Private practice vs hospital based practice

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chromuffin

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Hello all,

I’m looking into two different job offers right now. I’m a current anesthesia/pain fellow who is in the midst of finding a job.

1. Hospital Based
Pay: ~$75/wRVU with base guarantee approx 400k. Sign-on: ~50k for 4 years
Referral base is largely from small rural setting.
Malpractice with tail coverage
No Call; 4-day work week
Receptive administration; CEO is an MD
Practice currently has 1 other provider who I personally know. Very reasonable.
Cons: Less desirable living situation, productivity may be limited based on RVU data I have

2. Private Practice
Pay: Unclear; “eat what you kill” philosophy
50% overhead costs
Practice is comprised of a 5 site group spread across the state. I would be at the two most desirable locations.
I’m no expert at billing, which is a big concern and hesitation with this gig. Current provider states he is seeing ~15-25 new patients/day in clinic or ~25-35 return visits/day. 1-2 procedure days a week with approximately 10-15 procedures a day. Wide-variety of advanced procedures offered including SCS, IT pumps, kypho, vertiflex, MILD, intracept, reactiv8, PNS, etc. Large referral base.
One of the partners is very knowledgeable and has offered mentorship.
Future ASC ownership potential.
No call; 5-day work week
Cons: no malpractice coverage, no clear sign-on bonus (although no contract has been offered yet), no PSLF opportunity

My gut tells me the hospital offer is what I should take for the PSLF. My knowledge on billing is non-existent, so I’m not sure if this private practice offer would make sense for my experience level? The last thing I want to do is find myself in a role making <300k with 300k of loans to pay off.

Any advice would be appreciated or even resources for me to translate potential future earnings. I’m at a loss right now.
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chromuffin said:
Hello all,

I’m looking into two different job offers right now. I’m a current anesthesia/pain fellow who is in the midst of finding a job.

1. Hospital Based
Pay: ~$75/wRVU with base guarantee approx 400k. Sign-on: ~50k for 4 years
Referral base is largely from small rural setting.
Malpractice with tail coverage
No Call; 4-day work week
Receptive administration; CEO is an MD
Practice currently has 1 other provider who I personally know. Very reasonable.
Cons: Less desirable living situation, productivity may be limited based on RVU data I have

2. Private Practice
Pay: Unclear; “eat what you kill” philosophy
50% overhead costs
Practice is comprised of a 5 site group spread across the state. I would be at the two most desirable locations.
I’m no expert at billing, which is a big concern and hesitation with this gig. Current provider states he is seeing ~15-25 new patients/day in clinic or ~25-35 return visits/day. 1-2 procedure days a week with approximately 10-15 procedures a day. Wide-variety of advanced procedures offered including SCS, IT pumps, kypho, vertiflex, MILD, intracept, reactiv8, PNS, etc. Large referral base.
One of the partners is very knowledgeable and has offered mentorship.
Future ASC ownership potential.
No call; 5-day work week
Cons: no malpractice coverage, no clear sign-on bonus (although no contract has been offered yet), no PSLF opportunity

My gut tells me the hospital offer is what I should take for the PSLF. My knowledge on billing is non-existent, so I’m not sure if this private practice offer would make sense for my experience level? The last thing I want to do is find myself in a role making <300k with 300k of loans to pay off.

Any advice would be appreciated or even resources for me to translate potential future earnings. I’m at a loss right now.
Click to expand...
What does your S.O. say?

PSLF only kicks in if you work 10 years, right? Thats a big gamble.
 
SSdoc33 said:
What does your S.O. say?

PSLF only kicks in if you work 10 years, right? Thats a big gamble.
Click to expand...
That’s the right question!

Pslf is 10 years of payments, so it could be a shorter tenure demand. Stats say you won’t last 2 years, and if your SO hates it, it will be insufferable.

Ignore the $50k sign on. It’s a forgivable loan. Live like a resident for those 4 years regardless of the gig.

If your SO is on board, the first sounds good, unless you may need to uproot school-aged kids after a few years.
 
