Should I quit this job?

[Blackmateria]

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Large city in the Midwest, corporate ortho practice, W2, blue collar area

I see 25 to 30 patients a day, 5 days a week. I get a monthly draw that totals 250k for the year and then quarterly bonuses.

Last year was my first full year at the practice, brought in 9550 wrVU. My collections were around 110k a month, with bonuses my monthly income was around 30k pretax, and 20 k post tax.

I do only bread and butter procedures, no advanced procedures. There are stim and kypho candidates, but not enough to do more than 2 to 3 a month.

Referral base is from PCPs (who are all NPs lol), self referrals and internal orthos

Pros: It is fairly simple work, and my schedule is full with minimal marketing. I had more open slots when I first started last year, so I have room to grow. Orthos also mostly leave me alone.

Cons: It is a one hour drive from my house each way, wife and I do not really want to move closer. I have very little say in how overhead gets spent or hiring. There is no opportunity to buy shares in the practice, orthos own it all. All the income from imaging is considered "ancillary" and I don't see it at all, which amounts to 20k in collections each month.

Alternatives would be joining a smaller pain group, looking for a HOPD job, or starting my own (which I'd need to build up some capital for). I really don't want to do a full time W2 anesthesia job or academics. I am double boarded in anesthesia and pain.

Thanks for any guidance

 

[PM&ARGHH]

Procedures done in office or ASC? Either way, you are getting royally hosed and should leave.

 

[paindoc007]

That’s a bit low. 360k isn’t enough for that much work IMO. I’d be making double producing that equivalent wrvu (though I’m rural…)

 

[Blackmateria]

Procedures done in office or ASC? Either way, you are getting royally hosed and should leave.

Everything in office. There is an ASC, but we can't buy shares, so I didn't see the point.

 

[SSdoc33]

if you like the job, approach the orthos about buying in to the practice to share in the ancillaries. if the they say no, the only leverage you have is to leave. if you are collecting as much as you say, they will want you to buy in

 

[RoloTomassi]

Pretty low. 27/73 is not a great split. ~40/60 is more common.

 

[Agast]

Your take home seems oddly low if all the procedures are office-based. Are you covering 100% of the overhead related to your procedures by yourself?

 

[mille125]

I think only you can decide. If it is truly money, it appears that you are making less than you should at that RVU production rate.

Just remember though, the grass is not always greener. If it is purely salary and all other parameters are good, then I would try to negotiate with the current employer.

just my 2 cents.

 

[Dr. Ice]

PP orthos will never love you back lol

 

[Blackmateria]

Your take home seems oddly low if all the procedures are office-based. Are you covering 100% of the overhead related to your procedures by yourself?

Yes I am, with their cut on top. Their cut decreases by 25% after two years. With 9556 wrVU what is reasonable to expect for take home?

 

[specepic]

Yes I am, with their cut on top. Their cut decreases by 25% after two years. With 9556 wrVU what is reasonable to expect for take home?

If you were hosp employed you should be making $620,000 before taxes per year (give or take). I will let others with more private practice experience, comment what that would look like in that setting

 

[BobBarker]

You have a lot of other options. This is the type of job where orthopedic practices usually target non-fellowship trained PMR. Do you have a family or friend (other young doctors) that you can develop into your own practice closer to home? You just need a few people coming day one but you have to have a way to get them.

 

[Agast]

Yes I am, with their cut on top. Their cut decreases by 25% after two years. With 9556 wrVU what is reasonable to expect for take home?

So who built out the procedure room? Did they already have one for you to use or did you have to cover the cost of purchasing new equipment. Are you only paying for kit costs? What is their “cut” percentage right now on your procedures.

 

[Blackmateria]

You have a lot of other options. This is the type of job where orthopedic practices usually target non-fellowship trained PMR. Do you have a family or friend (other young doctors) that you can develop into your own practice closer to home? You just need a few people coming day one but you have to have a way to get them.
So who built out the procedure room? Did they already have one for you to use or did you have to cover the cost of purchasing new equipment. Are you only paying for kit costs? What is their “cut” percentage right now on your procedures.

Do you mean start my own practice? I have thought of that while doing locums anesthesia, but I'd imagine I'd need a good bit of startup money which I don't have. I should mention I'm not exactly young, I got my start late in life and finished fellowship at 40.

So who built out the procedure room? Did they already have one for you to use or did you have to cover the cost of purchasing new equipment. Are you only paying for kit costs? What is their “cut” percentage right now on your procedures.

Everything was built before I got there.

Avg collections each month was 100k. That's 80 k after ancillaries like MRI are removed. From that each month I paid 6 k in "physician rent", 30 k in "overhead", 8k in "corporate retention" and 7k in my own expenses. I'm told physician rent is charged to all the doctors. Overhead is my share of overhead for the entire practice, so all the docs staff, vending machines, electric bill goes into that. Corporate retention is their profit that they stop taking after 2 years. My own expenses is the 7k. So yes, I'm paying my expenses and the other docs, but only getting the benefit from work since I don't have shares.

