Pain in Ortho Group- Partnership?

Started by klumpke
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klumpke

klumpke

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7+ Year Member
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I've been in touch with an ortho group in the area that has ~15 orthos. They are looking to hire 2 pain docs to join the practice and say they are offering equal partnership after ~2 years with the practice. I'd share in their call pool seeing post op patients on the weekends (every few months) but would always have a backup in case something surgical was needed.

This seems like it could be a pretty good gig. Has anyone been in a similar set up before? Anything I should look out for so as to not get stuck in an unideal situation?

Thanks for the help!
 
klumpke said:
I've been in touch with an ortho group in the area that has ~15 orthos. They are looking to hire 2 pain docs to join the practice and say they are offering equal partnership after ~2 years with the practice. I'd share in their call pool seeing post op patients on the weekends (every few months) but would always have a backup in case something surgical was needed.

This seems like it could be a pretty good gig. Has anyone been in a similar set up before? Anything I should look out for so as to not get stuck in an unideal situation?

Thanks for the help!
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Totally depends on the setup. Does partnership include ASC shares? Do they have in office procedure space? How is overhead allocated? Are they expecting you to do opioid management for all their patients who are still in pain after surgery? Agree with Bob - hard to take call on something you’re not familiar with. Better to negotiate that you take home call on your own patients all the time. That’s how my group does it. The surgeons take turns on call but the answering service calls the individual doctor responsible for the patient for pain (no opioid management so it’s mostly post-procedural pain).
 
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They want to hire 2 at the same time? Thats an interesting move. Are they replacing outgoing physicians?
 
Agast said:
They want to hire 2 at the same time? Thats an interesting move. Are they replacing outgoing physicians?
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Its a bit complicated but the tldr is they were a private group that was bought by a large health system, hated it then bought themselves back and lost some people in the back and forth. They would hire one this summer then me finishing fellowship the following summer once hes ramped up
 
klumpke said:
I've been in touch with an ortho group in the area that has ~15 orthos. They are looking to hire 2 pain docs to join the practice and say they are offering equal partnership after ~2 years with the practice. I'd share in their call pool seeing post op patients on the weekends (every few months) but would always have a backup in case something surgical was needed.

This seems like it could be a pretty good gig. Has anyone been in a similar set up before? Anything I should look out for so as to not get stuck in an unideal situation?

Thanks for the help!
Click to expand...
Covering call for a surgery team sounds off. Your call if any should just be on pain patients.
 
Be very careful with ortho partnerships.

Get ASC shares, prob avoid the equal partner status. Do NOT take weekend call and round on their pts for them.

Bob's comment is a bullseye.
 
mille125 said:
Covering call for a surgery team sounds off. Your call if any should just be on pain patients.
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I take practice call - it’s just answering the phone and questions about post op pain, constipation, is this a fever, should I go to the ED. Anything concerning gets turfed to the primary ortho. Anything involving the hospital is handled by ortho.
 
Agast said:
I take practice call - it’s just answering the phone and questions about post op pain, constipation, is this a fever, should I go to the ED. Anything concerning gets turfed to the primary ortho. Anything involving the hospital is handled by ortho.
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Ya this is exactly what it sounds like, nothing too difficult and if it at all smells fishy, I think the ortho gets involved. How has this worked for you? Come across any issues?
 
MitchLevi said:
Be very careful with ortho partnerships.

Get ASC shares, prob avoid the equal partner status. Do NOT take weekend call and round on their pts for them.

Bob's comment is a bullseye.
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Wait why do you say avoid the equal partner status?
 
klumpke said:
Ya this is exactly what it sounds like, nothing too difficult and if it at all smells fishy, I think the ortho gets involved. How has this worked for you? Come across any issues?
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None so far. Although sometimes I’ve told the patient they should go to the ED and find out they really don’t want to. Then I just document the phone call and my advice.
 
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klumpke said:
Wait why do you say avoid the equal partner status?
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Maybe I worded it too strongly but ortho practices are fat. Very high overhead. It’s funny how dead on Bob was in his post. We lost several hundred thousand dollars in Visco recently. If the practice is large you’ll be paying on the electricity at locations that lose money overall, and you’ll be losing money on PT. There are many issues with ortho partnership. Get ASC shares and make plenty of money with no BS.