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Residency + fellowship equates to 5 years of PSLF. So I need to cover 5 years in a non-profit for PSLF. My SO predominantly wants work life balance but also would rather the more desirable location near friends. The hospital practice would make us live around 45 min-1 hr from all our close friends. My SO would tolerate this for a 5 year period but she wouldn’t love the idea. The caveat is that the hospital based practice has an 8 week vacation allotment. The private practice has 3 weeks. My wife and I would like to travel while we are still young and before kids.
 
chromuffin said:
Residency + fellowship equates to 5 years of PSLF. So I need to cover 5 years in a non-profit for PSLF. My SO predominantly wants work life balance but also would rather the more desirable location near friends. The hospital practice would make us live around 45 min-1 hr from all our close friends. My SO would tolerate this for a 5 year period but she wouldn’t love the idea. The caveat is that the hospital based practice has an 8 week vacation allotment. The private practice has 3 weeks. My wife and I would like to travel while we are still young and before kids.
Click to expand...
You are going to take the PP gig.

And i think you know it.

Its the wrong decision financially and for career development but probably the right decision for your life right now. You cant take the girl to middle of nowhere. She will be pissed and resentful even if she says she wont be.

You are supposed to take the hospital job first then move to PP later. You will be reversing it due to your situation.
 
chromuffin said:
Residency + fellowship equates to 5 years of PSLF. So I need to cover 5 years in a non-profit for PSLF. My SO predominantly wants work life balance but also would rather the more desirable location near friends. The hospital practice would make us live around 45 min-1 hr from all our close friends. My SO would tolerate this for a 5 year period but she wouldn’t love the idea. The caveat is that the hospital based practice has an 8 week vacation allotment. The private practice has 3 weeks. My wife and I would like to travel while we are still young and before kids.
Click to expand...
1 hour is a long drive. 2 hour roundtrip. hard to plan anything realistic. expensive uber ride or gotta get hotels. it gets old real quick. it's not possible once you have kids too.
 
chromuffin said:
Hello all,

I’m looking into two different job offers right now. I’m a current anesthesia/pain fellow who is in the midst of finding a job.

1. Hospital Based
Pay: ~$75/wRVU with base guarantee approx 400k. Sign-on: ~50k for 4 years
Referral base is largely from small rural setting.
Malpractice with tail coverage
No Call; 4-day work week
Receptive administration; CEO is an MD
Practice currently has 1 other provider who I personally know. Very reasonable.
Cons: Less desirable living situation, productivity may be limited based on RVU data I have

2. Private Practice
Pay: Unclear; “eat what you kill” philosophy
50% overhead costs
Practice is comprised of a 5 site group spread across the state. I would be at the two most desirable locations.
I’m no expert at billing, which is a big concern and hesitation with this gig. Current provider states he is seeing ~15-25 new patients/day in clinic or ~25-35 return visits/day. 1-2 procedure days a week with approximately 10-15 procedures a day. Wide-variety of advanced procedures offered including SCS, IT pumps, kypho, vertiflex, MILD, intracept, reactiv8, PNS, etc. Large referral base.
One of the partners is very knowledgeable and has offered mentorship.
Future ASC ownership potential.
No call; 5-day work week
Cons: no malpractice coverage, no clear sign-on bonus (although no contract has been offered yet), no PSLF opportunity

My gut tells me the hospital offer is what I should take for the PSLF. My knowledge on billing is non-existent, so I’m not sure if this private practice offer would make sense for my experience level? The last thing I want to do is find myself in a role making
Any advice would be appreciated or even resources for me to translate potential future earnings. I’m at a loss right now.
Click to expand...

Does your SO have control of their schedule? If so take the hospital job for the 4d workweek and extra vacation — take lots of long weekend trips and some longer international ones. Travel gets much harder/less enjoyable once you have kids (especially when they’re young).
 
Something doesn’t smell right with the private practice details you provided. Seeing that many new or f/u patients should get you a lot more than 1-2 days of 10-15 procedures. I do 25-30 procedures in a day, and even back when I first started out (PP job) I was seeing fewer clinic patients that that (16 new patients a day if that’s all I did), and still had 2-2.5 days a week of procedures, 20-25 a day.

