Questions to ask before joining as an associate? (serious)

[turftoebro24]

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I am interested in this associate position on the East Coast (not NY). I did a preliminary interview where they told me a salary range of 120k-140k base wage, as it is negotiable. 33% bonus after tripling your base. Every 6th weekend you round on the weekend, alternating schedule with the doctors. 2 weeks PTO but apparently can negotiate more.

They double scrub most elective cases at the local hospitals, which I prefer actually because I feel nervous about being alone in the OR despite 3 years at a fairly busy residency.

They offer malpractice and health insurance, not sure if they will pay for my credentialing and for insurance panels. No sign on bonus. Not sure about how many patients per day.

I have a round 2 interviews coming up real soon with them, was wondering how all this sounds so far and what other specific questions to ask about.

Thank you

 

[Adam Smasher]

If they want you to be on call, you are legally entitled to have call spelled out, how many nights per week, how many weekends per month. If there's rounding, what kind of census is there?

What kind of technology do they use to make the doctor's life easier? EHR vs paper charts? Cast orthotics vs 3d scanner? Are assistants taking the xr or are you expected to? Do they deal in diabetic shoes? If yes, how much of the administrative side are you expected to be responsible for? (Correct answer: none)

Credentialing and insurance panels should be covered by the business, it's pretty cheap from an owner's perspective.

 

[Retrograde_Nail]

Sounds like a typical associate contract

You are asking the wrong questions.

You should be demanding access to their books and see how much volume is actually going through that clinic and whether it is even possible to bonus at this practice. Where is your volume coming from? Are you they going to make you promote yourself? Are you going to have to knock on doors and make cookies for the local PCP offices? Most associate positions are not good situations. You essentially have to create your own practice and they are banking on that. That's why you have to triple your base to even bonus so they can make the lions share of profit off of you.

It's a pyramid scheme. All podiatry contracts are trash. All of them.

You are better off starting your own practice. But if you don't have the confidence then lose a couple of years wasting in this first contract to learn the business then leave and open up your own shop.

When and how do you partner? That should be made clear in the contract.

If the practice refuses to open their books or make partnership clear in the contract then run away

 

[wakaflocka88]

Why round every 6th weekend? Are you responsible for continuing to manage patients not under your care once The Weeknd is over? What happens if they need surgery?

What is their financial status like - need full transparency on the numbers. What type of DME are they providing. Skin graft fraud? Magic potions fraud?

How are new patient referrals scheduled? Do they cherry pick? How can you keep track of this?

Is the office manager a spouse/side affair/ex wife of one of the docs?

For this bonus - they need to spell it out exactly how it is calculated. Sign nothing until every question you have is spelled out on paper.

What are the terms of this malpractice - don’t forget about potential tail coverage if you ever leave, which you most likely will leave.

Are you sure you really want to double scrub and have them hawk over you, and possibly micro manage how you operate? Be different if you just want someone in there to help you hold a leg, do a little retraction and sit in the corner

IMO this sounds suspect

One of my PP contract offer was 85k base with 25% bonus after 170k, in a large metro city. Let that sink in

Just collect your base, do not advertise for this practice and continue to job hunt on the side. Do not do more than you need to

 

[Weirdy]

Gonna repeat the above.
Do they have the volume for you to reach bonus?
Are you walking into a full schedule day 1 or are you responsible for finding your own patients?
33% sounds great until you realize you need to bring in 3x 120-140k
There are associate mills in lower COL states offering 150k + 15-20% after 2-2.5x.
120-140k + 33% after 3x seems like they're taking advantage of you compared to that.

 

[Weirdy]

Credentialing + insurance panels should be on them completely.
If they already have 2 pods, it should be very easy to get you credentialed and onboarded with their current insurance panels.

 

[Weirdy]

Other things to note:
What's their non compete like?
How long is your contract? - are you planning to stay in the area that long?
Do they plan to have you stay in the area after your contract is over?
Buy in opportunities?
Surgery centers / profit sharing buy in?

 

[Retrograde_Nail]

Lots of experience on this thread. Lots of people with experience getting screwed over by mustache pods who won't retire because they still make a living still ripping off new associates. The profession is over saturated.

I've never worked in private practice but I have heard so many similar stories from friends, older and younger podiatrists. Same story over and over and over.

 

[Adam Smasher]

I have it on good authority from the attorney reviewing my contract, partnership clauses in contracts are completely unenforceable.

Conversely, be wary of owners excessively eager to take you on as partner: they want to cash out their business while leaving you as a minority voice in practice decision-making

 

[Weirdy]

Some more spam:
Like Retro mentioned above- how transparent are they in regards to you having access to your own performance?

There is no way to accurately tell if you are getting under paid bonus-wise unless you see incoming/outgoing cash flow.
Its easy to assume they'll just show you the books.
Its another to keep getting a base pay, zero bonus for the length of your contract, ask to see the books, and then get a generic printout of expenses with no real way to tell if they are withholding numbers from you.

A good owner/job/potential for long term growth should be showing you the books and saying "hey we WANT you to bonus, here's what's coming in, here's expenses, here's the number of patients you need to see daily to surpass your current rate, here's what you should bring in monthly and your projection for next year" etc.
Doesn't make any sense to stay in a place that is shady about their numbers or has no real goals or projections for you.

Doesn't make sense for them to hold you back either. The more money you make, the more the business (they) makes.
They should be rooting for your success and helping you get there if you have the work ethic and a basic skill level.

But lobsters gonna lobster.

