Pros/Cons to joining a private practice right out of training

[Yoyomama88]

I'm seeing $300-350k. These practices are offering health/dental/vision insurance, 2-4 weeks of vacation to start with, retirement match of 3-10%, at 30-32 clinical hours per week with 5-10 hours of admin time per week.

This sounds good. 10% match?!

---

Members don't see this ad.

 

[clozareal]

This sounds good. 10% match?!

the 10% practice is actually not a match, but rather just a contribution from the group practice once you've been there for more than a year. I know some in that practice whose productivity is so high that they max out their retirement without having to contribute any of their own paycheck to it.

 

[Stagg737]

I've seen that number as well, but not sure how that holds up in outpatient practice when 2-3 RVU's/follow-up is what some of these organizations are advertising. This would mean they're paying you $260+ an hour which I haven't seen anywhere...not sure where the discrepancy is.



Wow that sounds great - where are these practices located? I haven't seen any in the southeast come close to this. I'm guessing you're not given 30 min for follow-ups/1 hour for news though? I'd sign up without much hesitation if that were the case.


Right - but that's the total revenue for the practice, so you'd get some percentage of that. I would think with better payers you could get to >$200/hr after your contribution to overhead.

Here's the CMS physician fee schedule calculator, look up 90833 and 99214. My MAC locality reimburses $~180 for 99214+90833, so $360/hr. You'd only need a 55/45 split to hit >$200/hr. At a better split like 70/30 that's $252/hr which is just under $350k working 30 hour weeks for 46 weeks a year. 80/20 split with that schedule would put you just under $400k. That's also assuming 30 minute f/ups.

Overview of the Medicare Physician Fee Schedule Search | CMS

Overview This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS). It provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator and various payment policy indicators needed for...

www.cms.gov

 

[rjs2131]

Great feedback. To clarify, I'm specifically looking at a privately owned PP (not hospital based) and another larger PP organization (10-12 clinics) that functions more like a business (has a CEO, CMO, etc).

@clozareal your point about wRVU and tRVU - I thought these were only relevant for larger organizations/hospital systems. Does this mean that for an organization that is solely outpatient and takes insurance, they are getting some higher $/RVU from insurance companies that isn't factored into the equation? Didn't realize that.

@Candidate2017 what location are you seeing those offers in? I've also seen 70/30 split without benefits, and some practices have their own insurance/profit-sharing/etc you can 'buy' into.

I think the PP I'm talking to is fairly unique in that it is very much a stand-alone PP but has been around for a while (10+ MD's) and does offer a guaranteed salary the first year.

 

[calvnandhobbs68]

Here's the CMS physician fee schedule calculator, look up 90833 and 99214. My MAC locality reimburses $~180 for 99214+90833, so $360/hr. You'd only need a 55/45 split to hit >$200/hr. At a better split like 70/30 that's $252/hr which is just under $350k working 30 hour weeks for 46 weeks a year. 80/20 split with that schedule would put you just under $400k. That's also assuming 30 minute f/ups.

Overview of the Medicare Physician Fee Schedule Search | CMS

Overview This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS). It provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator and various payment policy indicators needed for...

www.cms.gov

Idk about you guys but from what I’ve seen an 80/20 split is very generous. 70/30 if you’re 1099 seems to be more common if you’re truly just joining on to a practice which is covering all the overhead (office space, EMR, secretary, office supplies, billing/collections, utilities, etc). Your overhead would likely be higher than just 20% if you set up a PP on your own and they’d definitely take more of a cut since it makes it simpler for the person joining on.

I’ve heard of more like 60/40 or 65/35 if you’re W2 getting benefits, malpractice, etc.

 

[Yoyomama88]

Here's the CMS physician fee schedule calculator, look up 90833 and 99214. My MAC locality reimburses $~180 for 99214+90833, so $360/hr. You'd only need a 55/45 split to hit >$200/hr. At a better split like 70/30 that's $252/hr which is just under $350k working 30 hour weeks for 46 weeks a year. 80/20 split with that schedule would put you just under $400k. That's also assuming 30 minute f/ups.

Overview of the Medicare Physician Fee Schedule Search | CMS

Overview This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS). It provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator and various payment policy indicators needed for...

www.cms.gov

Are there any other big fees assoc with medicare. These rates beat cigna and united health care ppo rates for a single doc pp psych in my locality. Also do you always collect these rates when you bill for them?

 

[calvnandhobbs68]

Also basing your income on billing 99214+90833 every visit is essentially maximum income and a little misleading. Unless you start with a completely full panel you’re not gonna be making that year one. You’d be doing a lot of intakes which will end up billing less overall per hour than follow ups. Every single visit is also not going to qualify as 99214.

 

[Sushirolls]

Also basing your income on billing 99214+90833 every visit is essentially maximum income and a little misleading. Unless you start with a completely full panel you’re not gonna be making that year one. You’d be doing a lot of intakes which will end up billing less overall per hour than follow ups. Every single visit is also not going to qualify as 99214.

Bingo. You nailed it. My 'Practice in Progress' thread backs that up.

 

[psyguru]

What kind of side gigs do people in private practice have that doesn't involve weekend or evening moonlighting or being on call?

Expert witness. For me its more than a side gig as I am a forensic psychiatrist.

 

[jbomba]

Expert witness. For me its more than a side gig as I am a forensic psychiatrist.

How difficult is it to get work doing this?