If the practice employs a few hundred ppl overall you’ll be dealing with disgruntled employees and lawsuits from IT guys and doctors threatening to leave bc they aren’t getting enough OR time when the reality is they’re slower than the total knee guy who is a freaking machine. You’ll be seeing his anterior hips and total knees soon enough btw.

Let a lawsuit go on two or more yrs and watch MILLIONS of dollars go to attorney fees. Ask me how I know.

Positives are most referrals are internal referrals and that often spares you opiate pts, they also pretty much leave you alone and let you do your thing. The call situation is a no go IMO. I would never do that bc a PA should be doing that.

You’ll see financial statements where the practice has millions and millions of dollars pouring in each month, but 75-80% of that goes to overhead.

What are the buy in costs and do you have to buy real estate shares? If you do, and the practice has multiple locations that real estate loan will be large.
 
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In my opinion, a partnership in the orthopaedic group without a surgical center is not a good deal. If you’re interested in the position, you should request the financial statement from the group. Office injection is a very important factor to consider when negotiating compensation.
 
What’s the point of partnership without ASC shares?
High overhead, I agree

It may be worth while from volume standpoint but see if you can buy your own c arm and do 1099.
Pay for what you use if they are providing volume
 
SpineandWine said:
What’s the point of partnership without ASC shares?
High overhead, I agree

It may be worth while from volume standpoint but see if you can buy your own c arm and do 1099.
Pay for what you use if they are providing volume
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You may be able to get ASC shares but not be a partner.
That is a fantastic deal under the right circumstances.
If that ASC is booming, you make a lot of money without shouldering a lot of the risk of the company.
 
The ASC could be a completely separate business. We have younger pain docs and urologists who are owners in our center. The books and business are completely different. We have doctors who are owners in our center that are w2 employees on rvu’s.
 
BobBarker said:
The ASC could be a completely separate business. We have younger pain docs and urologists who are owners in our center. The books and business are completely different. We have doctors who are owners in our center that are w2 employees on rvu’s.
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Yep. For many ppl, that’s a great deal depending on the volume of cases in that surgical center.
 
MitchLevi said:
Yep. For many ppl, that’s a great deal depending on the volume of cases in that surgical center.
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Yep, but to reiterate what mitch is saying from the other end, you need good volume in that ASC. I'm in a multi specialty, primarily Ortho group. Several of the docs own part of the ASC nearby. It is doing quite poorly and I certainly won't be buying shares at any point. Their volume simply can't keep up with the costs.
 
Ortho groups often tout multiple ASCs and multiple clinic sites, lure you in with potential ownership in these surgical centers, and you think, “I can own a piece of three ASCs,” and you can make no money in the process.

If you have to buy into each of them separately that’s an issue, some practices being an equal partner gets you ownership in the ASCs just off your practice buy in.

Again, please be aware the more real estate owned by practice means the bigger buy in, and the overhead gets higher and higher.

If there is a real estate buy in you’re going to be taking out potentially 500k or more in loans, which is usually a separate buy in from the partnership buy in.

If the practice has been around for a long time, the partners who own real estate shares likely bought in during a different market value, so they may have purchased shares for a small amount of money, and you’ll be having to buy shares at a far higher amount.

There is usually one ASC which is booming (main location) and they want the others to make money as well. Begin shunting cases to those locations and that may work out great of course. Problem is it doesn’t always work out that way, and the expansion of the practice keeps adding to the overhead and the satellites often lose money.
 
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Great risk, possible great reward. An Ortho friend of mine was part of a large group. He was always unhappy that they had 2 pain guys who earned more than almost all of the orthopods. Advice here is solid. You need sharp accountants/lawyer to reviews all of the details. They definitely should have PA covering Ortho call.
 
There’s no way I could compete with the total hip and knee guy that left us last yr. No way. Entire practice was set up for him. You’d have to be extremely busy, and I know there are some guys out there who could, but he was a freaking machine. Totally aloof guy, not a fan of him btw.
 
I worked for an ortho spine group and rounded on post op patients over the weekends. Always had “ortho backup”

Often this back up was out of the country on vacation. Large deformity cases with poor outcomes. Patients on vents and angry and concerned families asking questions. I would literally round at 6 am Saturday to avoid the families.

Practice thought is was great that I could bill separately as a different specialty within their global

Don’t round on their patients.
 