 

[Weirdy]

I have it on good authority from the attorney reviewing my contract, partnership clauses in contracts are completely unenforceable.

Good to know. Didn't realize that.

 

[heybrother]

I am interested in this associate position on the East Coast (not NY). I did a preliminary interview where they told me a salary range of 120k-140k base wage, as it is negotiable. 33% bonus after tripling your base. Every 6th weekend you round on the weekend, alternating schedule with the doctors. 2 weeks PTO but apparently can negotiate more.

They double scrub most elective cases at the local hospitals, which I prefer actually because I feel nervous about being alone in the OR despite 3 years at a fairly busy residency.

They offer malpractice and health insurance, not sure if they will pay for my credentialing and for insurance panels. No sign on bonus. Not sure about how many patients per day.

I have a round 2 interviews coming up real soon with them, was wondering how all this sounds so far and what other specific questions to ask about.

Thank you

1. Are they owned by private equity?
2. How / when and on what is your bonus paid.
3. What EHR do they use
4. How do they track collections per doctor
5. Will you be able to see the collections per patient as the money is collected
6. Do they see Medicaid / state managed care type plans. How are patients divided / assigned
7. If a patient is assigned to you - does that remain your patient or are they exchanged, moved between doctors
8. What ancillaries and self-pay/cash services will they "have available for you" -ie. expect you to push / sell
9. Will your surgeries be at hospitals / ASCs.
10. Are you expected to follow protocols or is care rendered based on your judgement
11. Who makes the determinations for the coding of visits
12. Round where, on who? Are these new patients being picked up from the emergency room, the floor, etc or are they your partner's in hospital post-ops. If people are being seen on weekends - who is seeing them during week days?
13. Is there a call expectations ie. at facilities? how many? where are they in relation to the town you'll be living in?
14. If the number of doctors "changes" - will your call frequency change? This is something that comes up in other medical forums. You were taking 4-5th day call and then a doctor decides not to take call or retires or whatever and you are no longer 6th day call - you are 4th day call.
15. Sick days?
16. Who chooses what hardware you can use on your surgeries?
17. Will you be the person making all the determinations for what is right for your patients?
18. Why do they double scrub? Presumably the answer is - surgical assistant fee though I'm not sure that's a real answer.
19. Will you be expected to perform RRA / ankle fractures / calcaneal fractures etc. Is this something you feel comfortable doing?
20. How many of the doctors in the group are partners? Is there a super partner?
21. MDs and DOs do not work 50 weeks a year. What holidays do they take off. If you operate are you expected in clinic afterwards?
22. Does the office have capitated plans? Who sees these patients. Who shares in the revenue / reimbursement if they exist.
23. Insurance companies sometimes grandfather older doctors allowing them to have better payment rates. Will all of your services be billed under your name?
24. What costs of business will they expect you to pay for ie. ABFAS dues, state license? Will they pay for exams? Will they pay for CME?
25. Do they have a diabetic shoe van?
26. Do they perform nursing home work? Will you be expected to perform nursing home work?
27. Do they routinely take care of hospital type patients without insurance?
28. Is the group compensated for any of the services you'll be performing at facilities ie. receiving a stipend. If so, do you share in it?
29. How many associates have left before becoming a partner
30. Are partners eat what you kill?

 

[Utvolsdpm]

😝 diabetic shoe van

 

[Feli]

In reality, PP contracts are pretty much as good as the people signing them.

Noncompete does matter. It's basically enforcable in the state... or it's not. Consult attorney on that. Be absolutely sure.
If it's not enforcable for physicians in that state/area, doesn't matter if they put 2 miles or 5 or 50... not enforcable. Ignore it and simply eval the rest of the contract/job.
If it is enforcable (for docs) in that state, be aware of it and it should be reasonable (but if you negotiate it, they will have clear tell that you're planning to leave soon).

The employer pays all costs related to you practicing if you're a w2: state license, malprac, credentialing, boards, marketing, all that. That is not for negotiation or things they "offer", lol. If that's not in the contract, it needs to be.

Compensation... obviously, the bigger base salary, the better.
Other than that base, owners have 101 ways to manipulate associate collections, undercount them, not count certain things like dme or otc or whatever. Again, consider the people you'd work for and with more than the exact terms. Talk to current and former associates; see what they have say. Don't focus a ton on % or when the bonus starts. CME and health/dental and various "bonuses" are nice, but again, don't take them as worth much. Do the best you can, but it's fairly rare you'll hit bonus well or early.

For most pod PPs, it's far more common they can't fill your schedule very well - or will minimize your collections even if you are busy and productive. It's common they expect you to "market yourself" or to get by with crummy and/or few staff supporting. They will likely encourage call and inpatient to get more productivity from associates. Remember: It should not be a long term plan to stay as a worker bee in podiatry anyways (PP associate, supergroup, etc). The long term is open your own PP solo or partner, work for a hospital as FTE pod (even rural or small or VA), or at minimum be a reasonably paid DPM in a supergroup or big group or MSG pod job with no room for advance - but at least a liveable wage given your debt and skill set.

Any meaningful partnership in a podiatry PP is about your same chance as getting a date with Rachel Stuhlmann. No joke. Get it out of your head. Don't worry about it in any contract; it's not enforceable and is typically just owner talk. Most medium/large groups for podiatry function basically just like Venture Capital groups or are being bought out by VC (just happened to largest pod supergroup in my state... all their docs are screwed to take the new contracts, or leave).