That big of an imbalance suggests lots of med management. or they’re somehow pushing to do the high dollar advanced procedures, which make a ton of money for the ASC but very little for you until you have shares.
 
you will be a cog in the machine for either job.

you could last longer at the hospital job because that PP job seems like it would burn through new grads


just because it is an hour away doesnt mean that your SO has to live an hour away. if 4 days a week, a 45 minute commute is not unreasonable, esp if there are major thoroughfares.

the first 4 years of my professional career, i lived 45 min from the hospital so i could be in town, closer to friends - and i did 12 hour shifts, roughly18 per month, day and night. and mostly backroad driving. very doable.
 
callmeanesthesia said:
Something doesn’t smell right with the private practice details you provided. Seeing that many new or f/u patients should get you a lot more than 1-2 days of 10-15 procedures. I do 25-30 procedures in a day, and even back when I first started out (PP job) I was seeing fewer clinic patients that that (16 new patients a day if that’s all I did), and still had 2-2.5 days a week of procedures, 20-25 a day.

That big of an imbalance suggests lots of med management. or they’re somehow pushing to do the high dollar advanced procedures, which make a ton of money for the ASC but very little for you until you have shares.
Click to expand...
From what I could gather, they do predominantly advanced procedures. Most injections are internal referrals from APPs seeing follow-ups. It seems unclear though. The hospital gig seems like the clear choice but personal conflict with the SO wanting to live closer to friends but also wanting a nice lifestyle.
 
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If you do decide the hospital job and go for PSLF then end up hating it in two years, will you be ok then again finding another hospital job in possibly a non-desirable area to complete the remainder? If so then maybe do hospital job, live in middle, 30min each way.
 
drusso said:
#2. You will be successful beyond your wildest dreams. All you have to do is want it. Go make yourself indispensable to the practice and never look back.
Click to expand...
Any resources to understand the billing aspect? I have no issue with working hard if it means I will be compensated fairly. I don’t want to be chewed up and spit out with a non-compete in the area while I’m making nothing.
 
chromuffin said:
Any resources to understand the billing aspect? I have no issue with working hard if it means I will be compensated fairly. I don’t want to be chewed up and spit out with a non-compete in the area while I’m making nothing.
Click to expand...

There are a TON of resources to understand the billing aspect. It's painful, though, that medical schools are still dropping the ball teaching doctors how they get paid. One almost wonders if it's a conspiracy NOT to teach doctors the economics of their craft.

Say that you conscientiously object to noncompetes and not sign one or sign the least restrictive one you can negotiate. This is what lawyers are for.
 
chromuffin said:
Any resources to understand the billing aspect? I have no issue with working hard if it means I will be compensated fairly. I don’t want to be chewed up and spit out with a non-compete in the area while I’m making nothing.
Click to expand...
this.

they will work you to the bone, chew a few times, then spit you out.

this is a large practice for which you are just a cog in the machine.

drusso has his head in the clouds if he thinks is a PP gig, and is extolling virtues because he is so anti-hospital based.
 
au bon pain said:
Does your SO have control of their schedule? If so take the hospital job for the 4d workweek and extra vacation — take lots of long weekend trips and some longer international ones. Travel gets much harder/less enjoyable once you have kids (especially when they’re young).
Click to expand...
My SO is fully remote. I think she would like the extra vacation time.

Realistically, drive time right now between the two would be:

PP: 1 hour drive each way; live where we do now

Hospital job: move for a 1 hour drive one way (and be 30-45 minutes from friends/family) or live where we do for a 1.5 hour drive one way.

I’m currently driving 45 minutes to an hour for fellowship and don’t really mind the long commute. 1.5 hrs seems daunting but not difficult since I like to drive. In places like Chicago, I know of people driving 1.5 to 2 hrs into the city for a life in the suburbs.
 