 

[clausewitz2]

Also basing your income on billing 99214+90833 every visit is essentially maximum income and a little misleading. Unless you start with a completely full panel you’re not gonna be making that year one. You’d be doing a lot of intakes which will end up billing less overall per hour than follow ups. Every single visit is also not going to qualify as 99214.

This is very true. However, I have been in private practice since August and in November 82% of my followups were 99214/99215 and 69% of my total visits (including intakes, that is). Generated about 15k in gross revenue with 44.5 clinical contact hours in that setting that month

 

[jbomba]

This is very true. However, I have been in private practice since August and in November 82% of my followups were 99214/99215 and 69% of my total visits (including intakes, that is). Generated about 15k in gross revenue with 44.5 clinical contact hours in that setting that month

So you're generating roughly 330/hr with insurance? That seems phenomenal.

 

[clausewitz2]

So you're generating roughly 330/hr with insurance? That seems phenomenal.

This is gross collections, mind, so not accounting for a single expense. Currently taking one insurance and about 15% private pay. Around here the two big insurers pay about 10% above medicare rates.

 

[rjs2131]

Also basing your income on billing 99214+90833 every visit is essentially maximum income and a little misleading. Unless you start with a completely full panel you’re not gonna be making that year one. You’d be doing a lot of intakes which will end up billing less overall per hour than follow ups. Every single visit is also not going to qualify as 99214.

Fair - but if you're doing 30-min follow-ups and 1-hour news, I would think you're either billing 99213+90833 or 99214+90833 for the follow-ups. The CMS lookup tool (when specifying NC/SC) gives a range of $285 - $355/hour if you do some combination of the above. I would think that for private practices that can pick and choose which insurance they take, they would only take insurances that bill around/above these values depending on the area.

I've seen the 70/30 split, but anything less doesn't make financial sense to me. Even 70/30 seems fairly generous - if you're working full time (30 clinical hours lets say), you would generate around 400k for the practice (this is assuming all 99213+90833's, ~30 hrs/week, 46.5 weeks/year). Could be more if you're working harder and/or seeing some 99214+90833's. If you take home 70% of this, that leaves ~100k for the practice...unless I"m mistaken, that could cover rent + EMR +/- some staff for a year for most practices. If there are multiple MD's, I would think your contribution wouldn't need to be more than 50-60k to cover 'expenses', beyond this is just profit for the practice.


I know of one private practice that has an upper limit of 60k/year for what the practice takes. Of course, no benefits with this model.

 

[Sushirolls]

A single front desk / assistant, etc for full time work will cost in total 50-60K and that doesn't include health insurance.

There is also the intangibles of the practice - referral patterns - brand name recognition / reputation in community - an established work flow - initial infrastructure of office equipment etc set up - lease which can vary widely (mine is being increased now to $3500/month) - and essentially the time to get things up and running.

So sure, you are right a practice taking X amount of dollars could be eye brow raising. But are you and every other doctor out there equipped with the spirit to walk, and then open your own practice to capture that difference? Start up and practice growth can go quickly like Clausewitz above notes in #61, or quite slowly like I am experiencing. This is a risk, and you don't know until you actually open your own. This unknow, this risk, is what the owners of the PP group get for being the originator, the ones with the real spirit.

Until more psychiatrists are willing to do just that and open their own practice, there will be the potential for an eye brow raising cut off the top. If a greater percentage open their own, then the Delta will decline and more favorable offers will present.

 

[calvnandhobbs68]

Fair - but if you're doing 30-min follow-ups and 1-hour news, I would think you're either billing 99213+90833 or 99214+90833 for the follow-ups. The CMS lookup tool (when specifying NC/SC) gives a range of $285 - $355/hour if you do some combination of the above. I would think that for private practices that can pick and choose which insurance they take, they would only take insurances that bill around/above these values depending on the area.

I've seen the 70/30 split, but anything less doesn't make financial sense to me. Even 70/30 seems fairly generous - if you're working full time (30 clinical hours lets say), you would generate around 400k for the practice (this is assuming all 99213+90833's, ~30 hrs/week, 46.5 weeks/year). Could be more if you're working harder and/or seeing some 99214+90833's. If you take home 70% of this, that leaves ~100k for the practice...unless I"m mistaken, that could cover rent + EMR +/- some staff for a year for most practices. If there are multiple MD's, I would think your contribution wouldn't need to be more than 50-60k to cover 'expenses', beyond this is just profit for the practice.


I know of one private practice that has an upper limit of 60k/year for what the practice takes. Of course, no benefits with this model.

Sure but we’re also talking about a pure 1099 position here. No benefits, pay both sides of the employer income tax, pay everything into your own 401k, get your own malpractice.

So that salary starts looking quite a bit smaller pretty quick.

I guess my main point is that these 300k+ pure outpatient no call positions are usually either 1099 so they aren’t all they’re cracked up to be or you’re working pretty decently or churning the meat (15min followups/45min intakes) in a W2 position. I’ve definitely seen high 200s though multiple times.

 

[jbomba]

A single front desk / assistant, etc for full time work will cost in total 50-60K and that doesn't include health insurance.

There is also the intangibles of the practice - referral patterns - brand name recognition / reputation in community - an established work flow - initial infrastructure of office equipment etc set up - lease which can vary widely (mine is being increased now to $3500/month) - and essentially the time to get things up and running.

So sure, you are right a practice taking X amount of dollars could be eye brow raising. But are you and every other doctor out there equipped with the spirit to walk, and then open your own practice to capture that difference? Start up and practice growth can go quickly like Clausewitz above notes in #61, or quite slowly like I am experiencing. This is a risk, and you don't know until you actually open your own. This unknow, this risk, is what the owners of the PP group get for being the originator, the ones with the real spirit.