BobBarker said:
Busy, interventional pain doc out earns any orthopedist both in the office and ASC setting. The ASC is partially due to them doing cases at 6 different facilities.
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What is considered a busy Interventional pain doc? How many office visits/day and procedures/day or yearly? How much are you working a year?
 
If you see 35 per day 4 days a week (50/50 procedures/office visits) and did 1-2 ASC procedures a week you would collect around $1.5M in professional collections. The surgery center will net profit around $200,000 minimum. Could be much more if you are doing SCS implants on commercial patients. Ortho can’t do that.
 
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BobBarker said:
If you see 35 per day 4 days a week (50/50 procedures/office visits) and did 1-2 ASC procedures a week you would collect around $1.5M in professional collections. The surgery center will net profit around $200,000 minimum. Could be much more if you are doing SCS implants on commercial patients. Ortho can’t do that.
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Problem is you simply can’t just take OR time bc you’re more profitable per hr. Simply isn’t gonna happen. If it is a long standing ortho practice, they will keep the surgeons in the surgical center regardless of who you are and what you’re capable of doing.

I’m kind of talking S again…My ASC spot is in no danger, and no one is taking my block from me. I was one of the first docs to do cases there, helped pay off the debt and was rewarded with ownership without paying a buy in…In 3 hrs I crank volume out of there, but in our oldest ASC if I want block time I come in at 0600 and do cases before the other guys start for the day.

If there is an old ortho guy who has been in the practice a long time you’re not bumping his spot. Simply isn’t gonna work that way no matter who you are.
 
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Linktones said:
How were you able to be rewarded shares in the ASC without a buy in?
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TIVAndy said:
if you are busy pain guy you will generate so much money for the asc that they will fear you taking cases elsewhere. they were generous to offer that though.
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I'm wondering about the legal implications. Being awarded ASC shares for bringing cases there is definitely in the realm of inducement and kickback.
 
It’s our own ASC. First floor of the building, second floor is the clinic and PT.

Nothing illegal about this. I was given shares as a part of my contract. It opened, took us a year to pay off the debt, now it produces. I paid $100 actually. I think the debt was paid and it became profitable in 14 months.

When I got here, it was still being built, finished and went through inspections and first ten cases were maybe 3M later. Overall opened maybe 3M after that. We just built a third and a fourth is coming soon.
 
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MitchLevi said:
It’s our own ASC. First floor of the building, second floor is the clinic and PT.

Nothing illegal about this. I was given shares as a part of my contract. It opened, took us a year to pay off the debt, now it produces. I paid $100 actually. I think the debt was paid and it became profitable in 14 months.

When I got here, it was still being built, finished and went through inspections and first ten cases were maybe 3M later. Overall opened maybe 3M after that. We just built a third and a fourth is coming soon.
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You guys paid off the construction loan in a year? That's crazy fast. We're halfway through a 9 year loan that's pretty painful.
 
RoloTomassi said:
You guys paid off the construction loan in a year? That's crazy fast. We're halfway through a 9 year loan that's pretty painful.
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I’m going to say it started producing dividends a year and a half after opening. Somewhere in that ballpark, maybe a few months longer than that? It finished construction late 2017, first ten cases were Dec if I recall, opened completely for business around April? First dividends were distributed prob 18 months later? Loans are taken out against it periodically however.
 
MitchLevi said:
It’s our own ASC. First floor of the building, second floor is the clinic and PT.

Nothing illegal about this. I was given shares as a part of my contract. It opened, took us a year to pay off the debt, now it produces. I paid $100 actually. I think the debt was paid and it became profitable in 14 months.

When I got here, it was still being built, finished and went through inspections and first ten cases were maybe 3M later. Overall opened maybe 3M after that. We just built a third and a fourth is coming soon.
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Ok so you paid for the building then?
 
It sounds like you weren’t really rewarded/given shares per se as the value of the ASC when you joined was basically nothing other than the contents. I just don’t want the younger docs just starting out to think they can just be given shares no matter how many cases they bring to the ASC without a proper fair market valuation and fair market buy in. As mentioned above, inducement and stark laws come into play. Either way you got in at a great time and glad it’s been a great investment for you. Congrats!
 