Need more info on what the PP compensation is realistically. Low volume procedures which is not congruent with the advanced procedures they claim. Need details on ASC ownership offer in writing otherwise just an empty promise
 
chromuffin said:
Practice currently has 1 other provider who I personally know. Very reasonable.
Click to expand...

Forgot to mention this—as it’s important for 2 reasons.

1) Working with decent people you know you can actually trust is a huge deal and can be tough to find, especially when starting out. Definitely increases appeal of this job

2) You are not a provider. Look in the mirror and repeat that 1000x over. From here on out you clearly identify yourself as a physician aka the most knowledgeable/skilled person in the hospital/clinic. And remind admin/practice owners often that you know your own worth. There’s nothing they’d like more than for you to do the opposite.
 
RoloTomassi said:
Need more info on what the PP compensation is realistically. Low volume procedures which is not congruent with the advanced procedures they claim. Need details on ASC ownership offer in writing otherwise just an empty promise
Click to expand...
The owner of the PP has partial ownership in 3 ASCs and full ownership at 2 ASCs. I would work and perform procedures at the 2 fully owned ASCs. He has stated there could be future ownership opportunity in the future but he’s not really provided much more than that.

Caveat to this: I found out about the PP group from a local rep. The rep explained that the guy has mixed reviews in the community but he would definitely provide good mentorship. I trust the rep for the most part. However, I know his views of people is purely from a physician-rep relationship and isn’t the most accurate.

au bon pain said:
Forgot to mention this—as it’s important for 2 reasons.

1) Working with decent people you know you can actually trust is a huge deal and can be tough to find, especially when starting out. Definitely increases appeal of this job

2) You are not a provider. Look in the mirror and repeat that 1000x over. From here on out you clearly identify yourself as a physician aka the most knowledgeable/skilled person in the hospital/clinic. And remind admin/practice owners often that you know your own worth. There’s nothing they’d like more than for you to do the opposite.
Click to expand...

Thank you for this. Both points. I know that personal connections provide a lot of trust in a group, which is another aspect that makes the hospital job so interesting. I’m also very new to the idea of having authority within the administrative realm and find it hard to justify my worth from someone with “20 years of experience”
 
chromuffin said:
The owner of the PP has partial ownership in 3 ASCs and full ownership at 2 ASCs. I would work and perform procedures at the 2 fully owned ASCs. He has stated there could be future ownership opportunity in the future but he’s not really provided much more than that.

Caveat to this: I found out about the PP group from a local rep. The rep explained that the guy has mixed reviews in the community but he would definitely provide good mentorship. I trust the rep for the most part. However, I know his views of people is purely from a physician-rep relationship and isn’t the most accurate.



Thank you for this. Both points. I know that personal connections provide a lot of trust in a group, which is another aspect that makes the hospital job so interesting. I’m also very new to the idea of having authority within the administrative realm and find it hard to justify my worth from someone with “20 years of experience”
Click to expand...
The private practice sounds like you’re going to be making a lot of money for the owner (and the rep) while always wondering why your collection numbers aren’t high enough to justify getting equity in the group or ASC. Hire, exploit for 3 years until the new grad realizes they’ll never make partner, rinse, repeat.
 
On the other hand.... CEOs do change, and there can be trauma with it.

Remember your own worth. Whichever job you choose will more than likely not be your final one. You can get up and move when it is right for you. Look for what is good now and what you think will be better in the long run, knowing there is a good chance - but not impossible- that you wont be there in the long run.....
 
Hosp based gig sounds pretty good. Hopefully SO/spouse recognizes that the right job > location. esp your first job. IMHO. Does she want to see you often or is ok with you driving all over the state, having very little vacation, and being stressed about pay? (I am making some assumptions mind you)

PP job sounds like a bit of a meat grinder. Possible upside is that you would learn some new procedures? Did you say no malpractice coverage???