 

[BobBarker]

I was talking about starting your own practice. At 40, just go work at a hospital. That is the fastest way to make money and much better than a private ortho practice.

 

[hopefulgasman]

Can’t speak to the intangibles of the job, but purely speaking return - the pay is atrocious, especially for the Midwest regardless of large city or not. Generating that number of RVUs would yield me 2x your pre and post tax salary while only working 4 days a week which makes my 45 minute fairly similar commute palatable.

 

[mdo1738]

Yes I am, with their cut on top. Their cut decreases by 25% after two years. With 9556 wrVU what is reasonable to expect for take home?

That level of production would be right at $600k for me at the hospital. You are generating significant physician enterprise value for them with the ancillaries and are quite underpaid.

 

[Dr. Ice]

Yes I am, with their cut on top. Their cut decreases by 25% after two years. With 9556 wrVU what is reasonable to expect for take home?

About 560k for me in New Jersey with that wrVU

 

[mille125]

If you were hosp employed you should be making $620,000 before taxes per year (give or take). I will let others with more private practice experience, comment what that would look like in that setting

I think that everyone is correct. I have my practice 3 days per week and work for HOPD for 2 days. In the short amount of time, I generated about 4500 rvus and that equates to about what you are making now. (350K) at high your rvu production.

Again though we have to compare apples to apples. HOPD payments will obviously be different than private practice ones.

 

[Ducttape]

the only way your pay makes sense is if you were doing 9950 RVU, not wRVU (though you did not mention the bonus you get quarterly). what you are doing is more inline with wRVU tho.

you are getting $25 per wRVU. going rate midwest is at least 68.

 

[drusso]

You laid out the numbers clearly, and they're bad.

At roughly 9,500 wRVUs and roughly $1.2–1.3M in annual collections, your effective compensation is about $360k pre-tax. That works out to roughly $25–30 per wRVU. That is far below market, especially in the Midwest.

The bigger issue is not just salary. You are paying your own procedural expenses, contributing to shared group overhead, paying physician rent, and paying “corporate retention,” while having no equity and no participation in ancillaries. You are effectively subsidizing enterprise value that you will never own.

Office-based procedures at your volume should be highly profitable. If overhead were fairly allocated, your take-home would already be much higher. The fact that it is not tells you everything you need to know about where the margin is going.

The commute matters. Two hours a day, combined with below-market compensation, is a permanent lifestyle tax.

The promise that the corporate cut will decrease after two years is not a real upside. In these models, it is almost always replaced with another line item.

If there is no realistic opportunity to own your own means of production with ancillary participation, this is a dead-end job. Orthopedic groups do not structure these arrangements to help pain physicians build wealth. Being an owner is part of The American Dream.

The rational move is to start looking quietly. Go find a smaller private group with a real partnership track would all be financially superior. Starting your own practice without capital is difficult, but staying where you are guarantees you never compound anything.

Bottom line: you are not underperforming. You are not failing to negotiate. You are in a structure designed to keep you busy, paid “well enough,” and permanently non-equity. Orthos will not love you back, but they will feel the revenue loss when you leave. Speak with your feet.

 

[mille125]

the only way your pay makes sense is if you were doing 9950 RVU, not wRVU (though you did not mention the bonus you get quarterly). what you are doing is more inline with wRVU tho.

you are getting $25 per wRVU. going rate midwest is at least 68.

I have seen as low as 60 but I agree that most fall between 65-75

 

[mille125]

You laid out the numbers clearly, and they're bad.

At roughly 9,500 wRVUs and roughly $1.2–1.3M in annual collections, your effective compensation is about $360k pre-tax. That works out to roughly $25–30 per wRVU. That is far below market, especially in the Midwest.

The bigger issue is not just salary. You are paying your own procedural expenses, contributing to shared group overhead, paying physician rent, and paying “corporate retention,” while having no equity and no participation in ancillaries. You are effectively subsidizing enterprise value that you will never own.

Office-based procedures at your volume should be highly profitable. If overhead were fairly allocated, your take-home would already be much higher. The fact that it is not tells you everything you need to know about where the margin is going.

The commute matters. Two hours a day, combined with below-market compensation, is a permanent lifestyle tax.

The promise that the corporate cut will decrease after two years is not a real upside. In these models, it is almost always replaced with another line item.

If there is no realistic opportunity to own your own means of production with ancillary participation, this is a dead-end job. Orthopedic groups do not structure these arrangements to help pain physicians build wealth. Being an owner is part of The American Dream.

The rational move is to start looking quietly. Go find a smaller private group with a real partnership track would all be financially superior. Starting your own practice without capital is difficult, but staying where you are guarantees you never compound anything.

Bottom line: you are not underperforming. You are not failing to negotiate. You are in a structure designed to keep you busy, paid “well enough,” and permanently non-equity. Orthos will not love you back, but they will feel the revenue loss when you leave. Speak with your feet.