...so, what should you look for in a PP contract? That you'll learn a bit, make a bit of money, hopefully work for decent docs. Past associates and docs who worked there should have fairy good things to say about the office/owner. You should be sure NOT have any noncompete and that you might learn area docs/facilities if it's an area you might want to stay. Everyone's out for themself, and you should be too.

 

[MicroPod]

I have it on good authority from the attorney reviewing my contract, partnership clauses in contracts are completely unenforceable.

Conversely, be wary of owners excessively eager to take you on as partner: they want to cash out their business while leaving you as a minority voice in practice decision-making

One of the attendings in my residency who let us scrub cases with them had a PP job with supposed eventual partnership. The owner backed out when it came time for him to buy in after 2 years (shocker). He called me a couple of months ago asking if there were any good openings where I’m at lol.

 

[Feli]

One of the attendings in my residency who let us scrub cases with them had a PP job with supposed eventual partnership. The owner backed out when it came time for him to buy in after 2 years (shocker). He called me a couple of months ago asking if there were any good openings where I’m at lol.

This is basically every PP job... talk of partnership, talk of ways to make more, might even be in the contract (vague or detailed)... no substance. It's simply a trick to keep the associate around awhile and/or to pad the income of the outgoing doc as they wind down/out.

The only successful podiatry PP partnerships are usually when two young DPMs start up an office/group together.
Buyouts can work also.... but buy-ins are nearly always overpriced for what the associate gains (usually their own collection/growth).

Sadly, this is not unique to podiatry.
^^^^ = absolutely great read regarding joining PP, going solo, partnership usually overpriced, VC buyouts, etc. It's ophtho docs, but much of the info applies to any PP setup.

 

[Hybrocure]

I think people here are ignoring one big thing - ask too many questions and appear too demanding, they may not want to even hire you to begin with.

Sure you’d probably turn that offer down anyways if they don’t meet x criteria for what you request, or if they’re shady about stuff. But if you’re in a position where this is your only opportunity in an area where you want to live, or a spouse has a job there, etc. Sometimes it helps to just read between the lines. Usually it’s easy to tell if the job has a jerk predatory owner or someone actually decent to work under without probing too hard. Ultimately the contract will spell things out and you can get it reviewed and ask questions then.


That being said - bare minimum should be letting you know what they bring in. Previous collections from associates. Are you reimbursed for DME? Things like that. The owner of my practice was super cool to offer up all this stuff and more up front before I even asked.


Podiatry pro tip: if the owner is an old guy w a bunch of young people working under him, and he has a mustasche and everyone else does call except him - run. Also if the job is on the east coast the likelihood of this is about 95%.

 

[Hybrocure]

In reality, PP contracts are pretty much as good as the people signing them.

Bingo.

By the time you’re ready to be an attending you should be good enough at spotting and reading people who would be bad to work for or who would take advantage of you and those who wouldn’t.

This is however one downside to working at a hospital/facility/govt job. Always expendable. And you are too in PP. But it helps when you can build a relationship with and actually get to know the person who employs you.

Can’t do that with the number crunchers at govt/hospital/insurance jobs. I’ve unfortunately seen just as many institutional pods get screwed over out of the blue as I have PP pods

 

[Retrograde_Nail]

Bingo.

By the time you’re ready to be an attending you should be good enough at spotting and reading people who would be bad to work for or who would take advantage of you and those who wouldn’t.

This is however one downside to working at a hospital/facility/govt job. Always expendable. And you are too in PP. But it helps when you can build a relationship with and actually get to know the person who employs you.

Can’t do that with the number crunchers at govt/hospital/insurance jobs. I’ve unfortunately seen just as many institutional pods get screwed over out of the blue as I have PP pods

How many podiatrists do you personally know who worked at hospital/VA/MSG jobs that got screwed over? I doubt it is of the same volume as podiatry private practice. In fact its not.

How a hospital can screw a DPM is that they don't give them an raise in base salary or RVU dollar amount when they have put in the volume and production. I've seen that. I've experienced that at my previous hospital job. You play hard ball and eventually can negotiate something better. If you can't then it is still something better than working in private practice.

VA podiatry jobs do not have high turnover rate. Once you get past the grace period which is like two years it would take the jaws of life to get you removed from a government job.

There is always the rare chance of not getting your contract renewed or fired but that falls on the head/fault of the podiatrist. Not something that is common place.

The frequent screwing over of associates in private practice is common place in podiatry. Again due to saturation. It will never end as long as we continue to graduate as many podiatrists as we are seeing with more schools opening up.

These old owner refuse to retire because they can see the gravy train will never stop. Its free money for them. That's the game.

 

[DYK343]

I dont understand the double scrub thing. Very suspect. Unless they want to ensure you're not really bad and tarnish their name. Proctor 10 cases or whatever. But every case for all time? What a waste of everyones time. Youre not getting 2 surgeon fees for a bunion. That 2nd surgeon is volunteering time.

Also, if you sit for ABFAS boards you cant double scrub cases. Auto fail that case.

Nout sure what ABPM stance is on that.

Something to think about

 

[Feli]

I dont understand the double scrub thing. Very suspect. ...

Billing... most states allow assistant fee (not another full fee, but it's a fraction... varies by state). Not volunteering.

Follow the money. I saw this done by TFP groups a bit in Michigan (although it's harder as -82 says no resident available, and many hospitals do have residents in Detroit). Sadly, $omething is better than nothing when podiatry is very saturated in many places (... and/or many podiatrists are very bad at surgery).