The PP is clearly inferior based on your write up. Multiple orange and some possible red flags. 5 locations spread throughout the state?! Where do you think they will send the new guy?
 
chromuffin said:
Any resources to understand the billing aspect? I have no issue with working hard if it means I will be compensated fairly. I don’t want to be chewed up and spit out with a non-compete in the area while I’m making nothing.
Click to expand...
You can consider doing what I did before you graduate. Befriend the billers and get their numbers. Ask them questions but don't annoy them. Stay in touch with them when you have questions. If it gets too late, call the west coast hospitals and ask to speak to the billing department when you have questions. Tell them you're freshly graduated and you want to make sure you're doing things correctly. This is a start.

Once you're out, do the billing on your own. It's the only way to learn and you'll learn the tricks the payers use to weasel out of paying you.

I hated billing for a long time while doing it but I stuck with it until I knew it thoroughly. Now, it's much better but I still hate it. I only spend a few hours per month on it since I now know how the system works.
 
chromuffin said:
My SO is fully remote. I think she would like the extra vacation time.

Realistically, drive time right now between the two would be:

PP: 1 hour drive each way; live where we do now

Hospital job: move for a 1 hour drive one way (and be 30-45 minutes from friends/family) or live where we do for a 1.5 hour drive one way.

I’m currently driving 45 minutes to an hour for fellowship and don’t really mind the long commute. 1.5 hrs seems daunting but not difficult since I like to drive. In places like Chicago, I know of people driving 1.5 to 2 hrs into the city for a life in the suburbs.
Click to expand...

You want to live close to work. Do not commute > 30 min. Preferably 15 min or less. I am 5 min from work and it fantastic.

Practice is a lot different than fellowship. There can be a lot of work/time outside of patient care, especially documentation, billing, meetings, etc. that he you do not have to deal with during fellowship. You want to be home quickly when the day is done and not wait another hour or an hour and a half to be in the doorway
 
Also wanted to get some insight into this as well. Planning to start really looking for jobs in TX and WA at the end of the year. Is the consensus to go hospital-based/HOPD over PP or starting solo to get experience?
 
GandalfTheWhite said:
Also wanted to get some insight into this as well. Planning to start really looking for jobs in TX and WA at the end of the year. Is the consensus to go hospital-based/HOPD over PP or starting solo to get experience?
Click to expand...

PP. Learn the business of medicine and how to get paid and run an efficient ship. Then, and only then, go stick it to the man.
 
drusso said:
PP. Learn the business of medicine and how to get paid and run an efficient ship. Then, and only then, go stick it to the man.
Click to expand...
isnt it harder to get on insurance panels and higher negotiated rates when starting out from PP vs a large hospital based system?
 
GandalfTheWhite said:
Also wanted to get some insight into this as well. Planning to start really looking for jobs in TX and WA at the end of the year. Is the consensus to go hospital-based/HOPD over PP or starting solo to get experience?
Click to expand...
find the job that is best, regardless of HOPD or PP.

determine what you feel is best. pay, or security, or relationship with co-workers, type of procedures, possibility for expansion, non-compete clause, work hours, ancillary services, etc.



then ask your wife where she wants to live.
 
chromuffin said:
Hello all,

I’m looking into two different job offers right now. I’m a current anesthesia/pain fellow who is in the midst of finding a job.

1. Hospital Based
Pay: ~$75/wRVU with base guarantee approx 400k. Sign-on: ~50k for 4 years
Referral base is largely from small rural setting.
Malpractice with tail coverage
No Call; 4-day work week
Receptive administration; CEO is an MD
Practice currently has 1 other provider who I personally know. Very reasonable.
Cons: Less desirable living situation, productivity may be limited based on RVU data I have

2. Private Practice
Pay: Unclear; “eat what you kill” philosophy
50% overhead costs
Practice is comprised of a 5 site group spread across the state. I would be at the two most desirable locations.
I’m no expert at billing, which is a big concern and hesitation with this gig. Current provider states he is seeing ~15-25 new patients/day in clinic or ~25-35 return visits/day. 1-2 procedure days a week with approximately 10-15 procedures a day. Wide-variety of advanced procedures offered including SCS, IT pumps, kypho, vertiflex, MILD, intracept, reactiv8, PNS, etc. Large referral base.
One of the partners is very knowledgeable and has offered mentorship.
Future ASC ownership potential.
No call; 5-day work week
Cons: no malpractice coverage, no clear sign-on bonus (although no contract has been offered yet), no PSLF opportunity

My gut tells me the hospital offer is what I should take for the PSLF. My knowledge on billing is non-existent, so I’m not sure if this private practice offer would make sense for my experience level? The last thing I want to do is find myself in a role making <300k with 300k of loans to pay off.