Until more psychiatrists are willing to do just that and open their own practice, there will be the potential for an eye brow raising cut off the top. If a greater percentage open their own, then the Delta will decline and more favorable offers will present.

Regarding the uncertainty of growth, wouldnt it be reasonably easy to rent an office one day a week or do telepsych while working another full time job and just expand days as you begin to fill?

 

[Sushirolls]

Regarding the uncertainty of growth, wouldnt it be reasonably easy to rent an office one day a week or do telepsych while working another full time job and just expand days as you begin to fill?

In theory yes. But as you build a practice patients want AM, or PM preferred time slots or certain days of the week. So you risk losing a few patients early on because of the lack of full time.

Secondly, Patient urgent phone calls, fax or electronic refill requests, or Prior Auths don't happen only on your PP Monday office hours. So you will still need to watch the fax, watch the electronic messages, watch the e-prescription messages. Then of course, the other big issue is talking with new possible patients. Some one needs to call them back. And if you wait a week, that patient will have likely already scheduled up with someone else. So you need to call back pretty quickly. In summary, you will still be doing some level of 'Admin' or front desk work on a daily basis. We haven't even begun to explore the random billing quirks that happen - and if you call the insurance company it will be a minimum of 30 minutes of your time. Or 90 day confirmations for insurance panels that all your details are updated and requires time to do. And then there is the pure ineptitude of insurance companies... 2 years out I'm still fixing/correcting the errors of insurance companies putting down the wrong contact details from past jobs or practice locations. By working multiple jobs while you slowly build a practice, count on the insurance companies mixing up your practice with the other job(s). Or you get a message/call about "where is my prescription?" when your e-script service shows it was clearly sent, so the question is did the patient goof, did the pharmacy goof, or somehow did you goof? This takes time to figure out and communicate to the appropriate party.

You get a message/call from patient. They are in crisis and really need a next day appointment ... or they go to the hospital? So, do you schedule a random appointment after hours or do you just point the patient to the hospital?

A cash doc in my area who is pollinating the local hospitals doing moonlighting and other side gigs to build their practice, recently got a bad online review for not getting back to the patients after like 7-14 days or something like that.

 

[rjs2131]

A single front desk / assistant, etc for full time work will cost in total 50-60K and that doesn't include health insurance.

There is also the intangibles of the practice - referral patterns - brand name recognition / reputation in community - an established work flow - initial infrastructure of office equipment etc set up - lease which can vary widely (mine is being increased now to $3500/month) - and essentially the time to get things up and running.

So sure, you are right a practice taking X amount of dollars could be eye brow raising. But are you and every other doctor out there equipped with the spirit to walk, and then open your own practice to capture that difference? Start up and practice growth can go quickly like Clausewitz above notes in #61, or quite slowly like I am experiencing. This is a risk, and you don't know until you actually open your own. This unknow, this risk, is what the owners of the PP group get for being the originator, the ones with the real spirit.

Until more psychiatrists are willing to do just that and open their own practice, there will be the potential for an eye brow raising cut off the top. If a greater percentage open their own, then the Delta will decline and more favorable offers will present.

Thanks for the input. So then I think the question becomes...what is a reasonable amount to take off the top for a joining MD? What should the PP owners with the 'real spirit' get for establishing the practice? Interested to hear what those who have their own practices would consider fair.

In general, it seems it is mutually beneficial to add an MD (more coverage, ability for the practice to expand/see more patients, additional income for the practice) and if the practice is already well-established with several MD's, the process of adding another doesn't seem particularly difficult.

Another question for the group - for practices that offer some type of partnership track after 1-2 years, what would you want to see to make it worth buying into a practice/becoming a partner? Anyone with experience with this?

 

[Sushirolls]

It doesn't look difficult on paper. But people = drama = HR needs. Odds are in your favor for no real big issues, but a single new addition to practice at what ever level has notable ripples and if a doc isn't a good fit then its a massive headache. Right now its me and an assistant. I oscillate back and forth on the long term clinical goals. Right now things are simple, quiet, no drama, functional. If I add a doc, this person might only churn thru patients hastily and contribute to irritated patients, which in turn gets back to some of my referral sources and negatively impacts the whole practice. Or conversely, the rate of panel growth is too slow for the new person that they are financially displeased and they quit after several months and I'm stuck cleaning up the pieces and the financial hit of that investment in a doc. Or with the addition of another doc it opens up the need for more support staff, but it might be an odd FTE need like 0.2 or 0.4FTE of clerical assistant - which is a very important need for a small practice - but potentially a very hard fill. So now your existing clerical staff get overworked and they might quit.

Partnerships are a true marriage and I could see how it could back fire on me and I get "abused" by someone who isn't pulling their weight but demanding more money from the practice. But to "divorce" is rife with so many costs. Which raises the idea of a more equitable employed status for new docs and crux of your real question. I've oscillated from thoughts of heavy skimming, because well that's what every Big Box shop is doing but this practice would at least offer greater control over patient selection. But then again I still carry the battle wounds of Big Box shops and do I want to be part of the problem even if smaller, or part of the solution as a refuge for fleeing docs?

How much of a cut off the top is a real good question, and I don't have a good answer. Definitely curious to see how others navigated this. I know Texas on here has a practice with a few people and might have some insights if willing to share.

In grand summary, all that was to say I don't know.