If they own the surgery center (OON ftw) and/or office nearby, it can also be worth it to assist speed the block of cases - even if the state assistant surgeon rate is fairly low end.

...Also, if you sit for ABFAS boards you cant double scrub cases. Auto fail that case.

Nout sure what ABPM stance is on that. ...

ABPM just passes everyone... no case review. That is why it's hot garbage.
One could have the "certification" (or the now defunct "CAQ surgery") with no cases ever reviewed.

Most of the pods double scrubbing everything aren't exactly aiming for ABFAS. It's a way to make more money and/or have better assist on cases.

 

[DYK343]

Billing... most states allow assistant fee (not another full fee, but it's a fraction... varies by state). Not volunteering.

Something is better than nothing when podiatry is very saturated in many places (... and/or many podiatrists are very bad at surgery).

If they own the surgery center (OON ftw), it can also be worth it to speed the cases - even if the state assistant surgeon rate is fairly low end.


ABPM just passes everyone... no case review. That is why it's hot garbage.
One could have the "certification" (or the "CAQ surgery") with no cases ever reviewed.

Most of the pods double scrubbing everything aren't exactly aiming for ABFAS. It's a way to make more money and/or have better assist on cases.

Certainly open to being wrong. But I though 2nd surgeon fees were only awarded and paid on large cases. Mostly general surgery, spine, etc.

Didnt know you could submit 2nd surgeon fees for a bunion, midfoot fusion, etc.

My google search said in a couple spots $500 to the assistant surgeon. Seems like a lot for a procedure that only requires 1 surgeon tobe done correctly.

 

[Feli]

Certainly open to being wrong. But I though 2nd surgeon fees were only awarded and paid on large cases. Mostly general surgery, spine, etc.

Didnt know you could submit 2nd surgeon fees for a bunion, midfoot fusion, etc.

My google search said in a couple spots $500 to the assistant surgeon. Seems like a lot for a procedure that only requires 1 surgeon tobe done correctly.

-82 can be used on anything.
It can also be denied on anything... but most elective has prior auth already (groups doing this will usually PA that assist also).
It is totally variable by state and payer... sometimes not allowed, but typically a % of the normal fee that payer allows for the CPTs.

 

[Hybrocure]

How many podiatrists do you personally know who worked at hospital/VA/MSG jobs that got screwed over? I doubt it is of the same volume as podiatry private practice. In fact its not.

How a hospital can screw a DPM is that they don't give them an raise in base salary or RVU dollar amount when they have put in the volume and production. I've seen that. I've experienced that at my previous hospital job. You play hard ball and eventually can negotiate something better. If you can't then it is still something better than working in private practice.

VA podiatry jobs do not have high turnover rate. Once you get past the grace period which is like two years it would take the jaws of life to get you removed from a government job.

There is always the rare chance of not getting your contract renewed or fired but that falls on the head/fault of the podiatrist. Not something that is common place.

The frequent screwing over of associates in private practice is common place in podiatry. Again due to saturation. It will never end as long as we continue to graduate as many podiatrists as we are seeing with more schools opening up.

These old owner refuse to retire because they can see the gravy train will never stop. Its free money for them. That's the game.

I don’t personally know them. I just inherited their patients. I’d love to turf some patients off to a “wound center” or hospital employed pod near me but they’ve all been dusted

 

[Adam Smasher]

my first year out, I helped my partner/boss with a mpj fusion, billed 28750-80. Got $80. It would have been more profitable for both of us if I was just in office grinding nails.

Lesson: assistant fees are for courtesy/charity but not a business strategy!

 

[heybrother]

my first year out, I helped my partner/boss with a mpj fusion, billed 28750-80. Got $80. It would have been more profitable for both of us if I was just in office grinding nails.

Lesson: assistant fees are for courtesy/charity but not a business strategy!

Assistant fees in network appear to be about 16%. My wondering out loud suspicion would be ...
-You have 2 people at the surgery center on the same day and you stack/alternate cases to try and maximize assistant fees on top
-Or maybe the office doesn't have enough rooms/patients to have all the doctors there so you try to "make" revenue elsewhere.

 

[deleted1162946]

That base sucks. I almost make double that as a base but I am also miserable so take it for what it’s worth.

 

[shadesofgrey]

My experience has been that most private pods have a very poor business sense and are also woefully ignorant of the amount of debt that new grads have incurred. The result is that they don't realize what kind of money a new grad needs and frankly may struggle to afford it because their overhead is running way to high. It's hard to offer close to 40% in collections when the overhead is running at 65%. The pod owner may also wonder why should the new grad earn 250k coming out when he earned 80k coming out in 1992? Now as a partner this has been challenging making older docs realize this.

There is a segment of PP owners that are truly malignant. They should be avoided at all costs.

I feel, if possible, PP should be avoided. The area I chose to live after residency, PP was all that was available, so I chose the practice based on my read of the personality of the docs and the track record of partnership. The offer I got wasn't great but the practice had a near 100% track record of turning associates into partners. It worked out. Associate years sucked, but they were true to their word and offered partnership. About 6 months before I was to be offered partnership, they even declined a fairly lucrative offer from a supergroup because the supergroup wasn't going to treat me as a partner. So if you have to work in PP, find good people.