Any advice would be appreciated or even resources for me to translate potential future earnings. I’m at a loss right now.
Click to expand...

What exactly is less desirable about the HOPD location? Is it that the job is in a bad location but there’s a good location about an hour away? (I assume that’s the case since you mentioned living an hour away from close friends there). Or are these jobs in totally different states, etc, to where there’s nowhere good to live even with a moderate commute to HOPD?

My payment is different, but the logistics of my job is quite similar to your HOPD job. 4 days a week, RVU based, in a remote location. We (my wife) chose to live in a suburb of the large metro nearby. It’s an easy commute because you would be going against traffic both ways, most of the other commuters are going from the small town to the city in the morning and the reverse at night. It’s an easy 40 minute commute.

Bear in mind: a 40 minute commute 4 times a week is the same as about a 30 minute commute (32 minutes of math in my head is right) 5 times a week. It’s not bad at all.

PP certainly can have a much higher ceiling but it’s a lot more unclear how much you should be getting paid. You’ll probably find yourself questioning how TF your paycheck is the way that is. RVU based is easily trackable.
 
mdo1738 said:
What exactly is less desirable about the HOPD location? Is it that the job is in a bad location but there’s a good location about an hour away? (I assume that’s the case since you mentioned living an hour away from close friends there). Or are these jobs in totally different states, etc, to where there’s nowhere good to live even with a moderate commute to HOPD?

My payment is different, but the logistics of my job is quite similar to your HOPD job. 4 days a week, RVU based, in a remote location. We (my wife) chose to live in a suburb of the large metro nearby. It’s an easy commute because you would be going against traffic both ways, most of the other commuters are going from the small town to the city in the morning and the reverse at night. It’s an easy 40 minute commute.

Bear in mind: a 40 minute commute 4 times a week is the same as about a 30 minute commute (32 minutes of math in my head is right) 5 times a week. It’s not bad at all.

PP certainly can have a much higher ceiling but it’s a lot more unclear how much you should be getting paid. You’ll probably find yourself questioning how TF your paycheck is the way that is. RVU based is easily trackable.
Click to expand...
The HOPD job is an hour and 15 min to 1.5 hrs away from my desired living area whereas the PP job is an hour. HOPD is 4 days a week, PP is 5 days a week. My wife refuses to make me drive over an hour one way and would make us move to about an hour away from the HOPD. The drive is all highway (about 70 miles) and would be a reverse commute. If I take the job I would probably just live in the city to split the difference
 
Ducttape said:
find the job that is best, regardless of HOPD or PP.

determine what you feel is best. pay, or security, or relationship with co-workers, type of procedures, possibility for expansion, non-compete clause, work hours, ancillary services, etc.



then ask your wife where she wants to live.
Click to expand...
No wife, no kids.

nvrsumr said:
Start your own practice where you want to live
Click to expand...
How do you suggest getting on insurance panels with good rates? Join an MSO?
chromuffin said:
Too business illiterate to survive or I would. That’s the plan in year 10+
Click to expand...
Same. But if anyone wants to set up shop in Dallas, Austin, or HoustonlantaVegas, LMK.
 
GlowInTheDark said:
In 10+ years we’re all gonna be working for Googazon Permante Health.
Click to expand...

giphy.gif
 
GandalfTheWhite said:
No wife, no kids.


How do you suggest getting on insurance panels with good rates? Join an MSO?

Same. But if anyone wants to set up shop in Dallas, Austin, or HoustonlantaVegas, LMK.
Click to expand...
Not a MSO


Ipa

Easiest way to get on all panels.
 
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