 

[dl2dp2]

Thanks for the input. So then I think the question becomes...what is a reasonable amount to take off the top for a joining MD? What should the PP owners with the 'real spirit' get for establishing the practice? Interested to hear what those who have their own practices would consider fair.

This can vary considerably in different geographies, and depends a lot on the payer mix. In general in larger markets overhead is higher. What I suggest is you to find out the billing rates for specific codes, generate an estimate of revenue and expenses, and go from there. First year guaranteed salary is what you really care about right now, and that's driven by the market alone, not how well the practice is being run.

I would also just judge more or less on your interpersonal match with the practice. Once you are in, the financial aspect gets much clearer. The bottom line is it's very difficult to speak on this with any degree of certainty without auditing the data. In fact, very expensive management consultants are often retained to scrutinize this very question ("i.e. is the pay of my staff 'fair' to the market?").

In general, it seems it is mutually beneficial to add an MD (more coverage, ability for the practice to expand/see more patients, additional income for the practice) and if the practice is already well-established with several MD's, the process of adding another doesn't seem particularly difficult.

Not necessarily. The most profitable practices on a per partner basis that I know of are solo cash. The only private viable model that's not solo cash that are very profitable have lots of mid-level employees. There are facility-based models that are highly profitable and are neither--we can go into that if you are interested, but they are related to institutional service coverage, insurance "carve-outs", etc..other boutiquey topics. MD services per se is typically low margin, actually. The main risk for the practice to take on is HR related risk: you can quit mid-year, or see very few patients for a variety of reasons, or be a trouble maker, etc.

Another question for the group - for practices that offer some type of partnership track after 1-2 years, what would you want to see to make it worth buying into a practice/becoming a partner? Anyone with experience with this?

Partnership is almost ALWAYS worth it for informational reasons. How much it's worth monetarily depends on what kind of profit can be generated, plus a plethora of other information, such as the prevailing risk-free interest rates. If you don't buy-in and become a partner, the financial details of the practice are opaque to you, and you will not have a voice one way or another, regardless of whether it's "fair".

In the current low rate environment, buy-ins are often inflated. Nevertheless, it's STILL a good idea to say that you are willing to buy-in as the very due diligence process alone allows you to make an informed decision. I wouldn't worry about the details--when the time comes the process will be explained to you and there's plenty of time for negotiations.

 

[AD04]

A lot of what's discussed about numbers are good. But projected numbers and reality are very often different. You must factor in human nature: greed and deceit and politics. On SDN, there seems to be a glorification of private practice. Understand that private practice is a double-edged sword. You can have a cush lifestyle making good money. Or you can get royally screwed over. The amount of control you have on the private practice will greatly effect which edge you will end up on.

I believe physicians, especially new graduates, are screwed over more by private practices (mini-for-profit entities) than by for-profit institutions like HCA. Many other physicians have said the same (in various specialties).

So if you must go into private practice under someone else, mitigate your risk:

1. Salary for year 1. Too many factors are out of your control when you are paid by collections, such as A) business incompetence or B) senior physicians taking picking and choosing the best patients first and you getting leftovers or C) over-hiring of physicians as it cost nothing to have more physicians if there is no fixed cost attached to them or D) lack of truthfulness or whatever. Whoever is hiring you must have skin in the game. After 1 year, you can better assess if the practice is somewhere you want to be and if the numbers quoted you on the day of interview is real or not. If it isn't the right place for whatever reason, at least you're not screwed out of a year of attending pay and you can move on unscathed.

2. If salary isn't an option and you must go into private practice, start with 1 day a week and get a job. Don't put all your eggs in one basket. (In this case, I would just start my own private practice and sub-lease an office.) And if you're paid on productivity, ensure there is transparency as lack of transparency encourages the decision-maker to skim off the top.

3. Include clauses in there if the practice fails to meet metrics, there will be a penalty (e.g. unable to supply you with x new patients / week, then the non-compete clause no longer takes effect -- why should you be locked out of a location due to factors out of your control).

There are private practices with business model of churning and burning through new graduates. Especially beware of practices with a solo owner or a husband / wife owner.

 

[rjs2131]

Thanks everyone. Very helpful advice - I've definitely tried to steer clear of smaller practices where I'd be one of 2 or 3 MD's as I can imagine dynamics become even more of an issue and if you don't get along with the owner, this can cause a number of issues. A few practices have a model where all major decisions are made by an executive board of 4-5 MD's which seems more promising/fair.

I agree that having a guaranteed salary for year 1 seems to be a good way to at least mitigate risk of lack of patients, variable reimbursement from insurance, etc and ensure some stability. There is always a risk of not fitting in/not being happy at a given practice, but I'd like to think there is more ability for control at a PP vs larger hospital system. Another factor that has been helpful is looking at how long MD's stay at a given practice...one of the practices I'm looking at essentially has folks join and stick around for most of their careers (the most recent hire has been there for 4-5 years). This seems to be a good sign given no non-compete/etc and plenty of other opportunities in that area.

 

[sloh]

Can you guys expand on the downsides of working for a big box shop? Thanks!

 

[Psychresy]

Thoughts on starting a pp and just supervising PA/NP?

 

[TexasPhysician]

There are pros/cons to every set-up. Nothing will be perfect. I prefer smaller private cash practices as it can be easily customized. Have a good chance at hanging with good colleagues. More likely to request and get the changes you want. If there is drama, it’s terrible. Big shops will not give you as much personal support or allow you to make changes as easily. You must follow the rules. There is more likely to be drama, but there is more people to avoid it. More colleagues to choose from.