In conclusion:

Best option: Don't become a podiatrist
2nd best option: Hospital/VA pod, something with loan forgiveness
3rd option: open own practice
last option: Associate for pod but with goal of partnership

 

[Retrograde_Nail]

My experience has been that most private pods have a very poor business sense and are also woefully ignorant of the amount of debt that new grads have incurred. The result is that they don't realize what kind of money a new grad needs and frankly may struggle to afford it because their overhead is running way to high. It's hard to offer close to 40% in collections when the overhead is running at 65%. The pod owner may also wonder why should the new grad earn 250k coming out when he earned 80k coming out in 1992? Now as a partner this has been challenging making older docs realize this.

There is a segment of PP owners that are truly malignant. They should be avoided at all costs.

I feel, if possible, PP should be avoided. The area I chose to live after residency, PP was all that was available, so I chose the practice based on my read of the personality of the docs and the track record of partnership. The offer I got wasn't great but the practice had a near 100% track record of turning associates into partners. It worked out. Associate years sucked, but they were true to their word and offered partnership. About 6 months before I was to be offered partnership, they even declined a fairly lucrative offer from a supergroup because the supergroup wasn't going to treat me as a partner. So if you have to work in PP, find good people.

In conclusion:

Best option: Don't become a podiatrist
2nd best option: Hospital/VA pod, something with loan forgiveness
3rd option: open own practice
last option: Associate for pod but with goal of partnership

Please clarify what your stipulations/criteria was to partner. Did you need to buy in? Generate a certain amount of revenue? This would provide even more information for readers. If you could. thanks!

 

[pod squad]

What are the typical benefits of partnership in a non-PE owned podiatry group? Higher percentage of collections kept? Equity in the practice (is that even worth anything?) Both?

 

[shadesofgrey]

Please clarify what your stipulations/criteria was to partner. Did you need to buy in? Generate a certain amount of revenue? This would provide even more information for readers. If you could. thanks!

The expectation was three years and then partnership was offered assuming good group fit and good patient care. There was not a discussion regarding a specific target revenue and in general I was middle of the pack in my production as an associate. Currently, we have an associate who is toward the bottom in regards to production and we fully intend to offer partnership based on her fit.

I did my research on the practice and docs before hand. They were a medium sized practice and had partnered every associate who had been there three years, with one exception. I questioned them on it and basically the associate had a very strong personality that did not gel with other docs. There was a buy in and it was a bit more than I expected, but the practice did guarantee the loan. All partners have equal shares and voting rights.

It has worked out for me, but I still don't advise joining a PP if possible, always try hospital jobs first. I was fully prepared for them to screw me up until the moment I signed the paperwork. I had backup plans stacked and ready to go if it didn't work out. Additionally, when you join a partnership there are often times established ways of doing things that can be tough to change. Things that seem common sense and easy to change to me, are completely foreign to some of my partners. It requires a mix of being laid back and also standing up for yourself. Often I think perhaps I should have just started my own practice, but I also know that would require me to be further involved in areas of a practice that I have no interest in.

What are the typical benefits of partnership in a non-PE owned podiatry group? Higher percentage of collections kept? Equity in the practice (is that even worth anything?) Both?

I can't speak for other groups, but for me it meant higher percentage of collections, offers to buy in to the surgery center, offers to buy into real estate associated with the practice, and a vote in the decision making process. I also have equity which is valuable if I leave the practice. There is also some retirement incentive if I practice as an owner for so long.

 

[icebreaker32]

What are the typical benefits of partnership in a non-PE owned podiatry group? Higher percentage of collections kept? Equity in the practice (is that even worth anything?) Both?

Usually the reasons are:

Higher percent of collections

A much greater degree of job stability (you can get voted out as partner, but rarely without very good cause)

Income from other areas: surgery center is the obvious one, but some groups have many other income sources also outside of direct patient care

Tax advantages as an owner

Some control over how you practice

 

[Adam Smasher]

Partnership is a lot like marriage:

1) You cannot legally force someone to commit to you. If you are not getting the commitment you seek, it is best to move on.

2) Beware anyone over eager to make you their partner, there's a good chance they just want the financial security

3) Marriage/partnership changes people, not always for the best. If there is unequal investment, at least one partner will experience discontent.

4) There is increased security but also increased responsibility.

5) Unions are cheap, separations are expensive, often acrimonious

 

[Feli]

My experience has been that most private pods have a very poor business sense and are also woefully ignorant of the amount of debt that new grads have incurred. The result is that they don't realize what kind of money a new grad needs ...

This has nothing to do with private pods, though. They didn't borrow the debt and don't pay the debt.
You are talking about tuition inflation that is out of control; that's mainly on podiatry schools' greed (and students' stupidity).
High interest rates don't help.
American materialism doesn't help (I've talked to many new pod grads trying to "buy" a house a year or two out of training or leasing a 6 figure car, no joke).

Also, it IS perfectly possible to pay off $300k student debt with $150k/yr income (definitely not fun... but quite possible).
That said, PP groups do need to be in the neighborhood (of VA, hospitals, MSGs, etc) with job offers if they want to get/retain good DPMs.

Remember: without PP podiatry jobs, you'd just have ~600 grad DPMs each year trying for ~100 hospital jobs.
The rest would get literally nothing - or must start up and office on their own immediately to survive (with little/no loans ability).
Yeah, you'd have HealthDrive or Upperline or some slop hiring a few dozen of pods, but they'd pay even lower (if not for the many PP jobs).

