pain]

First, I did what I call a poor man's demographic analysis. It was like I was going to war. I printed out massive google maps and taped the pieces together. I searched around the area I needed to be in. Then I marked all the pain docs in the area and the population of each area. The population numbers came from Wikipedia. This way, I was able to target an area with good catchment and low competition. I called each pain doctor to see how busy they were and how long it would take to make an appointment. I called primary care docs asking if they needed a pain doc to refer to. I finally pinpointed and settled on a location. I then called the physician recruiters from different hospitals in the area. One hospital took my idea and tried to hire their own pain doc. They were not successful so the recruiter contacted me a few weeks later and they flew me down and put me up in a nice hotel. It was about a decade ago so I don't remember exactly what I did but I believe I made a PowerPoint presentation to several of the top brass. I remember the CFO, CEO, some admins, and some doctors were there. I mentioned what I noted in my previous post. Not that it matters but I'm a graduate of both Harvard and Hopkins so I think they liked that. More importantly, I spoke confidently like I knew what I was doing which I did not. I attribute my lack of intimidation and confidence at the time to have grown up in NYC in the 80s and 90s. I fought a bit as a kid so I wasn't really scared of a few guys in suits. I brought them MGMA numbers and used them as a starting point for negotiations. I convinced them to fund my startup. My practice was profitable somewhere between the 2nd and 3rd months and I terminated the contract with the hospital after 10 months as I broke through the minimum income guarantee. I can't give out specific numbers but the hospital ended up dishing out quite a bit of moolah to me, more so than has been discussed in this post so far. The irony of the whole thing is that if they refused to offer me the income guarantee and loan forgiveness, I still would have started my practice there. Of course, I never let them know that.

Your methods are savage. And I love it.

 

[drusso]

First, I did what I call a poor man's demographic analysis. It was like I was going to war. I printed out massive google maps and taped the pieces together. I searched around the area I needed to be in. Then I marked all the pain docs in the area and the population of each area. The population numbers came from Wikipedia. This way, I was able to target an area with good catchment and low competition. I called each pain doctor to see how busy they were and how long it would take to make an appointment. I called primary care docs asking if they needed a pain doc to refer to. I finally pinpointed and settled on a location. I then called the physician recruiters from different hospitals in the area. One hospital took my idea and tried to hire their own pain doc. They were not successful so the recruiter contacted me a few weeks later and they flew me down and put me up in a nice hotel. It was about a decade ago so I don't remember exactly what I did but I believe I made a PowerPoint presentation to several of the top brass. I remember the CFO, CEO, some admins, and some doctors were there. I mentioned what I noted in my previous post. Not that it matters but I'm a graduate of both Harvard and Hopkins so I think they liked that. More importantly, I spoke confidently like I knew what I was doing which I did not. I attribute my lack of intimidation and confidence at the time to have grown up in NYC in the 80s and 90s. I fought a bit as a kid so I wasn't really scared of a few guys in suits. I brought them MGMA numbers and used them as a starting point for negotiations. I convinced them to fund my startup. My practice was profitable somewhere between the 2nd and 3rd months and I terminated the contract with the hospital after 10 months as I broke through the minimum income guarantee. I can't give out specific numbers but the hospital ended up dishing out quite a bit of moolah to me, more so than has been discussed in this post so far. The irony of the whole thing is that if they refused to offer me the income guarantee and loan forgiveness, I still would have started my practice there. Of course, I never let them know that.

You're a machine and inspiration for EVERY pain fellow! You should speak about your experiences at conferences and fellows' events!

 

[Ducttape]

very nice.


my experience was, uh, kinda 100% different.

I called and interviewed at all the local pain and hospital clinics that said yes. it is beneficial when you are interviewing in an area that you've lived in for 20 years. get to know people..

one hospital clinic said "all our docs are retiring. we have an opioid problem in our patient population."
I said "that's obvious."
they said "can you help? the other guys we interviewed are focused on injections and how much money they can make."
I said "I'm your huckleberry."

well, maybe not quite...

 

[Ronin1]

Hello all,

I am looking for contract advice. I have been offered a position at a middle-of-nowhere hospital, which currently has one pain physician who is looking to retire. He is currently doing med mgmt and some injections but is not heavily procedural. The hospital is looking for somebody to come in and do mostly procedures, including injections, stim, and possibly pumps. The contract they are offering for this is $400k base plus "15% production bonus" (have not gotten the RVU details yet). What they said was that the guy who is there now has made up to 650k in years where he has "worked hard". The rest of the deal is 6 weeks PTO plus 1 week CME, Full benefits paid. Malpractice paid.

In your expert opinion, is this a decent deal? Also, what is a reasonable RVU number to shoot for, if you are doing stim, injections, minimal med management, +/- pump. I need to know what to ask for if they have a minimum RVU level before production kicks in. Another offer I had was 10k RVU before production even starts, that sounds hardly attainable with a reasonable 8-4pm, 5 days/wk.