Midlevels require a lot of education, monitoring, and oversight. This reduces your productivity elsewhere unless you are getting 100% of remaining profit. Your license gets attached to them. I’ve seen a colleague lose his license for not monitoring intensively.

Partnerships mean almost nothing in private practice. There is little to no ancillary income to split in a typical practice. Exceptions exist if you have a dozen NP’s, TMS machines, lab center, dozen counselors, etc. Partnerships only matter when there is excess relatively passive income that you could obtain.

 

[rjs2131]

Can you guys expand on the downsides of working for a big box shop? Thanks!

From my understanding, the big issue would be lack of control - seems like once you're hired, big box shops can implement changes (see patients more quickly, more patients on schedule, request that you help on other services) unless you specifically account for these in your contract. Seems like there's also more bureaucratic stuff to deal with due to having a larger department. I'm not sure if this is true for all big box shops but I've also noticed a pattern of MD's joining for a few years and leaving for many of them, which isn't a great sign.

On the plus side, they seem to have attractive salaries/incentives for new hires so I would guess that many MD's join for these perks and then move on to something else after a few years (join, pay off loans/debts, find something better).

 

[Sushirolls]

Those "perks" of Big Box shops might actually just disappear. "oh that was an old benefit that got phased out... we don't do that anymore." Now you need to sue and that helps precipitate an exodus. Don't forget student loan benefits and sign on bonuses are all taxed and you really on get 0.6 of X. Or those retirement perks have a vesting period. Or its a 457 fund with an institution that could go under any minute (i.e. they go bankrupt they get to raid your 457 fund). I'm almost able to count past two hands how many people have had Big Box shops financially screw them over from their contract.

Or one day the all elusive employee handbook that everything in the contract alludes to, sneakily gets changed, and you may or may not have gotten the update. But if you didn't well, they'll say its something that wouldn't require a formal notice of X days in written form, and deal with it. For instance your vacation days can no longer requested X days in advance but have to be requested X + 30 days.

Or to keep you in the coal mines, your an OP only clinic, and they change the handbook on you to say that there must always be someone in the clinic. I.E. the clinic can't close and there has to be a doc working... but wait... your department is tiny and only has 1.5 FTE docs. So how does one effectively navigate vacation time to keep open the clinic that really doesn't have to be open every business day...

HR departments outside of talking about benefits are not your friend. They are there to protect the Big Box shop and let you get hit by the bus. You are the problem, not the institution. They will use tools like PIPs (performance improvement plans) to label you as a problem and then spell something out how you are supposed to fix it, but do it in a way that is so insulting you quit, or away that can never be achieved, but it helps the institution so if you were thinking of suing them now they have a bigger defense to say, nope, you were a bad apple and here is the paper trail. The only positive is PIPs full under the HR department and not medical staff so they don't follow you around nor are they reportable to anything. You have the right, depending on a state, to counter point respond to a PIP (get a lawyer to draft this with you) and it gets inserted in your HR file too. So, should anyone get ahold of this they see a counter point truth to the lies. I know several doctors who have been PIP'ed by Big Box Shops.

You are 'forced' to join hospital committees which will meet at times that block out your clinic, so you make less wRVUs - which counts against you - or you have to meet after hours and that steals away from family time [I used to believe this was good, part of the global sacrifice of being a physician for the betterment of our fellow man and colleagues].

Hospital bylaws are slowly being chipped away at, bit by bit by bit, to make the rules less fair play and even keel for all types of docs practicing in the shell of an entity, the sand box, that is the hospital.... noooo.... now it is becoming an additional strong arm enforcement wing for the Big Box Shop entity that owns the hospital so they can push out all the independent medical groups and permit more midlevel scope of practice and take away vestiges of voice and power that is physician to leave you a mere employee cog. The final result is that hospital bylaws serve no purpose, no unique benefit but an old ghost for the halls of history and a source of extra wasted bureaucracy you now go thru the motions on your - 2 or even 3 committees you sit on. Don't ever respond counter to "Praise be to the Big Box Shop!" [just look to the ED physicians getting fired for saying uh, ICU beds full, or uh we got now masks, etc]

Great ideas go to Big Box shops to die. You trained at cool academic Big Box Shop that perhaps was somewhat functional, you are young fresh and full of vigor and see services gaps or needs in your new community. They don't care... I could give personal example upon personal example of this, write pages but I'll skip it this time.

Here is an another metaphor that might resonate with the fresh grads, Big Box Shops are not Shaadi, Match, eHarmony; nope, Big Box Shops are tinder so use them as much as they will invariably use you.

 

[sloh]

Those "perks" of Big Box shops might actually just disappear. "oh that was an old benefit that got phased out... we don't do that anymore." Now you need to sue and that helps precipitate an exodus. Don't forget student loan benefits and sign on bonuses are all taxed and you really on get 0.6 of X. Or those retirement perks have a vesting period. Or its a 457 fund with an institution that could go under any minute (i.e. they go bankrupt they get to raid your 457 fund). I'm almost able to count past two hands how many people have had Big Box shops financially screw them over from their contract.

Or one day the all elusive employee handbook that everything in the contract alludes to, sneakily gets changed, and you may or may not have gotten the update. But if you didn't well, they'll say its something that wouldn't require a formal notice of X days in written form, and deal with it. For instance your vacation days can no longer requested X days in advance but have to be requested X + 30 days.

Or to keep you in the coal mines, your an OP only clinic, and they change the handbook on you to say that there must always be someone in the clinic. I.E. the clinic can't close and there has to be a doc working... but wait... your department is tiny and only has 1.5 FTE docs. So how does one effectively navigate vacation time to keep open the clinic that really doesn't have to be open every business day...