...It simply has no bearing on me if some kid is at $400k because s/he has private undergrad loans or didn't pay his loan interest in residency or took 5 years to finish podiatry school or they are trying to have a SAHM spouse or whatever. I didn't create that. It's not my problem.
Personally, I'd never hire an associate simply because they'd want too much and/or be looking to leave. Can't blame them (blame pod schools).
I would help a nearby hospital hire a pod (if they wanted to take that risk), but it's a unnecessary frustration for me to try myself.
It is also likely a PP just brings in a competitor in the increasing number of places with no enforced non-competes.
The smart thing these days is just to bring in a partner DPM you trust... or pass the office off to a DPM you like when done working. I have explored both. But hiring? It's nearly impossible with the tuition inflation constantly inflating what an associate will "need." Heck, I have enough finding and training and keeping top-level MA/front employees. 🙂

 

[Dermato Fight Club]

I have to second this post from Feli and piggyback on it. I've been wanting to post something like this for awhile but I guess I thought I'd get shamed somehow. So much on this forum has to do with TFP or the mustache Pod. While maybe some of it is deserved it's not the entire truth.

Put yourself into a PP owner's shoes. I'm there now after finishing residency 12 years ago and have no plan to hire an associate. I'm not busy enough. I feel like the only reasons to bring on an associate are if you are too busy (booked out 2 weeks and/or can't get an ingrown in the same day) or if you are slowing down to retire.

So here we have a PP doc who let's say is either too busy or wants to slow down. He/She decides they want to bring on an associate. He/she is expected to pay state license/malpractice/health insurance/401k/CME allowance/APMA dues etc.

From my experience that along with general overhead is going to be about 60% of what the new associate brings in. Likely much more in their first year or two as the new associate may not be collecting that much.

So you want the PP owner to guarantee let's say a 250k or so salary without any incentive for the associate to work harder/ i.e collect more. I would be very wary as a practice owner to bring anyone on that isn't on some sort of collection % bonus. The associate would have to collect 625k until the practice owner sees any profit. In my experience, collecting 625k/year is doable but not easy.

So we are expecting a PP owner to take on an associate, pay them 250k and essentially lose money on this deal?

If I were to ever hire an associate (unlikely as I am closer to retirement than residency) I would do something like 30% of the first 200k, 35% until like 4 or 500k and then 40% above 500k.

The owner needs to have some reason to take on an associate and be compensated appropriately otherwise why even take one on?

In my scenario the PP owner maybe makes 20-30k/year from the associate for having to deal with owner issues i.e HR issues. Hardly worth it.

Anyway, the whole point of this post was to recommend to you guys to put yourselves into PP owner's shoes and see maybe why these offers are the way they are. It's not necessarily PP owners being greedy. It's because there just isn't that much need for you guys.

Like what are you actually bringing to an established practice? if I hire the best trained associate now you're saying I can keep those 10-20 flat foot/ankle implants/difficult traumas etc. within my practice instead of referring them out. That makes me an extra about $500/year.

In other words......

 

[dtrack22]

33% bonus after tripling your base.

So you get 33% of collections with your base and then you “bonus” at…33% of your collections. It’s not a bonus and it doesn’t reward you for getting busier. Nor does it take into the fact that your share of the overhead (as a % of collections) decreases as you bring in more money.

not sure if they will pay for my credentialing and for insurance panels.

They better. They are taking $.67 of every dollar you bring in. That easily covers every penny of overhead you cost the practice. And last I checked, you have to maintain CME, a license, credntials and privileges, etc. in order to work. They are overhead expenses and if you are employed in any fashion, they should be your employers responsibility.

 

[PMG03470]

Anyway, the whole point of this post was to recommend to you guys to put yourselves into PP owner's shoes and see maybe why these offers are the way they are. It's not necessarily PP owners being greedy. It's because there just isn't that much need for you guys.

View attachment 396860

I am an unfortunate associate for the time being and I agree with everything you have said. I crunch the numbers all the time to make myself less mad. The only point that I think is left out here is taking into account larger practices… your logic is 100% correct as a single practitioner taking on one. But say it’s a group of somewhere between 4-10. The overhead of each doc of course is license, DEA, malpractice etc. But with each added doc assuming no new locations are added, the overhead to a degree is getting divided over each doc. Therefore, the more docs the % of overhead compared to collections should be going down assuming each doc is busy. This is what frustrates me about where I am because I know the owner where I am is pocketing a minimum of 100k from me each year beyond my overhead.

 

[Feli]

… your logic is 100% correct as a single practitioner taking on one. But say it’s a group of somewhere between 4-10. The overhead of each doc of course is license, DEA, malpractice etc. But with each added doc assuming no new locations are added, the overhead to a degree is getting divided over each doc. Therefore, the more docs the % of overhead compared to collections should be going down assuming each doc is busy. This is what frustrates me about where I am because I know the owner where I am is pocketing a minimum of 100k from me each year beyond my overhead.

It's more costly than you may realize.
EMR (per doc) usually costs same/more than malpractice these days. New location/rooms + staff should be added for a doc hire (unless they're a replace for retire/fired/left DPM)... dead days and half days of rent/utilities are inefficient.

Some owners truly support the associate (rooms, staff, marketing/intros, give them pts from their own pool/waitlist). Other owners just put them in extra space and send them the Medicaid. It varies. That's something to try to sniff out at visit/interview or from talking to current/past associates.

Try taking a look at the ophtho thread I linked above. Great points on both sides in there (associates sayinng it's easy and cheap to add one, owners/partners saying no its costly and a risk). They also talk of how salaries vary widely due to supply and demand and how hard or easy it is to get patients in various areas.

 

[turftoebro24]

That base sucks. I almost make double that as a base but I am also miserable so take it for what it’s worth.