Another question I had was regarding tail coverage. What is the current trend? Do employers pay this in the event of termination of contract? Or does the physician?

Many thanks in advance!

You need all the details. I just turned down a flyover location job with a high guarantee 675k but a very high bonus threshold (12k wrvu). Didn’t like this specific structure.

 

[Baron Samedi]

I'll say as someone going through it now that I will never recommend a new graduate go off somewhere they'll be totally alone, especially if there isn't already an infrastructure in place.

New graduates should be focused on solidifying their clinical skills. When you are off on your own you have no mentorship, no colleagues to discuss cases or troubleshoot with, you're on permacall for anything that comes up, and anything that you want to establish you have to do it 100% yourself with no support or experience.

As the solo guy you'll have the entire patient burden to yourself, field every consult, have to deal with staffing issues and conflicts, have to order supplies, have to meet with the hospital leadership when your only C-Arm dies, have to work to get OR access, and manage every pump without any help. In addition, you have no idea what the previous guy was doing with his patients so you might be inheriting a bunch of trainwrecks.

If you feel particularly adventurous go for it, but I went into my job with the idea that I would get to focus on my clinical practice and its been far from reality.

 

[epidural man]

As long as the OP is stuck in an RVU-based, "fixed-pie," "distributive bargaining," "Price-Is-RIght," frame, it is not a negotiation as much as it is a stick-up. "I think it should be $64/RVU; No, $63/RVU; Okay, let's settle for $63.50..." It's garbage. Ditto for MGMA. Garbage. These are sleight-of-hand tricks that more experienced HR and hiring managers use to distract physicians from having the REAL conversation: "How much is my work worth to you?" In order to answer that you need to know Enterprise Value. What is the value of ALL the activity the doctor is going to bring to the hospital: Facility fees, $O$, downstream revenue, labs, PT, etc, etc, etc.

If a doctor's employer is going to bill government payers (and of course most do), then the employer has to demonstrate that the compensation arrangement is "fair market value." It doesn't have to be RVU-based, MGMA-based, etc. There are a ton of creative ways they can work above and beyond FMV and still be compliant. It can be any method the EMPLOYER chooses. And, it is completely discretionary. Moreover, it is not up to the employee to make sure that the method is compliant.

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it. Then, I would say, "Okay are you ready to talk like adults now? How much money do you think I will bring in and how much of it do you think that I'm entitled to keep?" Once you have that number, the employer can backward engineer any comp method they want to drive the process to that result. That's the conversation that needs to happen here.

Great post

As long as the OP is stuck in an RVU-based, "fixed-pie," "distributive bargaining," "Price-Is-RIght," frame, it is not a negotiation as much as it is a stick-up. "I think it should be $64/RVU; No, $63/RVU; Okay, let's settle for $63.50..." It's garbage. Ditto for MGMA. Garbage. These are sleight-of-hand tricks that more experienced HR and hiring managers use to distract physicians from having the REAL conversation: "How much is my work worth to you?" In order to answer that you need to know Enterprise Value. What is the value of ALL the activity the doctor is going to bring to the hospital: Facility fees, $O$, downstream revenue, labs, PT, etc, etc, etc.

If a doctor's employer is going to bill government payers (and of course most do), then the employer has to demonstrate that the compensation arrangement is "fair market value." It doesn't have to be RVU-based, MGMA-based, etc. There are a ton of creative ways they can work above and beyond FMV and still be compliant. It can be any method the EMPLOYER chooses. And, it is completely discretionary. Moreover, it is not up to the employee to make sure that the method is compliant.

If I were the OP, I would take whatever offer was handed to me with the words "RVU" or "MGMA" on it and wipe my @ss with it. Then, I would say, "Okay are you ready to talk like adults now? How much money do you think I will bring in and how much of it do you think that I'm entitled to keep?" Once you have that number, the employer can backward engineer any comp method they want to drive the process to that result. That's the conversation that needs to happen here.

Great POST!

OP - using this info...try this.

Take the job - but negotiate into the contract, that EVERYTHING will be looked at in 1 year. That is, you will sit down with the hospital mgmt and go over your production, the value you brought to the hospital, etc.

Then, over the next year, work very hard to build a great practice. Make yourself invaluable to the hospital. Become the most likable and hard working employee they have.

Then, when it comes time to renegotiate (and you have some real hard numbers) - figure out what is fair. I would think at this point, you could negotiate more time off - which to me would be key.

400K base seems like great pay to me, for a W2 job (and all the benefits that come with that) - and if you are worth more than that, it will be obvious and they will gladly pay it. If you can't seem to generate the production needed to sustain that but you have become an integral part of the team, they will gladly continue to pay it.

 

[SommeRiver]

I was ALONE in a large ortho group. Had to learn everything myself with no one to help me.

I'm better at my job now bc of it.