HR departments outside of talking about benefits are not your friend. They are there to protect the Big Box shop and let you get hit by the bus. You are the problem, not the institution. They will use tools like PIPs (performance improvement plans) to label you as a problem and then spell something out how you are supposed to fix it, but do it in a way that is so insulting you quit, or away that can never be achieved, but it helps the institution so if you were thinking of suing them now they have a bigger defense to say, nope, you were a bad apple and here is the paper trail. The only positive is PIPs full under the HR department and not medical staff so they don't follow you around nor are they reportable to anything. You have the right, depending on a state, to counter point respond to a PIP (get a lawyer to draft this with you) and it gets inserted in your HR file too. So, should anyone get ahold of this they see a counter point truth to the lies. I know several doctors who have been PIP'ed by Big Box Shops.

You are 'forced' to join hospital committees which will meet at times that block out your clinic, so you make less wRVUs - which counts against you - or you have to meet after hours and that steals away from family time [I used to believe this was good, part of the global sacrifice of being a physician for the betterment of our fellow man and colleagues].

Hospital bylaws are slowly being chipped away at, bit by bit by bit, to make the rules less fair play and even keel for all types of docs practicing in the shell of an entity, the sand box, that is the hospital.... noooo.... now it is becoming an additional strong arm enforcement wing for the Big Box Shop entity that owns the hospital so they can push out all the independent medical groups and permit more midlevel scope of practice and take away vestiges of voice and power that is physician to leave you a mere employee cog. The final result is that hospital bylaws serve no purpose, no unique benefit but an old ghost for the halls of history and a source of extra wasted bureaucracy you now go thru the motions on your - 2 or even 3 committees you sit on. Don't ever respond counter to "Praise be to the Big Box Shop!" [just look to the ED physicians getting fired for saying uh, ICU beds full, or uh we got now masks, etc]

Great ideas go to Big Box shops to die. You trained at cool academic Big Box Shop that perhaps was somewhat functional, you are young fresh and full of vigor and see services gaps or needs in your new community. They don't care... I could give personal example upon personal example of this, write pages but I'll skip it this time.

Here is an another metaphor that might resonate with the fresh grads, Big Box Shops are not Shaadi, Match, eHarmony; nope, Big Box Shops are tinder so use them as much as they will invariably use you.

Thank you for the responses guys. I worked at a big box shop as PM&R. This encapsulates what I experienced as well. I wanted to see if it was also common for Psychiatry

 

[Sushirolls]

Thank you for the responses guys. I worked at a big box shop as PM&R. This encapsulates what I experienced as well. I wanted to see if it was also common for Psychiatry

I've seen Big Box shops spit out Gen Surg, Vascular Surg, Anesthesiology, Pain, Sleep Medicine, GI, FM/IM (in and outpatient), and also an entire EM group contracted for the hospital, and the entire lab/path services axed and then subcontracted out to one of the national entities. Big Box shops would rather hemorrhage money on locums then apply a little bit of money to keep their quality they have, or look internally to get rid of the bad mid management or upper management. Upper management is only temporary until they climb the ladder further for the next larger Big Box Shop and currently are only using your facility to pad their resume. Mid management is needed to be kept around because they some what actually do things, and don't want to move, so are willing to be stepped on by the upper management.

 

[When is graduation again?]

I've started planning my post-residency career and am looking to start a private practice, so I'm working on potential business models. I've brainstormed some promising cash models, but want to compare them to insurance taking models. How does one figure out how much insurers in an area will be willing to pay? Do you typically assume it will be close to the Medicare rates or is there another way?

 

[Sushirolls]

1) look at the websites of Psychiatric folks in the target area. See what insurance they list. Make an excel spread sheet of them. The ones that have a higher percentage of acceptance are likely to correlate with better rates.
2) Attempt to meat one, offer coffee, dinner, etc and see if they are willing to divulge some things even if in generalities.
3) Call up a tiny practice as a possible patient, and say hey, I'm about to become an independent contractor and buy my health insurance on the exchange or open market. I'd like to know that you guys would be able to take my insurance, what your top three you guys like? I've had Psychiatrists drop my insurance in the past and want to reduce that risk in the future. Now you know the top three from the receptionist/front desk person - who knows these details because its small practice and they are helping with the billing.

 

[hallowmann]

Here is an another metaphor that might resonate with the fresh grads, Big Box Shops are not Shaadi, Match, eHarmony; nope, Big Box Shops are tinder so use them as much as they will invariably use you.

So how exactly do you use the big box shops like Tinder? I am not hip on the online dating scene. Like get a job for a year and then peace out?

 

[jbomba]

1) look at the websites of Psychiatric folks in the target area. See what insurance they list. Make an excel spread sheet of them. The ones that have a higher percentage of acceptance are likely to correlate with better rates.
2) Attempt to meat one, offer coffee, dinner, etc and see if they are willing to divulge some things even if in generalities.
3) Call up a tiny practice as a possible patient, and say hey, I'm about to become an independent contractor and buy my health insurance on the exchange or open market. I'd like to know that you guys would be able to take my insurance, what your top three you guys like? I've had Psychiatrists drop my insurance in the past and want to reduce that risk in the future. Now you know the top three from the receptionist/front desk person - who knows these details because its small practice and they are helping with the billing.

Do the best paying ones typically go much beyond CMS rates?

 

[dl2dp2]

Do the best paying ones typically go much beyond CMS rates?

No.

You can also use FAIRHealth.