Agree to all points here but I am always one that suggests respectful dialog first

 

[Blackmateria]

Agree to all points here but I am always one that suggests respectful dialog first

If we were to negotiate, what would be reasonable to start with ? (Ie: less overhead, a cut of the ancillaries) We have asked for shares a few different times and were denied.

 

[BobBarker]

Ortho just doesn’t respect non-ortho a lot of times. They only want people to be partner that can take call so the sr partners don’t have to.

 

[mille125]

If we were to negotiate, what would be reasonable to start with ? (Ie: less overhead, a cut of the ancillaries) We have asked for shares a few different times and were denied.

I would say that you should go to a percentage of collections model. Even if their overhead is really high at 40%, you would make a lot more than you are now.

 

[BobBarker]

They probably have much higher than 50% overhead. Ortho practices have a lot of problems with more and more overhead that just keeps adding up. Too many satellite offices with casting, bracing, x ray sitting idle. Losing money in the PT department, etc.

 

[Ready_User_1]

if you like the job, approach the orthos about buying in to the practice to share in the ancillaries. if the they say no, the only leverage you have is to leave. if you are collecting as much as you say, they will want you to buy in

Wishful thinking they will ever see you as an equal or give you equity regardless of your value. They see you as a commodity. Ask me how I know.....

 

[Ready_User_1]

Orthos will not love you back, but they will feel the revenue loss when you leave. Speak with your feet.

This is what you need to hear. I had a similar deal as you are describing although more dishonest and antagonistic. I left after 8 months. It's a sunk cost. Best decision I made professionally and for my family. They are telling you exactly who they are and how little they value you. You have value.

 

[PM&ARGHH]

I think what you ask for depends what you want. It sounds like you are getting the worst of both worlds, treated like a true partner when it comes to overhead, and not when it comes to ancillaries. I would either ask for ancillaries (assuming they make it up), or be on a true employment model (% collections).

 

[polymyalgia_rheumatica]

They probably have much higher than 50% overhead. Ortho practices have a lot of problems with more and more overhead that just keeps adding up. Too many satellite offices with casting, bracing, x ray sitting idle. Losing money in the PT department, etc.

I agree with this. I was in a large ortho group earlier in my career and the overhead issue described here is very real. Lots of satellite offices, PT losing money, layers of admin. As an employee you end up absorbing the consequences without having any real control over it. I went through something similar and wish I had recognized sooner that this was structural and not something effort or volume would fix.

 

[clubdeac]

For two yrs I was in a neurology group with an in house epilepsy monitoring unit, sleep and infusion center. My overhead was about $60-65k per month! The neurologists were making 600-700k annually. Me not so much

Get out while you can!

 

[MitchLevi]

They probably have much higher than 50% overhead. Ortho practices have a lot of problems with more and more overhead that just keeps adding up. Too many satellite offices with casting, bracing, x ray sitting idle. Losing money in the PT department, etc.

Mmmmhmmmm...These practices take on a culture that isn't always employee friendly. Frequent lawsuits and NDA's being signed and all types of chaos. There are always legal issues and lawyers on retainers are expensive. Ortho practices live and die by their ASC profits. Overhead eats away your salary and bonus, your ASC dividend is your lifeline. We kept multiple locations open that were losers, our new CEO has shut some of that down. I won't disclose overhead in my practice on an open forum, but it is shockingly high. There are benefits on the flip side however, patient selection is FAR better for example.

 

[mille125]

For two yrs I was in a neurology group with an in house epilepsy monitoring unit, sleep and infusion center. My overhead was about $60-65k per month! The neurologists were making 600-700k annually. Me not so much

Get out while you can!

Man...that is insane

 

[au bon pain]

Yes I am, with their cut on top. Their cut decreases by 25% after two years. With 9556 wrVU what is reasonable to expect for take home?

Bro you gotta get outta there ASAP if they don't significantly increase your pay.
I used to work in a ultra-saturated top-10 metro and at 9550 there you'd be making in the 5s.
Where I'm at now, you'd probably be somewhere in the low 7s.

 

[dozitgetchahi]

They probably have much higher than 50% overhead. Ortho practices have a lot of problems with more and more overhead that just keeps adding up. Too many satellite offices with casting, bracing, x ray sitting idle. Losing money in the PT department, etc.

Ortho just doesn’t respect non-ortho a lot of times. They only want people to be partner that can take call so the sr partners don’t have to.

Yep and yep. I am a rheumatologist, but when I was interviewing for my current job I was recruited by a large ortho practice that had all of these issues. One of the biggest stumbling blocks for me was reading the contract and realizing that only the ortho bros could be partners - they were hiring neurologists and rheumatologists and PMR folks etc etc, but only the orthos and neuro spine surgeons were partnership track.

That for me was a hard pass…not to mention all the other ongoing issues.

 

[gaschicago]

@ OP : how many of the 25-30 patients are procedures? are they all patients you've seen or does it include direct procedure referrals on behalf of other physicians/surgeons. are you operating a near max capacity if you account for the staff limitations you mentioned?

Overall doesn't sound great. Get out if you can!