 

[specepic]

To the OP: that pay is not bad. Just get the details. What is your RVU target per month/year? What is your $/RVU, etc. Bonus threshold? What is your support staff? Who will be your go to admin person, etc.? Having a manager/admin person who is decent is huge. I work in a rural hosp x 10 years so feel free to DM me

 

[mid|ine]

if negotiating based on wRVUs you negotiate a base salary and a value per wRVU. When your production exceeds your base, you start getting bonuses.

If your base is
$400k
and your wRVU
is $65/wrvu
then after you exceed ~6154 wRVUs you get your bonus.

It would be better to divide your annual wRVU per pay period and be able to get bonused each pay period. So if you get paid every other week (26 pay periods), that is 237wRVUs per pay period. If you do 300 in a pay period you get your base, $15, 405 (237x65) plus $4095 bonus (63x65).

Negotiate how midlevel supervision is handled. I had mine act like a resident and I signed all notes and wRVU counted towards my goal and they paid NP salary.

Negotiage exclusivity. Hospital can't hire competition

Negotiage non-compete (if they don't renew your contract, you have NO non-compete and they have to notify patients your your new practice and you can keep patient list and are allowed to contact patients)

Negotiate control over clinic hours and staffing

 

[DOctorJay]

To the OP: that pay is not bad. Just get the details. What is your RVU target per month/year? What is your $/RVU, etc. Bonus threshold? What is your support staff? Who will be your go to admin person, etc.? Having a manager/admin person who is decent is huge. I work in a rural hosp x 10 years so feel free to DM me

The admin piece is indeed huge but realize they will change more times than you will. That’s the kicker. These people tend to be 2-5 year max in these positions.

 

[Got Em]

... Not that it matters but I'm a graduate of both Harvard and Hopkins so I think they liked that...

I think you may be discounting how big of an advantage this is. I know of several other fellows who went to Harvard/Hopkins who were able to land a position like this straight out of fellowship.

Just to be clear - was it Anes residency and Pain fellowship at these 2 places, or are you talking about undergraduate degree and/or medical school? I have a Master's from Harvard, but I really don't think this matters as much as being trained in Pain at Harvard/Hopkins.

 

[Pain Applicant1]

I think you may be discounting how big of an advantage this is. I know of several other fellows who went to Harvard/Hopkins who were able to land a position like this straight out of fellowship.

Just to be clear - was it Anes residency and Pain fellowship at these 2 places, or are you talking about undergraduate degree and/or medical school? I have a Master's from Harvard, but I really don't think this matters as much as being trained in Pain at Harvard/Hopkins.

Res and fellowship. I don't think it mattered back then but whether or not it did it definitely does not matter now. I don't hang any degrees or anything like that in my office and rarely if ever, mention it nowadays. Keep in mind that this wasn't a position. I was never an employee of anyone and was always self-employed so no one technically hired me.

 

[Got Em]

First, I did what I call a poor man's demographic analysis. It was like I was going to war. I printed out massive google maps and taped the pieces together. I searched around the area I needed to be in. Then I marked all the pain docs in the area and the population of each area. The population numbers came from Wikipedia. This way, I was able to target an area with good catchment and low competition. I called each pain doctor to see how busy they were and how long it would take to make an appointment. I called primary care docs asking if they needed a pain doc to refer to. I finally pinpointed and settled on a location. I then called the physician recruiters from different hospitals in the area. One hospital took my idea and tried to hire their own pain doc. They were not successful so the recruiter contacted me a few weeks later and they flew me down and put me up in a nice hotel. It was about a decade ago so I don't remember exactly what I did but I believe I made a PowerPoint presentation to several of the top brass. I remember the CFO, CEO, some admins, and some doctors were there. I mentioned what I noted in my previous post. Not that it matters but I'm a graduate of both Harvard and Hopkins so I think they liked that. More importantly, I spoke confidently like I knew what I was doing which I did not. I attribute my lack of intimidation and confidence at the time to have grown up in NYC in the 80s and 90s. I fought a bit as a kid so I wasn't really scared of a few guys in suits. I brought them MGMA numbers and used them as a starting point for negotiations. I convinced them to fund my startup. My practice was profitable somewhere between the 2nd and 3rd months and I terminated the contract with the hospital after 10 months as I broke through the minimum income guarantee. I can't give out specific numbers but the hospital ended up dishing out quite a bit of moolah to me, more so than has been discussed in this post so far. The irony of the whole thing is that if they refused to offer me the income guarantee and loan forgiveness, I still would have started my practice there. Of course, I never let them know that.

Had a couple more questions about this post if you don't mind sharing.

1) What was the specific set up between you and the hospital? Ex: Who paid for rent, staff, and build out?

2) How were you able to only do procedures in ASC for a few months and then bring it in-house? The hospital loses out on facility fee, so I'd imagine it would be a difficult negotiating factor. Also, when you brought procedures in-house, did you pay for the C-Arm, US, and RFA machines yourself?

3) You said you "broke the contract" with the hospital. What does this exactly mean and how were you able to do this without repercussions?

4) How were you able to find the specific pain medicine downstream valuations? I would assume CEOs want to know this.