There are also hybrid models (i.e. flat membership fee plus insurance reimbursement)--there are existing larger groups that do this (i.e. OneMedical) where psychiatrists charge a higher fee than PMDs.

There are insurance payouts that are close or even exceed cash. I know a couple but I can't share details due to NDA. The usual scenario: the larger employer wants high quality care for their employees and the employees complain that you can't find anything that takes their insurance, and so the employer contracts with a large institutional provider of good reputation to get mental health "carve-outs". The insurance company acts as the middle man to get such contracts implements. The institution gets a 30% bump on payout and the provider gets a 30% salary bump. Win-win-win.

However, solo PPs will never be offered such a deal. LOL.

 

[When is graduation again?]

No.

You can also use FAIRHealth.

There are also hybrid models (i.e. flat membership fee plus insurance reimbursement)--there are existing larger groups that do this (i.e. OneMedical) where psychiatrists charge a higher fee than PMDs.

There are insurance payouts that are close or even exceed cash. I know a couple but I can't share details due to NDA. The usual scenario: the larger employer wants high quality care for their employees and the employees complain that you can't find anything that takes their insurance, and so the employer contracts with a large institutional provider of good reputation to get mental health "carve-outs". The insurance company acts as the middle man to get such contracts implements. The institution gets a 30% bump on payout and the provider gets a 30% salary bump. Win-win-win.

However, solo PPs will never be offered such a deal. LOL.

I was looking into creating a subscription based cash model for my own future practice. I didn't realize insurance would allow a hybrid subscription model, but this could definitely make what I was planning to offer more affordable.

Is there any policy or legal issue, that would interfere with me (or the average solo practitioner) from adopting this approach?

 

[When is graduation again?]

1) look at the websites of Psychiatric folks in the target area. See what insurance they list. Make an excel spread sheet of them. The ones that have a higher percentage of acceptance are likely to correlate with better rates.
2) Attempt to meat one, offer coffee, dinner, etc and see if they are willing to divulge some things even if in generalities.
3) Call up a tiny practice as a possible patient, and say hey, I'm about to become an independent contractor and buy my health insurance on the exchange or open market. I'd like to know that you guys would be able to take my insurance, what your top three you guys like? I've had Psychiatrists drop my insurance in the past and want to reduce that risk in the future. Now you know the top three from the receptionist/front desk person - who knows these details because its small practice and they are helping with the billing.

Thanks for the advice. These are great tactics, though it's frustrating there isn't more transparency in insurance reimbursements.

 

[dl2dp2]

I was looking into creating a subscription based cash model for my own future practice. I didn't realize insurance would allow a hybrid subscription model, but this could definitely make what I was planning to offer more affordable.

Is there any policy or legal issue, that would interfere with me (or the average solo practitioner) from adopting this approach?

There are regulatory requirements which differ by state. U should look into a healthcare attorney who has experience in this. There are also now specialty consultant/franchising companies that help you with this. A simple google search should reveal several.

 

[Sushirolls]

Some states consider retainer practices to be "insurance companies." and if you do advance collect for services the must be put in an escrow account, or you simply can't pre-collect for services....

 

[Sushirolls]

Do the best paying ones typically go much beyond CMS rates?

Some locations, they can.

 

[Sushirolls]

So how exactly do you use the big box shops like Tinder? I am not hip on the online dating scene. Like get a job for a year and then peace out?

Treat it like a job.
Get a lawyer to review the contract before hand and get as many things favorable to you inserted in there.
Use all your vacation every year.
Use all your CME every year.
Counter intuitive to the typical 'go getter' mentality fostered in the medical school training gauntlet, is no, don't sign up for committees and things that don't pay you.

In simple terms with Big Box Shops, it is a business, and you are a tool to be used, and if deemed broken to be discarded and replaced. So in turn, you need to be selfish and think about and advocate for your self in the choices you make. Don't volunteer for things. Don't strive to make things better. Simply show up, keep your head down. Drop your resignation the instant things smell fishy or they cross the line in management.

Conversely the Big Box shops lack the understanding in what HR really means and how to retain talent. This creates more opportunities for locums!

 

[robellis]

Treat it like a job.
Get a lawyer to review the contract before hand and get as many things favorable to you inserted in there.
Use all your vacation every year.
Use all your CME every year.
Counter intuitive to the typical 'go getter' mentality fostered in the medical school training gauntlet, is no, don't sign up for committees and things that don't pay you.

In simple terms with Big Box Shops, it is a business, and you are a tool to be used, and if deemed broken to be discarded and replaced. So in turn, you need to be selfish and think about and advocate for your self in the choices you make. Don't volunteer for things. Don't strive to make things better. Simply show up, keep your head down. Drop your resignation the instant things smell fishy or they cross the line in management.

Conversely the Big Box shops lack the understanding in what HR really means and how to retain talent. This creates more opportunities for locums!

Exactly correct

 

[deleted1012620]

Treat it like a job.
Get a lawyer to review the contract before hand and get as many things favorable to you inserted in there.
Use all your vacation every year.
Use all your CME every year.
Counter intuitive to the typical 'go getter' mentality fostered in the medical school training gauntlet, is no, don't sign up for committees and things that don't pay you.

In simple terms with Big Box Shops, it is a business, and you are a tool to be used, and if deemed broken to be discarded and replaced. So in turn, you need to be selfish and think about and advocate for your self in the choices you make. Don't volunteer for things. Don't strive to make things better. Simply show up, keep your head down. Drop your resignation the instant things smell fishy or they cross the line in management.