Which state ?

 

[turftoebro24]

My experience has been that most private pods have a very poor business sense and are also woefully ignorant of the amount of debt that new grads have incurred. The result is that they don't realize what kind of money a new grad needs and frankly may struggle to afford it because their overhead is running way to high. It's hard to offer close to 40% in collections when the overhead is running at 65%. The pod owner may also wonder why should the new grad earn 250k coming out when he earned 80k coming out in 1992? Now as a partner this has been challenging making older docs realize this.

There is a segment of PP owners that are truly malignant. They should be avoided at all costs.

I feel, if possible, PP should be avoided. The area I chose to live after residency, PP was all that was available, so I chose the practice based on my read of the personality of the docs and the track record of partnership. The offer I got wasn't great but the practice had a near 100% track record of turning associates into partners. It worked out. Associate years sucked, but they were true to their word and offered partnership. About 6 months before I was to be offered partnership, they even declined a fairly lucrative offer from a supergroup because the supergroup wasn't going to treat me as a partner. So if you have to work in PP, find good people.

In conclusion:

Best option: Don't become a podiatrist
2nd best option: Hospital/VA pod, something with loan forgiveness
3rd option: open own practice
last option: Associate for pod but with goal of partnership

Sorry if this is a basic question, but what benefit does a partner see vs a regular associate?

 

[heybrother]

Sorry if this is a basic question, but what benefit does a partner see vs a regular associate?

Its going to be based on the nature of the partnership contract.

-Usually you are more difficult to terminate
-You might take on a higher base or a higher percentage of collections throughout the course of the year
-You might be given the opportunity to buy real estate or part of a surgery center
-You might receive a portion of left over cash/profit as distributions.

Consider the following:
3 podiatrists
potentially each with different collections
potentially each with different ways of doing things

At the end of the years there's $50,000 left over.

1. Split profits equally. What are the odds everyone contributed a similar work effort?
2. Take each doctors collections, divide by total collections - assign $ as a percentage of total collections. A rapid path to frustration if your collections are dramatically higher than other doctors.
3. Eat what you kill. Determine exact costs and collections of each doctor. Under this approach the entirety of left-over profit could be owed to one doctor.
4. Ortho eat what you kill. Determine exactly the expenses of each doctor and their collections. Non-performing doctor who didn't cover expenses owes money to the practice because they didn't cover their overhead.
5. Pay-out based on total ownership of the practice. ie. you own 20% of the practice, you keep 20% of profits. In fact, the left-over profit could be a bigger or smaller pot based on how everyone was paid through the course of the year.

 

[Dermato Fight Club]

Its going to be based on the nature of the partnership contract.

-Usually you are more difficult to terminate
-You might take on a higher base or a higher percentage of collections throughout the course of the year
-You might be given the opportunity to buy real estate or part of a surgery center
-You might receive a portion of left over cash/profit as distributions.

Consider the following:
3 podiatrists
potentially each with different collections
potentially each with different ways of doing things

At the end of the years there's $50,000 left over.

1. Split profits equally. What are the odds everyone contributed a similar work effort?
2. Take each doctors collections, divide by total collections - assign $ as a percentage of total collections. A rapid path to frustration if your collections are dramatically higher than other doctors.
3. Eat what you kill. Determine exact costs and collections of each doctor. Under this approach the entirety of left-over profit could be owed to one doctor.
4. Ortho eat what you kill. Determine exactly the expenses of each doctor and their collections. Non-performing doctor who didn't cover expenses owes money to the practice because they didn't cover their overhead.
5. Pay-out based on total ownership of the practice. ie. you own 20% of the practice, you keep 20% of profits. In fact, the left-over profit could be a bigger or smaller pot based on how everyone was paid through the course of the year.

This is what I do. I'm not sure I understand why it wouldn't be fair to the doctor that collects the most. I thought this was the fairest way to do it.

 

[heybrother]

This is what I do. I'm not sure I understand why it wouldn't be fair to the doctor that collects the most. I thought this was the fairest way to do it.

Its probably not. The higher collecting doctor will ultimately be given more money, but depending upon the exact circumstances they in fact are the person who earned the entirely of the profit for the practice. Consider that at my practice I'm hundreds of thousands ahead of my partner. Have you heard the expression - "a 10% loss of income can be a 100% loss of profit". Another way to think about it is - think about the last dollars that come in. Imagine your business had seen 1 extra patient a day. During the years its just " oh it was just 1 patient" but at the end of the year once the finances are known if you could travel back in time every extra patient would have been extra money on top.

If you have 2 partners and their collections are only ...$10,000 apart but there's $100,000 in extra cash - its not really an issue. Both have likely contributed. When one partner is $150-200K ahead in collections and there's $20-40K left at the end of the year - the higher earning partner is essentially entirely responsible for all of of the left-over cash/profit. If they had earned the same amount as their lower earning partner there probably would not have been any left over dollars.

 

[Adam Smasher]

Would love to write a longer message about this, but allocating profits in proportion to % share of collections is the fairest. Maybe some hybrid of that and splitting profits in proportion to ownership stake. But just like associates need to be rewarded for production, so too do partners.

Consider 2 doctors, Dr Mustache and Dr Fellowship Trained. Dr M has been in business for years and hires Dr FT to work as his associate. They get along harmoniously and have a common vision for the direction of the business. Dr M takes Dr FT on as partner.

Dr M has paid off his house and his kids have moved out. He is now receiving payments from Dr FT and does not need to work so hard in patient care because he has this ancillary personal income stream. He might reduce hours or simply downcode visits to finish charting quicker.