Linktones said:
It sounds like you weren’t really rewarded/given shares per se as the value of the ASC when you joined was basically nothing other than the contents. I just don’t want the younger docs just starting out to think they can just be given shares no matter how many cases they bring to the ASC without a proper fair market valuation and fair market buy in. As mentioned above, inducement and stark laws come into play. Either way you got in at a great time and glad it’s been a great investment for you. Congrats!
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Yes, there was nothing but a building full of debt. I paid (I think it was $100) the fee for legalities. Not a busy ASC, just debt. That market was primed for volume and basically untapped. Timing was just right. I also, by the nature of what we do for a living, provide a great service to the practice. Pain docs in ortho groups are valuable, whether you’re doing stim and advanced stuff or just bread and butter.

If a new hire wanted to own a piece of that ASC they would have to buy in.
 
MitchLevi said:
Problem is you simply can’t just take OR time bc you’re more profitable per hr. Simply isn’t gonna happen. If it is a long standing ortho practice, they will keep the surgeons in the surgical center regardless of who you are and what you’re capable of doing.

I’m kind of talking S again…My ASC spot is in no danger, and no one is taking my block from me. I was one of the first docs to do cases there, helped pay off the debt and was rewarded with ownership without paying a buy in…In 3 hrs I crank volume out of there, but in our oldest ASC if I want block time I come in at 0600 and do cases before the other guys start for the day.

If there is an old ortho guy who has been in the practice a long time you’re not bumping his spot. Simply isn’t gonna work that way no matter who you are.
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If you don't mind me asking, what sort of volume and cases are you pushing through?
 
MitchLevi said:
It’s our own ASC. First floor of the building, second floor is the clinic and PT.

Nothing illegal about this. I was given shares as a part of my contract. It opened, took us a year to pay off the debt, now it produces. I paid $100 actually. I think the debt was paid and it became profitable in 14 months.

When I got here, it was still being built, finished and went through inspections and first ten cases were maybe 3M later. Overall opened maybe 3M after that. We just built a third and a fourth is coming soon.
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Great timing for you.

I am definitely not a lawyer but the structure sounds off to me. If you had a healthcare attorney sign off on it, ignore me as I don't have all the details. If you did not, I would pay the thousand bucks to review.
 
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ED50 said:
If you don't mind me asking, what sort of volume and cases are you pushing through?
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Right this current moment I am losing my PA and training another so 2026 has been less busy but I like 6-8 per hr. That’s very easy to do in a clinic suite, but IMO you’re maxing an ASC at that rate. Single room, not flip flopping rooms. That’s basically epidurals and ablations. Intracept and implants take longer obviously, trials isually very quick.

Once my PA situations is fixed, it would be prob 30 bread and butter procedures in 4-5 hrs per week. Something like that. It’s 37% of my total procedures, the rest are on different days in a clinic suite.

Problem is I’m just much more comfortable in the clinic suite, and I’m used to that speed. ASC staff cannot do it, and they’ll get passive aggressive with you too.

If I do 3 hrs on Tuesday, then an hr on Friday, so 4 total hrs of ASC per week that is minimal overhead and that collects a lot of money. Majority of orthopedic surgeons cannot keep up with that on an hr to be basis. There are rare outliers, like I’ve mentioned before a guy who left us last yr was a freaking machine. Total hips and knees but the entire practice was set up for him.
 
BobBarker said:
If you see 35 per day 4 days a week (50/50 procedures/office visits) and did 1-2 ASC procedures a week you would collect around $1.5M in professional collections. The surgery center will net profit around $200,000 minimum. Could be much more if you are doing SCS implants on commercial patients. Ortho can’t do that.
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Wow, always thought ortho made more than this
 
Equal shares in ASC with orthopedists don’t motivate us to contribute more to surgical center settings, while the “eat what you can kill” model does. With the latter model, we can easily earn $500,000.
 
Our orthopedists struggle to make a profit after paying for hourly variable costs and implants. It isn’t fully fair as anesthesia is doing the blocks in the OR and that time is being assigned to the orthopedists OR time. So they are making a small profit most likely.
 
Our anesthesia team is performing blocks in the pre-holding area. Even this the orthopedic guys struggle to make a profit in the ASC setting compared to pain injections. the model does motivate them to do surgeries more efficiently, we have hand guys do CTS in 5 minutes, total hip in 30 minutes. 😉
 
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