Conversely the Big Box shops lack the understanding in what HR really means and how to retain talent. This creates more opportunities for locums

As a resident starting to look at job options, this scares me. But I don't necessarily want to deal with the hassles of starting my own practice, at least not right away.

What are the best employed options for someone who doesn't want to have productivity squeezed out of them like an Amazon warehouse worker?

 

[Sushirolls]

Read comments on Indeed and those other job forum sites before you walk into interviews.
Try to talk with the front desk / support staff who was there before, get a name and try to google them up and call them. Say you might interviewing for their old job.
Get more of the work load spelled out in the contract.
There are possibly some good places left, but they are rare for Big Box Shops.

 

[dl2dp2]

As a resident starting to look at job options, this scares me. But I don't necessarily want to deal with the hassles of starting my own practice, at least not right away.

What are the best employed options for someone who doesn't want to have productivity squeezed out of them like an Amazon warehouse worker?

There's very little hassle in starting a very small side gig solo cash practice in psychiatry. It's in my belief that EVERYONE who's able to do this (i.e. no formal non-compete) should do this. The overall cost is less than a couple of thousands if that. The procedure is also very well documented--APA literally has a downloadable manual that's well written and comprehensive, and I believe even free for members.

Adding a couple of insurances into the equation doesn't change the math all that much if you only aim to fill 5-10 hours a week.

Once you have a sense of how this works, it's much easier to talk on an informed basis with an employer about what words like "productivity" and "squeezing" even mean. The "hassle" in running a practice in psychiatry is primarily patient recruitment and management AFTER you start your practice, and the level of success can also vary tremendously. My estimate is that most US MD grads can sustain a full cash practice (i.e. 35 hours+) at the moment after a reasonable period of time (a year or two or so), if you set the rate right and don't do stupid things (like no marketing), but the total income may or may not exceed your facility-employed colleagues. This is why in surveys of solo/small group owners don't necessarily make more money per se than facility employees. The upper limit in cash (~5%) is much, MUCH higher, with (some) psychiatry being one of the top-paying specialties for pure clinical work in all of medicine. But if you don't start your practice, you won't know how any of this works, and whether you are good enough to be at the very top of this kind of work. It's also not easily predictable based on the obvious like residency institution ranking, location, etc. Some of the most profitable cash practices are in midsized cities/unremarkable suburbs. Some of the wealthiest/most profitable practice owners I know are IMGs--though the stories are typical that they own large insurance-driven practices--many of them also have second jobs at a facility.

There are several senior members of the board, the main advice whenever a junior person asks questions like what are the best-employed options, how do I avoid exploitation, how do I make more money, etc. is invariably to start your own practice. Start small and hedge with a facilities job. ANY facilities job would do. Then you'll learn by doing very fast. The best-employed options are the ones that look the most like the ideal owner-operated practice.

In my years of meeting with colleagues, NEVER HAS THERE been a single person who regretted starting their practice. Plenty of people regretted not starting their practice early enough. There are lots of people who had a practice but then later shut it down for various [valid] reasons, but NONE regretted doing it in hindsight. People who are most "exploited" in various ways (not just $) by systems are invariably people who had zero real-life (solo or otherwise) practice experience (i.e. always full time academic, employed, ER, etc). It's THAT useful as a learning exercise.

 

[hallowmann]

I will say that the posts here have really made the idea of a private practice more attainable in my mind, when before I had never considered going through the hassle of it. I could see starting at a position part-time and starting off 1/2-1 day a week with a psych private practice.

The biggest thing that I'm worried about is having to shut it down and lengthening my time to FIRE, but the potential payoff sounds worth it to practice the way you want and have something to fall back on.

 

[AD04]

There are several senior members of the board, the main advice whenever a junior person asks questions like what are the best-employed options, how do I avoid exploitation, how do I make more money, etc. is invariably to start your own practice. Start small and hedge with a facilities job. ANY facilities job would do. Then you'll learn by doing very fast. The best-employed options are the ones that look the most like the ideal owner-operated practice.

In my years of meeting with colleagues, NEVER HAS THERE been a single person who regretted starting their practice. Plenty of people regretted not starting their practice early enough. There are lots of people who had a practice but then later shut it down for various [valid] reasons, but NONE regretted doing it in hindsight. People who are most "exploited" in various ways (not just $) by systems are invariably people who had zero real-life (solo or otherwise) practice experience (i.e. always full time academic, employed, ER, etc). It's THAT useful as a learning exercise.

 

[ArdorAyurveda]

Would you all recommend paying off student loans before starting a private practice?

With moonlighting, it's possible to pay of student loans before finishing residency, though...

 

[dl2dp2]

Would you all recommend paying off student loans before starting a private practice?

With moonlighting, it's possible to pay of student loans before finishing residency, though...

Why? Some people never pay off their loans and get PSLF. Student loans and PP are unrelated except that if you are PP full time you are not eligible for PSLF.

 

[Merovinge]

I will say that the posts here have really made the idea of a private practice more attainable in my mind, when before I had never considered going through the hassle of it. I could see starting at a position part-time and starting off 1/2-1 day a week with a psych private practice.

The biggest thing that I'm worried about is having to shut it down and lengthening my time to FIRE, but the potential payoff sounds worth it to practice the way you want and have something to fall back on.

Unless you have a second life you're eagerly anticipating after FIRE, I would posit that being your own boss and being demonstrably responsible for all the benefit you would bring to your patients, even if on a very reduced hour basis, would be more enjoyable than 95% of the things people would do after early retirement.