Dr FT has 400k in student loans and a pregnant wife. Dr FT has every reason in the world to take on over bookings and expand service offerings.

My opinion is that Dr M should want for Dr FT to be able to realize the fruits of his efforts. If Dr FT sees more patients and does more for them, why shouldn't he take a larger slice of the pie?

Other dimensions: what happens if a partner becomes temporarily disabled? How do you handle DME? How do you handle retail? CME expenditures? What if Dr FT wants to spend practice money on a fungus laser that Dr M will never use, how is that expense split up? I could go on...

 

[Dermato Fight Club]

Its probably not. The higher collecting doctor will ultimately be given more money, but depending upon the exact circumstances they in fact are the person who earned the entirely of the profit for the practice. Consider that at my practice I'm hundreds of thousands ahead of my partner. Have you heard the expression - "a 10% loss of income can be a 100% loss of profit". Another way to think about it is - think about the last dollars that come in. Imagine your business had seen 1 extra patient a day. During the years its just " oh it was just 1 patient" but at the end of the year once the finances are known if you could travel back in time every extra patient would have been extra money on top.

If you have 2 partners and their collections are only ...$10,000 apart but there's $100,000 in extra cash - its not really an issue. Both have likely contributed. When one partner is $150-200K ahead in collections and there's $20-40K left at the end of the year - the higher earning partner is essentially entirely responsible for all of of the left-over cash/profit. If they had earned the same amount as their lower earning partner there probably would not have been any left over dollars.

Thanks. I get it. I guess there really isn't a perfect system unless you hire some outside accounting firm to come in and split overhead evenly then dividing the collections fairly which is something I am definitely not interested in doing and would also likely take away all of our profit.

Just curious what other guys are doing as far as partnership payout?

 

[turftoebro24]

Gonna repeat the above.
Do they have the volume for you to reach bonus?
Are you walking into a full schedule day 1 or are you responsible for finding your own patients?
33% sounds great until you realize you need to bring in 3x 120-140k
There are associate mills in lower COL states offering 150k + 15-20% after 2-2.5x.
120-140k + 33% after 3x seems like they're taking advantage of you compared to that.

Sorry for the basic questions, I just want to understand. So just to be clear, when they say 33% bonus after tripling the base that means it's 33% bonus for every dollar I make over that amount right?

So tripling a 120,000 base would obviously be 360,000$.

If I brought in 500,000$ for as an example (500k-360k=140k). 33% of 140k is a 46,200$ bonus.

Because I think some people think the bonus is calculated as (120k x 33%= 39,600k, once you've tripled the base)

 

[Weirdy]

Sorry for the basic questions, I just want to understand. So just to be clear, when they say 33% bonus after tripling the base that means it's 33% bonus for every dollar I make over that amount right?

So tripling a 120,000 base would obviously be 360,000$.

If I brought in 500,000$ for as an example (500k-360k=140k). 33% of 140k is a 46,200$ bonus.

Because I think some people think the bonus is calculated as (120k x 33%= 39,600k, once you've tripled the base)

Yes.
They pay you 120k
You bring in 500k
They subtract your 3x base (500-360 = 140k)
They fiddle with the numbers and subtract more for overhead or their girlfriend's Paris trip or gold plated nail nippers.
(Amount left over) x 0.33 = your bonus

Being facetious but you get the idea

Basic contract: base + (% x [whatever leftover after 2-3x base - remaining expenses] )

You can also negotiate for tiered % bonus like they mentioned above. Bring in 3x base. Every amount after x number gets higher increase in %.
Example: bring in 500k get 30%. Bring in 600K get 35%. Bring in 700k get 40%

Can also negotiate for straight % of production.
Example: salary = 40% x production. So bring in 360k, get .4 x 360k = 144k salary not including benefits whatever

 

[Weirdy]

This is also why you need to be sure they are being transparent with their books.
Can you imagine how convoluted this all gets if the only thing to track your performance is trusting whatever numbers they present to you?

 

[Feli]

This is also why you need to be sure they are being transparent with their books.
Can you imagine how convoluted this all gets if the only thing to track your performance is trusting whatever numbers they present to you?

Yes, this is the tripping point.
Owners will almost never be "transparent with their books."
The owners won't be accurate with the numbers for associate (collections, overhead, net, whatever).
Associate has no way to know who pays their bill, what insurance pays, what's denied, what is paid later, etc.
Bonus gets neutered... if paid at all.
Tale as old as time.

Remember the kid who was going to make "closer to $500k" with his PP job bonus? 🙂

 

[turftoebro24]

Yes.
They pay you 120k
You bring in 500k
They subtract your 3x base (500-360 = 140k)
They fiddle with the numbers and subtract more for overhead or their girlfriend's Paris trip or gold plated nail nippers.
(Amount left over) x 0.33 = your bonus

Being facetious but you get the idea

Basic contract: base + (% x [whatever leftover after 2-3x base - remaining expenses] )

You can also negotiate for tiered % bonus like they mentioned above. Bring in 3x base. Every amount after x number gets higher increase in %.
Example: bring in 500k get 30%. Bring in 600K get 35%. Bring in 700k get 40%

Can also negotiate for straight % of production.
Example: salary = 40% x production. So bring in 360k, get .4 x 360k = 144k salary not including benefits whatever

I know we're dealing with hypothetical numbers here but is billing for 500k annually realistic? That is close to 2000$ per working day